medical causes of the acute abdomen dr. t.h de klerk critical care 12 may 2014
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MEDICAL CAUSES OF THE ACUTE
ABDOMEN
Dr. T.H De KlerkCritical Care
12 May 2014
DEFINITION
• The term, acute abdomen, is the medical slang word that denotes an acute, serious abdominal condition, usually treated best by surgical operation.
• More appropriately referred to as a “surgical abdomen”.
EPIDEMIOLOGY
• Acute abdominal pain comprises 5% of all emergency medicine consultations (USA)
• 18-25% of these patients are admitted to hospital
• 10% of those admitted require surgery • 8% of admissions are purely medical
cases
ANATOMY AND PHYSIOLOGY
• Visceral pain – poorly localised to mainly the midline
• Parietal pain - better localised to a dermatomal distribution
• Referred pain – certain structures share central pathways due to their specific embryonic development
• Central pain – from thalamic and cortical structures
HISTORY
• Time course – hyperacute (seconds), acute (minutes) and gradual (hours)
• Location – often misleading, e.g. cholecystitis
• Radiation, exacerbating and relieving factors and associated symptoms
• Surgical conditions- pain generally preceeds vomiting
• Non-surgical conditions – vomiting generally preceeds pain
• Fever, vomiting, diarrhoea, leucocytosis are unhelpful
BACKGROUND
• Risk factors, e.g. DM, HPT, vascular or cardiac disease
• Previous surgical procedures - risk for obstruction
• Previous similar episode (consider medical cause)
• Familial disease• Age group specific diseases, e.g.
appendicitis in the young, or diverticulitis in the elderly
CLINICAL EXAMINATION
• Must be seen in the context of patient’s history and risk factors
• 2004 Israel study: more than 600 patients evaluated for acute abdomen clinically vs CT diagnosis 37% correlation between the groups, 8% of patients underwent surgery unnecessarily due to incorrect diagnosis
• The art of the abdominal examination: time very important, recurrent re-evaluation
• Abdominal x-rays: dilated bowel loops, intra-peritoneal air
• Abdominal ultrasound & CT scan: confirm diagnosis and plan further management
CATEGORIES OF MEDICAL CAUSES
• Referred pain – adjacent structures • Lung: pneumonia, pleuritis, pulmonary
embolus/infarct, empyema, pneumothorax
• Heart: myocardial infarction, myocarditis, pericarditis, congestive cardiac failure
• Oesophagus: oesophagitis, spasm, rupture
• Pelvis: PID, ovarian/testicular torsion, follicular rupture, ovarian hyperstimulation syndrome
MEDICAL CAUSES CONTINUED
• Metabolic• Adrenal insufficiency – gastric dysmotility,
serositis• DKA - gastritis, gastric distension, ileus• Thyrotoxicosis – unknown, probably ileus• Porphyria – visceral autonomic neuropathy• Hypercalcaemia – ileus, increased gastrin
which leads to gastritis, pancreatitis, ureterolithiasis
• Hyperlipidaemia – pancreatitis• Uraemia – ileus, gastritis • Haemochromatosis - SBP
MEDICAL CAUSES CONTINUED• Infection
• Toxins – tetanus, botulism• Dysentry – shigella, salmonella,
campylobacter, amoebiasis• Severe gastroenteritis – giardiasis,
isospora belli • Mesenteric lymphadenitis – yersinia,
extrapulmonary TB, CMV• Infestations – helminths,
schistosomiasis, obstruction• Infiltration – malaria, EBV• Translocation - SBP
MEDICAL CAUSES CONTINUED
• Vascular • Arterial – mesenteric ischaemia and
infarction, dissection (abdominal pain out of proportion to clinical findings)
• Vasculitis – large vessel: Takayasu, medium vessel: PAN, small vessel: Wegeners
• Coagulopathy – arterial and/or venous thrombosis, primary e.g. APLS, secondary e.g. malignancy
• Specific vascular syndromes, e.g. Budd-Chiari, portal vein thrombosis
MEDICAL CAUSES CONTINUED
• Haematological• Acute leukaemia, lymphoma –
infiltration, tumour necrosis • Haemolytic anaemia, Sickle cell
anaemia, polycythaemia vera – vascular spasm and/or thrombosis
• Haemophilia – abdominal wall haematomas
MEDICAL CAUSES CONTINUED
• Drugs and toxins• Mucosal irritants and corrosives – iron,
mercury, NSAIDs• Ileus – anticholinergics, narcotics
(opioid bowel syndrome)• Bowel ischaemia – cocaine,
amphetamines, ergotamines• Heavy metals – lead, arsenic• Biological – black widow spider:
hyperstimulation of NMJ
MEDICAL CAUSES CONTINUED
• Neurological • Central – abdominal migraine,
abdominal epilepsy, • Neuropathies – tabes dorsalis,
secondary to syphilis. Radiculopathy: degenerative spine disease, disc herniation, post-herpetic neuralgia
MEDICAL CAUSES CONTINUED
• Miscellaneous• Lactose intolerance • Eosinophillic gastroenteritis• SLE – pancreatitis, serositis, vasculitis• Periodic fever syndromes• Radiation enteritis• Glaucoma • Angioedema – C1-esterase inhibitor
deficiency, ACE inhibitors
SPECIAL POPULATION GROUPS • Pregnancy – abdominal examination difficult,
uterus obscures rest of abdomen• Neurological disease – no pain sensation,
quadroparesis, inability to communicate – delirium, dementia
• ICU patients – altered pain perception, 38% of patients with peritonits have peritoneal signs. Consider acalculus cholecystitis
• Post-procedural patients • vena cava filters which migrate, fracture,
thrombose etc• PEG tubes – peri-stomal leakage • Biopsies – subcapsular haematoma
• Immunocompromised• Blunted inflammatory response• Organ transplants lack nerve
innervation• Opportunistic infections, e.g. PCP, CMV• Weakening of connective tissue, e.g.
corticosteroids and bowel wall perforation
• Drugs: ARV’s (pancreatitis, lactic acidosis), Chemotherapeutic agents, e.g. vincristine
• Neutropenic enterocolitis (typhlitis)
• Elderly patients • Immunosenescence – decreased
immunosurveillance, decreased antibodies and T cells, decreased pyrogen response
• GI tract – decreased motility and secretion
• CNS – dementia, delirium, decreased peripheral sensation
• Increased amount of chronic diseases• Increased drug usage – decreased pain
and sympathetic response, increased drug interactions, e.g. digoxin toxicity
REMEMBER…
• An atypical presentation of a common condition is much more likely than the typical presentation of an uncommon condition
REFERENCES1. Farthing MJG. Pearls and Pitfalls in the Diagnosis of the
Acute Abdomen. Indian J Gastroenterol. 2006;25(1):33-35.
2. Cheng EH, Mills AM. Abdominal Pain in Special Populations. Emerg Med Clin N Am. 2011;29:449-458.
3. Ragsdale L, Southerland L. Acute Abdominal Pain in the Older Adult. Emerg Med Clin N Am. 2011;29:429-448.
4. Fields JM, Dean AJ. Systemic Causes of Abdominal Pain. Emerg Med Clin N Am. 2011;29:195-210.
5. Chang CC, Wang SS. Acute Abdominal Pain in the Elderly. Int J Gerontol. 2007 Jun;1(2):77-82.
6. Gajic O, Urrutia LE, Sewani H, Schroeder DR, Cullinane DC, et al. Acute Abdomen in the Medical Intensive Care Unit. Crit Care Med. 2002;30(6):1187-1190.
7. Mueller PD, Beneowitz NL. Toxicologic Causes of Acute Abdominal Disorders. Emerg Med Clin N Am. 1989;7:667-682.
THANK YOU
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