The Acute Abdomen

1. The Acute Abdomen Yingda Li 6th Oct, 2011 Royal Melbourne Hospital

2. Objectives • Develop a rational approach to assessing and managing the acute abdomen • Identify ‘red flags’ on history and examination • Have a set of ‘rules’ as safety nets • Familiarise with style of questions commonly asked in exams

3. Overview • Definitions • History • Examination • Investigations • Management • Multiple choice questions

4. Definitions • Pain • Acute • Severe • Requiring urgent attention • Not always surgical • Not always abdominal source Rule 1. Epigastric pain may be from supra-diaphragmatic source

5. Rule 2. Women of childbearing age are pregnant till proved otherwise History Rule 3. Never underestimate abdominal pain in the elderly • Demographics • Tempo • Site, radiation • Quality • Associated symptoms • Risk factors • Previous surgery • Gynaecological history • AMPLE Rule 4. Sudden onset pain equals perforation, vascular or torsion Rule 5. Vomiting is a key associated symptom

7. Red flags

8. Examination Rule 6. Vital signs are vital • Preparation (privacy, consent, exposure, positioning, chaperone) • End-of-the-bed appearance • Vital signs • Look, listen, feel • PR, PV, testicular • Eponymous signs • Bedside tests (FWT, bhCG, ECG, BSL) • Symptoms out of proportion to signs Do not hurt the patient! Rule 7. Is there peritonism, is there a hernia and is there a AAA?

9. Investigations • Laboratory • Radiology

10. Management

11. MCQs

14. Hepatitis serology Upper abdominal ultrasound Full blood examination ERCP Liver biopsy

15. CT kidney, ureter and bladder Ultrasound renal tract 24-hour urinary calcium excretion Plain X-ray kidney, ureter and bladder Mid-stream urine for phase microscopy