assessment and management of the acute abdomen yingda li neurosurgery hmo 23 september 2010
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Assessment and Management of the Acute Abdomen
Yingda LiNeurosurgery HMO23 September 2010
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ObjectivesDevelop a rational approach to
assessing and managing the acute abdomen in adults
Identify red-flags on history and examination
Consolidate information previously learnt about specific pathologies
Have a set of rules to fall back onFamiliarise with the style of questions
commonly asked in exams
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OverviewDefinitionHistoryExaminationInvestigationsManagementMulti-choice questions
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DefinitionAbdominal painAcute onsetUsually severeRequiring urgent attention
Not always surgicalNot always intra-abdominal
source
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Golden Rule 1Upper abdominal pain may be
from supra-diaphragmatic pathology
Acute myocardial infarct and lower lobe pneumonia should always be in your differential diagnosis
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HistoryDemographicsTempoSite and radiationQualityAssociated symptomsAntecedent eventsPre-morbiditiesPrior episodesMenstrualPreoperative history
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Golden Rule 2A woman of childbearing age is
pregnant till proved otherwiseA woman of childbearing age
who has acute abdominal pain is pregnant and has a ruptured ectopic till proved otherwise
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Golden Rule 3Never dismiss or underestimate
acute abdominal pain in an elderly patient
They probably have mesenteric ischaemia, ruptured AAA, perforated diverticular abscess or a strangulated hernia
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Golden rule 4Vomiting is the key associated
symptomPain before vomiting is usually
surgicalCombination of vomiting and
diarrhoea is usually gastroenteritis, but gastroenteritis must remain a diagnosis of exclusion
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Examination
General appearance and vital signs
Inspection and palpation
Bedside tests
Rectal, testicular and pelvic
Auscultation
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Golden Rule 5Vital signs are vitalYou can tell a lot just by looking
at a patient
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InvestigationsDiagnostic
Pancreatic enzymes, cardiac enzymes
US, CT, MRCPAngiographyLaparoscopy
MSU
SupportiveX-rayLFTs
Lactate, PO4
WCC, neutrophilspH, ketones
AssociatedUEC, CMP
PreoperativeGrp and Hold
Severity and PrognosisCRP, platelets
Clotting, albuminCT
Criteria
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ManagementResuscitative cascadeAirway, breathing, circulation
General measuresAnalgesia, antiemesisNBM, IV fluidsNGT, IDCSerial examinations
Specific measuresAntibiotics, image-guided drainageOpen surgery, laparoscopic-assistedERCPAngiographic interventionSigmoidoscopic decompression
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What is the difference between an incarcerated vs. obstructed vs. strangulated hernia?
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1. Hepatitis serology2. Upper abdominal
ultrasound3. Full blood examination4. ERCP5. Liver biopsy
What would be your clinical concern if he was febrile? What eponymous triad wouldthat constitute?
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How would you explain the low serum bicarbonate?
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A. Erect abdominal X-rayB. Full blood examinationC. Liver function testsD. Serum lipaseE. Upper G.I. endoscopy
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A. CT kidney, ureter and bladderB. Ultrasound renal tractC. 24-hour urinary calcium excretionD. Plain X-ray kidney, ureter and bladderE. Mid-stream urine for phase microscopy
What is phase microscopy designed to look for?
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What do you think is the most likely diagnosis?
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Golden rules1. Upper abdominal pain may be from
supra-diaphragmatic pathology2. Woman of childbearing age is
pregnant till proved otherwise3. Acute abdominal pain in elderly
patients must not be dismissed or underestimated
4. Vomiting is the key associated symptom
5. Vital signs are vital