the acute abdomen -...
TRANSCRIPT
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The Acute Abdomen
Dr. Ed SnyderDr. Melanie WalkerHuntington Memorial Hospital
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Causes of the Acute Abdomen
Hemorrhage in the…GI tractBlood vesselGU tract
Perforation of the…GI tract
UlcerInfectionParasitescancer
GU tract
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Causes of the Acute Abdomen
Inflammation Obstruction of the …GI tract
AdhesionsHerniaVolvulusTumorIntussusceptionParasites
GU tractStoneTumor
Vascular SystemThrombus, Embolus
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Signs
SIGNS are objective and reproducible findingsTendernessRigidityMassesAltered bowel sounds Evidence of malnutritionBleedingJaundice
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Symptoms
SYMPTOMS reflect a subjective change from normal function
PainAppetite: anorexia, nausea, vomiting, dysphagia, weight lossBowel habits: bloating, diarrhea, constipation, flatulence
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The Physiology of Abdominal Pain
Abdominal pain from any cause is mediated by either visceral or somatic afferent nervesSeveral factors can modify expression of pain
Age extremesVascular compromise (pain ‘out of proportion’)PregnancyCNS pathologyNeutropenia
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Visceral Pain
StimuliDistention of the gut or other hollow abdominal organTraction on the bowel mesenteryInflammationIschemia
SensationCorresponds to the embryologic origin of the diseased organ (foregut, midgut, hindgut)
foregut
midgut
hindgut
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Somatic Pain
StimuliIrritation of the peritoneum
SensationSharp, localized painEasily described
Cardinal signsPain GuardingReboundAbsent bowel sounds
Example: McBurney’s point in late appendicitis
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Patterns of Referred Pain
Gastric pain
Liver and biliary pain Biliary colic
Diaphragmatic irritation
Ureteral or kidney pain
Colonic painUterine and rectal pain
Pancreatic and renal pain
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History
PainWhen? Where? How?
Abrupt, gradualCharacter
Sharp, burning, steady, intermittent
Referral?Previous occurrence?
VomitingRelationship to painHow often? How much?
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History
Nausea? Anorexia?Bowel movements
NumberCharacterBloody?
Past Medical and Surgical HistoryTravel HistoryLast mealSystemic Review
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Physical Examination
Appearance and position of patientVital signsAppearance of abdomen
DistentionHerniaScars
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Physical Examination
TendernessRigidityMasses
Bowel soundsRectal and Pelvic ExaminationCareful exam of heart, lungs and skin
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Physical Examination: The Quadrants
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Diagnosis: Right Upper Quadrant (RUQ) Pain
InvestigationsXRay
Upright chestUpright and supine abdominal
Complete Blood countUrinalysisAmylase, Creatinine, BUN, Electrolytes
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Differential Diagnosis: RUQ Pain
CLUESCONDITION
Fever, tachypnea, bronchial breathingRight lower lobe pneumonia
Shift of pain, tendernessRetrocecal appendicitisEdema, dyspnea, elevated JVPCongestive heart failure
Dysuria, fever, costovertebral angle tenderness
Right pyelonephritis
Alcohol history, jaundice, medicationsAcute hepatitis
Recurrent attacks, tender over gall bladder area
Biliary colic, acute cholecystitis
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Diagnosis: Left Upper Quadrant (LUQ) and Epigastric Pain
InvestigationsUpright chest XRUpright and supine abdominal XRCBCAmylase and lipase (if available)
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Differential Diagnosis: LUQ and Epigastric Pain
CLUESCONDITION
Fever, XR findings, bronchial breathingPneumonia
Recurrent, relationship to meals, relationship to posture
Gastritis / Peptic ulcer disease
History of alcohol consumption, history of similar event, elevated labs
Pancreatitis
History of trauma, gross deformity, extreme tenderness on palpation
Fractured ribs
History of trauma or splenic diseaseSplenic rupture
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Diagnosis: Right Lower Quadrant (RLQ) Pain
InvestigationsUrinalysis (to exclude obvious urinary causes)Pregnancy testUltrasoundComplete blood count
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Differential Diagnosis: RLQ Pain
CLUESCONDITION
…see nextGynecologic causesRecurrent, several days historyCrohn’s disease
Tender swollen testis, usually young ageTorsed right testisColicky pain, hematuriaRight renal colicFever, inconstant signsMesenteric adenitis
Shift of pain, anorexia, localized tendernessAcute appendicitis
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Gynecologic Causes of RLQ Pain
CLUESCONDITION
Sudden onset, amenorrhea, shockPelvic inflammatory disease
Severe pain, vomitingRuptured ectopic pregnancy
Midcycle, sudden onsetTorsion of ovaryFever, cervical excitation, dischargeRuptured follicle
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Diagnosis: Left Lower Quadrant (LLQ) Pain
Pregnancy testUrinalysis to exclude unsuspected urinary sourceUltrasoundComplete blood countUpright and supine abdominal XRCT scan if diverticular disease is suspected
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Differential Diagnosis: LLQ Pain
Gynecologic causes as for RLQ pain
Tender, swollen testis, young ageTorsion of testis
CLUESCONDITION
Colicky pain, hematuriaLeft renal colic
Colicky pain, obstipationLarge bowel obstruction
Recurrent attacks, diarrhea (+/- mucus, blood)Inflammatory bowel disease
Dysuria, frequencyUrinary tract infection
Palpable bladder, difficulty passing urineAcute urinary retention
Elderly patient, recurrentDiverticular disease
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Diagnosis: Periumbilical Pain
InvestigationsCBCAmylase and lipase, if availableIf severe, unrelenting pain urgent surgical referralIf pain colicky and no flatus erect and supine abdominal XRIf diarrhea and vomiting stool tests
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Differential Diagnosis: Periumbilical Pain
CLUESCONDITION
Severe pain, tenderness less marked, rectal bleeding
Ischemic bowel
Colicky pain, vomiting, no flatusSmall bowel obstruction
Nausea, short historyEarly appendicitis
Recurrent diarrhea, +/- mucus and blood
Inflammatory bowel disease
Colicky pain, hard stoolConstipationVomiting and diarrheaGastroenteritis
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Common Gastrointestinal Causes of the Acute Abdomen
AppendicitisPerforated peptic ulcerIntestinal perforationMeckel’s diverticulumDiverticulitisChronic irritable bowel diseaseGastroenteritis
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Common Visceral Causes of the Acute Abdomen
Acute pancreatitisAcute calculous cholecystitisAcalculous cholecystitisHepatic abscessRuptured hepatic tumorAcute hepatitisSplenic rupture
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Common Gynecologic Causes of the Acute Abdomen
Ruptured ovarian cystOvarian torsionEctopic pregnancyAcute salpingitisPyosalpinxEndometritisUterine rupture
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Extra-Abdominal Causes of the Acute Abdomen
SupradiaphragmaticMyocardial infarctionPericarditisLeft lower lobe pneumoniaPneumothoraxPulmonary infarction
HematologicSickle cell diseaseAcute leukemia
DrugsMetabolicNervous System
Herpes ZosterTabes dorsalisNerve root compression
EndocrineDiabetic ketoacidosisAddisonian crisis
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Immediate Treatment of the Acute Abdomen
1. Start large bore IV with either saline or lactated Ringer’s solution
2. IV pain medication3. Nasogastric tube if vomiting or concerned about obstruction4. Foley catheter to follow hydration status and to obtain
urinalysis5. Antibiotic administration if suspicious of inflammation or
perforation6. Definitive therapy or procedure will vary with diagnosis
Remember to reassess patient on a regular basis.