The Acute Abdomen

Yingda Li6th Oct, 2011

Royal Melbourne Hospital

Objectives

1. Develop a rational approach to assessing and managing the acute abdomen

2. Identify ‘red flags’ on history and examination

3. Have a set of ‘rules’ as safety nets

4. Familiarise with style of questions commonly asked in exams

Overview

Definitions

History Examination Investigations Management

Multiple choice questions

Definitions

Pain Acute Severe Requiring urgent attention

Not always surgical Not always abdominal source

Rule 1. Epigastric pain

may be from supra-

diaphragmatic source

History

Demographics

Tempo Site, radiation Quality Associated symptoms

Risk factors Previous surgery Gynaecological history

AMPLE

Rule 2. Women of

childbearing age are

pregnant till proved

otherwise

Rule 3. Never underestimate

abdominal pain in the

elderly

Rule 4. Sudden onset pain equals perforation, vascular or

torsion Rule 5. Vomiting is a

key associated symptom

Red flags

Examination 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

Rule 7. Is there

peritonism, is there a hernia and is there a

AAA?

Rule 6. Vital signs are vital

Do not hurt

the patient!

Investigations

Laboratory

Radiology

DiagnosticPancreatic enzymes,

cardiac enzymesMSU

XR, USS, CT, MRLaparoscopy,

ERCP

SupportiveInflammatory

markersUEC, LFTs

Lactate

PrognosticCRP, platelets, clotting profile

CTCriteria

PreoperativeGroup and

screenCrossmatch

Management

ResuscitationAirwayBreathingCirculation

General measuresNBM, IV fluids, analgesia, antiemesisNGT, IDCSerial examination

Specific measuresAntibioticsOpen surgery, laparoscopyERCP, image-guided percutaneous drainage, sigmoidoscopic decompression, angioembolisation

MCQs

1. Hepatitis serology2. Upper abdominal

ultrasound3. Full blood examination4. ERCP5. Liver biopsy

A. CT kidney, ureter and bladderB. Ultrasound renal tractC. 24-hour urinary calcium excretionD. Plain X-ray kidney, ureter and bladderE. Mid-stream urine for phase microscopy