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2.Approach to apatient with acute abdomen.ppt
- 1. APPROACH TO APATIENT WITH ACUTE ABDOMEN AND IT’S MANAGEMENT Group Members : Natian Tsegaye Nebil Ahmed Nebiyu Abera Nebiyu Negash Negash Belihu
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- 3. OUTLINE Introduction Approachto a patient with acute abdomen Differential diagnosis of acute abdomen Management of acute abdomen 3
- 4. INTRODUCTION Acute abdomenis defined as a recent or sudden onset of abdominal pain. It requires a thorough and expeditious workup to determine the need for operative intervention and to initiate appropriate therapy. The acute abdomen does not always signify the need for surgical intervention 4
- 5. CLASSIFICATION Based onetiology Medical Surgical Obstructive Hemorrhage Ischemia Perforation infection 5
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- 7. Surgical Causes ofAcute Abdomen 7
- 8. Nonsurgical causes ofacute abdomen Endocrine and metabolic Hematologic Toxins or drugs 8
- 9. Pathophysiology of acute abdomen Visceral pain Visceral peritoneum is innervated bilaterally by the ANS Midline, vague, deep, dull, and poorly localized i.e foregut, midgut and hindgut structures based on their embryologic origin have pain at epigastric, periumblical and suprapubic region respectively. Triggered by inflammation, ischemia, and geometric changes such as distention, traction, and pressure. 9
- 10. Common locations forvisceral pain 10
- 11. Cont. Parietal pain Parietal peritoneum is innervated unilaterally via the spinal somatic nerves. Sharp, severe, and well localized Triggered by irritation of the parietal peritoneum by an inflammatory process or surgical incision. 11
- 12. Cont. Referred pain Arises from a deep visceral structure but is superficial at the presenting site. Is due to neural pathways that are common to the somatic nerves and visceral organs. 12
- 13. Common sites ofreferred pain 13
- 14. APPROACH TO APATIENT WITH ACUTE ABDOMEN The workup proceeds in the order of History Physical examination laboratory, and imaging studies 14
- 15. HISTORY Questions mustbe open-ended whenever possible As to the pain Location – where? Over an organ Epigastric Periumblical Suprapubic Onset Sudden onset Pain that develops and worsens over several hours Intermittent episodic pain Character Burning Crampy or colicky Tearing Dullache Chronology N.B. shifting pain Timing Severity Radiation 15
- 16. Cont. Exacerbating orrelieving factors to the pain are also important Eating Movement Positioning 16
- 17. Associated symptoms Canbe important clues to the diagnosis. Nausea and vomiting Diarrhea constipation Distention Site Association 17
- 18. Cont. Hematochezia ormelena Hematemesis Hematuria Abdominal masses 18
- 19. The past medicalhistory Can potentially be more helpful than any other single part of the patient's evaluation Re-expriencing of symptoms Prior surgery 19
- 20. A history ofmedications Narcotics NSAIDs Steroids Immunosuppressant agents Anticoagulants Chronic alcoholism Cocaine and methamphetamine ischemia 20
- 21. History of trauma In unexplained acute abdominal pain The gynecologic history Menstrual history Ectopic pregnancy, PID, mittelschmerz, or severe endometriosis 21
- 22. PHYSICAL EXAMINATION GeneralAppearance Facial expression Nature of breathing Lying still, Fidgeting Pallor, cyanosis, and diaphoresis 22
- 23. Cont. Vital signs PR, RR, BP, T0 C HEENT Sclerae Conjunctivae Buccal mucosa Chest 23
- 24. Abdominal examination Inspection Contour, symmetry and mass Movement with respiration Visible peristalisis scars Hernial sites Ecchymosis 24
- 25. Auscultation Bowel sounds Quantity Quiet or hypoactive Hyperactive Quality High pitched tinkling Echoic Bruits in high grade arterial stenoses 25
- 26. Palpation Provides moreinformation than any other single component of the abdominal exam. N.B. the examiner should apply consistent pressure to the abdominal wall starting away from the point of maximal pain while asking the patient to take a slow, deep breath. 26
- 27. Cont. Tenderness LocalisedVs generalised Direct Vs rebound Mass Site, Size and shape, Surface, edge and consistency, mobility and attachments Guarding and rigidity Organomegally Thoroughly search for hernias 27
- 28. Common Abdominal Examination Signs SIGNDESCRIPTION DIAGNOSIS/ CONDITION Blumberg's sign Transient abdominal wall rebound tenderness Peritoneal inflammation Cullen's sign Periumbilical bruising Hemoperitoneum Grey Turner's sign Local areas of discoloration around umbilicus and flanks Acute hemorrhagic pancreatitis Iliopsoas sign Elevation and extension of leg against resistance creates pain Appendicitis with retroce abscess Kehr's sign Left shoulder pain when supine and pressure placed on left upper abdomen Hemoperitoneum (especially from splenic origin) Murphy's sign Pain caused by inspiration while applying pressure to right upper abdomen Acute cholecystitis Obturator sign Flexion and external rotation of right thigh while supine creates hypogastric Pelvic abscess or inflammatory mass in pelvis 28
- 29. Percussion Tympany Dullness Fluid thrill Shifting dullness 29
- 30. Digital rectal examination Tenderness Content of the rectum Hard stool Mass Blood on examining finger Pelvic examination Speculum and bimanual evaluation 30
- 31. Referrences Sabiston textbookof surgery, 19th edition The Washington manual of surgery, 5th edition Bailey & Love’s short practice of surgery, 25th edition 31
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- 36. Intraperitoneal cause ofAA Inflammatory Peritoneal Chemical and nonbacterial peritonitis Perforated peptic ulcer/biliary tree, pancreatitis, ruptured ovarian cyst, mittelschmerz Bacterial peritonitis Primary peritonitis Pneumococcal, streptococcal, tuberculous Spontaneous bacterial peritonitis Perforated hollow viscus Esophagus, stomach, duodenum, small intestine, bile duct, gallbladder, colon, bladder Hollow visceral Appendicitis Cholecystitis Peptic ulcer Gastroenteritis Gastritis Duodenitis Inflammatory bowel disease Meckel diverticulitis Colitis (bacterial, amebic) Diverticulitis 36
- 37. Cont… Solid visceral Pancreatitis Hepatitis Pancreatic abscess Hepaticabscess Splenic abscess Mesenteric Lymphadenitis (bacterial, viral) Pelvic Pelvic inflammatory disease (salpingitis) Tubo-ovarian abscess Endometritis Mechanical (obstruction, acute distention) Hollow visceral Intestinal obstruction Adhesions, hernias, neoplasms, volvulus Intussusception, gallstone ileus, foreign bodies parasites Biliary obstruction Calculi, neoplasms, choledochal cyst, 37
- 38. Cont… Solid visceral Acute splenomegaly Acuteheptomegaly (congestive heart failure, Budd-Chiari syndrome) Mesenteric Omental torsion Pelvic Ovarian cyst Torsion or degeneration of fibroid Ectopic pregnancy Hemoperitoneum Ruptured hepatic neoplasm Spontaneous splenic rupture Ruptured mesentery Ruptured uterus Ruptured graafian follicle Ruptured ectopic pregnancy Ruptured aortic or visceral aneurysm Ischemic Mesenteric thrombosis Hepatic infarction (toxemia, purpura Splenic infarction Omental ischemia Strangulated hernia Traumatic 38
- 39. Extraperitoneal causes ofAA Genitourinary Pyelonephritis Perinephric abscess Renal infarct Nephrolithiasis Ureteral obstruction (lithiasis, tumor) Acute cycstitis Prostatitis Seminal vesiculitis Epididymitis Orchitis Testicular torsion Dysmenorrhea Threatened abortion 39
- 40. Cont… Pulmonary Pneumonia Empyema Pulmonary embolus Pulmonaryinfarction Pneumothorax Cardiac Myocardial ischemia Myocardial infarction Acute rheumatic fever Acute pericarditis Infectious Bacterial Parasitic (malaria) Viral (measles, mumps, infectious mononucleosis) Rickettsial (Rocky Mountain spotted fever) 40
- 41. Cont… Endocrine Diabetic ketoacidosis Hyperparathyroidism (hypercalcemia) Acuteadrenal insufficiency (Addisonian crisis) Hyperthyroidism or hypothyroidism Musculoskeletal Rectus sheath hematoma Arthritis/diskitis of thoracolumbar spine Neurogenic Herpes zoster Tabes dorsalis Nerve root compression Spinal cord tumor Inflammatory Schönlein-Henoch purpura Systemic lupus erythematosus Polyarteritis nodosa 41
- 42. Cont… Hematologic sickle cellcrisis Acute leukemia Pernicious anemia Vascular Vasculitis Periarteritis Toxins Bacterial toxins (tetanus, staphylococcus) Insect venom (black widow spider) Animal venom Heavy metals (lead, arsenic, mercury) Poisonous mushrooms Drugs Withdrawal from narcotics Retroperitoneal Retroperitoneal hemorrhage (spontaneous adrenal hemorrhage) Psoas abscess Psychogenic Hypochondriasis Somatization disorder 42
- 43. The mostcommon cause of acute abdomen 1. Acute appendicitis 2. Acute cholecystitis 3. Small bowel obstruction 4. Perforated peptic ulcer 5. Acute pancreatitis Age and Sex are important determining factors 43
- 44. Acute abdomenin TAH~ 2000 E.C (Berhanu K.) i. Acute Appendicitis=52% ii. Intestinal obstruction=26% ii. Small bowel=62.9% iii. Large bowel=37% (23 cases) 44
- 45. Investigation Laboratory tests CBC- Hct - WBC count with differential Serum electrolyte BUN and Cr LFT Serum amylase and lipase Serum glucose Urinalysis – RBC, WBC, glucose, ketone, specific gravity Pregnancy test for women on child bearing age 45
- 46. Imaging Plainabdominal X- ray 46
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- 49. Uses Intestinal obstruction Pneumoperitoneum in intestinal perforation Ureteral calculi Fecolith in appendicitis Obliteration of psoas shadow in retroperitoneal hematoma 49
- 50. Other U/S– gallstone,ovarian cyst, ectopic pregnancy CT scan– if dx is not resolved CXR 50
- 51. Management Acute abdomenof surgical condition that needs immediate laparotomy AAA, ruptured ectopic pregnancy, spontaneous hepatic or splenic rupture Underlying surgical condition that doesn’t necessitate immediate laparotomy but needs urgent laparotomy Acute appendicitis and perforated hollow viscera 51
- 52. Uncertain dxthat doesn’t necessitate immediate or urgent laparotomy Important to minimize unnecessary laparatomies Frequently observe and properly investigate Underlying non surgical condition Acute gastritis, hepatitis, SBP, Tb peritonitis 52
- 53. General measures Resuscitation Monitor vital sign Pain control?????? controversial 53
- 54. Specific measures 1. Acuteappendicitis The definitive Mx is surgery (Appendicectomy) 54
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- 56. Intestinal obstruction GastrointestinalDrainage Decompression Reduce risk of aspiration Fluid & e’ replacement Broad spectrum antibiotics 56
- 57. Surgical It dependson: Site of obstruction Nature of the obstruction Viability of the bowel The type of surgical procedure required depends on the cause of the obstruction. E.g. For adhesion = adhesionolysis volvulus= resection& anatomises 57
- 58. SIGMOID VOLVULUS Insertionof a flatus tube to deflate the gut Hartman’s procedure If loop is gangrenous and proximal bowel is loaded with fecal matter 6 wks – colorectal anastomosis Sigmoidopexy-if not gangrenous Exteriorisaton- Paul Mickulicz procedure If loop is gangrenous Poor patient condition in elderly, sever dehydration with impending septicemia 58
- 59. Acute cholecyctities Conservative Admission Aspiration with NGT Analgesics Antispsmodic 59
- 60. Surgery Early cholecystectomy Delayed cholecystectomy 60
- 61. Perforated PUD Supportive mgm’t GI-decompression IV-fluid Analgesia Broad spectrum Antibiotics 61
- 62. Surgery Exploratory lapartomy Peritoneal toilet/wash Identification of the perforation site Repair (preferably using omental patch) 62
- 63. Acute pancreatititis Mild attack IV- fluid Analgesia Anti-emetics 63
- 64. Severe attack Admitto ICU Aggressive fluid resuscitation Administer Oxygen Adequate analgesia Antibiotics Sphincterectomy- in case of gall- stone 64
- 65. Indication forsurgery Infected necrosis Pancreatic abscess Complication such as massive bleeding not responsive for conservative Tx 65
- 66. Reference ACS clinicalsurgery Uptodate Schwartz 66
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Editor's Notes
- #4 This can be new pain or an increase in chronic pain.
- #11 Parietal peritoneum is innervated unilaterally via the spinal somatic nerves that also supply the abdominal wall.
- #17 Vomiting may result from severe abdominal pain of any etiology or from mechanical bowel obstruction or ileus. Vomiting is more likely to precede the onset of significant abdominal pain in many medical conditions, whereas the pain of an acute surgical abdomen presents first and stimulates vomiting through medullary efferent fibers that are triggered by the visceral afferent pain fibers. Constipation or obstipation can be a result of either mechanical obstruction or decreased peristalsis. It may represent the primary problem and require laxatives and prokinetic agents, or merely be a symptom of an underlying condition. A careful history includes whether the patient is continuing to pass any gas or stool from the rectum. A complete obstruction is more likely to be associated with subsequent bowel ischemia or perforation due to the massive distention that can occur. Diarrhea is associated with several medical causes of acute abdomen, including infectious enteritis, inflammatory bowel disease, and parasitic contamination. Bloody diarrhea can be seen in these conditions as well as in colonic ischemia.
- #19 Previous illnesses or diagnoses can greatly increase or decrease the likelihood of certain conditions that would otherwise not be highly considered. Patients may, for example, report that the current pain is very similar to the kidney stone passage they experienced a decade prior. On the other hand, a prior history of appendectomy, pelvic inflammatory disease, or cholecystectomy can significantly shape the differential diagnosis. During the abdominal examination, all scars on the abdomen must be accounted for by the medical history obtained.
- #20 A history of medications and a gynecologic history of female patients are very important. Medications can both create acute abdominal conditions or mask their symptoms. Although a thorough discussion of the impact of all medications is beyond the scope of this chapter, several common drug classes deserve mention. High-dose narcotic use can interfere with bowel activity and lead to obstipation and obstruction. Narcotics also can contribute to spasm of the sphincter of Oddi and exacerbate biliary or pancreatic pain. Clearly, they also may suppress pain sensation and alter mental status, which can impair the ability to accurately diagnose the condition. Nonsteroidal anti-inflammatory agents are associated with an increased risk for upper gastrointestinal inflammation and perforation, whereas steroids can block protective gastric mucous production by chief cells and reduce the inflammatory reaction to infection, including advanced peritonitis Immunosuppressant agents as a class both increase a patient's risk for acquiring a variety of bacterial and viral illnesses and blunt the inflammatory response, diminishing the pain that is present and the overall physiologic response. Anticoagulants are much more prevalent in emergency patients as the population ages. These drugs may be the cause of gastrointestinal bleeds, retroperitoneal hemorrhages, or rectus sheath hematomas. They also can complicate the preoperative preparation of the patient and can cause substantial morbidity if their use goes unrecognized. Finally, recreational drugs can play a role in patients with an acute abdomen. Chronic alcoholism is strongly associated with coagulopathy and portal hypertension from liver impairment. Cocaine and methamphetamine can create an intense vasospastic reaction, which can create life-threatening hypertension as well as cardiac or intestinal ischemia Chronic alcoholism is strongly associated with coagulopathy and portal hypertension from liver impairment. Cocaine and methamphetamine can create an intense vasospastic reaction, which can create life-threatening hypertension as well as cardiac or intestinal ischemia.
- #21 The gynecologic history, and specifically the menstrual history, is crucial in evaluation of lower abdominal pain in young women. The likelihood of ectopic pregnancy, pelvic inflammatory disease, mittelschmerz, or severe endometriosis is heavily influenced by the details of the gynecologichistory
- #22 Despite newer technologies, including high-resolution computed tomography (CT) scanning, ultrasound, and magnetic resonance imaging (MRI), the physical examination remains a key part of a patient's evaluation
- #24 Abdominal inspection addresses the contour of the abdomen, including whether it appears distended or scaphoid or whether a localized mass effect is observed. Special attention is paid to all scars present, and if surgical in nature, scars need to correlate with the past surgical history provided. Fascial hernias may be suspected and can be confirmed during palpation of the abdominal wall. Evidence of erythema or edema of skin may suggest cellulitis of the abdominal wall, whereas ecchymosis is sometimes observed with deeper necrotizing infections of the fascia or abdominal structures such as the pancreas.
- #25 Mechanical bowel obstruction is characterized by high-pitched “tinkling” sounds that tend to come in rushes and are associated with pain. Far-away, “echoing” sounds are often present when significant luminal distention exists. Bruits heard within the abdomen reflect turbulent blood flow within the vascular system in the setting of high-grade arterial stenoses of 70% to 95% but can also be heard if an arteriovenous fistula is present.
- #26 In addition to revealing the severity and exact location of the abdominal pain, palpation can further confirm the presence of peritonitis as well as identify organomegaly or an abnormal mass lesion. Palpation always begins gently and away from the reported area of pain. If considerable pain is induced at the outset of palpation, the patient is likely to voluntarily guard and continue to do so, limiting the information obtained. Involuntary guarding, or abdominal wall muscle spasm, is a sign of peritonitis and must be distinguished from voluntary guarding. To accomplish this, the examiner applies consistent pressure to the abdominal wall away from the point of maximal pain while asking the patient to take a slow, deep breath. In the setting of voluntary guarding, the abdominal muscles will relax during the act of inspiration, whereas if involuntary, they remain spastic and tense.
- #27 Pain out of proportion to physical examination findings suggests mesenteric ischemia.
- #29 Percussion is used to assess for gaseous distention of the bowel, free intra-abdominal air, degree of ascites, or presence of peritoneal inflammation. Firmly tapping the iliac crest, the flank, or the heel of an extended leg will jar the abdominal viscera and elicit characteristic pain when peritonitis is present.
- #30 A pelvic examination is included in all women when evaluating pain located below the umbilicus. Gynecologic and adnexal processes are best characterized by a thorough speculum and bimanual evaluation. Tenderness or a mass on the right pelvic side wall is sometimes seen in appendicitis. A pelvic examination is included in all women when evaluating pain located below the umbilicus. Gynecologic and adnexal processes are best characterized by a thorough speculum and bimanual evaluation.