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Acute Abdomen

Acute Abdomen. Hani Albrahim ,MD Head of the EMS Unit Department of Emergency Medicine. Which one has the highest mortality rate ?. Ruptured AAA Perforated peptic ulcer Mesenteric ischemia Bowel obstruction. Which one has the highest mortality rate ?. Ruptured AAA

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Acute Abdomen

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  1. Acute Abdomen Hani Albrahim,MD Head of the EMS Unit Department of Emergency Medicine

  2. Which one has the highest mortality rate ? • Ruptured AAA • Perforated peptic ulcer • Mesenteric ischemia • Bowel obstruction

  3. Which one has the highest mortality rate ? • Ruptured AAA • Perforated peptic ulcer • Mesenteric ischemia • Bowel obstruction

  4. Pain is out of proportionis a characteristic feature of: • Mesenteric ischemia • Ruptured AAA • Perforated peptic ulcer • Intestinal obstruction

  5. Pain is out of proportionis a characteristic feature of: • Mesenteric ischemia • Ruptured AAA • Perforated peptic ulcer • Intestinal obstruction

  6. Is the most common presenting surgical emergency. It has been estimated that at least 50% of general surgical admissions are emergencies and 50% of them present with acute abdominal pain.

  7. ‘Acute abdomen’ is a term used to encompass a spectrum of surgical, medical and gynecological conditions, ranging from the trivial to the life-threatening, which require hospital admission, investigation and treatment.

  8. The acute abdomen may be defined generally as an intra-abdominal process causing severe pain requiring admission to hospital, and which has not been previously investigated or treated and may need surgical intervention.

  9. The mortality rate varies with age, being the highest at the extremes of age. • The highest mortality rates are associated with laparotomy for unresectable cancer, ruptured abdominal aortic aneurysm and perforated peptic ulcer. • Most common causes in any population will vary according to age, sex and race, as well as genetic and environmental factors.

  10. Causes- • Gastrointestinal- 1-Gut Acute appendicitis Intestinal obstruction Perforated peptic ulcer Diverticulitis Inflammatory bowel disease 2-Liver and biliary tract cholecystitis cholangitis Hepatitis 3-Pancreas Acute pancreatitis 4-Spleen Splenic infarct and spontaneous rupture

  11. Causes- B. Urinary tract Cystitis Acute pyelonephritis Ureteric colic Acute retention C. Vascular Ruptured aortic aneurysm Mesenteric embolus Mesenteric venous thrombosis Ischemic colitis D. Abdominal wall conditions Rectus sheath haematoma E. Peritoneum Primary peritonitis Secondary peritonitis

  12. Causes- F. Retroperitoneal Hemorrhage e.ganticoagulants G. Gynecological Torsion of ovarian cyst Ruptured ovarian cyst Fibroid denegeration Ovarian infarction Pelvic endometriosis Endometriosis

  13. Causes- H. Extra-abdominal causes Lobar pneumonia MI Sickle cell crisis Uremia DKA Addison’s disease

  14. Management • History • Physical examination • Management

  15. Characteristics of abdominal pain Site Time and mode of onset Severity Nature/Character Progression Radiation Duration Cessation Exacerbating/relieving factors Associated symptoms

  16. Symptoms--Pain Onset Sudden: perforation of bowel. Slow insidious onset: inflammation of visceral peritoneum Severity Patient asked to rate pain from 1-10 Ureteric colic is one of worst pains Character Aching-dull pain poorly localized Burning- peptic ulcer symptoms Stabbing-ureteric colic Gripping-smooth muscle spasm e.g. intestinal obstruction worse by movement .

  17. Symptoms--Pain Progression -Constant e.g. peptic ulcer -Colicky e.g. seconds(bowel), minutes(ureteric colic) or tens of minutes (gallbladder) Radiation of the pain Back: duodenal ulcer, pancreatitis, aortic aneurysm Scapula: gall bladder Sacroiliac region: ovary Loin to groin: ureteric colic Groin: testicular torsion

  18. Cessation- Abrupt ending- colicky pains Resolving slowly-inflammatory pain, biliary pain Exacerbating/relieving factors- Movement/Rest-inflammatory conditions Food- peptic ulcers

  19. History

  20. History Past history previous surgery trauma any medical diseases Drug history corticosteroid: mask pain anti-coagulant: intra-mural hematoma NSAIDS: gastritis, peptic ulcer Family history colon cancer IBD

  21. Physical Examination General appearance -Patient is lying motionless acute appendicitis, peritonitis -Rolling in bed ureteric colic, intestinal colic -Bending forward chronic pancreatitis

  22. Physical Examination Vital signs Temp. low grade: appendicitis, acute cholycystitis high grade: abscess General examination- Conjuctival pallor cyanosis jaundice Signs of dehydation lymphadenopathy

  23. Physical Examination Cardio-pulmonary examination -MI -basal pneumonia -pleural effusion

  24. Physical Examination Abdomen *Inspection *Palpation *Percussion *Auscultation

  25. Physical Examination Inspection -movement with respiration -distension, peristalsis, mass, scars and any obvious cough impulse at hernia site Palpation *Superficial palpation -tenderness, rebound tenderness, guarding, rigidity, masses, hernial orifices *Deep palpation -organomegaly

  26. Physical Examination Percussion -Tympanic note: intestinal obstruction -Dullness over bladder: acute retention Auscultation -Silent abdomen: peritonitis -Increase bowel sound: intestinal obstruction

  27. Investigation • CBC • Urea, electrolyte, creatinine, glucose • LFT • Lipase • Urinalysis • CXR • AXR • CT SCAN • U/S • Angiography • Pregnancy test

  28. Treatment 1. Relieve the pain 2. IV fluids and nasogastric suction 3. Antibiotics 4. Surgery if indicated

  29. Case #1 • 24 yo healthy M with one day hx of abdominal pain. Pain was generalized at first, now worse in right lower abd & radiates to his right groin. He has vomited twice today. Denies any diarrhea, fevers, dysuria or other complaints. No appetite today. • PMHx: negative • PSurgHx: negative • Meds: none

  30. Physical exam: • T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat: 100% room air • Uncomfortable appearing, slightly pale • Abdomen: soft, non-distended, tender to palpation in RLQ with mild guarding; hypoactive bowel sounds • Genital exam: normal • What is your differential diagnosis and what do you do next?

  31. Appendicitis • Classic presentation • Periumbilical pain • Anorexia, nausea, vomiting • Pain localizes to RLQ • Occurs only in ½ to 2/3 of patients • 26% of appendices are retrocecal and cause pain in the flank; 4% are in the RUQ • A pelvic appendix can cause suprapubic pain, dysuria • Males may have pain in the testicles

  32. Urinalysis abnormal in 19-40% • CBC is not sensitive or specific • CT scan • Pericecal inflammation, abscess, periappendicealphlegmon, fluid collection, localized fat stranding

  33. Appendicitis: CT findings Cecum Abscess, fat stranding

  34. Appendicitis • Diagnosis • WBC • Clinical appendicitis • Maybe appendicitis - CT scan • Not likely appendicitis – observe for 6-12 hours or re-examination in 12 hrs • Treatment • NPO • IVFs • Preoperative antibiotics – decrease the incidence of postoperative wound infections • Analgesia

  35. Case #2 • 68 yo F with 2 days of LLQ abd pain, diarrhea, fevers/chills, nausea; vomited once at home. • PMHx: HTN, diverticulosis • PSurgHx: negative • Meds: HCTZ

  36. Case #2 Exam • T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99% room air • Gen: uncomfortable appearing, slightly pale • CV/Pulmonary: normal heart and lung exam, no LE edema, normal pulses • Abd: soft, moderately TTP LLQ • Rectal: normal tone, guiacneg brown stool • What is your differential diagnosis & what next?

  37. Diverticulitis • Risk factors • Diverticula • Increasing age • Clinical features • Steady, deep discomfort in LLQ • Change in bowel habits • Urinary symptoms • Tenesmus • Paralytic ileus • SBO • Physical Exam • Low-grade fever • Localized tenderness • Rebound and guarding • Left-sided pain on rectal exam • Occult blood • Peritoneal signs

  38. Diverticulitis • Diagnosis • CT scan (IV and oral contrast) • Pericolic fat stranding • Diverticula • Thickened bowel wall • Peridiverticular abscess • Leukocytosis present in only 36% of patients

  39. Treatment • Fluids • Correct electrolyte abnormalities • NPO • Abx: gentamicin AND metronidazole OR clindamycin OR levaquin/flagyl • For outpatients (non-toxic) • liquid diet x 48 hours • cipro and flagyl

  40. Case #3 • 46 yo M with hx of alcohol abuse with 3 days of severe upper abd pain, vomiting, subjective fevers. • Med Hx: negative • SurgHx: negative • Meds: none; Allergies: NKDA

  41. Case #3 Exam Vital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat: 95% room air • General: ill-appearing, appears in pain • CV: tachycardic, normal heart sounds, pulses normal • Lungs: clear • Abdomen: mildly distended, moderately TTP epigastric, +voluntary guarding • Rectal: heme neg stool • What is your differential diagnosis & what next?

  42. Pancreatitis • Risk Factors • Alcohol • Gallstones • Drugs • Amiodarone, antivirals, diuretics, NSAIDs • Severe hyperlipidemia • Idiopathic • Clinical Features • Epigastric pain • Radiates to back • Severe • N/V

  43. Physical Findings • Low-grade fevers • Tachycardia, hypotension • Respiratory symptoms • Atelectasis • Pleural effusion • Peritonitis – a late finding • Ileus • Cullen sign* • Bluish discoloration around the umbilicus • Grey Turner sign* • Bluish discoloration of the flanks

  44. Pancreatitis • Diagnosis • Lipase • Elevated more than 2 times normal • Sensitivity and specificity >90% • Amylase • Nonspecific • CT scan • Insensitive in early or mild disease • NOT necessary to diagnose pancreatitis • Useful to evaluate for complications

  45. Treatment • NPO • IV fluid resuscitation • NGT if severe, persistent nausea • No antibiotics unless severe disease • E coli, Klebsiella, enterococci, staphylococci, pseudomonas • Imipenem or cipro with metronidazole • Mild disease, tolerating oral fluids • Discharge on liquid diet • Follow up in 24-48 hours • All others, admit

  46. Case #4 • 72 yo M with hx of CAD on aspirin and Plavix with several days of dull upper abd pain and now with worsening pain “in entire abdomen” today. Some relief with food until today, now worse after eating lunch. • Med Hx: CAD, HTN, CHF • SurgHx: appendectomy • Meds: Aspirin, Plavix, Metoprolol, Lasix • Social hx: smokes 1ppd, denies alcohol or drug use, lives alone

  47. Case #4 Exam • T: 99.1, HR: 70, BP: 90/45, R: 22, O2sat: 96% room air • General: elderly, thin male, ill-appearing • CV: normal • Lungs: clear • Abd: mildly distended and diffusely tender to palpation, +rebound and guarding • Rectal: blood-streaked heme + brown stool • What is your differential diagnosis & what next?

  48. Peptic Ulcer Disease • Risk Factors • H. pylori • NSAIDs • Smoking • Hereditary • Clinical Features • Burning epigastric pain • Sharp, dull, achy, or “empty” or “hungry” feeling • Relieved by milk, food, or antacids • Awakens the patient at night • Nausea, retrosternal pain and belching are NOT related to PUD • Physical Findings • Epigastric tenderness • Severe, generalized pain may indicate perforation with peritonitis • Occult or gross blood per rectum or NGT if bleeding

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