Acute Abdomen - An Introduction PDF - RCSI - 2023/2024

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Title Acute Abdomen – An Introduction Prof TN Walsh Class Year 2 Course Surgery Year 2023/2024  LEARNING OUTCOMES Define an “acute abdomen” List the common causes of an acute abdo...

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Title Acute Abdomen – An Introduction Prof TN Walsh Class Year 2 Course Surgery Year 2023/2024  LEARNING OUTCOMES Define an “acute abdomen” List the common causes of an acute abdomen Be able to elicit the salient features in the history Be able to Examine an acute abdomen Construct a differential diagnosis Discuss best investigations based on the history Suggest a management plan Department of Surgery, RCSI.  ACUTE ABDOMEN A group of potentially life threatening intra-abdominal conditions that require emergency treatment & intervention Peritonitis - General name for “presence of symptoms & signs of inflammation of peritoneum” Department of Surgery, RCSI.  CAUSES Perforation: Inflammatory: Perforated Peptic Ulcer Acute Appendicitis Ruptured AAA Acute Diverticulitis Perforated bowel Acute Pancreatitis Perforated bladder Acute Cholecystitis Ischaemia / Other: Obstructive: Acute Bowel Ischaemia Small Bowel Obstruction Mesenteric ischaemia Large Bowel Obstruction Torsion Intussusception Gynaecological Emergencies Department of Surgery, RCSI.  ACUTE ABDOMEN Essential to be able to recognise an acute abdomen Understand that resuscitation & initial medical treatment decides the outcome (morbidity & mortality) Essential to understand role of Triage Many patients will require surgery … …but … …conservative management is best for many acute conditions Department of Surgery, RCSI.  TAKING A MEDICAL HISTORY Understanding of pain is extremely important Onset - Did pain come on suddenly or gradually/rapidly – Sudden – perforation – Gradual/Rapid – inflammation Character - What does pain feel like? Constant pain – likely inflammatory process Colicky pain – likely obstructive process Location - Where do you have pain? Ask the patient to draw a circle around it [the size of the circle also helpful] Referral – Many pain have specific referral location patterns Department of Surgery, RCSI.  SOCRATES - MNEMONIC S = Site; O = Onset C = Character R = Radiation A = Associated symptoms T = Timing E = Exacerbating or Relieving factors S = Severity Department of Surgery, RCSI. NATURE / CHARACTER OF PAIN Colicky Pain – obstruction of a muscular viscus Constant pain – usually due to inflammation. If pain exacerbated by movement or coughing- parietal peritoneum involved = “peritonitis” Constant pain of sudden onset typical of a perforation  RADIATION OF PAIN Does pain radiate (travel) anywhere? ✓ Right shoulder = gallbladder (Collin’s sign) ✓ Around flank to groin = kidney/ureter ✓ Appendix pain starts centrally, then goes to RIF ✓ Back - AAA, PUD, pancreatitis (Pain in back or flank in a male > 50 should be considered an AAA until proven otherwise) Department of Surgery, RCSI.  HISTORY OF OTHER PRESENTING COMPLAINTS Anorexia… Nausea… Vomiting… Hematemesis, or “Coffee Grounds”? Was there blood in first vomit ? If not – Mallory Weiss Change in bowel habits, Melaena? Change in urinary habits - Urine appearance and smell? Department of Surgery, RCSI. REST OF THE MEDICAL HISTORY Past Medical History female-sign2 – Any previous medical / surgical history – Any previous abdominal operations Menstrual History – Last menstrual period? Regular / Irregular – OCP? Abnormal bleeding/ discharge? Drug history Allergies Family History Social History - Occupation, Accomodation; Smoking; – Alcohol, Drugs etc Systems Review – Sweep through all systems as patients may forget REGIONS OF THE ABDOMEN PHYSICAL EXAM Vital signs (HR, BP, RR, Temp, O2 Sats, Urinary output) ABCDE Inspection – Note incisions, scars, movement Palpation - Superficial – Note tenderness, guarding (involuntary), rebound, rigidity – Work toward area of pain Palpation – Deep – Masses, Liver, Spleen, AAA Percussion – Organs or fluid Auscultation – Ileus or enteritis Groins + external genitalia Rectal examination WORKUP Bedside Laboratory Investigations Imaging Investigations History & FBC (esp White cell count) Erect CXR Examination ECG C-reactive protein (CRP) Abdominal X-ray Erect and Supine Abdomen Urine dipstick & ABG/VBG (lactate) & repeat if Ultrasound abdomen Beta HCG abnormal Glucose check Kidney function tests & Serum CT Abdomen & Pelvis electrolytes LFT’s, serum amylase/lipase MRI Abdomen & Pelvis Coagulation profile ERCP Interventional Radiology UNIVERSAL MANAGEMENT PLAN Admit Airway, Breathing, Circulation, Disability, Exposure Oxygen – if in doubt - until blood gasses (ABG) available IV Fluids – 100ml/hour until losses known – Intake/output chart – ?urinary catheter Analgesia – opiates usually necessary but BEWARE… Anti-emetics - occasionally Antibiotics – Nobody will criticise you – Co-amoxiclav NPO +/- NG if vomiting Type and screen – if you think theatre might be necessary DVT prophylaxis – always Role of Surgery? Timing?  ACUTE CHOLECYSTITIS Inflammation of gallbladder Commonly associated with gallstones RUQ pain, nausea, vomiting,, Tenderness, guarding, fever, + Murphy’s sign Department of Surgery, RCSI. GALLBLADDER - NO INFLAMMATION SURGERY RELATIVELY EASY AND SAFE GALLBLADDER: INFLAMMATION – 1-3 DAYS SURGERY MORE DIFFICULT BUT USUALLY SAFE Gallbladder: Inflammation 4-6 days Surgery can be much more difficult and dangerous Inflammation 6 days to 6 weeks Surgery very difficult and dangerous Gallbladder Inflammation at 3 months Surgery straightforward and safe again  PANCREATITIS Causes: Ethanol & Gallstones + others Digestion of the pancreatic acini and release of digestive enzymes and cytokines throughout the body Constant epigastric pain – band-like, radiating straight through to back Relieved by bending forward Nausea, vomiting; Abdominal tenderness Needs fluid and O2 Department of Surgery, RCSI.  PANCREATITIS Complications – Systemic - Organ failure – Local – Necrosis, abscess, collections of fluid Prognosis – Prognostic Score – P PaO2 < 60 mmHg – A Age > 55 years – N Neutrophils > 15x10ꝰ – C Calcium < 2mmol/l – R Raised Urea > 16mmol/l – E Enzyme (LDH) > 600units/l – A Albumen > 32mmol/l – S Sugar > 10mmol/l “ These identify evidence of organ failure: >3 = Severe pancreatitis Pancreatitis - Early PEPTIC ULCER DISEASE Epigastric pain – relieved by eating (DU) – precipitated by food (GU) “Burning”, “gnawing”, “aching” Increased by coffee, stress, spicy food, smoking Improved by alkaline food, antacids, milk  PEPTIC ULCER DISEASEM - COMPLICATIONS GI bleed Perforation = intense, steady pain, pt lies still, rigid abdomen Department of Surgery, RCSI. BLEEDING DU PERFORATED DUODENAL /GASTRIC ULCER Pain - Sudden onset, epigastric Tenderness, Guarding, Rigidity Abdomen silent on auscultation X-Ray - Erect Chest – Air under diaphragm Perf DU – Early Perf DU - late  APPENDICITIS Appendix becomes inflamed, gangrenous, possibly perforated Usually – faecolith obstruction Hy. Pain begins in periumbilical area - moves to RIF Anorexia, Nausea, vomiting, Examination. Tender, guarding, rebound in RIF Low grade pyrexia Department of Surgery, RCSI. APPENDICECTOMY COMPLICATIONS OF ACUTE APPENDICITIS Perforation Appendix Mass – after 6 days Appendix Abscess – spiking temp Adhesions  BOWEL OBSTRUCTION Causes: adhesions, herniae, impactions, tumours Presentation – Abdominal pain - Crampy; – Abdominal distension, – Vomiting - nausea, - depending on level of obstruction – Constipation – again, depending on level of obstruction Bowel sounds ↑ if mechanical obstruction; and ↓ if ileus Imaging – Plain films – Erect and Supine Abdomen – CT Abdomen to identify lesion  BOWEL OBSTRUCTION Department of Surgery, RCSI. CT ABDOMEN CLINICAL CASE 38yo male p/w severe epigastric pain for last 5hrs What comes next?  ABDOMINAL AORTIC ANEURYSM Aneurysm - Localized weakness of blood vessel wall with dilation (like bubble on tire) AAA - Pulsating mass in abdomen Can cause lower back pain Rupture, shock, significant mortality Repair by open or Endovascular Department of Surgery, RCSI. ABDOMINAL AORTIC ANEURYSM  KIDNEY STONE Mineral deposits form in kidney, move to ureter Often associated with history of recent UTI Severe flank pain, radiates to groin & scrotum ("loin to groin") Nausea, vomiting (due to pain) Haematuria Extreme restlessness Department of Surgery, RCSI.  SUMMARY Recognize that a patient has an acute abdomen Construct a Differential Diagnosis – Be aware of Surgical & Medical DDx Plan appropriate Investigations Management based on ABCDE principals This introduction to the acute abdomen hopes to stimulate your further interest Department of Surgery, RCSI. ACUTE ABDOMEN Thank you Any questions?