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    Acute Abdomen

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    mazin89
    The document discusses the acute abdomen, including its basic definition as signs and symptoms of intra-abdominal disease requiring surgery. It covers characterizing pain, considering a broad differential diagnosis including inflammation, obstruction, ischemia and perforation. The decision to operate depends on signs of peritonitis, severe unrelenting pain, or hemodynamic instability. Non-surgical causes and atypical presentations are also reviewed.

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    Acute Abdomen

    Uploaded by

    mazin89
    360 views19 pages
    The document discusses the acute abdomen, including its basic definition as signs and symptoms of intra-abdominal disease requiring surgery. It covers characterizing pain, considering a broad differential diagnosis including inflammation, obstruction, ischemia and perforation. The decision to operate depends on signs of peritonitis, severe unrelenting pain, or hemodynamic instability. Non-surgical causes and atypical presentations are also reviewed.

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    The document discusses the acute abdomen, including its basic definition as signs and symptoms of intra-abdominal disease requiring surgery. It covers characterizing pain, considering a broad differential diagnosis including inflammation, obstruction, ischemia and perforation. The decision to operate depends on signs of peritonitis, severe unrelenting pain, or hemodynamic instability. Non-surgical causes and atypical presentations are also reviewed.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    360 views19 pages

    Acute Abdomen

    Uploaded by

    mazin89
    The document discusses the acute abdomen, including its basic definition as signs and symptoms of intra-abdominal disease requiring surgery. It covers characterizing pain, considering a broad differential diagnosis including inflammation, obstruction, ischemia and perforation. The decision to operate depends on signs of peritonitis, severe unrelenting pain, or hemodynamic instability. Non-surgical causes and atypical presentations are also reviewed.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 19

    Acute Abdomen

    Acute Abdomen

    Tad Kim
    UF Surgery
    Acute Abdomen

    Overview
    • Basic Definition and Principles
    • Clinical Diagnosis / DDx
    – Characterizing the pain
    – Other history to elicit
    – Ways to remember such a broad differential
    – History & Physical / Labs / Imaging
    – Non-surgical causes of acute abdomen
    • Clinical Management
    • Decision to Operate
    • Atypical presentations
    Acute Abdomen

    Basic Definition and Principles


    • Signs and symptoms of intra-abdominal
    disease usually best treated by surgery
    • Proper eval 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” scenario
    • But remember medical causes of abd pain
    Acute Abdomen

    Clinical Diagnosis
    • Characterizing the pain is the key
    – Onset, duration, location, character
    • Visceral pain → dull & poorly localized
    – i.e. distension, inflammation or ischemia
    • Parietal pain → sharper, better localized
    – Sharp “RUQ pain”(chol’y), “LLQ pain”(divertic)
    • Kidney / ureter → flank pain
    Acute Abdomen

    Clinical Diagnosis – Pain cont’d


    • Location
    – Upper abdomen → PUD, chol’y, pancreatitis
    – Lower abdomen → Divertic, ovary cyst, TOA
    – Mid abdomen → early app’y, SBO
    • Migratory pattern
    – Epigastric → Peri-umbil → RLQ = Acute app’y
    – Localized pain → Diffuse = Diffuse peritonitis
    Acute Abdomen

    Clinical Diagnosis
    • “Referred pain”
    – Biliary disease → R shoulder or back
    – Sub-left diaphragm abscess → L shoulder
    – Above diaphragm(lungs) → Neck/shoulder

    • Acute onset & unrelenting pain = bad


    • Pain which resolves usu. not surgical
    Acute Abdomen

    Other history
    • GI symptoms • Drinking history
    – Nausea, emesis (? (pancreas)
    bilious or bloody) • Prior surgeries
    – Constipation, obstipation (adhesions → SBO, ?
    (last BM or flatus) still have gallbladder &
    – Diarrhea (? bloody) appendix)
    – Both Nausea/Diarrhea • History of hernias
    present usu. medical
    – Change in sx w eating? • Urine output
    (dehydrated)
    • NSAID use (perf DU)
    • Constituational Sx
    • Jaundice, acholic
    – Fevers/chills
    stools, dark urine
    • Sexual history
    Acute Abdomen

    Clinical Diagnosis
    • Location of pain by
    organ
    • RUQ
    – Gallbladder
    • Epigastrum
    – Stomach
    – Pancreas
    • Mid abdomen
    – Small intestine
    • Lower abdomen
    – Colon, GYN pathology
    Acute Abdomen

    Clinical Diagnosis
    Acute Abdomen

    Think Broad categories for DDx


    • Inflammation
    • Obstruction
    • Ischemia
    • Perforation (any of above can end here)
    – Offended organ becomes distended
    – Lymphatic/venous obstrux due to ↑pressure
    – Arterial pressure exceeded → ischemia
    – Prolonged ischemia → perforation
    Acute Abdomen
    Inflammation versus Obstruction
    Organ Lesion Location Lesion
    Stomach Gastric Ulcer Small Bowel Adhesions
    Duodenal Ulcer Obstruction Bulges
    Cancer
    Biliary Acute chol’y +/- Crohn’s disease
    Tract choledocholithiasis Gallstone ileus
    Intussusception
    Pancreas Acute, recurrent, or Volvulus
    chronic pancreatitis
    Large Bowel Malignancy
    Obstruction Volvulus: cecal
    Small Crohn’s disease or sigmoid
    Intestine Meckel’s diverticulum Diverticulitis

    Large Appendicitis
    Intestine Diverticulitis
    Acute Abdomen

    Ischemia / Perforation
    • Acute mesenteric ischemia
    – Usually acute occlusion of the SMA from
    thrombus or embolism
    • Chronic mesenteric ischemia
    – Typically smoker, vasculopath with severe
    atherosclerotic vessel disease
    • Ischemic colitis
    • Any inflammation, obstructive, or ischemic
    process can progress to perforation
    • Ruptured abdominal aortic aneurysm
    Acute Abdomen

    GYN Etiologies
    Organ 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 & Imaging


    Test Reason Test Reason
    CBC w diff Left shift can be KUB SBO/LBO,
    very telling
    Flat & Upright free air,
    BMP N/V, lytes, stones
    acidosis,
    dehydration Ultrasound Chol’y, jaundice
    GYN pathology
    Amylase Pancreatitis,
    perf DU, bowel
    ischemia
    CT scan Anatomic dx
    LFT Jaundice,hepati
    -Diagnostic Case not
    tis
    accuracy straightforward
    UA GU- UTI, stone,
    hematuria

    Beta-hCG Ectopic
    Acute Abdomen

    CT scan

    What is the diagnosis? Acute appendicitis


    Acute Abdomen
    Non-Surgical Causes by Systems
    System Disease System Disease
    Cardiac Myocardial infarx Endocrine Diab ketoacidosis
    Acute pericarditis Addisonian crisis

    Pulmonary Pneumonia Metabolic Acute porphyria


    Pulmonary infarx Mediterranean fever
    PE Hyperlipidemia
    GI Acute pancreatitis Musculo- Rectus muscle
    Gastroenteritis skeletal hematoma
    Acute hepatitis
    GU Pyelonephritis CNS Tabes dorsalis (syph)
    PNS Nerve root
    compression
    Vascular Aortic dissection Heme Sickle cell crisis
    Acute Abdomen

    Decision to operate
    • Peritonitis
    – Tenderness w/ rebound, involuntary guarding
    • Severe / unrelenting pain
    • “Unstable” (hemodynamically, or septic)
    – Tachycardic, hypotensive, white count
    • Intestinal ischemia, including strangulation
    • Pneumoperitoneum
    • Complete or “high grade” obstruction
    Acute Abdomen

    Special Circumstances
    • Situations making diagnosis difficult
    – Stroke or spinal cord injury
    – Influence of drugs or alcohol
    • Severity of disease can be masked by:
    – Steroids
    – Immunosuppression (i.e. AIDS)
    – Threshold to operate must be even lower
    Acute Abdomen

    Take Home Points


    • Careful history (pain, other GI symptoms)
    • Remember DDx in broad categories
    • Narrow DDx based on hx, exam, labs, imaging
    • Always perform ABC, Resuscitate before Dx
    • If 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 situations
    • For acute abdomen, think of these commonly (below)

    Perf DU Appendicitis Diverticulitis Bowel


    +/- perforation +/- perforation obstruction
    Cholecystitis Ischemic or Ruptured Acute
    perf bowel aneurysm pancreatitis

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