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Acute Abdomen

Acute Abdomen. David Gavriel MD Surgical department SZMC. 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

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Acute Abdomen

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  1. Acute Abdomen David Gavriel MD Surgical department SZMC

  2. 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

  3. 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

  4. Visceral vs. Parietal Pain innervation

  5. 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

  6. 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

  7. 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

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

  9. Physical Examination • Observation of the patient • Position of patient • Activity of patient • Appearance of abdomen • Auscultation • Bowel sounds, bruits • Percussion • Palpation • Masses, tenderness, rebound, hernias

  10. Examination Patterns (Signs)

  11. Evaluation Studies

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

  13. Clinical Diagnosis

  14. Inflammation versus Obstruction

  15. Localization of Pain

  16. Localization of Pain – cont.

  17. Localization of Pain – cont.

  18. Non-Surgical Causes by Systems

  19. Non Surgical Causes

  20. Surgical Acute Abdominal Diseases

  21. 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

  22. 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

  23. GYN Etiologies

  24. Labs & Imaging

  25. What do you see?

  26. Abdominal X ray

  27. Abdominal X ray

  28. CT Scanning

  29. CT scan What is the diagnosis? Acute appendicitis

  30. CT Scanning

  31. CT Scanning

  32. Findings Suggesting Surgical Disease

  33. Intra Abdominal Pressure Monitoring • Increased abdominal pressure can be a symptom of disease or the cause • Can decrease abd. visceral blood flow • Can decrease cardiac venous return • Can cause respiratory embarrassment • Can lead to GERD and aspiration

  34. Abdominal Compartment Syndrome

  35. “VAC-Pac” Closure

  36. Differential Diagnosis • Correct diagnosis made 80% of time after history and physical exam • Sometimes diagnosis cannot be made preoperatively • Diagnostic laparoscopy can be helpful adjunct • Peritoneal lavage can be performed at bedside in ICU/ER in unstable patient

  37. Pregnant Patients • Special emphasis placed on Gyn and surgical diagnoses • Hesitancy to operate and to perform X Ray imaging can delay diagnosis • Presentation patterns can be altered by pregnancy • Delayed diagnosis can threaten both mother and fetus

  38. Pregnant Patient • Most common non-obstetrical surgical diseases in pregnancy are: • Appendicitis (1:1500) • Biliary tract disease (1-6:10,000) • Bowel obstructions (1:4,000) • Pancreatitis

  39. Appendicitis in Pregnancy • Classic symptoms 60% of time • Nausea, vomiting, lower abd pain • Fever is uncommon • Leukocytosis present in normal pregnancy

  40. Appendicitis in Pregnancy

  41. Algorithms in Acute AbdomenAcute Severe Generalized Pain

  42. Algorithms in Acute AbdomenGradual Onset Severe Generalized Pain

  43. Algorithms in Acute AbdomenRight Upper Quadrant Pain

  44. Algorithms in Acute AbdomenRight Lower Quadrant Pain

  45. Algorithms in Acute AbdomenLeft Lower Quadrant Pain

  46. 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

  47. 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

  48. 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)

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