laparoscopic management of acute abdomen

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Recent Advances in surgery 31 , acute abdomen as appendicitis , holecystitis , diverticulits , intestinal obstruction , perforated duodenal ulcer

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Diagnosis and Management of Acute Abdominal Pain:

Diagnosis and Management of Acute Abdominal Pain Dimitri Raptis and Alec Engledow

Definition1:

Definition 1 Acute abdominal pain (AAP): Presentation of previously undiagnosed abdominal pain Lasting 1/52 or < Prior to a clinical encounter in 1 0 or 2 0 care 1 De Dombal FT. Diagnosis of acute abdominal pain . New York: Churchill Livingstone; 1991.

Introduction:

Introduction > 1000 causes exist 2 NSAP (34%) Acute appendicitis (28%) Acute chlecystitis (10%) SBO (4%) Perforated PU (3%) Pancreatitis (3%) Diverticular disease (2%) Others (13%) 20-40% admission rates 50-65% inaccurate initial diagnosis 2 De Dombal FT, Margulies M. Acute abdominal pain. Surgery 1996;

Pathophysiology:

Pathophysiology Visceral pain Distention, inflammation or ischaemia in hollow viscous & solid organs Localisation depends on the embryologic origin of the organ: Forgut to epigastrium Midgut to umbilicus Hindgut to the hypogastric region Parietal pain is localised to the dermatome above the site of the stimulus. Referred pain produces symptoms, not signs e.g. tenderness

Generalized AP:

Generalized AP Perforation AAA Acute pancreatitis DM Bilateral pleurisy

Central AP:

Central AP Early appendicitis SBO Acute gastritis Acute pancreatitis Ruptured AAA Mesenteric thrombosis

Epigastric pain:

Epigastric pain DU / GU Oesophagitis Acute pancreatitis AAA

RUQ pain:

RUQ pain Gallbladder disease DU Acute pancreatitis Pneumonia Subphrenic abscess

LUQ pain:

LUQ pain GU Pneumonia Acute pancreatitis Spontaneous splenic rupture Acute perinephritis Subphrenic abscess

Suprapubic pain:

Suprapubic pain Acute urinary retention UTIs Cystitis PID Ectopic pregnancy Diverticulitis

RIF pain:

RIF pain Acute appendicitis Mesenteric adenitis (young) Perf DU Diverticulitis PID Salpingitis Ureteric colic Meckel’s diverticulum Ectopic pregnancy Crohn’s disease Biliary colic (low-lying gall bladder)

Loin pain:

Loin pain Muscle strain UTIs Renal stones Pyelonephritis

LIF pain:

LIF pain Diverticulitis Constipation IBS PID Rectal Ca UC Ectopic pregnancy

Limitations:

Limitations Limitations based on the relationship between Overlying tenderness Underlying surgical disease 35% of intra-operative diagnoses are considered to have had atypical presentations 3 3 Staniland, JR, Br Med J 3:393, 1972

Key points on history:

Key points on history Site Nature & character Duration Intensity Precipitating & relieving factors Associated symptoms

Classification by nature:

Classification by nature Colicky pain Baseline of no pain in true colic IBS Bowel obstruction

Nagging & Grumbling :

Nagging & Grumbling Biliary colic Cholecystitis PID UTI

Stabbing:

Stabbing AAA

Burning or boring:

Burning or boring PUD Oesophagitis

Gnawing:

Gnawing Pancreatitis Pancreatic Ca

Associated symptoms:

Associated symptoms Fever Genitourinary Gynaecological Vascular

PMSH:

PMSH Previous episodes of AP Investigations Operations Chronic disease Immunosuppression Medications (NSAIDs)

Physical examination:

Physical examination OBS are important Observation Bending Forward: Chronic Pancreatitis Jaundiced: CBD obstruction Dehydrated: Peritonitis, Small Bowel obstruction

Systemic Examination:

Systemic Examination Abdomen: Inspection - Scaphoid or flat in peptic ulcer - Distended in ascites or intestinal obstruction - Visible peristalsis in a thin or malnourished patient (with obstruction)

Systemic Examination:

Systemic Examination Palpation Check for Hernia sites Tenderness Rebound tenderness Guarding- involuntary spasm of muscles during palpation Rigidity- when abdominal muscles are tense & board-like. Indicates peritonitis.

Systemic Examination:

Systemic Examination Local Right Iliac Fossa tenderness: Acute appendicitis Acute Salpingitis in females Low grade, poorly localized tenderness: Intestinal Obstruction Tenderness out of proportion to examination: Mesenteric Ischemia Acute Pancreatitis Flank Tenderness: Perinephric Abscess Retrocaecal Appendicitis

Slide 28:

Important Signs in Patients with Abdominal Pain Sign Finding Association Cullen's sign Bluish periumbilical discoloration Retroperitoneal haemorrhage Kehr's sign Severe left shoulder pain Splenic rupture Ectopic pregnancy rupture McBurney's sign Tenderness located 2/3 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 Obturator's sign Internal rotation of flexed right hip causing abdominal pain Appendicitis Grey-Turner's sign Discoloration of the flank Retroperitoneal haemorrhage 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

Physical examination :

Physical examination Auscultation BS > 2min to confirm absent High pitched, hyperactive or tinkling Bruit in epigastrium

Systemic Examination:

Systemic Examination PR Examination: - tenderness - induration - mass - frank blood

Systemic Examination:

Systemic Examination PV Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour

Surgical Myths:

Surgical Myths Rebound tenderness, considered the clinical indicator of peritonitis, has a high (25%) false -ve rate 4 Rigidity, referred tenderness & cough pain are sufficient evidence for peritonitis 5 Except for detection of blood, routine PR exams add little to clinical assessment 6 Administration of analgesics prior to surgical consultation does not obscure the diagnosis, but improves accuracy 7 4 Liddington, MI and Thomson, WH, Br J :795, 1991 5 Bennett, DH Br Med J 308:1336, 1994 6 Manimaran, N et al. Ann Roy Col Surg Engl 86:292 2004 7 Brewster, GS et al. 2000 West J Med 172:209

Initial management :

Initial management 1st 20 sec there are only 3 diagnoses: Very ill: Going to die? ask for help & resus ill: stable for couple h? Urgent investigations, initial diagnosis & management Reasonably well: Investigate as appropriate formulate diagnosis.

Initial management:

Initial management ABCDE Resuscitation & analgesia (opioid IV) Full monitoring (including UO) Low threshold in seeking senior help

Investigations:

Investigations FBC (Hb & WCC) Amylase (Pancreatitis) U&Es, LFTs Clotting (acute pancreatitis, sepsis, DIC, liver disease) Glucose (BM) G&S (X-match if necessary) ABG ECG Cardiac enzymes (if appropriate)

Investigations:

Investigations Attention to the WCC as a screening test only if substantially elevated. 25% of patients with elevated WCC do not have different outcomes from those with a normal WCC 8 FBC has a limited clinical utility

Investigations:

Investigations Urinalysis Cheap Simple & readily available test High yield when results fit with the clinical scenario MSU Pregnancy test

Investigations:

Investigations Radiology Erect CXR Supine AXR USS (?gynae pathology) IVU (renal/ureteric colic)

Investigations:

Investigations Plain X-rays have limited utility in the evaluation of AAP Low diagnostic yield High incidence of misleading incidental findings Lack of impact on management Exception: Bowel obstruction or perforation

CT scanning:

CT scanning No significant advantage in DD of AAP Delay of necessary treatment Routine use not justified Hx taking & physical examination are the basis of correct diagnosis 8 Hx, physical examination & lab investigations are often non-specific CT is now 1st-line imaging modality in pts with APP. MDCT is now faster with thinner slices High diagnostic accuracy 9 8 Keeman JN, New diagnostic imaging technology offten offers no advantage in the differential diagnosis of acute abdomen. Ned Tijdschr Geneeskd. 1999. Nov. 6:143(45):2225-9 9 Leschka et al,Multi-detector computer tomography of acute abdomen. Eur Radiol. Dec;15(12):2435-47. 2005

Laparoscopy10,11 :

Laparoscopy 10,11 Early diagnostic laparoscopy may result in: accurate, prompt, efficient management of AAP Reduces the rate of unnecessary laparotomy Increases the diagnostic accuracy May be a key to solving the diagnostic dilemma of NSAP. 10 Golash and Willson. Early laparoscopy as a routine procedure in the management of acute abdominal pain: a review of 1320 patients. Surg Endosc. 2005 Jul;19(7):882-5 11 Keller et al. Diagnostic laparoscopy in acute abdomen. Chirurg. 2006 Nov;77(11):981-5

Suggestions:

Suggestions Audit of all patients referred with AAP to assess: Initial diagnosis Choice & diagnostic efficacy of investigations Treatment Timing (length of stay) Cost effectiveness

Thank you:

Thank you

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