02 The acute abdomen.pdf

Surgery II MD 420 Coordinator: Dimitrios Ntourakis MD, PhD, FACS The Acute Abdomen Surgery II MD420 Dimitrios Ntourakis MD, PhD, FACS Objectives 1 2 3 4 Describe the acute abdomen syndromes Define the diagnostic procedure Explore the differential diagnosis and identify patients in need of surgical t...

Surgery II MD 420 Coordinator: Dimitrios Ntourakis MD, PhD, FACS The Acute Abdomen Surgery II MD420 Dimitrios Ntourakis MD, PhD, FACS Objectives 1 2 3 4 Describe the acute abdomen syndromes Define the diagnostic procedure Explore the differential diagnosis and identify patients in need of surgical treatment Discuss the preoperative management Introduction No previous injury Acute abdomen:  sudden spontaneous abdominal pain  from a non-traumatic disorder  may require surgical treatment Subjective Objective Assessment & Plan = SOAP Introduction S O  History and physical examination for differential diagnoses  Laboratory and radiological studies confirm the diagnosis A P  Decision between: additional tests, medical treatment, early surgical treatment Gastrointestinal tract Common causes of acute abdomen These are mostly emergency that need to be properly identified Nonspecific abdominal pain Appendicitis Bowel obstruction Perforated peptic ulcer Diverticulitis Hepatobiliary and pancreas Acute cholecystitis Acute pancreatitis Urinary system Ureteral or renal colic Gynecologic Acute salpingitis Ruptured ectopic pregnancy Cardiovascular Myocardial infarction Inferior surface Abdominal aneurysm rupture History of presenting complaint  Abdominal pain  Location of pain  Mode of onset and progression  Character  Other associated symptoms S O C R A T E S O P Q R S T Can be numeric or w/ a ruler Location of pain  Visceral pain  By afferent C fibers No receptors for heat, pain or pressure, if bowels are cut. Pain will arrive peritonitis but not as the cut of the bowels  Response to distention, inflammation or ischemia  Not well localized, dull slow in onset, in the midline  Levels of pain  Epigastrium: SDHP stomach, duodenum, hepatobiliary, pancreas  Umbilical region: JIACKAo jejunum, ileum, appendix, cecum, kidneys, aorta  Hypogastrium: CRIr colon, rectum, internal reproductive organs Location of pain  Parietal pain  By C and A delta fibers  Acute, sharp, better localized pain  Direct irritation of the parietal peritoneum (T6-L1) Innerveted by the intercostal nerves Location of pain Pain in another anatomic region  Referred pain  Subdiaphragmatic lesions => shoulder  Retroperitoneal lesions => back or flank What nerve innvert the area ? => 2K Location of pain DEFINITION => Visceral pain => Parietal pain  Shifting pain  Acute cholecystitis: epigastrium => right shoulder  Acute appendicitis: peri-umbilical => right iliac fossa Fom the side, through the paracolic gater (?)  Perforated peptic ulcer: epigastrium => right iliac fossa Mode and onset of pain Abrupt excruciating pain:  Myocardial infarction  Perforated ulcer  Biliary colic Px will not stand still  Ruptured abdominal aneurysm  Ureteral colic Px will not stand still Mode and onset of pain  Rapid onset of severe constant pain  Acute pancreatitis  Mesenteric thrombosis / bowel strangulation  Ectopic pregnancy rupture  Gradual steady pain  Acute cholecystitis, acute cholangitis, acute hepatitis  Acute appendicitis  Diverticulitis Other associated symptoms If pain then vomiting => colic pain If vomiting then pain => cannot specify, investigate more  Nausea / Vomiting  Pain usually proceeds vomiting  Constipation / obstipation  Paralytic ileus  Diarrhea  Blood stained diarrhea (UC, Crohn’s, dysentery, ischemic colitis)  Rectal bleeding, melena, hematemesis  Jaundice  Hematuria Gynecological history Menstrual cycle Dysmenorrhea Past history Drug history Anticoagulants NSAIDs Oral contraceptives Corticosteroids Family history Travel history Operative history Emergency Setting If you feel the patient is critical S A M P L E Symptoms & Signs Allergies Medication Past medical history Last Meal (last menstruation) Events leading to  In acute care setting  Paired with ABCDE Physical examination Initial assessment  General observation:  calm, writhing (colic)  rigidly motionless (peritonitis)  Vital signs: HR, BP, RR, SpO2, T  Systemic signs: pallor, sweating, jaundice Physical examination Abdominal examination  Inspection  Auscultation  Percussion / coughing to elicit pain  Palpation  Guarding  Tenderness  Abdominal masses  Inguinal and femoral ring examination  Rectal examination  Pelvic examination Physical examination Abdominal examination  Inspection  Auscultation  Percussion / coughing to elicit pain  Palpation  Guarding  Tenderness  Abdominal masses  Inguinal and femoral ring examination Physical examination Abdominal examination  Rectal examination  Pelvic examination Physical examination Signs:  Mc Burney sign  Murphy sign Inflammation of gallbladder. Px during inspiration won’t be able to take a full breath  Iliopsoas sign  Obturator sign  Giordanno sign = punch tenderness (Costovertebral angle tenderness) Physical findings By pathology Perforation Bleeding Strangulation Peritonitis Acute Abdomen Intestinal ischemia Abscess Inflammation Intestinal obstruction Physical findings If perforation => peritonitis. Except if retroperitoneal Gastrointestinal perforation => peritonitis Condition Physical finding Perforation Abdominal guarding / rigidity Rebound tenderness Distention / loss of liver dullness Diminished bowel sounds Abscess Palpable tender mass Punch tenderness Physical findings Prolonged obstruction => bowel paralysis Condition Physical finding Intestinal obstruction Intestinal px w/ obstruction(late), but no bowel abdominal distention Distention, hyperperistaltism => quietIf abdomen sounds, it’s very bad as it means the hyperperistaltism => quiet abdomen (late) diffuse colicky pain without rebound tenderness diffuse colicky pain without rebound tenderness bowel is about to rupture obstruction Paralytic ileus Paralytic ileus Distention, minimal bowel sounds, no localized abdominal distention hypoperistaltism tenderness Secondary to other pathology Physical findings If bowel necrosis and it is not identifiied, px will die of it Condition Physical finding Intestinal ischemia / strangulation severe pain with little tenderness peritoneal signs (when necrosis) obstruction signs (late) If constipated, stoll will not pass here Px w/ hernia or ischemie will come w/ severe pain but little findings. Physical findings Condition Physical finding Bleeding pallor Hypovolemia - hypoxia cold clammy extremities shock palpable mass (aneurysm) rectal bleeding Blood loss distention (hemoperitoneum) Laboratory studies  Blood:  Complete blood count  Serum electrolytes, urea, creatinine  Serum amylase / lipase  Liver function test  Hemostasis tests  Blood group & cross-matching  Arterial blood gasses Laboratory studies  Urine tests:  Concentrated urine (SG)  Hyperbilinuria  Microscopic hematuria / pyuria  Pregnancy test  Stool tests:  occult fecal blood  Smear and culture Imaging studies  Erect chest X-ray (pneumoperitoneum)  (Plain abdominal X-ray)  Ultrasonography  Acute appendicitis  Liver and biliary pathologies  Gynecological pathologies Imaging studies  CT scan  Routine exam in patients not clearly indicated for surgery  Gastrointestinal contrast studies  With water soluble contrast (Gastrographin) Other studies  Endoscopy  Rectosigmoidoscopy  Gastroscopy  Paracentecis  Peritoneal lavage (blood, bile, bowel content)  Laparoscopy  Diagnostic & therapeutic Differential diagnosis Most frequent pathologies Older patients acute cholecystitis Children acute appendicitis Most misdiagnosed acute appendicitis Young women Non-specific abdominal pain + salpingitis undiagnosed bacterial or viral infections dysmenorrhea appendicitis intestinal obstruction acute intestinal ischemia ovarian cyst complication non-specific abdominal pain intestinal obstruction urinary tract infections ectopic pregnancy irritable bowel syndrome abdominal wall pain psychosomatic pain Medical (non surgical) causes of acute abdomen No emergency surgery Toxins & drugs Endocrine and metabolic uremia diabetic crisis Addisonian crisis acute intermittent porphyria hereditary Mediterranean fever lead poisoning narcotic withdrawal Infections & inflammatory tabes dorsalis herpes zoster Henoch-Schonlein purpura systemic lupus erythematosus polyarteritis nodosa Hematologic Referred pain sickle cell crisis acute leukemia myocardial infarction pneumonia pulmonary embolism Definitive surgical treatment => Emergency surgical treatment Pathology  Acute appendicitis  Acute cholecystitis  Intestinal occlusion  Perforation  Meckel’s diverticulitis  Complicated diverticulitis  Ruptured ectopic pregnancy  Intra-abdominal abscess  Acute intestinal ischemia  Ruptured aortic aneurysm NEED TO BE OPERATED Can cause peritonitis Definitive surgical treatment => Emergency surgical treatment  Clinical findings:  Generalized peritonitis  Abdominal findings with patient in septic shock, hemorrhagic shock, suspicion of intestinal ischemia  Radiological findings:  Pneumoperitoneum  Acute mesenteric ischemia  Extravasation of contrast  Endoscopic findings:  Perforation  Uncontrollable bleeding Preoperative management  Initial assessment - ABCDE  Parenteral analgesics (titration)  Fasting for probable surgery  Administer only essential drugs (insulin, cortisol, cardiac drugs)  Consider nasogastric tube  Consider urinary catheter  Informed consent Questions Summary About 80% of diagnosis is clinical  Acute abdomen is a sudden spontaneous abdominal pain from a nontraumatic disorder that may require surgical treatment.  History and physical examination focus on the characteristics of pain and accompanying symptoms. Then laboratory and radiological tests are undertaken to confirm the diagnosis.  The most usual pathologies responsible for the acute abdomen are acute cholecystitis, appendicitis, intestinal obstruction, acute intestinal ischemia and non-specific abdominal pain.  Medical conditions not requiring surgical treatment may mimic acute abdomen.