A Cute AbdomenA Cute Abdomen

GoalGoal

notnot exact diagnosis exact diagnosis but that a surgical condition existsbut that a surgical condition exists

““The general rule can be The general rule can be laid down that the laid down that the majority of severe majority of severe abdominal pains that abdominal pains that ensue in patients who ensue in patients who have been previously have been previously fairly well, and that last fairly well, and that last as long as six hours, are as long as six hours, are caused by conditions of caused by conditions of surgical import.”surgical import.”

Silen W: Cope’s Early Diagnosis of the Acute Abdomen. 1996,p.6.

Diagnose EarlyDiagnose Early

• Better outcomeBetter outcome

• Pain relief (narcotics)Pain relief (narcotics)

• AntibioticsAntibiotics

HistoryHistory• AgeAge• Onset - Onset - how long ago how long ago

sudden or gradualsudden or gradual• Distribution - Distribution - area of maximal painarea of maximal pain

localizationlocalizationradiationradiation

• Character - Character - sharp or dull, burning,sharp or dull, burning,steady or crampingsteady or cramping

HistoryHistory• Nausea, vomiting, anorexiaNausea, vomiting, anorexia• Diarrhea, constipation, flatus, blood, tenesmusDiarrhea, constipation, flatus, blood, tenesmus• Menstruation - where in the cycleMenstruation - where in the cycle

sexual activitysexual activity• Previous episodes - Previous episodes -

relationship to meals:relationship to meals:

2 - 2 2 - 2 11//22 hrs = duodenal hrs = duodenalworse with food = gastricworse with food = gastric

fatty foods = gallstonesfatty foods = gallstonesweight loss?weight loss?

VomitingVomiting• Relationship to pain Relationship to pain

appendicitis - pain precedes vomitingappendicitis - pain precedes vomitinggastroenteritis - vomiting precedes paingastroenteritis - vomiting precedes pain

• Character - Character - feculent vomiting pathognomonic of feculent vomiting pathognomonic of obstruction of distal small intestine, rare in obstruction of distal small intestine, rare in colonic obstructioncolonic obstruction

Physical ExaminationPhysical Examination• General appearance -General appearance -

restlessness = colicrestlessness = colic immobility immobility with knees flexed = peritonitiswith knees flexed = peritonitis

• Blood pressureBlood pressure• Pulse - Pulse - “too optimistic a friend to be relied upon…”“too optimistic a friend to be relied upon…”• Respiratory rate - may suggest a thoracic originRespiratory rate - may suggest a thoracic origin• Temperature - could be normal, high or lowTemperature - could be normal, high or low

> 104> 104ooF (40F (40ooC) suggests thorax or kidneyC) suggests thorax or kidney

Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996,p.32.

PE: ChestPE: Chest

• InspectionInspection

• PalpationPalpation

• PercussionPercussion

• AuscultationAuscultation

PE: AbdomenPE: Abdomen• Inspection - distention, herniasInspection - distention, hernias

DON”T FORGET THE FEMORAL DON”T FORGET THE FEMORAL CANALCANAL

• Auscultation Auscultation • Palpation -Palpation -

rigidityrigidity area area of greatest pain lastof greatest pain last

• Percussion - “rebound”, cough tendernessPercussion - “rebound”, cough tendernessRosving’s signRosving’s sign

Levien: Intro to Surg 1987, p.41.

PE: AbdomenPE: Abdomen

““of all the modalities of physical diagnosis of all the modalities of physical diagnosis of the abdomen, auscultation is one of of the abdomen, auscultation is one of the least valuable and most misleading.”the least valuable and most misleading.”

Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996,p.43.

PE: PelvisPE: Pelvis

• Pelvic examination -Pelvic examination -bimanualbimanual

• Rectal examination -Rectal examination -mass, tenderness, mass, tenderness,

bloodblood

““Overreliance on laboratory tests and Overreliance on laboratory tests and radiological evaluations will very often radiological evaluations will very often mislead the clinician, especially if the mislead the clinician, especially if the history and physical examination are history and physical examination are less than diligent and complete.”less than diligent and complete.”

Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996,p.57.

Laboratory TestsLaboratory Tests• CBC - leukocytosis, anemiaCBC - leukocytosis, anemia

• Urinalysis - infection, blood, pregnancyUrinalysis - infection, blood, pregnancy

• Electrolytes - renal function, dehydrationElectrolytes - renal function, dehydration

• Amylase, lipaseAmylase, lipase

• LFTsLFTs

Radiographic StudiesRadiographic Studies• Flat & upright abdomen - Flat & upright abdomen -

air-fluid levels, distended loops, edema air-fluid levels, distended loops, edema in bowel wall, volvulus, fecolithin bowel wall, volvulus, fecolith

• CXR - free air, lower lobe pneumoniaCXR - free air, lower lobe pneumonia

• Contrast studies - Contrast studies - HH22O soluble if perforationO soluble if perforation

disadvantage - aspiration, qualitydisadvantage - aspiration, quality

AppendicitisAppendicitis

• FecolithFecolith• YoungYoung

1. Dull pain in midepigastrium1. Dull pain in midepigastrium

2. Nausea/vomiting 2. Nausea/vomiting followsfollows painpain

3. Localizes to RLQ3. Localizes to RLQ

* * AnorexiaAnorexia

++ Fever Fever• LeukocytosisLeukocytosis

Reginald H. Fitz1843 - 1913

McBurney C: McBurney C: NY State Med JNY State Med J 1889;50,676-684. 1889;50,676-684.McBurney C: McBurney C: Ann Surg Ann Surg 1894;20,38-43.1894;20,38-43.

McBurney’s IncisionMcBurney’s Incision

Graham RR: Surg Gynecol Obstet 1937;64,235-238.

Perforated UlcerPerforated Ulcer• Sudden onsetSudden onset• Previous episodes of Previous episodes of

pain ~ 2 hrs after pain ~ 2 hrs after eatingeating

• CXR - free airCXR - free air

PancreatitisPancreatitis• AlcoholAlcohol

• GallstonesGallstones

• TraumaTrauma

• HyperlipidemiaHyperlipidemia

• HyperparathyroidismHyperparathyroidism

• Drugs - thiazide diureticsDrugs - thiazide diuretics

• Unknown (10%)Unknown (10%)

PancreatitisPancreatitis• Excruciating painExcruciating pain

• Fever - almost alwaysFever - almost always

• Ranson’s criteriaRanson’s criteria

• Grey Turner signGrey Turner sign

• Cullen’s signCullen’s sign

Cullen TS: Cullen TS: Am J ObstetAm J Obstet 1918;78(Sept),457. 1918;78(Sept),457.Turner GG: Turner GG: Brit J SurgBrit J Surg 1920;7(Jan),394-395. 1920;7(Jan),394-395.

Ranson’s CriteriaRanson’s CriteriaAdmissionAdmission

1. Age > 551. Age > 55

2. WBC > 16,000/mm2. WBC > 16,000/mm33

3. Glucose > 200 mg/100 ml3. Glucose > 200 mg/100 ml

4. LDH > 350 I.U./L4. LDH > 350 I.U./L

5. SGOT > 250 Frankel units %5. SGOT > 250 Frankel units %

During Initial 48 HoursDuring Initial 48 Hours1. Hematocrit fall > 10%1. Hematocrit fall > 10%

2. BUN rise > 5%/mg/100 ml2. BUN rise > 5%/mg/100 ml

3. Ca3. Ca++++ < 8 mg/100 ml < 8 mg/100 ml

4. Arterial pO2 < 60 mmHg4. Arterial pO2 < 60 mmHg

5. Base Deficit > 4 meq/L5. Base Deficit > 4 meq/L

6. Fluid sequestration > 6 L6. Fluid sequestration > 6 L

Ranson et al: Ranson et al: Surg Gynecol ObstetSurg Gynecol Obstet 1974;139,69. 1974;139,69.

AmylaseAmylase• PancreatitisPancreatitis• CholecystitisCholecystitis• High intestinal High intestinal

obstructionobstruction• Acute renal insufficiencyAcute renal insufficiency• Perforated ulcerPerforated ulcer• & others& others

CholecystitisCholecystitis

• Radiopaque gallstones (10-15%)Radiopaque gallstones (10-15%)

• Pain - RUQ, “colic”, radiates to the Pain - RUQ, “colic”, radiates to the ipsalateral ipsalateral scapulascapula

• Pain brought on with fatty foodsPain brought on with fatty foods

• US - stones, thickening, fluid, air in wallUS - stones, thickening, fluid, air in wall

Intestinal Intestinal ObstructionObstruction

• pain - colicpain - colic

• Vomiting, distentionVomiting, distention

• ObstipationObstipation

• Auscultation - quiet to high-pitched, tinkling Auscultation - quiet to high-pitched, tinkling rushes to borborygmirushes to borborygmi

• X-ray - air-fluid levels, fixed loopsX-ray - air-fluid levels, fixed loops

Small Bowel ObstructionSmall Bowel Obstruction

1. Adhesions (74%)1. Adhesions (74%)11//22 2 2oo to gynecologic or colonic operations to gynecologic or colonic operations

2. Neoplasm (8.6%)2. Neoplasm (8.6%)

3. Hernias (8.1%)3. Hernias (8.1%) most most common cause in childrencommon cause in children

• Inflammatory bowel disease (5.2%)Inflammatory bowel disease (5.2%)• Gallstone ileus, radiation enteritis, intussusceptionGallstone ileus, radiation enteritis, intussusception• UnknownUnknown

Bizer et al: Bizer et al: SurgerySurgery 1981;89,407-413. 1981;89,407-413.

Adynamic IleusAdynamic Ileus

• 22oo to general peritonitis, severe chest injuries, after to general peritonitis, severe chest injuries, after myocardial infarction, pneumonia, operations on the myocardial infarction, pneumonia, operations on the spine or abdomen, or narcoticsspine or abdomen, or narcotics

• Auscultation - quiet, no borborygmiAuscultation - quiet, no borborygmi• Involves both small & large bowelInvolves both small & large bowel• Gaseous distention of both small & large bowel Gaseous distention of both small & large bowel

Large Bowel Large Bowel ObstructionObstruction

1. Cancer (70%)1. Cancer (70%)

2. Volvulus (10%)2. Volvulus (10%)

3. Diverticulitis (5%)3. Diverticulitis (5%)• Intussusception, uremiaIntussusception, uremia

VolvulusVolvulus• Sigmoid (most common)Sigmoid (most common)• IleocecalIleocecal• Transverse (rare)Transverse (rare)• Barium enema is diagnostic Barium enema is diagnostic

& often therapeutic& often therapeutic• Sigmoidoscopy - alternative Sigmoidoscopy - alternative

diagnostic & therapeutic diagnostic & therapeutic modalitymodality

“bent inner tube sign”

DiverticulitisDiverticulitis• LLQ painLLQ pain

• Fever, leukocytosisFever, leukocytosis

• CT scan - pericolic abscessCT scan - pericolic abscess

• Antibiotics, NPO, NG decompressionAntibiotics, NPO, NG decompression

• Operation for persistent symptoms (7 days) Operation for persistent symptoms (7 days) or recurrent episodesor recurrent episodes

HerniasHernias• Indirect inguinal most common in both males Indirect inguinal most common in both males

& females& females

• Femoral is more common in femalesFemoral is more common in females

• Direct inguinal, umbilical, ventral, incisional, Direct inguinal, umbilical, ventral, incisional, Spigelian, Richter’s, lumbar, obturator, etc.Spigelian, Richter’s, lumbar, obturator, etc.

Renal ColicRenal Colic

• Radiopaque ureteral calculus (85-90%)Radiopaque ureteral calculus (85-90%)• Pain radiating to the testicle or vulvaPain radiating to the testicle or vulva• VomitingVomiting• Microscopic hematuriaMicroscopic hematuria

Female DisordersFemale Disorders• Ectopic pregnancy, PID, mittelschmerz, Ectopic pregnancy, PID, mittelschmerz,

appendicitisappendicitis

• Chandelier signChandelier sign

• UrinalysisUrinalysis

• UltrasoundUltrasound

• LaparoscopyLaparoscopy

Mesenteric Vascular Mesenteric Vascular Occlusion Occlusion

• Pain out of proportion to physical examinationPain out of proportion to physical examination• Risk factors - atrial fibrillation, digitalis, diuretics, Risk factors - atrial fibrillation, digitalis, diuretics,

cardiopulmonary bypasscardiopulmonary bypass• Barium enema may show “thumbprinting”Barium enema may show “thumbprinting”• Angiography, MRIAngiography, MRI• Mortality = 50%Mortality = 50%

SummarySummary

notnot exact diagnosis exact diagnosis but that a surgical condition existsbut that a surgical condition exists