acute abdomen david gavriel md surgical department szmc
TRANSCRIPT
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Acute Abdomen
Acute Abdomen
David Gavriel MDSurgical department
SZMC
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Acute Abdomen
Overview
• Basic Definition and Principles• Clinical Diagnosis / DDx
– Characterizing the pain– Other history to elicit– Ways to remember such a broad differential– History & Physical / Labs / Imaging– Non-surgical causes of acute abdomen
• Clinical Management• Decision to Operate• Atypical presentations
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Acute Abdomen
Basic Definition and Principles
• Signs and symptoms of intra-abdominal disease usually best treated by surgery
• Proper eval and management requires one to recognize:– 1. Does this patient need surgery?– 2. Is it emergent, urgent, or can wait?
• In other words, is the patient unstable or stable?
• Learn to think in “worst-case” scenario• But remember medical causes of abd pain
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Acute Abdomen
Visceral vs. Parietal Pain innervation
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Acute Abdomen
Clinical Diagnosis
• Characterizing the pain is the key– Onset, duration, location, character
• Visceral pain → dull & poorly localized– i.e. distension, inflammation or ischemia
• Parietal pain → sharper, better localized– Sharp “RUQ pain”(chol’y), “LLQ pain”(divertic)
• Kidney / ureter → flank pain
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Acute Abdomen
Clinical Diagnosis – Pain cont’d
• Location– Upper abdomen → PUD, chol’y, pancreatitis– Lower abdomen → Divertic, ovary cyst, TOA– Mid abdomen → early app’y, SBO
• Migratory pattern– Epigastric → Peri-umbil → RLQ = Acute app’y– Localized pain → Diffuse = Diffuse peritonitis
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Acute Abdomen
Clinical Diagnosis
• “Referred pain”– Biliary disease → R shoulder or back– Sub-left diaphragm abscess → L shoulder– Above diaphragm(lungs) → Neck/shoulder
• Acute onset & unrelenting pain = bad
• Pain which resolves usu. not surgical
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Acute Abdomen
Other history• GI symptoms
– Nausea, emesis (? bilious or bloody)
– Constipation, obstipation (last BM or flatus)
– Diarrhea (? bloody)– Both Nausea/Diarrhea
present usu. medical– Change in sx w eating?
• NSAID use (perf DU)• Jaundice, acholic
stools, dark urine
• Drinking history (pancreas)
• Prior surgeries (adhesions → SBO, ?still have gallbladder & appendix)
• History of hernias• Urine output
(dehydrated)• Constituational Sx
– Fevers/chills
• Sexual history
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Acute Abdomen
Physical Examination
• Observation of the patient– Position of patient– Activity of patient– Appearance of abdomen
• Auscultation– Bowel sounds, bruits
• Percussion
• Palpation– Masses, tenderness, rebound, hernias
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Acute Abdomen
Examination Patterns (Signs)
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Acute Abdomen
Evaluation Studies
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Acute Abdomen
Clinical Diagnosis• Location of pain by
organ• RUQ
– Gallbladder
• Epigastrum– Stomach– Pancreas
• Mid abdomen– Small intestine
• Lower abdomen– Colon, GYN pathology
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Acute Abdomen
Clinical Diagnosis
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Acute Abdomen
Inflammation versus Obstruction
Organ Lesion
Stomach Gastric Ulcer
Duodenal Ulcer
Biliary Tract
Acute chol’y +/-choledocholithiasis
Pancreas Acute, recurrent, or chronic pancreatitis
Small Intestine
Crohn’s disease
Meckel’s diverticulum
Large Intestine
Appendicitis
Diverticulitis
Location Lesion
Small Bowel Obstruction
Adhesions
Bulges
Cancer
Crohn’s disease
Gallstone ileus
Intussusception
Volvulus
Large Bowel
Obstruction
Malignancy
Volvulus: cecal or sigmoid
Diverticulitis
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Acute Abdomen
Localization of Pain
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Acute Abdomen
Localization of Pain – cont.
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Acute Abdomen
Localization of Pain – cont.
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Acute Abdomen
Non-Surgical Causes by SystemsSystem Disease System Disease
Cardiac Myocardial infarction
Acute pericarditisEndocrine Diab ketoacidosis
Addisonian crisis
Pulmonary Pneumonia
Pulmonary infarction
PE
Metabolic Acute porphyria
Mediterranean fever
Hyperlipidemia
GI Acute pancreatitis
Gastroenteritis
Acute hepatitis
Musculo- skeletal
Rectus muscle hematoma
GU Pyelonephritis CNS
PNS
Tabes dorsalis (syph)
Nerve root compression
Vascular Aortic dissection Heme Sickle cell crisis
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Acute Abdomen
Non Surgical Causes
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Acute Abdomen
Surgical Acute Abdominal Diseases
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Acute Abdomen
Think Broad categories for DDx
• Inflammation
• Obstruction
• Ischemia
• Perforation (any of above can end here)– Offended organ becomes distended– Lymphatic/venous obstrux due to ↑pressure– Arterial pressure exceeded → ischemia– Prolonged ischemia → perforation
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Acute Abdomen
Ischemia / Perforation
• Acute mesenteric ischemia– Usually acute occlusion of the SMA from
thrombus or embolism
• Chronic mesenteric ischemia– Typically smoker, vasculopath with severe
atherosclerotic vessel disease
• Ischemic colitis• Any inflammation, obstructive, or ischemic
process can progress to perforation• Ruptured abdominal aortic aneurysm
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Acute Abdomen
GYN EtiologiesOrgan Lesion
Ovary Ruptured graafian follicle
Torsion of ovary
Tubo-ovarian abscess (TOA)
Fallopian tube Ectopic pregnancy
Acute salpingitis
Pyosalpinx
Uterus Uterine rupture
Endometritis
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Acute Abdomen
Labs & ImagingTest Reason
CBC w diff Left shift can be very telling
BMP N/V, lytes, acidosis, dehydration
Amylase Pancreatitis, perf DU, bowel ischemia
LFT Jaundice,hepatitis
UA GU- UTI, stone, hematuria
Beta-hCG Ectopic
Test ReasonKUBFlat & Upright
SBO/LBO, free air, stones
Ultrasound Chol’y, jaundice
GYN pathology
CT scan-Diagnostic
accuracy
Anatomic dx
Case not straightforward
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Acute Abdomen
What do you see?
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Acute Abdomen
Abdominal X ray
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Acute Abdomen
Abdominal X ray
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Acute Abdomen
CT Scanning
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Acute Abdomen
CT scan
What is the diagnosis? Acute appendicitis
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Acute Abdomen
CT Scanning
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Acute Abdomen
CT Scanning
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Acute Abdomen
Findings Suggesting Surgical Disease
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Acute Abdomen
Intra Abdominal Pressure Monitoring
• Increased abdominal pressure can be a symptom of disease or the cause
• Can decrease abd. visceral blood flow• Can decrease cardiac venous return• Can cause respiratory embarrassment• Can lead to GERD and aspiration
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Acute Abdomen
Abdominal Compartment SyndromeAbdominal Compartment Syndrome
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Acute Abdomen
““VAC-Pac” ClosureVAC-Pac” Closure
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Acute Abdomen
Differential Diagnosis
• Correct diagnosis made 80% of time after history and physical exam
• Sometimes diagnosis cannot be made preoperatively
• Diagnostic laparoscopy can be helpful adjunct
• Peritoneal lavage can be performed at bedside in ICU/ER in unstable patient
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Acute Abdomen
Pregnant Patients
• Special emphasis placed on Gyn and surgical diagnoses
• Hesitancy to operate and to perform X Ray imaging can delay diagnosis
• Presentation patterns can be altered by pregnancy
• Delayed diagnosis can threaten both mother and fetus
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Acute Abdomen
Pregnant Patient
• Most common non-obstetrical surgical diseases in pregnancy are:– Appendicitis (1:1500)– Biliary tract disease (1-6:10,000)– Bowel obstructions (1:4,000)– Pancreatitis
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Acute Abdomen
Appendicitis in Pregnancy
• Classic symptoms 60% of time
• Nausea, vomiting, lower abd pain
• Fever is uncommon
• Leukocytosis present in normal pregnancy
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Acute Abdomen
Appendicitis in Pregnancy
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Acute Abdomen
Algorithms in Acute AbdomenAcute Severe Generalized Pain
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Acute Abdomen
Algorithms in Acute AbdomenGradual Onset Severe Generalized Pain
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Acute Abdomen
Algorithms in Acute AbdomenRight Upper Quadrant Pain
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Acute Abdomen
Algorithms in Acute AbdomenRight Lower Quadrant Pain
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Acute Abdomen
Algorithms in Acute AbdomenLeft Lower Quadrant Pain
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Acute Abdomen
Decision to operate
• Peritonitis– Tenderness w/ rebound, involuntary guarding
• Severe / unrelenting pain
• “Unstable” (hemodynamically, or septic)– Tachycardic, hypotensive, white count
• Intestinal ischemia, including strangulation
• Pneumoperitoneum
• Complete or “high grade” obstruction
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Acute Abdomen
Special Circumstances
• Situations making diagnosis difficult– Stroke or spinal cord injury– Influence of drugs or alcohol
• Severity of disease can be masked by:– Steroids– Immunosuppression (i.e. AIDS)– Threshold to operate must be even lower
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Acute Abdomen
Take Home Points• Careful history (pain, other GI symptoms)• Remember DDx in broad categories• Narrow DDx based on hx, exam, labs, imaging• Always perform ABC, Resuscitate before Dx• If patient’s sick or “toxic”, get to OR (surgical emergency)
– Ideally, resuscitate patients before going to the OR
• Don’t forget GYN/medical causes, special situations• For acute abdomen, think of these commonly (below)
Perf DU Appendicitis +/- perforation
Diverticulitis +/- perforation
Bowel obstruction
Cholecystitis Ischemic or perf bowel
Ruptured aneurysm
Acute pancreatitis