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

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