acute abdomen - rccbcacute cholecystitis, biliary colic, acute hepatitis, duodenal ulcer, right...
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Acute AbdomenAcute Abdomen
Andreas M Andreas M KluftingerKluftinger MD FRCSCMD FRCSC
Kelowna General HospitalKelowna General Hospital
DisclosureDisclosure
• Hernia Advisory Panel
– Ethicon Johnson& Johnson
• Medical Director of Surgcial Weight Loss• Medical Director of Surgcial Weight Loss
– IQuest Healthcare and Fitness Centre
ObjectivesObjectives
• Understand the Pathophysiology and etiology of the acute abdomen
• Approch to acute abdomen in rural • Approch to acute abdomen in rural practice
• Case presentations
Stedman's Medical Dictionary Stedman's Medical Dictionary
27th Edition27th Edition
“any serious acute intra-abdominal condition attended by pain, tenderness, and muscular rigidity, and for which and muscular rigidity, and for which emergency surgery must be considered."
Acute Abdominal PainAcute Abdominal Pain
• 5-10 % of ER visits
• Complex “black box”
• Delays in diagnosis can increase morbidity
• Excessive consultations (+/- transport) and • Excessive consultations (+/- transport) and imaging can be costly and tax resources.
• Primary assessment and triage are key
History & PhysicalHistory & Physical
• Onset, nature, duration, location, radiation
• Aggravating and relieving factors
• Associated GI or GU symptoms
• Past history (Surg and Med)• Past history (Surg and Med)
• Review of Systems
• Full physical exam
Stereotypes of Pain Onset and Associated Pathology
•Sudden onset (full pain in seconds)
•Rapid onset(initial sensation to
full pain over
minutes or hours)
•Gradual onset
(hours)
•Perforated ulcer
•Mesenteric infarction
•Ruptured abdominal
aortic aneurysm
•Strangulated hernia
•Volvulus
•Intussusception
•Acute pancreatitis
•Appendicitis
•Strangulated hernia
•Chronic pancreatitis
•Peptic ulcer disease aortic aneurysm
•Ruptured ectopic
pregnancy
•Ovarian torsion or
ruptured cyst
•Pulmonary embolism
•Acute myocardial
infarction
•Acute pancreatitis
•Biliary colic
•Diverticulitis
•Ureteral and renal
colic
•Peptic ulcer disease
•Inflammatory bowel disease
•Mesenteric lymphadenitis
•Cystitis and urinary retention
•Salpingitis and prostatitis
Abdominal Abdominal InnervationInnervation
Simplified in ThirdsSimplified in Thirds
Embryologic Structures Nerves Arteries Pain Location
Foregut Esophagus,
stomach,3/4
duod,liver, gb
panc
Thoracic
splanchnics,
vagus
Coeliac Epigastrium
panc
Midgut ¼ duod to
splenic flexure
Thoracic
splanchnics,
vagus
SMA Periumbilical
Hindgut Left colon,
rectum, GU
tract
Pelvic
splanchnics,
lesser thoracic
splanchnics
IMA Hypogastrium
Possible Causes of Pain by Location
Location of Pain Associated Diseases
Right upper quadrant(liver, kidney, gallbladder)
Acute cholecystitis, biliary colic, acute hepatitis, duodenal ulcer, right lower lobe pneumonia
Right lower quadrant(ascending colon, appendix, ovary,
fallopian tube)
Appendicitis, cecal diverticulitis, ectopic pregnancy, tubo-ovarian abcess, ruptured ovarian cyst, ovarian torsion
Left upper quadrant(pancreas, spleen, kidney)
Gastritis, acute pancreatitis, splenic pathology, left lower lobe pneumonia
Left lower quadrant(sigmoid and descending colon,
ovary, fallopian tube)
Diverticulitis, ectopic pregnancy, tubo-ovarian abcess, ruptured ovarian cyst, ovarian torsion
Midline or periumbilical Appendicitis (early), gastroenteritis, mesenteric lymphadenitis, myocardial ischemia or infarction, pacreatitis
Flank Abdominal aortic aneurysm, renal colic, pyelonephritis
Front to back Acute pancreatitis, ruptured abdominal aortic aneurysm, retrocecalappendicitis, posterior duodenal ulcer
Suprapubic or lower abdominal Ectopic pregnancy, mittelschmerz, ruptured ovarian cyst, pelvic inflammatory disease, endometriosis, urinary tract infection
Sign Finding Association
Cullen's sign
Grey Turner’s sign
Bluish periumbilical
discoloration
Bluish flank discoloration
Retroperitoneal
hemorrhage
pancreatitis,
abdominal aortic
aneurysm rupture)
Kehr's sign Severe left shoulder pain Splenic rupture
Ectopic pregnancy
McBurney's sign Tenderness located 2/3 distance from
ASIS to umbilicus on right side
Appendicitis
Murphy's sign Abrupt interruption of inspiration on
palpation of right upper quadrant
Acute cholecystitis
Iliopsoas sign Hyperextension of right hip
causing abdominal pain
Appendicitis
Obturator's sign Internal rotation of flexed right hip
causing abdominal pain
Appendicitis
Chandelier sign Manipulation of cervix causes patient
to lift buttocks off table
Pelvic inflammatory
disease
Rovsing's sign Right lower quadrant pain with
palpation of the left lower quadrant
Appendicitis
Referred Pain
Structure Irritated Location of Referred Pain
Diaphragmatic Supraclavicular area (Kehr's sign)
Ureteral Hypogastrium, groin, inner thigh
Cardiac pain Epigastrum, jaw, shoulder
Appendix Periumbilical via T10 nerveAppendix Periumbilical via T10 nerve
Duodenum Umbilical region via greater thoracic
splanchnic nerve
Hiatal hernia Epigastrum via T7 and T8 nerves
Pancreas or gallbladder Epigastrum
Gallbladder and bile duct Epigastric pain that wraps around to the
scapula
Imaging for AppendicitisImaging for Appendicitis
Imaging AccuracyImaging Accuracy
in in
AppendicitisAppendicitis
Modality Sensitivity Specificity Pos PredValue Neg Pred ValueModality Sensitivity Specificity Pos PredValue Neg Pred Value
Plain Film 10% 90%
Ultrasound 85-90% 92-96% 95% 80-90%
CT 95-97% 95% 97% 95-100%
MRI 93% 91% 92% 100%
Laboratory in AppendicitisLaboratory in Appendicitis
Test Sensitivity Neg Pred Value
1. WBC >10.5 85%
2. Neutrophils >75% 78% 94%
3. C reactive protein 93-96%
1+2 96%
1+3 92.3%
1+2+3 99.2% (81% in children)
Urinalysis in AppendicitisUrinalysis in Appendicitis
• 30% of appendicitis patients have some urinary syptoms
• 14% have >10 WBC/hpf
• 18% have > 3 RBC/hpf• 18% have > 3 RBC/hpf
Imaging in PregnancyImaging in Pregnancy
• Ultrasound
– Safest
– Useful for fetal assessment (dates, viability,
placenta, amniotic fluid)placenta, amniotic fluid)
– NPV for appendicitis 80-90%
– PPV for appendicitis 95%
Imaging in PregnancyImaging in PregnancyProcedure Fetal Exposure
Chest radiograph (2 views) 0.02-0.07 mrad
Abdominal film (single view) 100 mrad
Intravenous pyelography >1 rad*
Hip film (single view) 200 mrad
Mammography 7-20 mrad
Barium enema or small bowel series 2-4 rad
CT (computed tomography) scan head
or chest
<1 rad
CT scan abdomen and lumbar spine 3.5 rad
CT pelvimetry 250 mrad
No evidence of teratogenesis or fetal loss if cumulative dose < 5 rads
Acute AbdomenAcute Abdomen
Caused by PregnancyCaused by Pregnancy
• Early pregnancy
– Ruptured ectopic pregnancy
– Septic abortion with peritonitis
– Acute urinary retention due to retroverted gravid uterus
– Torsion of the pregnant uterus
• Later pregnancy • Later pregnancy
– Red degeneration of myoma
– Torsion of pedunculated myoma
– Placental abruption, Placenta percreta
– HELLP (hemolysis, elevated liver function, and low platelets) syndrome
– Spontaneous rupture of the liver
– Uterine rupture
– Chorioamnionitis
Conditions Associated with Conditions Associated with PregnancyPregnancy
• Acute pyelonephritis
• Acute cystitis
• Acute cholecystitis
• Acute fatty liver of pregnancy • Acute fatty liver of pregnancy
• Rupture of rectus abdominis muscle
Case #1Case #1
• 68 male, 48 hrs RLQ pain
• Quick onset, in RLQ
• No nausea or anorexia
• No urinary syptoms• No urinary syptoms
• PHx: GERD, dyslipidemia
• Tender RLQ and flank with peritonism
• WBC 9.2 Urine clear
CT abdomenCT abdomen
Case #2Case #2
• BW 41 yo electrician
• collapsed at home with chest, abd pain
• CPR by family, EHS to KGH• CPR by family, EHS to KGH
• PHx: appe Meds: ASA
• Exam: BP 60 sys, HR 100 RR 16
Chest clear Abdomen tender, acute
InvestigationsInvestigations
• Hb 108 WBC 8.9 Plts 256
• Hep panel – normal
• Lipase 43
• ECG – normal• ECG – normal
• Trop < 0.1
CT with Aorta ProtocolCT with Aorta Protocol
LaparotomyLaparotomy
• 3 litres blood
• intact liver, spleen, viscera
• blood from lesser sac
• rupured splenic artery aneurysm at hilum• rupured splenic artery aneurysm at hilum
• splenectomy, distal pancreatectomy
• 4 units FP, 6 units RBC
• Recovery uneventful