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PITTFALLS ON ACUTE ABDOMEN
1st Surabaya Gastrointestinal and Emergency Surgery (SuGIES), Hotel Novotel Surabaya, 19 – 20 May 2017
Prof. Dr. P. Soetamto Wibowo, Sp.B-KBD – Dep/SMF I. Bedah FK. Unair/RSUD Dr. Soetomo Surabaya
An error the breath of a single hair can lead one a thousand miles astray Chinese Proverb
WHY ?
Medicine : High Risk System with High Error Rate
Cross Industry Comparison of size, productivity and efficiency (the Advisory Board Company 2005 )
Complications and Adverse Events
in Surgery
10% of hospital admission suffer harm, half is preventable [1,2]
50% - 75% of hospital wide adverse events are attributable to surgical care.
Most errors occur in the OR [3]
[1] Thomas EJ, Clinical Risk Management Enhancing Patient Safety, BMJ Publ. 2001 : 31-44 [2] Vincent C. System Approaches to Surgical
Quality and Safety, Ann. Surg. 2004; 239 : 475-482 [3] Healey MA, Complications of Surgical Patients, Arch Surg. 2002; 137 : 611 – 618
Insurance Premium $ 30,000 - $ 300,000 / yr
Health Cost
Rising Cost of Health Care is just a symptom
WHAT IS THE REAL DISEASE ?
→ GREED and INCOMPETENCE ?
Do not count for double digit
(Thomas A Lee, HBR, Apr 2010)
Pitfalls on Acute Abdomen
The Paradox
Institute of Medicine (IOM) 1999 :
“To Err is Human” (1)
not an explanation accepted by the media, the public, the insurance companies, or lawyer.
(1) Institute of Medicine. To Err is Human. Washington DC. National Academies Press, 2000.
Pitfalls on Acute Abdomen
Taking Ownership
Leape and Berwick (1) 2004 :
“ We will not became safe until we chose to become safe” → Patient’s safety.
(1) Leape L, Berwick D. Five years after To Err is Human – What we have learned ? JAMA 2005 : 293 : 2384 – 2390
Leadership
Performance
Pitfalls on Acute Abdomen
Errors in Human Performance
Errors Categories (1) :
Knowledge base
Lack of experience or knowledge or misintepretation of the problem
Rules based
Misperception or misapplication of the rule
Skill based = “slips”
Reason J. Human error. Cambridge, MA. Cambridge University Press 1992
Case 1
54 years old man with sudden right upper abdominal pain for 5 days
Fever + → ED
PE : Abdomen – RUQ
Rigidity +
Murphy signs +
General peritonitis −
USG : Gallbladder – stone +
Thicken wall
Double layer
Pericystic fluid
Perforated gallbladder ?
Rules Tokyo Guidelines → Surgery ?
Evidence Based Golden Rules
Emergency Surgery
Usually doing less is betterbut
Occasionally doing more may be life saving
Acute Abdomen :Operate only when necessary and do the minimum possible
butDo not delay a necessary operation
and do the maximum when indicated
Pitfalls on Acute Abdomen
Errors Training
Whoever refuses to admit error may be a great scholarbut
He is not a great learnerJohann Wolfgang von Goethe 1749 – 1832
Fitts and Posner Model (1) :
If you commit any mistake – there are 3 things to do :
Admit it
Learn from it
Don’t repeat it
(1) Fitts P, Posner MI. Human Performance, Belmont, CA : Brooks / Cole Publ. 1969
Compassion
Pitfalls on Acute Abdomen
Acute Abdomen
Definition :
Pain of non traumatic origin with a maximum
duration of 5 days (1)
Account 7 – 10 % of all Emergency Department
(ED) (2)
(1) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 – 31
(2) Hasting RS, Power s RD. Abdominal pain in the ED. A 35 years retrospective . Am.J. Emerg.Med 2011; 29 711 – 716.
Pitfalls on Acute Abdomen
Acute Abdominal Pain (AAP)
Great caution – Problem
AAP can be caused by variety of diseases from mild –self limiting – live threatening diseases
Early – accurate diagnosis → better outcomes
Diagnostic practice varies within hospitals and within specialities
Despite substantial improvement in diagnostic approach, pitfalls remain → misdiagnosis → error
Medicolegal Litigation
Pitfalls on Acute Abdomen
Cause of Acute Abdomen (1)
Urgent – Treatment within 24 hours
Non Urgent – Not requiring treatment within 24 hours
(1) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 – 31
Pitfalls on Acute Abdomen
Diagnostic Pathway
Step 1 :
Medical History
Physical Examination
Laboratory : CRP > 100 mg/dl
WBC > 15x109/L
Correct Diagnosis in 46% - 48% (1,2)
Higher sensitivity for differentiating urgent from non urgent than for specific diagnosis (EL A2) (1,2)
(1) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 – 31
(2) Lameris W, von Randen A, von ES HW et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain;
diagnostic accuracy study. BMJ 2009; 339 : 62431
Pitfalls on Acute Abdomen
Medical History – History – History
Previous similar pain
Previous abdominal surgery
Previous major illness
Gynecologic history
Drug history
nset sudden – chronicrovocative Progress What make it better – worse
no change – movement uality Colicky – sharp – burning egion General – localized
radiated – migrated – reverseverity Mild – moderate - severe ime begin - duration
O
P
QR
S
T
Pitfalls on Acute Abdomen
Medical History
Case 1
9 yrs old boy – abdominal discomfort
+ diarrhoea → ED : Dx gastroenteritis
The clinical notes did not cerroberate
4 days → no better → ED : ongoing GE
Overnight the boy deteriorated → ED
ED → Dx : burst appendix abscess → surgery
→ 2 weeks discharge
claim → out of court settlement
Pitfalls on Acute Abdomen
Medical History
Case 2
70 yrs old woman with sudden abdominal pain for one day + fever + vomiting
→ ED : there was no written note to support the doctor in charge contention that the abdomen was examined.
Lab : WBC 13x109/L Blood sugar 250 gm/dl
→ Consult internist : urine shutdown, s.creatinine 2.5 gm/dl
→ Consult Nephrologist resuscitation – ICU
Day 1 → GCS → Consult Neurologist
Day 2 → her condition deteriorated → ?
Abd X-ray : Free air : positive → surgeon : perforated peptic ulcer
Pitfalls on Acute Abdomen
Diagnostic Pathway
Step 2
Urgent condition → imaging :
1. Conventional Radiography
Plain chest x-ray
Plain abdomen : upright position
supine
left lateral decubitus
Diagnostic accuracy 47% - 56% (ELA2) (1,2)
No added value on top of clinical assessment
in discriminating urgent or non urgent causes (ELA2 (1,2)
Only for bowel obstruction
(1) Lameris W, von Randen A, von ES HW et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain;
diagnostic accuracy study. BMJ 2009; 339 : 62431
(2) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 – 31
Pitfalls on Acute Abdomen
Diagnostic Pathway
2. Ultrasound (US)
Advantages : widely available
no risk of radiation
no risk of nephropathy
Downside : operator dependent
Clinical + USG dx accuracy 53% - 83% (ELA2 (1,2)
(1) Lameris W, von Randen A, von ES HW et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain;
diagnostic accuracy study. BMJ 2009; 339 : 62431
(2) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 – 31
Pitfalls on Acute Abdomen
Diagnostic Pathway
3. Computed Tomography (CT)
Clinical + Radiography + CT accuracy final diagnosis 61.6% - 96%
(ELA2) (1,2)
Prefer i.v. contrast → eGFR > 45 ml/min/1.73m2 (3)
Recom (1,2) :
USG CT (conditional)
Laparoscopy : No Research (1,2)
MRI : No place yet (1,2) → non urgent
Pregnant woman
(1) Lameris W, von Randen A, von ES HW et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain;
diagnostic accuracy study. BMJ 2009; 339 : 62431
(2) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 – 31
(3) Katzberg RW, New house JH : Intravenous contrast medium induced nephro toxicity is the medical risk really as great as we have come to
believe ? Radiology 2010 ; 256 : 21 – 28.
inconclusive
Pitfalls on Acute Abdomen
Cause of AAP – Evidence
n %
Nonspecific Abdominal Pain (NSAP) 1.680 31.46
Renal Colic 1.665 31.18
Biliary 411 7.70
Appendicitis 203 3.80
Diverticulitis 194 3.63
Urologic 147 2.75
Peptic Ulcer 143 2.68
Others
Cervellin G (1) – Parma – Italy 2014 N = 5,340 = 5.76% ED visit
(1) Cervellin G, Mora R, Ticinesi A et al . Epidemiology and Outcomes of acute abdominal pain in a large urban Emergency Department
: retrospective analysis of 5,340 cases. Ann Transl Med 2016; 4(19) : 362.
Pitfalls on Acute Abdomen (ED) (1)
Laurell – Sweden 1997 – 2000 (n=2851)
Accuracy of Diagnosis
n Accuracy
NSAP 1058 0.48
Appendicitis 277 0.74
Gallstone 208 0.84
Diverticulitis 134 0.91
Constipation 130 0.88
Ureteric stone 107 0.94
Cholecystitis 100 0.88
Gyn. Diagnosis 101 0.94
Pancreatitis 92 0.93
Intestinal Obstruction 78 0.93
Gastro Enteritis 64 0.94
Peptic Ulcer 34 0.93
Incarcerated hernia 22 0.99
Colonic Obstruction 14 0.97
Laurell H., Hanson LE, Gunnarsson V : Diagnostic pitfall and accuracy of diagnosis in acute abdominal pain. Scandinavian J.G.enterol
2006; 41 : 1126 – 1131
Pitfalls on Acute Abdomen
Final Diagnosis Correlated to the preliminary diagnosis
Laurell H. Sweden 1997 – 2000 (n=2851)
Preliminary Diagnosis
NSAP n=1058
Appendicitis n=277
Gallstone n=208
Colonic Obstr. n=14
Peptic Ulcer n=34
NSAP 458 (43%) 24 (9%) 19 (9%)
Appendicitis 132 (12%) 222 (80%) 3 (1%)
Gallstone 75 (7%) 2 (10.5%) 141 (68%) 9 (26%)
Peptic Ulcer 20 (2%) 1 (0,5%) 4 (29%)
Colonic Obstruction
4 (1%) 1 (0,5%)
Laurell H., Hanson LE, Gunnarsson V : Diagnostic pitfall and accuracy of diagnosis in acute abdominal pain. Scandinavian J.G.enterol 2006;
41 : 1126 – 1131
Pitfalls on Acute Abdomen
Emergency General Surgery EGS) USA (2008-2011) (1)
7 types of surgery account 80.1% of EGS
80.3% of deaths
78.9% of complication
80% inpatient cost
Surgery n Mortality Rate (%) Morbidity Rate (%)
Appendectomy 682.043 0.008 7.27
Cholecystectomy 619.197 0.22 8.06
Partial Colectomy 138.992 5.33 42.80
Peritoneal adhesion 102.856 1.59 28.09
Small bowel Resection 78.478 6.47 46.94
Peptic Ulcer disease 31.571 6.83 42.00
Laparotomy 9.412 23.71 40.15
Overall Mortality 1.23%
(1) Scott JW, alufajo DA, Brat GA et al : Use of National burden to define Operative Emergency General Surgery. JAMA Surg 2016 , April 27th
Pitfalls on Acute Abdomen
Surabaya Experience 2016
Emergency General Surgery Dr. Soetomo General Hospital 2016
Digestive Oncology Head & Neck Th. Card .Vasc. General Total
437 (63.80%) 2 (0,3%) 133 (19.4%) 108 (15.8%) 5 (0,7%) 685
Emergency Digestive Surgery
Dr. Soetomo General Hospital – 2016
n %
Appendicitis 87 28.15
Peptic Ulcer Disease 60 19.87
Colorectal Malignancy 57 18.87
Incarcerated Hernia 46 15.23
Intestinal Adhesion 14 4.64
Small Intestine Perforation 10 3.31
Diverticulitis 8 2.65
Intestinal Strangulation 7 2.32
Hepatobiliary pathology 7 2.32
Others 8 2.65
Re-Laparotomy 62 (20.93%)
Pitfalls on Acute Abdomen
Soetomo General Hospital Pitfalls
January – February – March 2017
Primary Dx Final Diagnosis
Perforated Appendix 1 Perforated Diverticulitis
(n = 7) 2 Perforated ileal (Typhoid)
3 Perforated Endometriosis
4 Perforated Endometriosis
5 Perforated Ulcerative Colitis
6 Perforated Crohn Ileitis
7 Gallbladder perforation
Pitfalls on Acute Abdomen
RS. Tulungagung 2016
Emergency Digestive Surgery 580
n %
1 Acute appendicitis / perforation 110 51.89
2 General peritonitis (laparotomy) 44 20.75
3 Incarcerated hernia 32 15.09
4 Intestinal obstruction 19 8.96
5 Peptic Ulcer perforation 7 3.30
Total 212
Pitfalls on Acute Abdomen
Special Case
Obesity
Clinical Diagnostic ? → CT
Pregnancy → Clinical diagnostic : appendicitis
Imaging ? → USG
Operate ?
→ Gallbladder stone
USG
Operate ?
Pitfalls on Acute Abdomen
Antibiotic
Antibiotic therapy within the first hour of recognition of sepsis (1)
Morphin – Analgetic ?
Administration of opioids / analgesic decrease the intensity of the pain and DOES NOT affect the accuracy of physical examination and diagnostic (ELA2) (2,3,4,5)
(1) Intensive Care Medicine : Surviving Sepsis Campaign : International Guidelines for Management of Sepsis and Septic Shock; 2016
(2) Lo Veccio F, Osler N, Sturmann K et al : the use of analgesic in patients with acute abdominal pain. J.Emeg 1997; 15 : 775 – 779
(3) Gallagher EJ, Esses D, Lee C et al : Randomized Clinical Trial of Morphin in acute abdominal pain. Ann Emerg Med 2006; 48 : 150 – 160
(4) GungorF, Kartal M, Bektas F et al : Randomized Controlled Trial of Morphine in elderly patients with acute abdominal pain. Turkish J of
trauma & emergency surgery 2012; 18 (5) : 397 – 404
(5) Gans SL, Pols MA, Stoker J et al : Guideline for the Diagnostic Pathway in Patients with acute abdominal pain. Dig Surg 2015; 32 : 23 – 31.
Pitfalls on Acute Abdomen
Take Home Message
Unconsciously
Incompetent
Consciously
Incompetent
Unconsciously
Competent
Consciously
Competent
IGNORANCE
KNOWLEDGE
(1) Dreytas HE, Dreifus SE. Mind over machine. New York : New York Free Press , 1982
STEPS TO MASTERY (1)
AWAREUNAWARE
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