Acute Abdomen in the Acute Abdomen in the ICU PatientICU Patient

Simon Kimm and Edward MelkunSimon Kimm and Edward Melkun

December 11, 2006December 11, 2006

DefinitionDefinition

Acute abdominal pathology that if Acute abdominal pathology that if left untreated will increase patient left untreated will increase patient M&MM&M

PhysiologyPhysiology

Visceral and parietal peritoneumVisceral and parietal peritoneum Peritoneal fluid normally <50mlPeritoneal fluid normally <50ml Absorbed via lymphatics in Absorbed via lymphatics in

omentum and diaphragmatic omentum and diaphragmatic peritoneum (30%)peritoneum (30%)

Omentum acts as physiologic Omentum acts as physiologic “patch” for perforation or “patch” for perforation or infectioninfection

PhysiologyPhysiology

Pain – somatic and visceralPain – somatic and visceral Somatic from direct irritation of Somatic from direct irritation of

parietal peritoneum, visceral parietal peritoneum, visceral follows embryologic origin or follows embryologic origin or major splanchnic vesselsmajor splanchnic vessels

Refered pain – ex. Shoulder and Refered pain – ex. Shoulder and phrenic nervephrenic nerve

PathophysiologyPathophysiology

Similar incidence of common Similar incidence of common diseases as general population plus diseases as general population plus more unique processesmore unique processes

Post-surgical statePost-surgical state Hypotension and low flow statesHypotension and low flow states Antibiotic therapy (Overgrowth ex. C. Antibiotic therapy (Overgrowth ex. C.

diff)diff) NarcoticsNarcotics Poor nutritionPoor nutrition Co-morbiditiesCo-morbidities TraumaTrauma

PresentationPresentation

Always start with ABCs, eyeball Always start with ABCs, eyeball test, and adjuncts to ABCstest, and adjuncts to ABCs

H&PH&P If possible review symptoms in If possible review symptoms in

awake patientawake patient OLDCARTSOLDCARTS

HistoryHistory

Location gives Location gives clues to clues to pathologypathology

Character – Character – crampy usually crampy usually from hollow from hollow viscusviscus

Progression Progression often more often more important in important in post op patientspost op patients

PhysicalPhysical

Again difficult in non-awake Again difficult in non-awake patientspatients

VitalsVitals Remember lines and woundsRemember lines and wounds Inspect, auscultate, percuss, Inspect, auscultate, percuss,

palpatepalpate Genital and rectal examGenital and rectal exam

LabsLabs

CBC – wbc trend, left shift, anemiaCBC – wbc trend, left shift, anemia UA – wbcs, LE, NitriteUA – wbcs, LE, Nitrite LFTs – tbili can be elevated in biliary LFTs – tbili can be elevated in biliary

dz, sepsis, hemolysis, and dz, sepsis, hemolysis, and cholestasis from TPNcholestasis from TPN

Amylase/Lipase – amylase elevated Amylase/Lipase – amylase elevated in pancreatitis, perfed ulcer, in pancreatitis, perfed ulcer, mesenteric ischemia, parotid injury mesenteric ischemia, parotid injury or inflam, and ruptured ectopicor inflam, and ruptured ectopic

ABG – acidosis, hypoxiaABG – acidosis, hypoxia

ImagingImaging

• Bedside films vs. in department

• CXR – free air,PNA, effusions

• Abd films – colonic volvulus, obstruction, stones, pneumobilia

• US – biliary system

• CT – little use in 1st post-op week for abscess

• Angio – mesenteric ischemia, GI bleeds

• Nuclear scans – tagged rbc

ImagingImaging

Endoscopy – UGI bleed, colonic Endoscopy – UGI bleed, colonic ischemia, ? Role in C. diff (1/3 ischemia, ? Role in C. diff (1/3 negative toxin assays)negative toxin assays)

Postoperative ConsiderationsPostoperative Considerations

BleedingBleeding Anastamotic leakAnastamotic leak Fascial DehiscenceFascial Dehiscence Bowel obstructionBowel obstruction AbscessAbscess Abdominal Compartment Abdominal Compartment

SyndromeSyndrome

Bowel obstructionBowel obstruction

Diagnosis often Diagnosis often confounded by confounded by normal post-op normal post-op adynamic illeusadynamic illeus

Patients on Patients on narcotic pain medsnarcotic pain meds

Management per Management per standard protocolstandard protocol

Complete Complete obstruction or obstruction or nonresolving/ nonresolving/ worsening PSBO worsening PSBO requires requires reoperationreoperation

LeakLeak

In cases where leak controlled by In cases where leak controlled by drainage with little or no peritoneal drainage with little or no peritoneal contamination, may not need early contamination, may not need early operative interventionoperative intervention

Percutaneous drainagePercutaneous drainage NPO, TPN, ? octreotideNPO, TPN, ? octreotide If peritoneal spillage or signs of If peritoneal spillage or signs of

intraabdomial sepsis, need emergent intraabdomial sepsis, need emergent reoperationreoperation

AbscessAbscess

Need approximately 7 Need approximately 7 post op days to post op days to organize an abscessorganize an abscess

Small may only require Small may only require abxabx

Larger or those with Larger or those with continued enteric continued enteric contamination (leak) contamination (leak) require drainagerequire drainage

Percutaneous, Percutaneous, operative if not operative if not accessibleaccessible

CholecystitisCholecystitis

Acalculous – may see Acalculous – may see sludge in GB in US or sludge in GB in US or nonvisualization on HIDA nonvisualization on HIDA (hepato-iminodiacetic acid)(hepato-iminodiacetic acid) scan scan

Can see these findings in nl Can see these findings in nl patients maintained on TPNpatients maintained on TPN

Percutaneous Percutaneous cholecystostomy tube for cholecystostomy tube for critically ill patientscritically ill patients

Ischemic BowelIschemic Bowel

Low flowLow flow EmbolicEmbolic Abd films – pneumatosis, Abd films – pneumatosis,

pneumobilia, free air, double pneumobilia, free air, double wall signwall sign

CTACTA Lactate levelsLactate levels