dr.ramate wongwilairat. md somdejphajaotaksin hospital

DR.RAMATE WONGWILAIRAT. MD

SOMDEJPHAJAOTAKSIN HOSPITAL

OUTLINE

DIFINITION ACUTE ABDOMENANATOMY AND PATHOPHYSIOLOGY

ABDOMINAL PAINETIOLOGY OF ACUTE ABDOMENCLINICAL ASSESSMENT HISTORY TAKING PHYSICAL EXAMINATION LABORATORY INVESTIGATION IMAGING STUDYKEY FEATURES OF COMMON CAUSES

OF ACUTE ABDOMINAL PAINQUESTION

DIFINITION diagnosis and treatment immediately

medical or surgical condition

timimg 1-4 wk

Anatomy relate t o abdominal pain

Peritoneum visceral and parietal peritoneum

abdominal organ intraabdominal and retroperitoneal organ

Abdominal wall

pathophysiology

Intraabdominal organ

NERVE1.Parietal peritoneum Abdominal wall inferior epigastric a. somatic sipinal nerve T7-L2

2.Intraabdominal organ Visceral peritoneum celiac trunk , SMA , IMA

autonomous system

Type of abdominal pain

Visceral painSomatic painRefered painMigratory pain

Viscera l pain

abdominal organ parasympathetic and sympathetic

C-fiber ,slow transmitter dull and crampy not localized

midline pain (bilaterallity) Stretching , compression , torsion, distention

Viscera l pain foregut epigastium

midgut periumbilical

hindgut suprapubic

Somati c pain

Irritate to Parietal peritoneum

A-delta fiber , spinal nerve

fast transmitters sharp and exquisite localized

peritoneal sign : localized tender , guarding

MigratorypainAcute appendicitis

Migratory pain

Peptic ulcer perforate

Refere d pain

pain felt at a site distant from a disease

processPathophysiology multiple pain afferents in the posterior horn of spinal cord

Common nerve root

Spinal nerve r 4ootC

Right shoulder diaphragm

gall bladder

liver capsule

peumoperitomeun

•Left shoulder diaphragm spleen tail of pancrease stomach splenic flexure of colon

The thoracic a - ffernt T6 T8

Right scapular gall bladder

biliary treeLeft scapular spleen tail of pancrease

Refere d pain

Groin/genitalia ureter kidney Back- midline pancrease duodenum aorta

ETIOLOGY OF ACUTE ABDOMINAL PAIN

1. INFLAMMATION /INFECTION

A. PERITONEUM PRIMARY PERITONITIS ; ASCITES SCONDARY PERITONITIS: HOLLOW VICUS ORGAN PERFORATE TERTIALY PERITONITIS : TB

B. HOLLOW VICUS ORGAN APPENDICITIS , CHOLECYSTITIS , GASTROENTERITIS DIVERTICULITIS, PEPTIC ULCER

C. SOLID VISCERA PANCREATITIS , HEPATITIS

D. MESENTERY LYMPADINITIS

E. PELVIC ORGAN PID , ENDOMETRIOSIS , TUBOOVARIAN ABSCESS

2. MECHANICAL ( OBSTRUCTION /ACUTE DISTENTION)

A.HOLLOW VISCUS ORGAN GUT OBSTRUCTION ; HERNIA ,TUMOR INTUSSUSCEPTION BILIARY TRACT OBSTRUCTION: CALCULI TUMOR

B.SOLID ORGAN ACUTE HEPATOMEGALY , SPLENOMAGALY

C.MESENTERY OMENTAL TORSION

D.PELVIC ORGAN OVARIAN CYST , ECTOPIC PREGNANCY

3. VASCULAR

A.INTRAPERITONEAL BLEEDING RUPTURE LIVER AND SPLEEN RUPTURE AORTA , SPLENIC ANEURYSM RUPTURE ECTOPIC PREGNANCY

B.INTRAPERITONEAL ISCHEMIA MESENTERY THOMBOSIS HEPATIC INFRACION : TOXIMIA , PURPURA SPLENIC INFRACTION OMENATAL INFRACTION

Abdominal pain pathway

InflammationInfectionObstructionDistentionBleedinginfarction

Intraabdominal organParietal peritoneum

Spinothalamic tract

vagus

Spinal nervesympathetic

Somatic painVisceral painRefer pain

History takingPEinvestigation

HISTORY TAKING

CLINICAL ASSESSMENT

duration Site of pain 1. maximum point of pain

2. initial location of pain

Nature in o nset of pain

Sudden onset hollow viscus organ perforate

ischemic process passage stoneGradual onset inflammmation process

Progressi on of pain

Intermittent pain Colicky seconds( bowel)

minutes (ureteric)

tens of minutes (biliary)

Constant pain peptic ulcer,

pancreatitis

Subside early colicMore severe late colic

Characteri stic of pain

Burning peptic ulcer

Sharp or stabbing ureteric colic

Crampy gut ostruction

gastroenteritis

Aggravate or r elieve of pain

Posture lying still

rolling around

GI function type of food

Associatedsymptom

Vomitting type of vomitus

timing frequentAnorexiaBowel habitsfever

HISTORY TAKING

age menstruation past illness familial history

organ systemic review

medication

Physical examination

CLINICAL ASSESSMENT

BASIC CONSIDERATIONA large number of different

structures Small abdominal cavityPelvic cavity and dome of

diaphargmAbdominal wall muscleThe brain cannot distinguish depend on tecnique

of examination

preparation

The environment warm and private good daylight and oblique

The bed hard bed with a backrest

rest head on pillow and flex hip

preparation

Exposure uncover the patients from nipple to knees

genitalia and hernia orifices

Get the patients to relax rest his arm on his side breathe regularly and slowly

preparation

The position of the examination

right side , hand and forearm horizontal position

clean and warm hand short nail

The routine of examination

InspectionAuscultation

Percussionpalpation

INSPECTATION

Look at the whole abdomen symmetry buldging : organomegaly , mass distended : gas , ascitis, fat , mass scaphoid abdomen: malnutrition

inspectation

ScarSpider nevi , superficial vien dilate

Visible peristalsisGrey tunner and cullen sign

Herniaumbilicus

Spider nevi

Bowels sound (all quadrants)

peritalsis ; gurgling noise…mixture gas and air

low pitched , every few seconds

no bowel sound over a 15-30 seconds

paralytic ileus intestinal obtruction : high pitch , freqent

Systolic bruit aortic or iliac aneurysm

Splashing sounds gastric outlet obstruction

percussion

Percussion

Tympanic or hypotympanic (dullness) on percussion liver or spleen dullness (span) loss of liver dullness????? shifting dullness (ascites ) hypertympanic ( gut obstruction or ileus)Determining the extent of the tender area

Liver span

Shifting dullness

Fist test (tender on percussion)

palpation

Pressing gently and lightly

Symmetrical over all the abdomen

Begin palpation on nontender area

principle

Light palpationfor tenderness

Assess the degree

mild tenderness

moderate tenderness guarding

severe tenderness rebound

Localized or generallized

• Subcutaneous mass

Deep palpation

Masses position tenderness shape fluctuation size , surface, edge , consistency

pulsatile

deep palpation(bimanual)

Deep Palpate the normal solid organ

liverHand on the right side

transvesely of abdomenStart at umbilicusPatient takes a deep breatheThe inferior edge of enlarged

liver bumpThe index finger .. Irregular or

smoothWhen cannot palpate the liver, please move up the hand to the

costal margin

Spleen normal spleen is not palpable

palpate with the finger tips on

the left and below the umbillicus

the patients takes deep breathe

move the right hand toward

the left costal margin left hand lift the lower cage forwards

Kidneys puts left hand behind the right loin

, between the 12th rib and iliac crest

lift the loin and kidney forwards

puts the right hand on the right side

of abdomen just above the level of

the anterior superior iliac spine

the patients take deep breathe

Palpation donot forget

Supraclavicular fossa

Hernial orificeFemoral pulseExternal genitalia

Special examination

Murphy sign

OBTURATOR SIGN

Pitfall in physic al examinationElderly , childrenMask factor; analgesic , steroid

Immuno-compromised host

Repeatly in PE ReliabilityAs a whole

DIFFERENTIAL DIAGNOSIS

Differentialdiagnosis

Differentialdiagnosis

notice

Medical causeSiteSolid or hollow viscusCongenital , trauma , tumor

Infectionincidence

INVESTIAGATION

CLINICAL ASSESSMENT

Diagnosis investigation

Confirm diagnosisExclusion diagnosis Pre op evaluation depend on facility and policy

Always required history taking

physical examination

CBC

Hct or Hb GI loss dehydrate

leukocytosis infective condition

ischemic process

LFT bilirubin alkaline phosphatase

liver enzymeUrianalysis KUB stone infectionAmylase pancreatitisBUN Cr e renal, e imbalance

Blood sugar DM., acute pancreatitis

Urine pregnancy test ectopic pregnancy

Hemoculture sepsis, cholangitis

pyogenic liver abcess

Diagnosis imaging

plain film abdomen; supine , CxR , upright

free air PUP

bowel gas pattern gut obstruct

abnormal calcification gall stone KUB stone chro.pancreatitis

Ultra sound hepatobiliary system , solid organ

gynecologic condition KUB systemCT scan acute diverticulitis complication severe pancreatitis

Contrast media unnessary barium enema

colonic obstruction

pseudo obstruction

intussusception

Laparoscope diagnosis treatment unidentify diag pelvic pain

PID. Acute appendicitis endometriosis

KEY FEATURE COMMON CAUSE OF ACUTE ABDOMINAL PAIN

ACUTE APPENDICITISCilnical assesment

HISTORY Gradual onset , fever ,anorexia(90%) , nuasea vomitting(70%) migratory pain, pelvic pain, dysuria, diaarhea, testicular painTypical sequence : anorexia –abdominal pain – vomitting (95%)

PE. Depend on antomical site fever ,tenderness, guarding at RLQ guarding (Mac Burney) and rebound PR. Tenderness at right side rousing , obturator sign

Lab investigation film acute abdomen is not helpful minimal WBC in urine leukocytosis

PEPTIC ULCER PERFORATEClinical assessment

HISTORY sudden onset ,severe pain generalized abominal pain ,migratory pain , risk factor to peptic ulcer PE abdominal distention decrease bowel sound, generalized guarding rebound tenderness ( broad like rigidity)

Lab investigation film acute abdomne free air (70 %)

ACUTE PANCREATITISClinical assesssment

HISTORY haevy alcohol drinking one of exlusion : same , PUP , acute cholecystitis gradual onset ,severe pain after meal usually epigastric pain , dullness and radiate to the back relieved by the patient leaning forward

PE mark tender , voluntary or involuntary guarding rebound tenderness positive Grey tunner and Cullen sign

Investigate film acute abdomen. Colon cut off sign , Sentineal loop rising serum amylase(30 %), urine amylase rising lipase

DIVERTICULITISClinical assessment

History : old age with chronic constipation, pain in left lower abdominalrefer suprapubic and goin or back dysuria (irritate bladder)

PE : terderness , guarding , rebound at LLQ. mass palpable(phlegmon or abscess) pelvic peritonitis PR: trnderness at Cul de sac

INVESTIGATE : clinical diagnosis CT (investigate of choice) and ultrasound

INTESTINAL OBSTRUCTION CLINICAL ASSESSMENT

HISTORY intermittent onset , colicky abdominal pain frequent vomtting , constipation hernia , previous surgery

PE abdominal distention ,visible peritalsis, hyperactive bowel sound , hypertympanic on percussion localized tenderness , mass ? , surgical scar , incarcerated hernia

Investigation film acute abdomen . Dilate bowel , air fluid level

MESENTERIC ISCHEMIACLINICAL ASSESSMENT

HISTORY hyperlipidemia, CVA , MI , AF intestinal angina , acute onset and constant Extrem pain unresponsive to narcotic

PE abdominal distention , hypoactive bowel sound generalized tenderness , guarding , rebound (pain is out of porportion to PE )

INVESTIGATION leukocytosis film acute abdomen: non specific , bowel dilate

A 69-year-old woman presents with 3 day history of constipation and constant pain in left lower abdomen.The pain has suddenly become much worse and she has collapsed and been admitted to casualty. On examination she has a tachycardia and is hypotensive. There is severe lower abdominal pain with guarding throughout the mid-and lower abdomen

A. 42 –year-old woman with a history of biliary colic and intermittent faundice is admitted as an emergency with a 2-day history of more severe abdominal pain radiating into her back, associated with profuse vomiting. On examination she is morbidly obese, is dehydrated, has a tachycardia and generalized vague abdominal tenderness.

A.78-year-old man presents with a 3 – day history of vomiting faeculent fluid, He has a grossly distended abdomen and a palpable mass in the right groin.The mass is firm,slightly tender and lies below and lateral to the pubic tubercle

A. 60 year-old man presents with a 48-hour history of sudden onset epigastric pain radiating through to the back after an alcoholic binge. Examination reveals the patient to be apyrexial,tachycardic and normotensive.The patient is diffusely tender with guarding in the epigastrium.An erect chest x – ray is normal,but the blood gas analysis reveals hypoxia

A 22-year-old woman presents with pain in the right iliac fossa. The patient is anorexic,has not vomited,but had some dysuria and frequency.Her temperature is 37.5 co The patient is flushed and has localized guarding in the right iliac fossa and suprapubic region.

A 50-year-old obese woman presents with epigastric pain. On examination her temperature is 38.5 co She is tender in the upper abdomen and Murphy’s sign is positive.

CONCLUSION

ABDOMINAL PAIN DIFFERENTIAL DIAG PROVISIONL DIAG

CLINICAL ASSESSMENTHISTORY TAKINGLAB INVESTIGATION

PATHOPHYSIOLOGYANATOMYKNOWLAGE

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ศ�ลยศาสืตรั� ทั่� วิไป กรั งเทั่พฯ : กรั งเทั่พเวิชสืารั 2548 . หนัา 100 – 108• ชวินัรั�ฐ สื วิ�ภะบภรัณ�ก ล . ในั : สื�โรัจุนั� กาญจุนัป)ญจุพล , บรัรัณาธิ�การั . ศ�ลยศาสืตรั�ทั่� วิไป. กรั งเทั่พ : กรั งเทั่พเวิชสืารั -109119 1989 : 1061-1067• รั�งสืรัรัค์� ก ภพ�นั�มี�ตรั . การัดู-แลผู้-ป0วิยทั่� มีาดูวิยเรั� องปวิดูทั่องเฉี�ยบพล�นั ในั : สื เทั่พ กลชาญ วิ�ทั่ธิ�2 , บรัรัณาธิ�การั โรัค์ทั่างเดู�นัอาหารัและการัรั�กษา กรั งเทั่พ ซ โรังพ�มีพ�จุ ฬาลงกรัณ�

มีหาวิ�ทั่ยาล�ย, 2548 หนัา -19•Norman L.Browse. The abdomen In : Introduction to

the symptom and sign of surgical disease second edition 1991:363-403•Helen Sweetland. Kevin Conway. Acute abdominal

pain in Crush Course Surgery second edition 2004:1-7 •Seymour I. Schwartz. Manifestations of gastrointestinal disease In ; Seymour IS, editor . Principle of

surgery 5 th edition New York 1989:1061-1067