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The Acute Abdomen

The Acute Abdomen. Raymond Yiu Surgery Team 3. Abdo pain <1week. Life-threatening Emergency admissions (30-50% surgical admissions) May require Emergency surgery or intervention. By Aetiology. INTRABDOMINAL Imflammatory Peritonitis Traumatic Obstructive Vascular. EXTRAABDOMINAL

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The Acute Abdomen

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  1. The Acute Abdomen Raymond Yiu Surgery Team 3

  2. Abdo pain <1week Life-threatening Emergency admissions (30-50% surgical admissions) May require Emergency surgery or intervention

  3. By Aetiology • INTRABDOMINAL • Imflammatory Peritonitis • Traumatic • Obstructive • Vascular EXTRAABDOMINAL Cardiovascular MI Metabolic DKA Abdominal wall rectus sheath haematoma Neurogenic referred pain

  4. Acute abdomen Peritonitis Traumatic Obstructive Vascular

  5. Gynaecological and urological causes • Urological • Renal colic (mimic leaking AAA) • Pyelonephritis • Cystitis • Torsion of testis (referred pain—mimic appendicitis) • Epidydimo-orchitis (mimic “strangulated hernia) • Gynaecological • PID (Fitz-hugh-Curtis Syndrome) • Midcycle pain • Ruptured ovarian cysts • Torsion of ovarian tumor • Endometriosis

  6. All individual diseases covered in detail

  7. Acute abdomen: Aetiology by Incidence

  8. Most common causes

  9. Uncommon conditions (1% or less)

  10. Non-specific abdominal painaccounts for 35% of admissions • Viral infections • Bacterial gastroenteritis • Worm infestation • Irritable bowel syndrome • Gynecological causes • Psychosomatic • Abdominal wall pain: (rib tip pain, nerve root pain, hernias, myofascial syndromes) BJS 1987

  11. Non-specific abdominal pain • Further ix like early diagnostic laparoscopy has reduced the incidence of NSAP to 28% • Note that 10% of patients over the age of 50 admitted with abdo pain subsequently are found to have malignancy • 50% of these patients were discharged from hospital with diagnosis of NSAP before CAUTION!

  12. Mortality from acute abdomen • 30-day mortality 4% • Perioperative mortality 8% <60yr 2% 60-69yr 12% >80yr 20% • Common causes of mortality irresectable tumor 28% Rupture AAA 23% PPU 16% Colonic resection 14% N=1190 BJS 1989

  13. Management of acute abdomen

  14. Establishment of Diagnosis (or DDx) • Resuscitation and analgesia • Triage • Definitive treatment Can proceed hand in hand

  15. Establishment of Diagnosis (or DDx) • Triage • Resuscitation and analgesia • Definitive treatment

  16. Establishment of diagnosis • Clinical features (Hx and exam) • Baseline Ix (blood tests, CXR, AXR) • Special Ix (USS, CT, contrast studies) 50-60% Improves accuracy further to 90-100%

  17. Abdominal PainClues to cause • Time Course • Quality • Location • Radiation • Associated Symptoms

  18. Onset • Sudden onset: sudden events such as rupture AAA, pancreatitis, cholangitis, perforated viscus • Insiduous onset: suggests chronic disease such as biliary colic, intestinal obstruction (lower)

  19. Types of Abdominal Pain • Pain from Hollow Viscera • crampy/paroxismal • often poorly localized • related to peristalsis • patient writhing on exam table • Site depends on visceral innervation of automonic nerves • Pain from Peritoneal Irritation • Sharp pain from somatic nerves of parietal peritoneum • steady/constant • Often well localized • Worse with movement and sneezing/cough • Patient lies still with knees up

  20. Referred pain

  21. Localisation and pathology

  22. Localisation of signs and pathology Pancreatitis Liver abscess PPU Cholecystitis Cholangitis Diverticultis Meckels diverticultis Small bowel perf Appendicitis

  23. Associated symptoms • Systemic (sepsis) Fever, Tachycardia, Chills/rigors Dehydration • Symptoms suggestive of affected organ bowel, genitourinary *Mandatory to ask about menstrual history, gynecological symptoms and possibility of pregnancy in women of childbearing age

  24. Peritoneal signs (early) Light palpation tenderness, guarding Localised Percussion tenderness Rebound tenderness

  25. Peritoneal signs (late) • Generalised peritonism / boardlike rigidity • absent BS, abdominal distension due to paralytic ileus

  26. How to arrive at a working diagnosis?Pattern Recognition from experience

  27. Pattern Recognition Central colicky abdo pain shifts to RLQ region RLQ peritoneal signs + Temp 38 C Young male = appendicitis + + RUQ peritoneal signs (Murphys)+ Temp 38 C Middleaged Obese female = Acute cholecystitis + + RUQ pain

  28. Elderlymale arteriopath Middleaged male hepB carrier Sudden Epigastric pain radiating to back Sudden Epigastric/ RUQ pain Pulsatile mass in epigastrium Abdo distension + shock = = Leaking AAA Rupture HCC + + + + Pattern Recognition

  29. CEPOD • Confidential Enquiry into Post-operative deaths 1990 (Uk gov) • Outcome for patients requiring emergency surgery is improved is senior surgical staff are involved in preop care, surgery, postop care.

  30. “Shakiness of the hand may be some bar to the successful performance of an operation, but he of a shaky mind is hopeless” Sir Frederick Treeves

  31. Baseline Laboratory testing ECG Blood tests Plain X-rays Preparation for OT May aid Diagnosis

  32. WBC WBC > 11,000 Nonspecific (not necessarily surgical cause) Indicative of sepsis Differential count may be useful (neutrophils)

  33. Liver function tests • ↟ Bilirubin/ALP suggestive of biliary obstruction • ↟ Bilirubin/ ALT suggestive of hepatitis • LFT may be normal in 40% patients with acute cholecystitis • May be deranged in all types of sepsis (MOF). Not specific for any disease entity

  34. Amylase • ↟ in acute pancreatitis • May be normal in 40% cases of pancreatitis (especially delayed presentation) • Raised in other intra-abdominal conditions eg PPU, hyperamylassaemia, renal failure

  35. Urinalysis • Pregnancy test ------> Mandatory for all young females (ectopic preg) • WBC: UTI • RBC Renal colic/ ureteric stone (beware of false positive in menstruation) *Hematuria occurs in up to 30% with AAA *Most common misdiagnosis in AAA is kidney stone

  36. Plain X-rays • Aerobilia (RPC, GS ileus) • Sensitive for free air 90-95% • Bowel obstruction- • 70% sensitive Erect CXR Supine AXR

  37. Plain X-rays Renal stones 90% radio-opaque • GS 10% • Normal X-rays does not exclude acute abdomen!

  38. This should not happen!

  39. Summary of clinical assessment and the use of routine blood tests and plain x-ray • The decision to operate/intervention depends on the underlying diagnosis (ie peritontis) rather than on blood tests (clinical decision) • Good surgical judgement with experienced surgical staff improves perioperative outcome • Useful blood tests: Amylase (exclude pancreatitis) LFTs (cholangitis/hepatitis) • Useful radiographs CXR-erect: sensitive in detecting free intraperitoneal gas AXR supine: can detect IO, renal stones

  40. Hx & P/E and baseline lab tests have about a 50-60 % accuracy • Advance Imaging (CT , USS, contrast studies) are indicated in • Patients that have uncertain diagnosis • Equivocal peritoneal signs • Patients should be clinically stable

  41. Imaging-Ultrasound Good first line investigation for most intra-abdominal conditons Non-invasive, no radiation Cons: operator dependent

  42. Imaging-Ultrasound Biliary tract Cholecystitis (95% ) Cholangitis Appendicitis (80-90%) Vascular emergencies AAA Gynaecological conditions Ovarian cysts (rupture, torsion) Ectopic(TVS) Urological conditions (renal, ureteric stones, hydronephrosis)

  43. CT scan High accuracy in most acute abdominal conditions • GI Small/ large bowel obstruction (cut-off/tumor/staging) Diverticulitis (hinchey grading) • Vascular AAA (esp leaking) retroperit haematoma Aortic dissection double lumen Mesenteric ischemia occlusion/stenosis • Hepatobiliary Biliary tract dilatation/stones Rupture HCC tumor/free ip blood Pancreatitis oedema/ necrosis

  44. LBO (sigmoid ca) Diverticulitis SBO (adhesion)

  45. Rupture HCC Leaking AAA

  46. Contrast Studies • Oral contrast study • PPU: to confirm a suspected case of PPU not shown up on plain x-ray • SBO: to determine whether the obstruction will resolve or not (controversial: nowadays CT more fashionable)

  47. Contrast Enema LB obstruction Vs Colonic pseudo-obstruction

  48. Establishment of Diagnosis (or DDx) • Resuscitation and analgesia • Triage • Definitive treatment

  49. ABC Severely ill patients (ie MOF) may need ICU Establish iv access: may need > 1 large bore iv cannulas (bleeding 2) Rehydate (N/S or colloid 500mls stat) Monitoring (BP/PR/UO/CVP/SaO2) Resuscitation

  50. Analgesia • Historically, painkillers were thought to “mask” the peritoneal signs leading to misdiagnosis • It has now been shown that early administration of opiate analgesia has no detrimental effect on subsequent clinical assessment • Opiate analgesia (pethidine) and anti-emetic (stemetil) are commonly used and should not be withheld

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