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The ACUTE ABDOMEN

The ACUTE ABDOMEN. Simon Lau Mike Bozin. The Acute Abdomen : an acute change in the condition of the intra abdominal organs Usually related to inflammation or infection Demands IMMEDIATE and accurate diagnosis (but this does not always correlate with the need for an operation).

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The ACUTE ABDOMEN

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  1. The ACUTE ABDOMEN Simon Lau Mike Bozin

  2. The Acute Abdomen: an acute change in the condition of the intra abdominal organs • Usually related to inflammation or infection • Demands IMMEDIATE and accurate diagnosis (but this does not always correlate with the need for an operation)

  3. Abdominal Pain • One of the most frequent presentations to EDs • Most are self limiting • Some are not!

  4. Case 1 • 27yo female presents with 1d of abdominal pain • Associated with: • Anorexia • Nausea, no vomiting • Some diarrhoea

  5. Visceral vs Parietal • Visceral Pain: • Related to stretching of the walls of hollow viscera, or the capsules of solid ones • Dull • Poorly localised but usually central

  6. Visceral vs Parietal Pain • Parietal Pain • Origin anywhere in the abdominal wall from the skin to the parietal peritoneum • Intense • Well localised • Transition from Visceral to Parietal • Initial visceral pain irritates parietal peritoneum, causing parietal pain wherever they are in contact

  7. Cont Case 1 • Abdominal Pain: • Initially midline/umbilical • Over 24/24 transitioned to the RIF • Severe, constant

  8. Applied Anatomy • What anatomical structures reside in the Right Iliac Fossa? (in a girl)

  9. The Right Iliac Fossa • Caecum • Appendix • Ileocaecal junction/valve • Right Ovary/Fallopian tube • Right Ureter

  10. Examination • HR110 BP95/70 O2: 98% 4LNP RR20 T37.8⁰C • Abdo Ex: • RIF tenderness • Percussion tenderness • Rovsing Sign • PR: nil blood, nil melena

  11. Investigations • FBE: 120/15.2/214 neut 11.2 • UEC: 140/4.3 Cr 64 eGFR >90 • INR: 1.0 • β-HCG: neg • Urinalysis: NAD • Imaging???

  12. DDx?

  13. Acute Appendicitis • Inflammation of the appendix, usually secondary to obstruction of the appendiceal lumen • Alvarado Score • Complications of untreated appendicitis? • Perforation and peritonitis • Appendiceal abscess

  14. Other DDx’s • GIT: • Diverticulitis • Bowel obstruction • Volvulus/strangulation • Cx of hernias • Gynaecological: • Ectopic pregnancy • Adnexal torsion • Urological: • Pyelonephritis • Renal stones • Testicular torsion • Vascular: • Ischaemic colitis

  15. Case 2 • 46yo male presents with 12hrs of worsening abdominal pain • Moderate in severity • Initially colicky but now constant • Located in the RUQ with radiation to the tip of the right shoulder • Associated with nausea and vomiting and fevers

  16. Applied Anatomy • What structures are found in the RUQ?

  17. The Right Upper Quadrant • Liver • Gall Bladder • Biliary Tree • Pancreas • Stomach • Duodenum • Right kidney

  18. Examination • HR: 115 BP: 120/70 RR: 19 O2: 99% 2L NP T: 38.1⁰C • Abdo Ex: • Tender RUQ with some (voluntary) guarding • Murphy’s sign positive

  19. Investigations • FBE: 123/13.9/285 neut 10.2 • UEC: normal • LFTs: bilirubin, GGT and ALP elevated • Imaging??

  20. DDx?

  21. Cholecystitis • Inflammation of the gallbladder, most commonly from obstruction of the cystic duct • Cf with choleduocholithiasis and cholangitis and biliary colic

  22. Cont Cholecystitis • Imaging: US Abdo or CT A/P • Treatment • IV resus • Analgesia • Abx • Laproscopiccholecystectomy

  23. Other DDx’s? • Hepatobiliary: • Choleduocholithiasis • Cholangitis • Pancreatitis • GIT: • Perforated peptic/duodenal ulcer • Gastritis/GORD • Urological: • Pyelonephritis • Renal stones

  24. Case 3 • 87yo male presents to the ED with sudden onset abdominal pain • Severe and constant • Initially developed in the LIF but quickly became widespread • Associated with one large passage of bloody diarrhoea

  25. Cont Case 3 • PMHx: • IHD – AMI 2yrs ago with PCI • T2DM – OHG only • AF – warfarinised recently • PVD – Fem-Pop Bypass Graft 4yrs ago • Nil history of abdominal surgery • Meds: • Warfarin, β-blocker, ACE-I, metformin, aspirin, statin • Active smoker 4-5 cigarettes per day, 40+ PYH

  26. Examination • HR: 130, BP: 90/60, O2: 99% 2LNP, RR: 17, T: 37.9⁰C • Looks flat/sick. Unwilling to move much. Drowsy • Abdo Ex: • Abdominal guarding and rigidity

  27. Investigations • FBE: 75/15.2/246 neut 11.2 • UEC: 150/3.2 Cr 265 eGFR 30 (baseline Cr 125) • LFTs: normal • Coags: INR 1.6 • ABG: pH 7.29 pCO2 29 HCO3 19 lactate 5.2 • AXR: dilated oedematous bowel loops

  28. DDx? Use Applied Anatomy!

  29. Descending and Sigmoid Colon • Ureter • Left Ovary/Fallopian Tube

  30. Treatment: • IV resuscitation • Blood Cultures and Abx • NGT, IDC • Vit K (IV) to reverse INR • Consent for urgent laparotomy + washout +/- proceed (eg Hartman’s). • Consider need for intraoperative Angiogram

  31. Hartman’s Procedure

  32. Lets go back to Case 1 • 27yo female presents with 1d of abdominal pain • Abdominal Pain: • Initially midline/umbilical • Over 24/24 transitioned to the RIF • Severe, constant • Further Hx: • LMP 8 weeks ago • No PV bleding • Smoker • Hx of chlamydia • Previous laparoscopic surgery for endometriosis

  33. O/E • Pain 2/10 after 10mg morphine IV • Obs: HR110 BP95/70 O2: 98% 4LNP RR20 T37.8⁰C • Abdominal examination as above • What else do you need to do? • ALL FEMALE PATIENTS OF REPRODUCTIVE AGE ARE PREGNANT UNTIL PROVEN OTHERWISE - b-HCG! • Speculum examination and bimanual examination

  34. O&G Differentials

  35. ACUTE ABDOMEN + POSITIVE PREGNANCY = ECTOPICuntil proven otherwise..

  36. Risk factors for Ectopic pregnancy • Smoking • Clomiphene • IUD • PID • Previous ectopic pregnancy • Adhesions • Pelvic and tubal surgery • Endometriosis • Pelvic masses • Chromosomal abnormalities

  37. Investigation • Cultures: urine B-HCG • Bloods: FBE, UEC, LFT, G+H, COAG, Serum B-HCG, Serum progesterone • Serum B-HCG >1500 I/U should see gestational sac • Serum B-HCG > 10,000 should see heart beat • Serum B-HCG should double every 48 hours • Imaging: Transvaginal ultrasound • Scopic: Diagnostic laparoscopy

  38. FIRST RESUSCITATITE, then..

  39. IF PATIENT IS UNSTABLE DESPITE RESUSITATION URGENT LAPAROTOMY IS INDICATED

  40. Management Medical: • ONLY if fulfill criteria • Methotrexate • Anti-D if mum Rh-ve • Follow up • Contraception for 3 months as methotrexate teratogenic! Surgical: • Anti-D if mum Rh-ve • Diagnostic Laparoscopy if patient is haemodynamically stable • Laparotomy if patient unstable • Salpingectomy or Salpingotomy

  41. Management

  42. Ovarian Torsion • Torsion of ovary on its vascular, tubal and ligamentous pedicle (adnexal torsion) • Results in ischaemia and eventual infarction if not relieved • GYNAECOLOGICAL EMERGENCY • Risk factors: • Ovarian mass • Cyst • More common in reproductive age • Sudden onset lower quadrant visceral pain • Radiate to flank or inner thigh • N+V • Can sometimes develop slowly • Tender lower quadrant • Adnexal tenderness on bimanual examination +/- palpable mass

  43. Investigation and Management • B-HCG to rule out ectopic pregnancy! • WCC – tubo-ovarian abscess • Urinalysis • Doppler Ultrasound • >50% sensitivity for torsion, but arterial flow does not rule out • Absence of arterial flow high predictive value • Laparoscopy / laparotomy +/- salpingo-oophorectomy

  44. Ovarian Torsion

  45. Other Differentials NOT TO MISS • ΑAA • Testicular torsion • AMI • Lower lobe pneumonia

  46. Questions???

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