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The Acute Abdomen
Acute Abdomen Definition
• Intraabdominal process causing severe pain and often requiring surgical intervention.
• 2 considerations– Surgical or non surgical causes
General Causes
• Divided into 6 broad categories– Inflammatory - ie appendicitis– Mechanical - ie acute small bowel obstruction– Neoplastic - ie cancer– Vascular - ie mesenteric vascular occulsion– Congenital defects - ie Intussusception– Traumatic - ie mesenteric bleeds due to
trauma
Red Flags in Acute Abdomens• › Signs of impending shock• › Hypotension, tachycardia, tachypnea• › Septic appearance• › Confusion• › Signs of dehydration• › Rigid abdomen• › Absent bowel sounds• › Patient lying still or writhing• › Involuntary guarding• › Tenderness to percussion• › Hematemesis, hematochezia• › Abdominal pain prior to vomiting• › Abdominal pain localized to the periphery • of the abdomen or pelvis
Pathophysiology
• Visceral– From abdominal viscera– innervated by autonomic nerve fibers– Responds to sensation of distention &
muscular contraction– Poorly localized
Pathophysiology con’t
• Parietal– From parietal peritoneum– Innervated by somatic nerves– Responds to irritation from infectious,
chemical or other inflammatory processes.– Sharp and well localized
Pathophysiology con’t
• Referred– Perceived distant from source– Results from convergence of nerve fibers at
spinal cord– Eg. Scapular pain due to biliary colic or groin
pain due to renal colic
Abdominal P/E
• Inspection• Auscultation• Percussion• Palpation
Abdominal P/E
• Looking for– Distension– Rigidity– Guarding– Eviseration/Ecchymosis– Rebound tenderness– Rebound tenderness– Masses
Acute Abdominal Pain
Acute Abdomen Non-Rigid
Acute Upper Abdomen
Acute Lower Abdomen
Review
• Right lower quadrant pain, fever, leukocytosis, McBurney’s point localization of pain is most associated with:A. Diverticulitis.
B. Ulcerative colitis.
C. Appendicitis.
D. Tubo-ovarian abscess.
E. Cholecystitis.
Review - ANSWER
• Right lower quadrant pain, fever, leukocytosis, McBurney’s point localization of pain is most associated with:A. Diverticulitis.
B. Ulcerative colitis.
C. Appendicitis.
D. Tubo-ovarian abscess.
E. Cholecystitis.
Review
• A complete small bowel obstruction might be suspected in a patient with:A. Hypoactive bowel sounds.
B. Pain out of proportion to physical exam findings.
C. Crampy abdominal pain that waxes and wanes.
D. Diarrhea.
E. A flat, rigid abdomen.
Review - ANSWER
• A complete small bowel obstruction might be suspected in a patient with:A. Hypoactive bowel sounds.
B. Pain out of proportion to physical exam findings.
C. Crampy abdominal pain that waxes and wanes.
D. Diarrhea.
E. A flat, rigid abdomen.
Liver Infections
Hepatic Abscess• uncommon• 3 major forms
- pyogenic, aerobes & anaerobes (80%)
- amebic, Entamoeba histolytica (10%)
- fungal, Candida species (10%)
Liver Infections
1. Pyogenic Liver Abscess• usually gram (-) aerobic bacteria• from appendicitis or diverticulitis• ascension in biliary tree• systemic source from dental procedures• trauma• biliary instrumentation (iatrogenic)
Liver Infections
1. Pyogenic Liver Abscess• fever, chills, pain, weight loss• tender liver, jaundice, hepatomegaly• Ultrasound• CT scan• percutaneous drainage• antibiotics
Liver Infections
2. Amebic Liver Abscess• parasitic Entamoeba histolytica• tropical climates• young men account for 90% of cases• RUQ abdominal pain• fever, chills, nausea, vomiting, anorexia,
weight loss
Liver Infections
2. Amebic Liver Abscess• percutaneous drainage• amebicidal agents-paromomycin-luminal
agent.• metronidazole-tissue agent• chloroquine and emetine
Liver Infections
3. Fungal Liver Abscess-Hepatosplenic Candidiasis or Chronic Disseminated Candidiasis
• Candida albicans• multiple abscesses• immunocompromised• leukemia, HIV• systemic antifungal therapy (Amphotericin
B)
Abdominal Wall Hernias
Classification:• inguinal hernia (direct or indirect)• femoral hernia• umbilical hernia• epigastric hernia• Spigelian hernia (lateral ventral hernia)• ventral / incisional hernia
Groin Hernias
Inguinal Hernia (96%)• more common in men than women• indirect (80%) [Internal inguinal ring]• direct (20%) [Hesselbach’s triangle]Femoral Hernia (4%)[medial femoral canal]• Lifetime risk of developing a groin
hernia is- 25% for men- 5% for women
Inguinal Hernia Presentation
• Soft non-tender mass in the groin.• Local burning or aching.• Enlargement of the mass by coughing
(any maneouver that increase intra-abdominal pressure).
Inguinal Hernia RepairIndications for Elective Surgery• pain / discomfort• limits / restrictions on activity• increasing size of hernia• small risk of incarceration &
strangulation• cosmetic
Indications for Emergency Surgery• incarceration & strangulation
Ventral Hernia
• 11 – 20% of laparotomies• incarceration 5 – 15%• risk of strangulation 2%• recurrence rates = 50% with tension
repair• 50% of incisional hernias appear in the
first
6 months following laparotomy• most occur within 2 years
Appendicitis
Clinical Presentation• intermittent, crampy, periumbilical pain• obstruction of appendiceal lumen with
a fecalith• nausea follows the pain• anorexia• low grade fever• pain migrates to RLQ within 24 hrs and
changes to constant & sharp pain
AppendicitisPhysical Examination• RLQ tenderness & localized peritonitis• Rovsing’s sign (RLQ pain with LLQ
palpation)• obturator sign suggests a pelvic
appendix• psoas sign suggests a retrocecal
appendix• in females, must do pelvic exam to rule
out adnexal mass or tenderness.
Possible Positionsof the Appendix
P/E• McBurney's point tenderness:1.5 to 2
inches from ASIS to the umbilicus.• Rovsing's sign: pain in the RLQ w/
palpation of LLQ (rt-sided local peritoneal irritation).
• Psoas sign: (retrocecal appendix) RLQ pain with passive right hip extension.
• Obturator sign: (pelvic appendix) RLQ pain with rt hip/knee flexion and internal rotation.
Appendicitis
Laboratory Examination• WBC count• urinalysis• urine β-HCG to rule out pregnancy
AppendicitisImaging Studies• Ultrasound
- may be useful (sensitivity 80%, spec 90%)
- highly operator dependent
- useful to rule out gynecologic pathology
• CT scan
- more accurate than U/S for appendicitis, sens and spec 95%.
Appendicitis
Treatment of Nonperforated Appendicitis• laparoscopic vs open appendectomy
ASAP• fluid & electrolyte imbalance usually
minor• prophylactic IV antibiotics to prevent
wound infection.• post-op hospital discharge 24-48 hrs
Appendicitis
Treatment of Perforated Appendicitis• may be acutely ill• significant dehydration & electrolyte
disturbance• CT scan – appendiceal abscess or
phlegmon• percutaneous drainage of abscess• may choose to delay surgery for months• interval appendectomy
BREAK
VASCULAR EMERGENCIES
Vascular Emergencies
Mesenteric Ischemia• low blood flow to bowel• embolic event to SMA (atrial fibrillation)• thrombosis of SMA• nonocclusive mesenteric ischemia (low
flow
states in critically ill patients) - vasoconstriction
Vascular Emergencies
Mesenteric IschemiaDiagnosis• angiography• CT scan with contrastTreatment• operative attempts to restore mesenteric
flow• need to resect any nonviable bowel• thrombolytic therapy an option
Vascular Emergencies
Ruptured Abdominal Aortic Aneurysm (AAA)
• common surgical emergency• many pts do not know they have an
aneurysm until it ruptures• risk factors include smoking, >60 yrs,
HTN, CAD, dyslipidemia, FmHx.
AAA
Vascular EmergenciesClinical Presentation Ruptured AAA• acute abdominal or back pain• usually sudden onset• lightheadedness or collapse due to
sudden hypotension• immediate CT scan if pt
hemodynamically stable.• if unstable, diagnosis with Hx, P/E,
ultrasound
Vascular Emergencies
Ruptured Abdominal Aortic Aneurysm (AAA)
Treatment• immediate OR• laparotomy with X-clamp proximal aorta &
repair aneurysm with interposition tube graft
• fluid & blood resuscitation• ICU post-op
Bifurcated TubeGraft forAAA Repair
Abdominal Trauma
Principles of the Initial Assessment
• ATLS®
• Airway, Breathing, Circulation
• prioritizing life-threatening injuries• assessment & resuscitation simultaneous
Abdominal Trauma
Purpose of Diagnostic Work-up
• most important decision is to determine
whether or not the patient requires an
emergent laparotomy
Diagnosis of Abdominal Trauma
• history & physical exam• FAST (Focused Assessment with
Sonography for Trauma)• CT scan• DPL (diagnostic peritoneal lavage)
Diagnostic Test of Choice ?
• ALL PATIENTS FAST
If FAST is not available, then in general:• unstable patients DPL• stable patients CT scan
FAST ( Trauma Ultrasound )Advantages• portable• inexpensive• rapid assessment• can be easily repeated during work-up• accurate for the presence of
intraperitoneal free fluid• can be performed by trained non-
radiologist
Look for free fluid
in 4 places:• perihepatic• perisplenic• pelvis• pericardium
FAST Technique
CT Scan
• hemodynamically stable patients only• very specific and sensitive for solid
organs• quantify / grade severity of organ injury• contrast extravasation (implications)• CT scan not needed if indication for
laparotomy exists• may miss bowel injury, ruptured
diaphragm
DPL
• sensitive for presence of intraperitoneal
blood• open or closed technique• positive = gross blood
red cell count > 100,000/mm3
• rarely used in blunt trauma if FAST available
Approach to Penetrating Abdominal Trauma
Categorization of the anatomical site of injury:
• stab wound to anterior abdomen• GSW to anterior abdomen• thoracoabdominal penetrating trauma• tangential GSW• back & flank penetrating trauma• transpelvic GSW
Stab Wound to Abdomen
Anatomy (anterior abdomen)• costal margin• anterior axillary line• inguinal ligament
Stab Wound to Abdomen
Indications for laparotomy• hemodynamic instability• peritonitis• blood in NG, foley, rectal exam• evisceration• retained stabbing implement• positive FAST or DPL (100,000 RBCs)
Management of GSW abdomen
• ABC• IV lines above & below diaphragm• log roll early to find all bullet wounds• plain film X-rays to localize bullets• determine need for surgery• tetanus / antibiotics• communicate with blood bank
GSW Abdomen - Indications for Laparotomy
• hemodynamic instability• peritonitis• path of bullet• blood in foley, NG, rectal exam• pneumoperitoneum• evisceration• positive FAST or DPL (RBC count >
5,000)
Summary
• history & physical exam of acute abdominal
conditions• diagnostic tests• resuscitation• surgical treatment
Red Herrings
• Nerve root impingement
Red Herrings
• Herpes Zoster