24
Acute Abdomen, Pancrea00s, & Abdominal Compartment Syndrome Ben deBoisblanc, MD, FACP, FCCP, FCCM LSU Health Sciences Center New Orleans, LA

Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Embed Size (px)

DESCRIPTION

Critical care board review

Citation preview

Page 1: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Acute&Abdomen,&Pancrea00s,&&&Abdominal&Compartment&Syndrome&

Ben&deBoisblanc,&MD,&FACP,&FCCP,&FCCM&

LSU&Health&Sciences&Center&

New&Orleans,&LA&!

Page 2: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Disclosures&&No&poten0al&conflicts&of&interest&to&disclose.&

&Objec0ves&&1)&Iden0fy&risk&factors&for&and&management&

of&severe&pancrea00s,&ischemic&coli0s,&acalculous&cholecys00s,&&&C.#difficile#coli0s.&&2)&Recall&diagnos0c&criteria&for&and&

management&of&abdominal&compartment&syndrome.&3)&Differen0ate&bowel&obstruc0on&syndromes.&&

Page 3: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Differen0al&Dx&of&Acute&Abdomen&•  Appendici0s&

•  PUD&

•  Cholecys00s&&

•  Pancrea00s&pancrea00s&

•  Intes0nal&ischemia&

•  DKA&&

•  Diver0culi0s&

•  Ectopic&

pregnancy&

•  Perforated&viscus&

•  Ureteral&colic&

•  Biliary&colic&

•  Volvulus&

•  Pyelonephri0s&

•  Biliary&colic&

•  Adrenal&crisis&

Page 4: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review
Page 5: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Case&45&y/o&woman&with&acute&pancrea00s.&Which&of&

following&are&true&regarding&nutri0on?&

a.   She&should&receive&TPN&un0l&she&has&bowel&sounds&

b.   She&should&be&fed&via&PEJ&c.   &She&should&be&held&NPO&

un0l&her&pain&resolves&

d.   She&should&be&fed&a&low&fat&diet&

e.   She&may&be&fed&p.o.&ad&lib&

Salma Akram
Page 6: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Case&48&y/o&alcoholic&with&severe&epigastric&pain.&&BP&100/60,&P&138,&Hct&

55%,&lactate&3&mmol,&lipase&1925.&&CT&boggy&pancreas.&Aber&15&L&

of&crystalloid&BP&90/50,&P&135,&Hct&38%,&lactate&4&mmol,&lipase&

1500,&P/F&390,&Pplat&60&with&Vt&500&ml.&The&next&most&

appropriate&step&would&be:&

a.   Reduce&VT&b.   Transfuse&2&U&PRBC&c.   CTA&of&chest&with&PE&protocol&

d.   Measure&intravesicular&pressure&

e.   Echocardiography&

Salma Akram
Page 7: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Predictors&of&Mortality&

•  Shock&•  ALI&•  AKI&•  GI&bleeding&•  Necrosis/abscess&•  APACHE&II&>&8&•  CRP&>&6&at&24&hrs&•  Stones&•  Dynamic&CT&Grade&

Salma Akram
Salma Akram
Salma Akram
Page 8: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Infected&Necro0zing&Pancrea00s&

• Usually&aber&1st&week&• Risk&propor0onal&to&CT&&grade:&&

•  A&g&Normal&•  B&–&Enlargement&•  C&–&Peripancrea0c&

inflamma0on&•  D&g&Single&fluid&collec0on&•  E&–&Mul0ple&collec0ons&

• Prophylac0c&Abx:&–  No&if&A,&B&

–  Perhaps&if&&>30%&necrosis&by&

dynamic&CT&

• Imipenem&

Salma Akram
the highest the necrosis / ct grade the higher the risk for infection.
Salma Akram
Page 9: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Necro0zing&Pancrea00s:&Tx&

•  Serial&CT,&US,&or&EUSgaspira0on&for&culture&dx&

–  Gg&60%,&G+&50%,&fungi&25%&

•  NG&or&NJ&feedings&if&tolerated&

•  ERCP&for&stone&

•  Surgical&&drainage&for&abscess&

•  IR&or&EUS&drainage&if&poor&opera0ve&candidate&

Salma Akram
Salma Akram
Page 10: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Abdominal&Compartment&Syndrome&•  Intragabdominal&HTN&+&

organ&dysfunc0on&

–  Renal,&hemodynamic,&splanchnic,&pulmonary,&CNS,&skin&

•  Mortality&10g70%&•  Risks:&&

–  >5&L/24&hr&resuscita0on&–  intragabdominal&trauma&–  cirrhosis,&pancrea00s,&peritoneal&dialysis,&AAA&

–  lower&with&“damage&control&laparotomy”&

Salma Akram
Page 11: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

ACS:&Dx&•  Suspect&in&high&risk&pt&

•  Organ&dysfunc0on&+&IAH&&

•  Measure&Bladder&pressure&•  Normal&<&10&

•  Grade&I&=&10g15&•  Grade&II&=&16g25&•  Grade&III&=&26g35&•  Grade&IV&=&>35&

mid+axilla#_____#

Salma Akram
Salma Akram
Page 12: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

ACS:&Tx& •  Grade&IIgIII&&–  gut&decompression&muscle&relaxants&&&observa0on&

•  Grade&IV&

–  Surgical&decompression&with&delayed&fascial&closure&

– Monitor&for&hyperkalemia,&lac0c&acidosis&

Salma Akram
Salma Akram
Page 13: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Case&19&y/o&Type&1&diabe0c&man&with&3&day&hx&N&V&&&epigastric&pain.&&

ABG&pH&7.10,&pCO2&20,&HCO3g&6,&serum&ketones&posi0ve.&&Aber&6&

L&crystalloid,&intravenous&insulin,&&&electrolyte&replacement&pH&

7.35,&pCO2&35,&HCO3g&19,&however&he&con0nues&to&complain&of&

abdominal&pain.&&U/S&of&abdomen&is&ordered.&

Your&next&step&should&be:&

a.   ERCP&b.   Trial&of&IV&somatosta0n&

c.   Surgical&consulta0on&

d.   HIDA&scan&e.   Observa0on&

Salma Akram
Salma Akram
lucency outside the gall bladder consistent with fluid collection and suggestive of acalculus cholecystitis.
Page 14: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Acalculous&Cholecys00s&

•  5g10%&of&all&acute&cholecys00s&

•  Common&to&cri0cal&illness,&HIV,&EBV,&&&TPN&>3&months&&&

•  Pathogenesis&–  SIRS&+&biliary&stasis&+&increased&lithogenicity&+&ischemia&

•  40g60%&incidence&of&gangrene&&&perfora0on&

Page 15: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Acalculous&Cholecys00s&

•  Imaging&CT&&&U/S:&–  distension&–  thickening&of&wall&–  pericholecys0c&fluid&–  intramural&gas&– mucosal&sloughing&&&sludging&

•  HIDA&scan&NPV<25%&•  Tx:&percutaneous&cholecystostomy&or&cholecystectomy&

Salma Akram
Salma Akram
sludge
Page 16: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Case&24&y/0&with&chest&&&abdominal&pain&aber&using&cocaine.&

EKG&shows&anterolateral&ST∆&but&normalizes&over&20&

min.&&His&abdomen&diffusely&tender.&Next&day&he&

passes&small&amount&of&BRB&per&rectum.&&A&

colonoscopy&is&ordered.&&Treatment&might&include:&

a.   IV&vasopressin&b.   Proton&pump&inhibitor&

c.   Oral&vancomycin&

d.   Papaverine&e.   IV&fluids&&&observa0on&

Salma Akram
Salma Akram
Mesenteric ischemia
Page 17: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Mesenteric&Ischemia&

•  Severe&pain,&distension,&fecal&occult&blood&

•  Splenic&flexure&or&transverse&colon&•  E0ology:&–  30%&embolic&(cardiac)&

–  30%&atheromatous&

–  30%&nonocclusive&(shock,&CHF,&hypovolemia,&cocaine,&digitalis,&midodrine)&

–  Rarely&mesenteric&vein&thrombosis&(thrombophilia,&portal&HTN,&pancrea00s,&CA)&

Salma Akram
Page 18: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Mesenteric&Ischemia&•  Dx:&•  CTA&~&70%&sensi0ve:&thrombus,&mesenteric&venous&gas,&pneumatosis&intes0nalis,&bowel&thickening/dilata0on,&fat&stranding,&ascites&

•  Colonoscopy&•  Tx:&Normalize&

circula0on,&papaverine,&embolectomy,&an0coagula0on&

Salma Akram
Salma Akram
Page 19: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Case&80&y/0&with&progressive&lethargy&over&6&mos&is&admised&to&ICU&for&

respiratory&failure&due&to&CHF.&BP&90/60,&P&38/min&(sinus),&T&

35oC.&LVEF&10%.&His&abdomen&is&distended,&tympanic,&

hypoac0ve&BS,&nongtender.&The&most&appropriate&treatment&for&

this&pa0ent&is:&

a.   Egmycin&

b.   Milrinone&

c.   Enteral&feedings&

d.   Neos0gmine&

e.   Thyroid&hormone&

Salma Akram
Salma Akram
treat underlying cause of ileus: hypothyroidism in this case
Page 20: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Bowel&Obstruc0on&Syndromes&•  Arrested&Peristalsis&–  Gastroparesis&–  Small&bowel&ileus&–  Colonic&pseudogobstruc0on&

•  Mechanical&obstruc0on&–  Adhesions&–  Volvulus&–  Intussuscep0on&–  Tumors&–  Fecal&impac0on&

Page 21: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Mechanical&SBO&•  Colicky&pain,&copious&vomi0ng,&

abdominal&disten0on,&high&

pitched&BS&&

•  Compromise&of&venous&blood&flow&

g&bowel&ischemia&&&necrosis&

•  Late&:&silent&abd,&tenderness,&leukocytosis,&hypotension,&

tachycardia&

•  Tx:&–  85%&resolve&with&NG&suc0on&,&IVFs&–  Early&surgery&for&infarc0on&

Salma Akram
Page 22: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Small&Bowel&Ileus&&&Colonic&PseudogObstruc0on&(Ogilvie’s)& •  Risk&factors:&

–  GI&surgery&–  Cri0cal&Illness&–  Electrolytes&–  Opiates,&an0cholinergics&–  Hypothyroidism&–  Elderly&&&debilitated&

•  Tx:&–  NPO?&–  Tube&decompression&–  Fluids&vs&fluid&restric0on?&–  Correct&electrolytes&–  Avoid&precipita0ng&drugs&–  Egmycin,&neos0gmine,&lactulose&

•  PEJ/Cecostomy&for&refractory&cases&

Salma Akram
Page 23: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Case&80&y/o&admised&to&ICU&from&rehab&ward.&Previously&healthy,&she&

fell&on&cruise&ship&&&sustained&a&hip&Fx&for&which&she&had&a&THR.&&

5&days&postgop&she&developed&diarrhea&&&abdominal&pain.&&BP&

88/48,&P120,&T38.9oC.&Her&abdomen&is&now&tense,&silent,&&&she&

has&rebound&tenderness.&&Blood&cultures&growing&2&GNRs.&

Possible&Tx&&includes:&

a.   IV&vancomycin&

b.   Total&colectomy&

c.   Soapsuds&enemas&

d.   Neos0gmine&

e.   Loperamide&

Salma Akram
Salma Akram
Severe C diff
Page 24: Acute Abdomen/Pancreatitis/Abdominal compartment Syndrome/CCM Board review

Severe&C.#difficile#Coli0s&

•  BI/NAP1,&ribotype&027&– More&virulent,&toxic&megacolon&–  Increased&Toxin&A&&&B,&binary&toxin,&more&sporula0on&

–  Sep0c&shock,&culture&neg&or&polymicrobial&

– Mortality&~&20%&–  Eliza&sensi0vity&75%&

•  Risk&factors:&–  Epidemics,&age,&PPI,&feeding&tube,&prior&flouroquinolone&

•  Tx:&–  Oral&vancomycin&preferred?&–  Colectomy&&&ileostomy&for&severe&disease&

Salma Akram
Salma Akram
Salma Akram
Salma Akram