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THE ACUTE ABDOMEN. Hugh M. Foy, MD Harborview Medical Center University of Washington School of Medicine. “BEGIN WITH THE END IN MIND”. Stephen Covey The 7 Habits of Highly Effective People. Acute Abdominal Pain. Considerations: VS: stable or unstable? PQRST

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The acute abdomen
THE ACUTE ABDOMEN

Hugh M. Foy, MD

Harborview Medical Center

University of Washington

School of Medicine


Begin with the end in mind
“BEGIN WITH THE END IN MIND”

Stephen Covey

The 7 Habits of Highly Effective People


Acute abdominal pain
Acute Abdominal Pain

  • Considerations:

    • VS: stable or unstable?

    • PQRST

      • Precipitating or alleviating factors

      • Quality-bright, sharp, dull, achy

      • Radiation- scapula, inguinal, supraclav

      • Severity- 1 to 10 scale

      • Timing- sudden, insidious

        • Crampy or continuous


Hpi part 2
HPI part 2

  • Past Surgical History

    • Previous abdominal or pelvic operation

    • Prior work-up for abdominal pain

  • Past Medical History

    • IDDM

    • ASCVD


Common abdominal conditions
Common Abdominal Conditions

  • Ileus from narcotics

  • Constipation/Obstipation

  • Appendicitis

  • Cholecystitis/Biliary Colic

  • Small Bowel Obstruction

  • Perforated Peptic Ulcer

  • Pancreatitis


Past medical history
Past Medical History

  • Medications

    • Valproic acid

  • Allergies

  • Bugs, bites or stings


The acute abdomen
LOOK

  • Description of abdominal habitus

    • scaphoid,

    • Flat

    • Rotund

      Scars, wounds, erythema

      Anatomic Confines


Anatomic landmarks
Anatomic Landmarks

  • Divided in quadrants

    • RUQ, LUQ, RLQ, LLQ

  • Anatomic:

    • Epigastrium

    • Umbilical

    • Suprapubic (hypogastrium)


Listen
Listen

  • Listen with stethoscope

    • Not necessary in all quadrants

  • Quantitative

    • Absent

    • Decreased

    • Hyperactive

  • Qualitative

    • Normal

    • Borbyrigmy

    • Obstructive

    • Bruits


Bowel tones
Bowel Tones

  • Pathologic

    • Obstructive

      • Hollow

      • Air-fluid interface

        • Like a pebble dropped in to a partially filled barrel

        • “Tinkles and Rushes”


Percussion
Percussion

  • Abdomen

    • Tympanitic gas

    • Dull fluid (ascites or blood)

  • Liver Span

    • mid clavicular line by convention

  • Bladder, Uterus

    • Rising out of the pelvis

      Percussion is also a very sensitive sign of peritonitis


Palpation
PALPATION

Prepare the patient

  • warn them

  • make them comfortable

  • take tension off the abdominal wall

    • Pillow or bend the knees

  • Expose the entire abdomen

    • Xiphoid to pubis


Palpation1
PALPATION

  • Note the patient’s attitude

    • (physically and emotionally)

  • Watch their eyes as you touch them

  • After percussion:

    • Softly at first

    • Deeper

      • LUQ-RUQ note liver edge

      • Then LLQ-RUQ


The painful abdomen
The Painful Abdomen

  • Pain vs Tenderness

    • Distinction is critical to making the diagnosis

    • Be precise:

      • Conceptually,

      • Verbally

      • Written Documentation

        Pain- is a subjective symptom

        Tenderness is an objective sign


Pain vs tenderness
Pain vs Tenderness

  • Based on abdominal innervation:

    • Visceral Pain

      • Sense stretching and ischemia only

      • mediated via Visceral Afferent fibers

        • Follow the blood supply

        • Difuse, not mapped 1:1 on sensory cortex


Pain and tenderness continued
Pain and Tenderness(continued)

  • Tenderness

    • Somatic Afferent Innervation

      • Parietal peritoneum

      • Abdominal Wall

    • Precisely mapped on sensory cortex


Examination of the acute abdomen
Examination of the Acute Abdomen

  • Observe the pt.

  • Reassure

  • Auscultate

  • Percuss and Palpate

    • Begin in quadrant opposite the suspected pathology

    • Percussion is very sensitive peritoneal sign


Examination of the acute abdomen ii
Examination of the Acute Abdomen II

  • Guarding

    • Voluntary

    • Involuntary

  • Peritoneal Signs:

    • Rebound

    • Percussion tenderness


Peritoneal tenderness associated findings
Peritoneal TendernessAssociated findings

  • Eyes dilate,

  • Exquisitely tender

  • “bright tenderness”

  • akin to fracture tenderness

  • “electric shock-like”


Examination of the painful abdomen
Examination of the Painful Abdomen

  • Advanced palpation tricks

    • Sneak up on them

    • Distract with conversation

    • Watch their eyes

    • Palpate with the stethoscope

    • Bump the stretcher


Advanced and adjuvant exams
Advanced and Adjuvant Exams

  • Shifting Dullness

  • CVA Tenderness

  • Digital Rectal Exam

  • Bimanual Pelvic Exam

  • Listening to lower lung fields


Exam for ascites
Exam for Ascites

  • Fluid Wave

  • Shifting Dullness

  • Associated findings:

    • Caput Medusa

    • Spider Angioma


6 dermatomal pain syndrome
“6 Dermatomal” Pain Syndrome

  • Due to poorly localizing visceral innervation, diseases can present in vague, confusing manner

    • Pneumonia

    • Acute MI

    • GERD

    • Biliary Colic

    • PUD

    • Pancreatitis

    • Hepatitis


Diagnostic approach
Diagnostic Approach

  • Essential Questions:

    • Stable or Unstable?

    • Do I need the surgeon now?

    • Is it obvious that they need an operation?


Diagnostic approach1
Diagnostic Approach

  • What is your clinical Diagnosis?

  • Options:

    • Upright CXray and Abdomen, KUB

    • CT + IV or PO contrast

    • Ultrasound

    • Nothing


Diagnostic modalities
Diagnostic Modalities

  • CT: 15-20% false negative for acute perforation

    • Poor study for gallstones

    • Contrast obscures kidney stones


When to call the surgeon
When to call the surgeon?

  • Unstable VS- call immediately

  • Obvious peritonitis

  • Work up complete in stable, less obvious

    • CBC, coags

    • Blood gas

    • Lytes

    • Amylase

    • Bilirubin(s)

    • LFTs

    • Imaging


Chores in the interim
Chores in the interim

  • ABCs

    • Does this pt need intubated, O2?

    • IVs- large bore, 2 if unstable

      • Resuscitation- NS vs LR

      • Bolus therapy- 20cc/kg, repeat if necessary

    • Foley Catheter

    • ?Central line

  • Type and Cross

  • Antibiotics- Gram Neg and Anaerobic

    • Cipro/Flagyl

    • Pip-Tazo

    • Cefotetan

  • Pain Medication?


Common pitfalls
Common Pitfalls

  • Acute Mesenteric Ischemia

  • Intestinal Volvulus

  • Gallstone “Illeus”

  • AAA and backpain

  • “It’s just gastroenteritis”


Evaluation of abdominal pain summary
Evaluation of Abdominal PainSummary:

  • Patient Condition guides the urgency

  • Clinical Diagnosis is the first step

  • Imaging studies depend on Clinical Dx.

  • Patient Preparation is crucial to outcome