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Acute Abdomen

Acute Abdomen. Melissa Cunha Transplant Fellow Manchester Royal Infirmary 28 th February 2011. Objectives. Definition Approach Commonest causes History Clinical Examination Investigations Management Cases. Definition.

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Acute Abdomen

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  1. Acute Abdomen Melissa Cunha Transplant Fellow Manchester Royal Infirmary 28th February 2011

  2. Objectives • Definition • Approach • Commonest causes • History • Clinical Examination • Investigations • Management • Cases

  3. Definition • Someone who becomes acutely ill and signs are chiefly related to the abdomen has an acute abdomen

  4. A systematic approach • History, Examination, Investigations, Treatment Plan • May require simultaneous resuscitation and treatment.

  5. Final diagnosis in UK • Non-specific abdominal pain 30-40% • Appendicitis 20-25% • Cholecystitis / Biliary Colic 7-8% • Peptic ulcer disease 4% • Urinary retention 4% • Acute pancreatitis 3% • Small bowel Obstruction 3% • Renal Colic 3% • Trauma 3% • Malignant disease 2-4% • Medical diagnosis 2-4% • Acute diverticulitis 2% • Large bowel obstruction 2% • Vascular Disease 2% • Gynaecological disease 1%

  6. History • Pain • SOCRATES • Site • Onset • Character • Radiation • Associated symptoms • Time course • Exacerbating/relieving factors • Severity

  7. Specific questioning • GI symptoms • Similar episodes • Swellings in groin or abdomen • Gynaecological and Obstetric history • Vaginal discharge

  8. History • Past medical history • Past surgical history • Drug history and allergies • Social history • Alcohol • Tobacco • Family history • Systemic inquiry

  9. Clinical Examination • General state & demeanour of patient • Dehydration • Jaundice • Anaemia • Cyanosis • Oedema

  10. Clinical Examination • ALWAYS: • BP, HR, RR, Temperature, SpO2 • Cardiovascular Examination • Respiratory Examination

  11. Clinical examination • Abdominal examination: • Inspection • Palpation • Percussion • Auscultation

  12. Clinical Examination • Always include: • Back • Groins • Hernias • Perineum and genitalia • Consider patient’s dignity

  13. Clinical Examination • Abdominal examination findings: • Murphy’s sign • Rovsing’s sign • Iliopsoas’ sign • Obturator’s sign • Guarding • Rebound

  14. Murphy’s sign • Elicitation: Palpate the right subcostal area while the patient inspires deeply • Positive response: The patient feels pain upon this manoeuvre and may have an associated inspiratory cessation

  15. Rovsing’s sign • Elicitation: Palpate the left lower quadrant of the abdomen • Positive response: The patient feels pain in the right lower quadrant

  16. Iliopsoas’ sign • Elicitation: patient on left lateral decubitus and examiner extends patients right leg at the hip • Positive response: The patient feels pain in the right lower quadrant

  17. Obturator’s sign • Elicitation: flexion and external rotation of the hip • Positive response: The patient feels pain in the right lower quadrant

  18. Bedside investigations • Vomit • Stools • Urine

  19. Basic Blood Tests • Full Blood Count • Urea and Electrolytes • Liver Function Tests • Bone Profile • Amylase • Coagulation Screen • Pregnancy test

  20. Other investigations • Urine test • Stools culture

  21. Radiology • Chest X-Ray: • Pneumonia, Perforation, Subphrenic abcess • Abdominal X-Ray: • Ileus, Obstruction, Stones, Air above liver. • Contrast studies: • Gastrograffin, barium enema • USS • CT • MRI

  22. Ultrasound • Gallstones, Liver abscess, Biliary tree, Pancreas • Urinary Tract: Hydronephrosis, Stones • Pelvis: Abscess, appendicitis, Gynaecological conditions, ectopic pregnancy • Ascites • Abdominal Aortic Aneurysm

  23. CT Scan • Useful for retroperitoneal structures • Pancreatitis • Abdominal Aortic aneurysm

  24. Management • Resuscitate • Conservative treatment • Medical management • Surgical treatment

  25. Case 1 • Male, 35 years old • Central abdominal pain, colic in nature that then shifts to RIF and becomes constant • Anorexia • Constipation • Otherwise fit and well

  26. Case 1 • What are the possible findings from Physical examination?

  27. Physical examination • Tachycardia • Low grade fever • Lying still • Foetor • Tenderness and guarding RIF • Rebound tenderness • PR: painful on right

  28. Case 1 • What are the differential diagnosis?

  29. Differential Diagnosis • Appendictis • Mesenteric adenitis • Salpingitis/PID • UTI • Cholecystitis • Diverticulitis • Chrohn’s disease • Food poisoning/gastroenteritis

  30. Case 1 • What tests would you request?

  31. Investigations • U&E, FBC, CRP • Urine sample • Pregnancy test • CXR and AXR • USS • CT abdomen • Do not rely on tests for appendicitis

  32. Case 1 • How would you manage this case?

  33. Appendicitis • RIF pain, low grade fever • Guarding and tenderness RIF • Raised WCC and CRP • Management: • IV fluids • IV antibiotics • Surgery: • Laparoscopic • Open

  34. Other causes RIF pain • Gynaecological and Obstetric causes: • Salpingitis • Pelvic inflammatory disease • Ectopic pregnancy • Medical causes • Crohn’s disease

  35. Case 2 Female, 40 years old, obese Sudden onset of right upper quadrant pain associated with nausea and vomiting after eating pork pie. Feels hot and unwell. No changes in bowel habit. No urinary symptoms. PMH: nil

  36. Case 2 What are the possible findings from Physical examination?

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