the acute abdomen: assessment & diagnosis • review assessment strategy for the acute abdomen...

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The Acute Abdomen: Assessment & Diagnosis Alice A. Gervasini, PhD, RN Nurse Director, Trauma & Emergency Surgical Services Massachusetts General Hospital Instructor in Surgery Harvard Medical School

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Page 1: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

The Acute Abdomen: Assessment & Diagnosis

Alice A. Gervasini, PhD, RN

Nurse Director, Trauma & Emergency Surgical Services

Massachusetts General Hospital

Instructor in Surgery

Harvard Medical School

Page 2: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

DISCLOSURES

None of the planners or presenters of this session have disclosed any conflict or commercial interest

Page 3: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Objectives

• Review assessment strategy for the acute abdomen

• Discuss management strategy for common sources of abdominal pain/the surgical abdomen in both the out patient and in patient environment.

Page 4: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

What is serious and what is not?

Page 5: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Presenting Factors

• Pain

• Upper GI concerns

• Lower GI concerns

• Non-specific concerns

Page 6: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Visceral Pain

• Typically associated with Autonomic System

• Symptoms: • Pallor, sweating, N/V, changes in VS’s

• Pain is often dull or aching

• Emotional reaction • Anxiety

• No pain but complaints of ‘discomfort’

• Slow pain

• Organ specific

Page 7: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Visceral Pain

• Often vague • Gradual onset • Poor discrimination • General versus specific complaints • Usually lasts longer • Associated with tissue damage:

• Stretching/distention • Ischemia/chemo receptors • Cramping/mechanical or spasm of muscle • Chemical/enzyme release

Page 8: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

• Progression of nerve signal through the autonomic bundle often results in referred pain

Page 9: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Referred Pain

Page 10: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Somatic Parietal Pain

• Fast pain

• Rapid onset

• Often described:

• Excruciating

• Sharp/severe

• Peritonitis

• Signal is sent directly into local spinal nerves

Page 11: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Gallbladder Peptic ulcer pancreatitis

Gastric ulcer GERD/Perforated esophagus MI Pancreatitis/gall stones Epigastric hernia

Gastric ulcer Splenic pathology Pancreatitis Basal pleurisy

Kidney stone Urine infection Lumbar hernia constipation

Stomach ulcer Early appendicitis Stomach ulcer IBD Small bowel disease Umbilical hernia

Kidney stones Diverticular disease IBD constipation

Appendicitis Constipation Tubo-ovarian pathology Groin (hernia)

Urine infection Appendicitis Tubo-ovarian pathology IBD Divertiular disease

Diverticular disease Tubo-ovarian pathology Groin disease

Slide by Dr. Sanjay Gupta SNHMC - 2013

Page 12: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Causes of Abdominal Pain

•Obstructive

•Inflammation

•Perforation

Page 13: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Obstructive Pain

• Visceral

• Gradual onset

• Growing over time

• Nausea and Vomiting

• SBO

• Renal Stone

• CBD Stone

• Usually Urgent, not Emergent

• Mechanical in nature

Slide by Dr. Fred Millham -2013 South Shore Hospital

Page 14: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Inflammation

• Visceral early, may be come somatic

• Vague

• Increasing intensity

• Early appendicitis

• Gastritis

• PUD (non-perforated)

• Colitis

• Ischemia without infarction

• Usually an urgent, not emergent problem

Slide by Dr. Fred Millham – 2013 South Shore Hospital

Page 15: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Perforation

• Somatic-Parietal Pain

• Peritoneal

• Sudden onset

• Usually an Emergency

Slide by Dr. Fred Millham – 2013 South Shore Hospital

Page 16: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Free air under the diaphragm

Page 17: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Free Air

Page 18: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Clinical Evaluation

• Comprehensive exam

• Evaluate the chief complaint in detail

• Co morbid conditions

• 10 essential components

• Focused exam

• Performed to assess the effectiveness of tx’s

• ID complications

• Illicit changing signs & symptoms

Page 19: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Clinical Evaluation

• History:

• Dimensions of pain

• Onset, duration, frequency, character, location, radiation, intensity

• Presence or absence of any aggravating or alleviating factors & associated symptoms

• Obtaining a good history is often the most critical component in the diagnostic process for acute abdominal pain

Page 20: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Clinical Evaluation-continued

• Physical Exam • Organized and methodical approach

• General appearance

• Do they look sick?

• Do they appear to be in distress?

• The patient should be resting in a ‘comfortable’ supine position

Page 21: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Clinical Evaluation-continued

Inspection ◦ Always look before you touch Make note of – surgical scars, hernia, distention, obvious masses,

ecchymosis, visible pulsations or peristalsis Auscultation ◦ Bowel sounds ◦ Bruits Percussion ◦ Tympani

Palpation – most helpful!

Page 22: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Clinical Evaluation-continued

• Palpation: • Useful to determine the extent & severity of the patients

tenderness/pain • Diffuse – generalized peritoneal inflammation

• Mild diffuse without guarding – inflammatory intestinal process without peritoneal inflammation (gastroenteritis)

• Localized tenderness – early stage of a process

• Additional exam: • Perineal exam

• Vaginal exam

Page 23: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Flaws in Assessments

• Lack of clear definitions of terms:

• Mild/moderate/severe

• Guarding

• Diffuse

• ‘peritoneal signs’

Page 24: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Abdominal Pain

• Characteristics: Can you describe the pain (sharp, dull, superficial, or deep)? Is the pain intermittent or continuous? Was the onset sudden or gradual? Can you point to where the pain is located? What makes the pain better, worse?

• Associated factors: Are there other symptoms associated with the pain—fever, nausea, vomiting, diarrhea, constipation, anorexia, weight loss, dyspepsia?

• History: Any family history of GI cancer, ulcer disease, inflammatory bowel disease? Any previous history of tumors, malignancy, or ulcers?

Page 25: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Index of Suspicion

• Learned patterns

• Known entities

• Experiential advantage

• If you don’t have this – you need to develop this – and you develop this through shared learning, clinical/skill level expertise and a genuine curiosity factor!

Page 26: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Clinical Reasoning

• Process of collecting data

• Coming to some conclusions

• What is wrong with the patient?

Page 27: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

•At this point, it is much easier to be Acute Care versus Primary Care!

Page 28: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

What to do next?

• If your index of suspicion is low: • No fever

• Diffuse pain

• No progression over a couple of days

• Associated N/V diarrhea

• No confounding variables that puts the patient at risk

• Reliable patient

• Send patient out with clear instructions

Page 29: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

What about this….

• Diffuse abdominal pain • Gradual to sudden onset • Mild anorexia • One episode of diarrhea • Low grade fever • Possibly localizing

• PE

• Vaginal & rectal

• Lab work

• WBC

• H/H

• U/A

• Pregnancy test

• Other studies?

• Spiral CT has a sensitivity of 90-100%, a specificity of 91-99%, a positive predictive value of 95-97%, and an accuracy of 94-100%.

• US

• Plain film of the abdomen

• Differential Dx’s

Page 30: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …
Page 31: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

What about this….

• Epigastric pain

• Often excruciating

• Post prandial

• PE – including rectal

• Lab work

• WBC

• U/A

• Liver Enzymes

• Other studies?

• U/S

• CT

• Differential Dx’s

Page 32: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …
Page 33: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Cholecystitis

• ↑ WBC

• ↑ Temp

• Referred Pain

• N/V

• ↑ Liver enzymes

• Positive Murphy’s Sign

Page 34: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

• No fever

• Normal liver function

• Normal WBC

• Referred Pain

• Negative Murphy's Sign

• Biliary Colic

Page 35: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Gall Stones in the Common Bile Duct

• No fever

• ~WBC

• ↑ Serum Bilirubins

• ↑ Liver enzymes

• ? Jaundice

• Cholelithiasis

• Role of ERCP

Page 36: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

What about this….

• Gradual onset LLQ pain

• Decreasing appetite

• Fever

• Altered bowel habit

• Bloating

• PE- rectal exam

• Labs

• WBC

• U/A

• Other Studies • CT

• U/S

• Plain Film

• Differential Dx’s

Page 37: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

What do you think?

Page 38: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Diverticulitis with Abscess

Page 39: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Ileus

• Inhibition of the intestinal muscle function

• Diminished or absent motility

• This can be representative of a post operative problem or a symptom of an inflammatory process, or in response to partial or complete obstruction

Page 40: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Ileus

• Diagnostic work up

• Chest/abdominal x-ray (flat & upright)

• ? WBC – if patient ‘sick’ with this; febrile, tachycardic

• With persistent ileus

• Abdominal CT is often necessary to assess for:

• Obstruction

• Collections

Page 41: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Gall Stone Ileus

Page 42: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Bowel Obstruction

• Most common surgical emergencies

• ¾ of events occur in the small bowel

• Mechanical blockage • Partial or complete

• Results from intra-luminal obstruction • Tumor

• Gall stone

• Results from extra-luminal obstruction • Adhesions

• Tumor

Page 43: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Bowel Obstruction

• Diagnostic work up

• Labs

• Abd flat plate and upright

• CT

• Colonoscopy

Page 44: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Gas Pattern Consistent with SBO

Page 45: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Non-specific gas pattern

Page 46: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Abscess/Collection

Page 47: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

What about this?

• Acute Pancreatitis with normal lipase.

• Excrutiating pain

• Epigastric region

• Referred pain to the back

• Degree of sickness varies

• Recovery can be prolonged

• Cause - varies

Page 48: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

• Gall Stone Pancreatitis

Page 49: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

• Acute Pancreatitis

Page 50: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

What about special populations?

Page 51: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Management strategies

• Index of suspicion

• Awareness of diagnostic test results

• Integration of test results

• Awareness of clinicians concerns

• Consistency with reassessment

Page 52: The Acute Abdomen: Assessment & Diagnosis • Review assessment strategy for the acute abdomen • Discuss management strategy for common sources of abdominal …

Summary

• Excellent skills with:

• H & P

• Establishing a clear picture / timeline of S & S

• Linking differential dx’s with diagnostic work-up

• Index of suspician