Download - Acute Abdomen PRESENTATION (Ingles)[1]
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American College of SurgeonsPrepared by
the Advisory Council for Surgery
and
Gayle Minard, MD, FACS
The Acute Abdomen
in the Adult
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Overview
DefinitionPathophysiologySymptomsSigns
Work-upSpecific Diseases
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Definition ofAcute Abdomen
Sudden onset
Severe pain
Requires urgentdecision/diagnosis
Treatment often surgical
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Acute Abdomen
10% of ER visits or admitted patients 40% discharged from ER with pain of
unknown etiology
60% discharged from ER have wrongdiagnosis
The older the patient, the less accuratethe diagnosis
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Pathophysiology of
Abdominal Pain Referred painPain sensed at a considerable
distance from source Somatic painSegmental spinal nerves
Visceral painSympathetic, parasympathetic, or
somatic pathways
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History
Description of pain
Associated symptoms Gynecologic/GU history Past medical history
Family, social history
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Description of PainThe abdominal pain checklist
Onset and duration
Character and severity
Location and radiation
What makes it better
What makes it worse
Progression of pain
Associated symptoms
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Associated Symptoms
Nausea, vomiting Fever, chills
Anorexia, weight loss Food intolerance Pulmonary symptoms Change in bowel habits GU complaints
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Gynecologic / GU History
Last menses Contraception
Sexual history Obstetric history Vaginal discharge, bleeding Previous STDs Urinary symptoms
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Past Medical History
Cardiac or pulmonary disorders GI, vascular diseases
Diabetes, HIV Medications Recent invasive procedures Trauma Recent URI or strep throat
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Family & Social History
Inflammatory bowel disease Connective tissue disorders
Bleeding diatheses Cancer Recent travel
Environmental hazards Drugs, alcohol
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Physical Examination
General appearance ChestAbdomen Rectal
Pelvic GU
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General Examination
Distress
Acutely or chronically ill
Body position Color
Vital signs
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Chest Examination
Cardiac arrhythmias
Murmurs Mechanical heart valves Signs of pneumonia
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Abdominal Exam - LOOK
Distention Breathing pattern,
patient movement DiscolorationCullens sign
Grey Turners sign
Scars, hernia
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Abdominal Exam - LISTEN
Percussion
Auscultation
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Abdominal Exam - FEEL
Area of maximal tenderness CVA or flank tenderness
Masses Hernia Peritoneal signsinvoluntary guarding
pain on motion
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Abdominal ExamSpecial Signs
Rovsings sign
Murphys sign Psoas sign Obturator sign
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Method of eliciting psoas sign
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Method of performing obturator test
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Pelvic / Rectal / GU Exam
Tenderness
Masses Hernias Discharge, bleeding
Blood - occult or gross
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Work-up of Acute AbdomenBasic
UrinalysisAmylase, lipase
Pregnancy test Liver tests EKG Chest x-ray, abdominal films CBC
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Work-up of Acute Abdomen
Complex Ultrasound (US) Computed tomography (CT)
AngiographyBarium enema or endoscopy
never with peritonitis
Laparoscopy, especially inyoung women
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Common Causes
of Acute Abdomen
Appendicitis Diverticulitis
Cholecystitis Pancreatitis Bowel obstruction Perforated bowel Perforated ulcer
IBD Ectopic pregnancy
PID / TOA Gastroenteritis Mesenteric
ischemia
Nephrolithiasis
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Appendicitis
History: periumbilical cramping painmigrating to RLQ; anorexia
Exam: tenderness in RLQ and on rectal or
pelvic + Rovsings sign, Psoas sign, obturator
sign
US useful in young women
CT in doubtful cases Laparoscopy in young women and doubtful
cases
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Small Bowel Obstruction
History of previous abdominaloperation or hernia
Triad of diagnostic symptomscramping abdominal pain
vomitingobstipation
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Small Bowel Obstruction
Quartet of physical findings
Distention
Early: little or no tendernessLate: tenderness and guarding
Borborygmi
Radiographic findingsAir-fluid levels with J loops
Absence of air in colon
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Perforated Peptic Ulcer
History: PUD, NSAIDS,steroids, critical illness
Exam: generalized peritonitis Free air seen on plain
radiographs or CT
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Diverticulitis
History: constipation, LLQ pain,fever, diarrhea
Exam: LLQ tenderness, mass Laboratory tests
Pyuria, WBC elevatedCT - up to 93% sensitivity
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Pancreatitis
History: gallstones, alcohol, epigastricpain radiating to the back
Exam: generalized upper abdominaltenderness, most marked in epigastrium Increased amylase and lipase values
US - detects gallstones CT - 70-100% accuracy
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Cholecystitis
History: cramping epigastric and RUQpain, fatty food intolerance,
+ family history
Exam: RUQ tenderness, + Murphyssign, jaundice+
US - thickened GB wall,pericholecystic fluid
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Ureterolithiasis
History: flank pain, hematuria,radiation to groin, previous attacks
Exam: restless; no abdominaltenderness, flank tenderness
Urinalysis: RBCs, crystals CT, IVP and US useful
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Inflammatory BowelDisease
History: intermittent crampingabdominal pain, diarrhea, low
grade fever, weight loss Exam: localized abdominal
tenderness, + stool for blood
CT and Barium studies usuallydiagnostic
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Ectopic Pregnancy
History: menstrual irregularities,+ sexual history, symptoms of early
pregnancy Exam: adnexal mass on pelvic; may
have hypotension and tachycardia
Pregnancy test + US and laparoscopy diagnostic
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PID / TOA
History: premenopausal woman,midcycle, previous STD, vaginal
discharge, dysuria, Kehrs sign Exam: cervical motion
tenderness, adnexal mass
Pyuria US useful to diagnose
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Gastroenteritis
History: diarrhea, vomiting,crampy pain
Exam: no localizingperitoneal signs
Normal WBC
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Mesenteric Ischemia /
Infarction
History: intestinal angina, arrhythmias, lowflow, hypercoagulable state
Exam: pain out of proportion to findings WBC and amylase elevated Acidosis, stool + for blood
Thumb printing on plain film Angiography indicated - urgent!
Oth C f
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Other Causes ofAcute Abdomen
Volvulus Cholangitis
PneumoniaAcute M I Ovarian torsion / cyst
Hepatitis Sickle cell disease
Diabeticketoacidosis
Uremia Porphyria Intussusception Lupus HIV intestinal
disease
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Pitfalls
Old age Spinal cord injury
HIV Steroids
Very young? Very old? Very odd?
Be very careful.
F.T. de Dombal, MA , MD
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Summary
History and physical examinationmuch more important than
laboratory tests Making the management decision
is more important than making
the diagnosis
Treatment is often surgical