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- 1. Author: Sizipiwe Memka Moderator:Dr Mokone The Acute Abdomen: Diagnosis and Management
- 2. Definition Acute onsetof abdominal pain ( 2 weeks or less) Signifies major intra-abdominal pathology Symptoms and signs predominantly abdominal When talking about an acute abdomen in general surgery we are usually excluding trauma as a cause Commonest reason for admission to General surgery ward Usually indicates major intra-abdominal pathology Resus and surgery is usually the Management
- 3. Syndromic approach toan acute abdomen Normal anatomy and physiology Differential causes Clinical picture Management: Investigations Treatment
- 4. Anatomy Abdominal painmay be: Visceral Parietal
- 5. Anatomy/physiology – Visceralsensation Gut division Anatomy Vascular supply Site of pain Foregut Oesophagus, stomach, proximal duodenum, pancreas Coeliac artery Epigastric Midgut D4 to mid-transverse colon Superior mesenteric artery Peri-umbilical Hindgut Distal colon, rectum Inferior mesenteric artery Supra-pubic
- 6. Pain and theAbdomen Visceral sensation Poorly localized Sensitive to obstruction and distention Colic type pain progressing to constant Visceral pain may be accompanied by sweating, restlessness, gastro-intestinal Upset Source of pain Stretching/ distension Inflammation Ischemia of peritoneal Direct invasion of nerves by malignancy Associated symptoms Autonomic NS ( sweat, restlessness, nausea, gastro-intestinal Upset)
- 7. Anatomy / physiology– Parietal sensory innervation Parietal peritoneum, abdominal wall, retroperitoneum Richly innervated with somatic innervation corresponding to segmental nerve roots – particularly sensitive, with referral to relevant dermatome Sudden, sharp/intense, well localised pain Sensitive to touch and temperature Exquisite ‘aahh’ type pain Via somatic fibres (like fingers) Localisation of pain: Some conditions progress from visceral to parietal e.g. appendicitis (peri- umbilical to well localised right iliac fossa pain)
- 8. Pain and theAbdomen Manoeuvres that exacerbate parietal peritoneal irritation intensify the pain resulting in: Somatic sensation Guarding Rebound tenderness Percussion tenderness Peritonism
- 9. Causes of anAcute Abdomen Gastro-intestinal Vascular Gynaecological Genito-urinary Non-surgical
- 10. Gastro-intestinal Inflammatory Stomach oGastric, duodenal ulcer (perforation) Biliary tract o Cholecystitis, CBD stones Pancreas o Acute/recurrent/chronic pancreatitis Small intestine o Crohn’s, Meckel’s diverticulum, Mesenteric ischaemia Large intestine o Appendicitis, diverticulitis, ischaemia, U/C Obstruction Jejunum o Hernia, malignancy, volvulus, adhesions, intussusception Ileum o Hernia, malignancy, volvulus, adhesions, intussusception Colon o Hernia, malignancy (perforation, obstruction), volvulus, diverticulitis
- 11. Vascular Leaking /ruptured aortic aneurysm Aortic dissection
- 12. Gynaecological Ovary o RupturedGraafian follicle/ovarian cyst o Bleed into ovarian cyst o Ovarian torsion Fallopian tube o Ectopic pregnancy o Acute salpingitis/PID o Pyosalpinx Uterus o Miscarriage o Uterine rupture o Endometritis
- 13. Genito-urinary Pyelonephritis Uretericobstruction – Renal stones Epidydimo-orchitis Testicular torsion Renal tract malignancy
- 14. Non-surgical Causes Cardiac oMI o Pericarditis Pulmonary o Pneumonia o Pulmonary infarction Gastro-intestinal o Gastro-enteritis o Hepatitis Endocrine o DKA o Acute adrenal insufficiency Metabolic o Acute porphyria Musculoskeletal o Rectus muscle haematoma Central/peripheral nervous system o Nerve root compression Genito-urinary o Pyelonephritis o Acute salpingitis Haematological o Sickle cell crisis
- 15. Clinical picture ASK ABOUTPAIN THOROUGHLY: define the presenting complaint Location and radiation Where is it, and where does it radiate to? o RUQ- liver or biliary tree o Shoulder tip- diaphragmatic irritation o Back- retroperitoneal pathology o Groin-renal or iliopsoas disease o RIF- appendix/ ileocaecal disease o LIF- colon Temporal elements The onset, frequency, and duration of the pain are helpful features o Neoplasms = gradual and persistent o Perforation with localized abscess = sudden onset & high intensity Severity The severity of the pain generally is related to the severity of the disorder, especially if acute in onset o High intensity= advanced malignancy/ abscess Precipitants or ameliorating factors Identify what precipitates or improves the pain o pancreatitis = strong association with alcohol intoxication
- 16. ASK ABOUT PAINTHOROUGHLY: define the presenting complaint GIT symptoms o Nausea, vomiting= gastric outlet obstruction due to gastric cancer? o Constipation= colorectal malignancy o Jaundice = HPB malignancy or chronic pancreatitis Genitourinary symptoms o Hematuria= renal cell carcinoma Gynaecological history o Menstrual history (LMP, previous period, cycle length) – make sure the patient is NOT PREGNANT o Dyspareunia or dysmenorrhea- possible uterine or ovarian neoplasms Constitutional symptoms Fevers, rigors= peritonitis, UTI, cholangitis Fatigue, weight loss, and anorexia =malignancy, TB, systemic illnesses, inflammatory bowel disease Note in bowel obstruction: Distal to ampulla of vater = bile stained Proximal to ampulla of Vater = clear Longstsanding SBO = faeculent Also ask: Menstrual changes Co-morbidities Medication use Past surgeries Substance use e.g. amphetamines = vasoactive and cause vasospasm
- 17. TAKE A COMPREHENSIVEHISTORY: this allows you to consider other causes, and contextualize the patient’s fitness for intervention Cardio-respiratory symptoms Does the patient have co-morbidities? o cough, shortness of breath, orthopnea, exertional dyspnea, angina o Consider AAA in patients with CVS co-morbidity Past medical history o Previous abdominal surgery = ? bowel obstruction or recurrent cancer o Recent trauma= ? traumatic pancreatitis & pseudocyst o HIV+ve = abdominal tuberculosis o Previous malignancy= cancer recurrence/ obstruction? Precipitants & other aetiological factors o Alcohol = acute or chronic pancreatitis? o Recent blunt or penetrating trauma= delayed bowel perforation, pancreatitis, diaphragmatic herniae, liver haematoma, false aneurysm
- 18. Examination General • Pyrexia= peritonitis,TB, UTI, PID • Anaemia= malignancy , chronic disorders, AAA • Jaundice= biliary obstruction • Peripheral adenopathy= malignancy Hydration status Weight loss Position/movement o Hip flexion (psoas muscle involved) o Agitated vs avoiding motion Abdomen Inspection o Scaphoid, flat, distended (5 F’s) o Scars, hernias, masses o Distension o Examine the groins & scrotum- remember to exclude testicular tumours! Palpation Tenderness, guarding, rigidity, rebound/percussion tenderness peritonism surgery with a few exceptions o Generalised/localised o + Murphy’s (cholecystitis) o Guarding: voluntary vs involuntary Tenderness with hip flexion – retro-caecal appendicitis, psoas muscle involment Masses (define size, shape, consistency, tenderness, mobility, pulsation) Causes of an abdominal mass o Fat, fetus, fibroids, fluid (ascites or urine), flatus, faeces, fatal tumour
- 19. Abdominal examination Percussion Tenderness Tympany Punch tenderness Auscultation Ileus, bowel obstruction Bruit or murmur= AAA, renal artery aneurysm PV/Rectal examination o Stool bolus= Fecal impaction & obstruction in older adults o Tender PR = pelvic abscess o Blood PR= colorectal malignancy All women must have a pelvic examination o Is there a uterine or ovarian mass?
- 20. Investigations Bedside o Checkurine, pregnancy test, ECG, point of care ultrasound, blood gas Laboratory o FBC / differential, U & E, crp, INR / PTT, glucose, LFT’s, lipase/amylase, tumour markers Imaging o ECG o CXR/AXR
- 21. Investigations - imaging CXR / AXR • Gas: o Free (sub diaphragmatic) o Bowel wall o in portal, mesenteric venous system o gallbladder o urinary tract o Retroperitoneal CXR / AXR • Calcifications o Vascular, stones, appendicoliths, chronic pancreatitis • Air fluid levels / bowel obstruction
- 22. Investigations - imaging Ultrasound o Solid organs / masses, interfaces, calculi o Liver /GB/biliary tree, spleen, kidneys, pancreas, gynae organs, masses, ? appendix o Fluid / collections o Rapid, safe, low cost but operator dependant, not as sensitive as CT o Thin patient, good in biliary and gynae pathology CT scan o gas o Intra-abdominal collections / inflammation o Masses o Bowel pathology / obstruction MRI • Adds extra information in some pancreatic or liver cases • very expensive, least availability
- 23. Other investigations toconsider Contrast study • Can demonstrate obstructions or tumors arising from the GIT, especially from the esophagus and stomach Endoscopy • If suspecting a gastric or colonic neoplasm • Widely available allows for histological diagnosis Laparoscopy • Excellent to differentiate TB or metastatic disease • Commits patient to surgery, • uses theatre resources, • requires surgical expertise Angiography • Vascular cases with occult bleeding or false aneurysm • Requires very specific endovascular skills
- 24. Treatment Resuscitation Supportivecare in conservative Management: fluids, antibiotics, drainage of collections, pain relief Surgery indicated if: • Diffuse peritonism, with few exceptions • Increasing localised tenderness • Radiological evidence of perforation • Unexplained sepsis • Organ dysfunction • Difficult assessment: immunity, neurologically impaired • Failed conservative Management
- 25. Surgical intervention Pre-opprep • Resuscitation to p of 100b/min, BP of 100 mm Hg systolic • IV line, fluids, electrolyte replacement • Antibiotics, analgesia • Nasogastric tube • Urinary catheter – output of 0,5 ml /kg • Diabetic control • Baseline meds, ?steroid replacement Invasive & Minimally invasive procedures • Laparoscopy o Diagnostic o Therapeutic • Laparotomy
- 26. References A ClinicalApproach To Common Surgical Scenarios: Eugenio Panieri & Francois Malherbe EM Guidance Medscape
Editor's Notes
- #5 Abdominal pain has two central forms, depending on its relationship to the peritoneal lining; Visceral and Parietal. Visceral nerve fibers accompany the arterial supply to the abdomen now this helps define the abdominal viscera relating to the gut into 3 main divisions.