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A Cute Abdomen

A Cute Abdomen. Goal. not exact diagnosis but that a surgical condition exists.

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A Cute Abdomen

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  1. A Cute Abdomen

  2. Goal • not exact diagnosis • but that a surgical condition exists

  3. “The general rule can be laid down that the majority of severe abdominal pains that ensue in patients who have been previously fairly well, and that last as long as six hours, are caused by conditions of surgical import.” Silen W: Cope’s Early Diagnosis of the Acute Abdomen. 1996,p.6.

  4. Diagnose Early • Better outcome • Pain relief (narcotics) • Antibiotics

  5. History • Age • Onset - how long ago sudden or gradual • Distribution - area of maximal pain localization radiation • Character - sharp or dull, burning, steady or cramping

  6. History • Nausea, vomiting, anorexia • Diarrhea, constipation, flatus, blood, tenesmus • Menstruation - where in the cycle sexual activity • Previous episodes - relationship to meals: 2 - 2 1/2 hrs = duodenal worse with food = gastric fatty foods = gallstones weight loss?

  7. Vomiting • Relationship to pain appendicitis - pain precedes vomiting gastroenteritis - vomiting precedes pain • Character - feculent vomiting pathognomonic of obstruction of distal small intestine, rare in colonic obstruction

  8. Physical Examination • General appearance - restlessness = colic immobility with knees flexed = peritonitis • Blood pressure • Pulse - “too optimistic a friend to be relied upon…” • Respiratory rate - may suggest a thoracic origin • Temperature - could be normal, high or low > 104oF (40oC) suggests thorax or kidney Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996,p.32.

  9. PE: Chest • Inspection • Palpation • Percussion • Auscultation

  10. PE: Abdomen • Inspection - distention, hernias DON”T FORGET THE FEMORAL CANAL • Auscultation • Palpation - rigidity area of greatest pain last • Percussion - “rebound”, cough tenderness Rosving’s sign

  11. Levien: Intro to Surg 1987, p.41.

  12. PE: Abdomen “of all the modalities of physical diagnosis of the abdomen, auscultation is one of the least valuable and most misleading.” Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996,p.43.

  13. PE: Pelvis • Pelvic examination - bimanual • Rectal examination - mass, tenderness, blood

  14. “Overreliance on laboratory tests and radiological evaluations will very often mislead the clinician, especially if the history and physical examination are less than diligent and complete.” Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996,p.57.

  15. Laboratory Tests • CBC - leukocytosis, anemia • Urinalysis - infection, blood, pregnancy • Electrolytes - renal function, dehydration • Amylase, lipase • LFTs

  16. Radiographic Studies • Flat & upright abdomen - air-fluid levels, distended loops, edema in bowel wall, volvulus, fecolith • CXR - free air, lower lobe pneumonia • Contrast studies - H2O soluble if perforation disadvantage - aspiration, quality

  17. Appendicitis • Fecolith • Young 1. Dull pain in midepigastrium 2. Nausea/vomiting follows pain 3. Localizes to RLQ * Anorexia + Fever • Leukocytosis Reginald H. Fitz 1843 - 1913

  18. McBurney’s Incision McBurney C: NY State Med J 1889;50,676-684. McBurney C: Ann Surg 1894;20,38-43.

  19. Perforated Ulcer • Sudden onset • Previous episodes of pain ~ 2 hrs after eating • CXR - free air Graham RR: Surg Gynecol Obstet 1937;64,235-238.

  20. Pancreatitis • Alcohol • Gallstones • Trauma • Hyperlipidemia • Hyperparathyroidism • Drugs - thiazide diuretics • Unknown (10%)

  21. Pancreatitis • Excruciating pain • Fever - almost always • Ranson’s criteria • Grey Turner sign • Cullen’s sign Cullen TS: Am J Obstet 1918;78(Sept),457. Turner GG: Brit J Surg 1920;7(Jan),394-395.

  22. Admission 1. Age > 55 2. WBC > 16,000/mm3 3. Glucose > 200 mg/100 ml 4. LDH > 350 I.U./L 5. SGOT > 250 Frankel units % During Initial 48 Hours 1. Hematocrit fall > 10% 2. BUN rise > 5%/mg/100 ml 3. Ca++ < 8 mg/100 ml 4. Arterial pO2 < 60 mmHg 5. Base Deficit > 4 meq/L 6. Fluid sequestration > 6 L Ranson’s Criteria Ranson et al: Surg Gynecol Obstet 1974;139,69.

  23. Amylase • Pancreatitis • Cholecystitis • High intestinal obstruction • Acute renal insufficiency • Perforated ulcer • & others

  24. Cholecystitis • Radiopaque gallstones (10-15%) • Pain - RUQ, “colic”, radiates to the ipsalateral scapula • Pain brought on with fatty foods • US - stones, thickening, fluid, air in wall

  25. Intestinal Obstruction • pain - colic • Vomiting, distention • Obstipation • Auscultation - quiet to high-pitched, tinkling rushes to borborygmi • X-ray - air-fluid levels, fixed loops

  26. Small Bowel Obstruction 1. Adhesions (74%) 1/2 2o to gynecologic or colonic operations 2. Neoplasm (8.6%) 3. Hernias (8.1%) most common cause in children • Inflammatory bowel disease (5.2%) • Gallstone ileus, radiation enteritis, intussusception • Unknown Bizer et al: Surgery 1981;89,407-413.

  27. Adynamic Ileus • 2o to general peritonitis, severe chest injuries, after myocardial infarction, pneumonia, operations on the spine or abdomen, or narcotics • Auscultation - quiet, no borborygmi • Involves both small & large bowel • Gaseous distention of both small & large bowel

  28. Large Bowel Obstruction 1. Cancer (70%) 2. Volvulus (10%) 3. Diverticulitis (5%) • Intussusception, uremia

  29. Volvulus • Sigmoid (most common) • Ileocecal • Transverse (rare) • Barium enema is diagnostic & often therapeutic • Sigmoidoscopy - alternative diagnostic & therapeutic modality “bent inner tube sign”

  30. Diverticulitis • LLQ pain • Fever, leukocytosis • CT scan - pericolic abscess • Antibiotics, NPO, NG decompression • Operation for persistent symptoms (7 days) or recurrent episodes

  31. Hernias • Indirect inguinal most common in both males & females • Femoral is more common in females • Direct inguinal, umbilical, ventral, incisional, Spigelian, Richter’s, lumbar, obturator, etc.

  32. Renal Colic • Radiopaque ureteral calculus (85-90%) • Pain radiating to the testicle or vulva • Vomiting • Microscopic hematuria

  33. Female Disorders • Ectopic pregnancy, PID, mittelschmerz, appendicitis • Chandelier sign • Urinalysis • Ultrasound • Laparoscopy

  34. Mesenteric Vascular Occlusion • Pain out of proportion to physical examination • Risk factors - atrial fibrillation, digitalis, diuretics, cardiopulmonary bypass • Barium enema may show “thumbprinting” • Angiography, MRI • Mortality = 50%

  35. Summary • not exact diagnosis • but that a surgical condition exists

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