ACUTE ABDOMEN

ACUTE ABDOMEN : 

ACUTE ABDOMEN DR SRIRANGARAJAN MD EM

DEFINITION : 

DEFINITION Acute abdominal pain of less than 1 week’s duration.

SYMPTOM : 

SYMPTOM Primary Symptom Is Abdominal Pain Pain Has Lasted Less Than 7 Days Medical or Surgical Diagnoses (Non-Traumatic) Etiologies Can Be Trivial or Life-Threatening

Slide 5: 

Acute appendicitis. Acute peptic ulcer and its complications. Acute cholecystitis. Acute pancreatitis. Acute intestinal ischemia Diabetic Ketoacidosis. Acute Diverticulitis. Ectopic Pregnancy with tubal rupture. Acute peritonitis. Bowel perforation with free air or bowel contents in the abdominal cavity. Acute ureteral colic. Bowel volvulus. Acute pyelonephritis.

Type : 

Type VISERAL (AUTONOMIC) PARIETAL(SOMATIC) REFERRED (AFFERENT STIMULI)

Pathophysiology : 

Pathophysiology Visceral abdominal pain Stretching of the fibers innervating the walls or capsule of hollow or solid organs ischemia /inflammation. Steady ache or vague discomfort to excrutiating /colicky pain. Determined by embriologic origin involved Intraperitonial visceral pain is felt in the mid line. Eg: appendicitis –T10

visceral pain : 

visceral pain

parietal pain : 

parietal pain Irritation of fibers that innervate the parietal peritonium ,usually the portion covering the anterior abdominal wall. Localised to dermatome superficial to the site of the painful stimulus. Tenderness /guarding /rigidity (peritonitis)

Referred pain : 

Referred pain Referred pain is felt at a location distance from the diseased organ. Produces symptoms not signs Usually ipsilateral to the involved organ and are based upon developmental embryology Eg: ureteric obstruction ipsilateral testicular pain Similar dermatomal sharing Eg: supra/subdiaphragmatic irritation and ipsilateral supraclavicular

Cause : 

Cause 3G’s GI (Gastrointestinal) GU (Genitourinary) GYN( Gynecologic) Vascular emergency

CAUSES : 

CAUSES Hemorrhage in the… GI tract Blood vessel GU tract Perforation of the… GI tract Ulcer Infection Parasites cancer GU tract

Differential Diagnosis By Location : 

Differential Diagnosis By Location Epigastrium • Acid/Peptic Disease • Ulcer, GERD, Gastritis • ACS (Angina, MI) • Aortic Aneurism • Cholelithiasis, Choledocholithiasis • Diaphragmatic Defect Related • Paraesophageal Hernia, Gastric Volvulus, Congenital Diaphragmatic Hernias • Gastroenteritis • Pancreatitis • Tumor • Gastric Cancer, Pancreatic Cancer, etc.

Right Upper Quadrant : 

Right Upper Quadrant • Appendicitis (Retrocecal or Malrotated) • Cholelithiasis, Choledocholithiasis • Liver Related • Hepatitis, Abscess, Malignancy • Renal Related • Pyelonephritis, Nephrolithiasis/Ureterolithiasis • Subdiaphragmatic Process • Abscess

Left Upper Quadrant : 

Left Upper Quadrant • Colonic Ischemia • Pancreatic • Pancreatitis, Tumor • Renal • Pyelonephritis, Nephrolithiasis/Ureterolithiasis • Splenic • Infarct, Abscess • Subdiaphragmatic Process • Abscess.

Mid-Abdomen/Periumbilical : 

Mid-Abdomen/Periumbilical • Aortic Aneurism • Appendicitis • Small Bowel Obstruction • Ischemia (“Intestinal Angina”) • Gangrene

Suprapubic : 

Suprapubic • Colon Cancer • Diverticulitis • Gynecological • Endometritis, Endometriosis, PID • Prostatitis • UTI

All Locations … : 

All Locations … • Gastrointestinal Infections • Porphyria • Sickle Cell Crisis • Spontaneous Bacterial Peritonitis • Irritable Bowel Syndrome

History : 

History • Where? • When? • What Kind of Pain? • Does It Radiate? • Did It Move? • Previous Episodes? • Modifying Factors?

WHERE : 

WHERE • Possibly the Most Important Piece of Information to Determine • Helps Direct the Assessment • Narrows the List of Suspects Considerably • See “Differential Diagnosis By Location

What Kind of Pain? : 

What Kind of Pain? • Some Classical Patterns • Tearing (Aneurism) • Crescendo- Decrescendo or Colicky (Obstruction) • Burning (Ulcer)

Does It Radiate? : 

Does It Radiate? • Typical Radiation Patterns • Right Upper Back (Biliary Colic) • Upper Mid-Back (Pancreatitis, Aortic Aneurism) • Groin/Testicle (Renal Colic)

Did It Move? : 

Did It Move? • Typical Migratory Patterns • Per umbilical to Right Lower Quadrant (Appendicitis)

Previous Episodes? : 

Previous Episodes? Repetitive episodes • Biliary Colic • Diverticulitis • Intestinal Angina

Modifying Factors? : 

Modifying Factors? Food • Makes It Worse (Biliary Colic) • Makes It Better (Duodenal Ulcer) Position • Sitting (PID)

Non-Surgical Causes by Systems : 

Non-Surgical Causes by Systems

Clinical diagnosis : 

Clinical diagnosis location of pain by organ RUQ Gallbladder Epigastrum Stomach Pancreas Mid abdomen Small intestine Lower abdomen Colon, GYN pathology

Most Common Causes of Acute Abdominal Pain : 

Most Common Causes of Acute Abdominal Pain Final Diagnosis Proportion of >10,000 Patients Nonspecific abdominal pain (NSAP) 34% Appendicitis 28% Biliary tract disease 10% Small bowel obstruction 4% Acute gynecologic disease 4%   Salpingitis 68%   Ovarian cyst 21%   Ectopic 6%   Incomplete abortion 5% Pancreatitis 3% Renal colic 3% Perforated peptic ulcer 3% Cancer 2% Diverticular disease 2% Other (<1% each) 6%

Inflammation versus Obstruction : 

Inflammation versus Obstruction

Basic Lab and X-Ray Evaluation : 

Basic Lab and X-Ray Evaluation • Labs and Basic X-Rays Designed to Narrow Down Diagnosis Recommended in Almost All Cases • Include CXR, EKG, Liver Functions, and Amylase/Lipase in All Upper Abdominal Pain Cases • β-HCG for Any Lower Abdominal Pain in Females of Childbearing Age

Acute Abdominal Series : 

Acute Abdominal Series • Consists of CXR, KUB, and Upright or LLD of Abdomen can Be Diagnostic • e.g. Small Bowel Obstruction, Perforation with Free Air • Worth Doing Routinely, Even in the Age of CT Scans

cont : 

cont Ultrasound (U/S) • Better for Specific Inquiries (Biliary Tract, Appendicitis, or Acute Female Pelvic Pathology) CT Scan • Better as a More Generalized Abdominal Survey • Especially Useful for Certain Diagnoses • Appendicitis, Diverticulitis, Bowel Obstruction, Colitis,Abdominal Sepsis, Tumor • Useful for Occult Diagnosis (“Fishing Expedition”)

USG : 

USG

CT : 

CT

Others : 

Others • Other Radiographic Studies • Nuclear Medicine, Angiography, etc. • Endoscopy • Laparoscopy • Exploratory Laparotomy

Labs & Imaging : 

Labs & Imaging

Important Signs in Patients with Abdominal Pain : 

Important Signs in Patients with Abdominal Pain Cullen's sign Bluish periumbilicaldiscoloration Retroperitoneal hemorrhage(hemorrhagic pancreatitis, abdominal aortic aneurysm rupture) Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy rupture McBurney's sign Tenderness located2/3 distance from anterior iliac spine to umbilicus on right side Appendicitis Murphy's sign Abrupt interruption of inspiration on palpation of right upper quadrant Acute cholecystitis Iliopsoas sign Hyperextension of right hip causing abdominal pain, Appendicitis

CONT- : 

CONT- Obturator's sign Internal rotation of flexed right hip causing abdominal pain, Appendicitis Grey-Turner's sign Discoloration of the flank Retroperitoneal hemorrhage (hemorrhagic pancreatitis, abdominal aortic aneurysm rupture) Chandelier sign Manipulation of cervix causes patient to lift buttocks off table, Pelvic inflammatory disease Rovsing's sign Right lower quadrant pain with palpation of the left lower quadrant Appendicitis

Managment : 

Managment NPO IV FLUIDS - crystalloids ANALGESICS ANTIBIOTICS (Specific) ANTIMETIC

Thank u : 

Thank u