Acute Abdomen Hossam Hassan. Acute AbdomenOverview Basic Definition and Principles Clinical Diagnosis / DDx Characterizing the pain Other history to elicit.
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Acute Abdomen
Acute AbdomenAcute AbdomenHossam Hassan
Acute Abdomen
OverviewOverviewBasic Definition and PrinciplesClinical Diagnosis / DDxCharacterizing the painOther history to elicitWays to remember such a broad differentialHistory & Physical / Labs / ImagingNon-surgical causes of acute abdomen
Clinical ManagementDecision to OperateAtypical presentations
Acute Abdomen
Basic Definition and Basic Definition and PrinciplesPrinciplesSigns and symptoms of intra-abdominal disease usually best treated by surgeryProper evaluation and management requires one to recognize:
1 .Does this patient need surgery?2 .Is it emergent, urgent, or can wait?
In other words, is the patient unstable or stable?
Learn to think in “worst-case” scenarioBut remember medical causes of abd pain
Acute Abdomen
Clinical DiagnosisClinical Diagnosis
Characterizing the pain is the keyOnset, duration, location, character
Visceral pain → dull & poorly localizedi.e. distension, inflammation or ischemia
Parietal pain → sharper, better localizedSharp “RUQ pain”(chol’y), “LLQ pain”(divertic)
Kidney / ureter → flank pain
Acute Abdomen
Clinical Diagnosis – Pain Clinical Diagnosis – Pain cont’dcont’dLocationUpper abdomen → PUD, chol’y, pancreatitisLower abdomen → Divertic, ovary cyst ,
Mid abdomen → early app’y, SBO
Migratory patternEpigastric → Peri-umbil → RLQ = Acute app’yLocalized pain → Diffuse = Diffuse peritonitis
Acute Abdomen
Clinical DiagnosisClinical Diagnosis
“Referred pain”Biliary disease → R shoulder or backSub-left diaphragm abscess → L shoulderAbove diaphragm(lungs) → Neck/shoulder
Acute onset & unrelenting pain = badPain which resolves usu. not surgical
Acute Abdomen
Other historyOther historyGI symptomsNausea, vomiting
?( bilious or bloody)Constipation, obs. constipation (last BM or flatus)Diarrhea (? bloody)Both Nausea/Diarrhea present usu. medicalChange in symtomes with eating?
NSAID use (perf DU)Jaundice, pale stools, dark urine
Drinking history (pancreas)Prior surgeries (adhesions → SBO, ?still have gallbladder & appendix)History of herniasUrine output (dehydrated)Constituational SymptomesFevers/chills
Sexual history
Acute Abdomen
Clinical DiagnosisClinical DiagnosisLocation of pain by organRUQGallbladder
EpigastrumStomachPancreas
Mid abdomenSmall intestine
Lower abdomenColon, GYN pathology
Acute Abdomen
Clinical DiagnosisClinical Diagnosis
Acute Abdomen
Think Think BroadBroad categories for categories for DDxDDxInflammationObstructionIschemiaPerforation (any of above can end here)Offended organ becomes distendedLymphatic/venous obstruction due to ↑pressureArterial pressure exceeded → ischemiaProlonged ischemia → perforation
Acute Abdomen
Inflammation versus ObstructionInflammation versus Obstruction
Organ Lesion
Stomach Gastric Ulcer
Duodenal Ulcer
Biliary Tract
Acute chol’y +/-choledocholithiasis
Pancreas Acute, recurrent, or chronic pancreatitis
Small Intestine
Crohn’s disease
Meckel’s diverticulum
Large Intestine
Appendicitis
Diverticulitis
Location Lesion
Small Bowel Obstruction
Adhesions
Bulges
Cancer
Crohn’s disease
Gallstone ileus
Intussusception
Volvulus
Large Bowel
Obstruction
Malignancy
Volvulus: cecal or sigmoid
Diverticulitis
Acute Abdomen
Ischemia / PerforationIschemia / Perforation
Acute mesenteric ischemiaUsually acute occlusion of the SMA from thrombus or embolismChronic mesenteric ischemiaTypically smoker, vasculopath with severe atherosclerotic vessel diseaseIschemic colitisAny inflammation, obstructive, or ischemic process can progress to perforationRuptured abdominal aortic aneurysm
Acute Abdomen
GYN EtiologiesGYN EtiologiesOrgan Lesion
Ovary Ruptured graafian follicle
Torsion of ovary
Tubo-ovarian abscess )TOA(
Fallopian tube Ectopic pregnancy
Acute salpingitis
Pyosalpinx
Uterus Uterine rupture
Endometritis
Acute Abdomen
Labs & ImagingLabs & ImagingTest Reason
CBC w diff Left shift can be very telling
BMP N/V, lytes, acidosis, dehydration
Amylase Pancreatitis, perf DU, bowel ischemia
LFT Jaundice,hepatitis
UA UTI, stone, hematuria,Gl.,
Ketones
Beta-hCG Ectopic
Test ReasonKUBFlat & Upright
C XR
SBO/LBO, free air, stones
Ultrasound Chol’y, jaundice
GYN pathology
CT scan-Diagnostic
accuracy
Anatomic dx
Case not straightforward
Acute Abdomen
CT scanCT scan
What is the diagnosis? Acute appendicitis
Acute Abdomen
Non-Surgical Causes by SystemsNon-Surgical Causes by Systems
System Disease System DiseaseCardiac Myocardial infarction
Acute pericarditisEndocrine Diab ketoacidosis
Addisonian crisis
Pulmonary Pneumonia
Pulmonary infarction
PE
Metabolic Acute porphyria
Mediterranean fever
Hyperlipidemia
GI Acute pancreatitis
Gastroenteritis
Acute hepatitis
Musculo- skeletal
Rectus muscle hematoma
GU Pyelonephritis CNS
PNS
Tabes dorsalis )syph(
Nerve root compression
Vascular Aortic dissection Heme Sickle cell crisis
Acute Abdomen
Decision to operateDecision to operatePeritonitisTenderness w/ rebound, involuntary guarding
Severe / unrelenting pain“Unstable” (hemodynamically, or septic)
Tachycardic, hypotensive, white count
Intestinal ischemia, including strangulationPneumoperitoneumComplete or “high grade” obstruction
Acute Abdomen
Special CircumstancesSpecial Circumstances
Situations making diagnosis difficultStroke or spinal cord injuryInfluence of drugs or alcohol
Severity of disease can be masked by:
SteroidsImmunosuppression (i.e. AIDS)Threshold to operate must be even lower
Acute Abdomen
Management of Management of Abdominal PainAbdominal PainAlways right to start with ABC’sIV accessFluid administrationAntiemeticsAnalgesicsDirected testing and imagingRe-evaluationsAntibioticsConsultantsSurgeons, OB/GYN, urologists, cardiologists, etc
Acute Abdomen
Pearls, Pitfalls and MythsPearls, Pitfalls and MythsDo not restrict the diagnosis solely by the location of the pain.Consider appendicitis in all patients with abdominal pain and an appendix, especially in patients with the presumed diagnosis of gastroenteritis, PID or UTI.Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain.The WBC count is of little clinical value in the patient with possible appendicitis.
Acute Abdomen
Pearls, Pitfalls and MythsPearls, Pitfalls and MythsDo not restrict the diagnosis solely by the location of the pain.Consider appendicitis in all patients with abdominal pain and an appendix, especially in patients with the presumed diagnosis of gastroenteritis, PID or UTI.Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain.The WBC count is of little clinical value in the patient with possible appendicitis.
Acute Abdomen
Pearls, Pitfalls and MythsPearls, Pitfalls and MythsAny woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative.Pain medications reduce pain and suffering without compromising diagnostic accuracy.
Acute Abdomen
Pearls, Pitfalls and MythsPearls, Pitfalls and Mythselderly patient with abdominal pain has a high likelihood of surgical disease.Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain.A patieAn nt with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis; they need an operation.The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA.
Acute AbdomenSimplified rules for the Simplified rules for the diagnosis of acute abdominal diagnosis of acute abdominal painpain..Think in terms of the area of the pain.Common conditions are common.Disease prevalence changes with age.Different patterns of disease between men and women.
Acute Abdomen
Take Home PointsTake Home PointsCareful history (pain, other GI symptoms)Remember DDx in broad categoriesNarrow DDx based on hx, exam, labs, imagingAlways perform ABC, Resuscitate before DxIf patient’s sick or “toxic”, get to OR (surgical emergency)Ideally, resuscitate patients before going to the OR
Don’t forget GYN/medical causes, special situationsFor acute abdomen, think of these commonly (below
Acute Abdomen
Perforated DUCholecystitisAppendicitis +/- perforationIschemic or perf bowelDiverticulitis +/- perforationRuptured aneurysmAAABowel obstruction Acute pancreatitis
Acute Abdomen
THANK YOU
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