Acute Abdomen.pdf

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...

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. ACUTE ABDOMEN Essential to be able to recognise an acute abdomen It is essential to understand that resuscitation & initial medical treatment is vitally important in the outcome (morbidity & mortality) Many patients will require surgery … …but … …conservative management is best for many acute conditions 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. TAKING A MEDICAL HISTORY Understanding of pain is extremely important Onset - Did pain come on suddenly or gradually/rapidly – Sudden – perforation – Gradual/Rapid – inflammation Location - Where do you have pain? Ask the patient to point to the site of pain – or draw a circle around it [the size of the circle can be helpful] Abdominal pain locations may not correlate well with source as it may be referred pain. Character - What does pain feel like? Constant pain – likely inflammatory process Colicky pain – likely obstructive process Department of Surgery, RCSI. HISTORY OF PRESENTING COMPLAINT – MOST FREQUENTLY - PAIN Was the onset of pain gradual or sudden? Sudden = perforation / haemorrhage / infarct Gradual = peritoneal irritation / hollow organ distension (e.g. bowel obstruction) Exacerbating or relieving factors SOCRATES S=Site; O=Onset C=Character R=Radiation A=Associted symptoms T=Timing E=Exacerbating or Relieving factors S=Severity Department of Surgery, RCSI. NATURE / CHARACTER OF PAIN Colicky Pain – obstruction of a muscular viscous Constant pain caused by inflammation. Pain often made worse by movement or coughing 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, was there blood in first vomit ? “Coffee Grounds”? Change in bowel habits, Melaena? Change in urinary habits, Urine appearance? Department of Surgery, RCSI. REST OF THE MEDICAL HISTORY Past Medical History – 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 previous incisions/scars 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. PANCREATITIS Causes: Ethanol & Gallstones + others Nausea, vomiting; abdominal tenderness; constant epigastric pain radiating from upper abdomen straight through to back Department of Surgery, RCSI. PEPTIC ULCER DISEASE Steady, well-localized epigastric pain – relieved by eating (DU) – precipitated by food (GU) “Burning”, “gnawing”, “aching” Increased by coffee, stress, spicy food, smoking Decreased by alkaline food, antacids, milk PEPTIC ULCER DISEASE May cause massive GI bleed Perforation = intense, steady pain, pt lies still, rigid abdomen Department of Surgery, RCSI. PERFORATED DUODENAL /GASTRIC ULCER Pain - Sudden onset, epigastric Tenderness, Guarding, Rigidity Abdomen silent on auscultation X-Ray - Erect Chest Perf DU – Early APPENDICITIS Appendix becomes inflamed, gangrenous, possibly perforated Usually – faecolith obstruction Hy. Pain begins periumbilical; moves to RIF Anorexia, Nausea, vomiting, Examination. Tender, guarding, rebound RIF Low grade pyrexia Department of Surgery, RCSI. 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; – Vomiting - nausea, – abdominal distension, – Constipation Bowel sounds increased if mechanical or decreased if ileus Imaging BOWEL OBSTRUCTION Department of Surgery, RCSI. 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. 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. REMEMBER ! Recognize acute abdomen is present Produce a Differential Diagnosis – Be aware of Surgical & Medical DDx Investigate as appropriate Start with ABCDE principals Analgesia This is merely an introduction to the acute abdomen Department of Surgery, RCSI.