Acute abdomenAcute abdomenfirst aidfirst aid

高醫外傷科高醫外傷科林杏麟林杏麟

外科外科 ? ? 內科內科 ??

• The critical distinction, then, is not betwThe critical distinction, then, is not between acute and nonacute pain, but betweeen acute and nonacute pain, but between surgical and nonsurgical conditions. en surgical and nonsurgical conditions.

外科外科

• serious condition : arises suddenly and iserious condition : arises suddenly and is continuous, progressively worse, and ls continuous, progressively worse, and long lasting, begins during inactivity; and ong lasting, begins during inactivity; and is not near the umbilicus is not near the umbilicus

Gastrointestinal TractGastrointestinal Tract

• Appendicitis, acute*Appendicitis, acute*Meckel's diverticulitis*Meckel's diverticulitis*Perforated bowel*Perforated bowel*Perforated peptic ulcer*Perforated peptic ulcer*Small and large bowel obstruction*Small and large bowel obstruction*Strangulated hernia*Strangulated hernia*DiverticulitisDiverticulitisGastritisGastritisGastroenteritisGastroenteritisInflammatory bowel diseaseInflammatory bowel diseaseMesenteric lymphadenitisMesenteric lymphadenitis

Liver, Spleen, and Biliary TractLiver, Spleen, and Biliary Tract

• Cholangitis, acute*Cholangitis, acute*Cholecystitis, acute*Cholecystitis, acute*Hepatic abscess*Hepatic abscess*Ruptured hepatic tumor*Ruptured hepatic tumor*Ruptured spleen*Ruptured spleen*Biliary colicBiliary colicHepatitis, acuteHepatitis, acuteSplenic infarctSplenic infarct

PeritoneumPeritoneum

• Intra-abdominal abscess*Intra-abdominal abscess*Primary peritonitisPrimary peritonitisTuberculous peritonitis Tuberculous peritonitis

PancreasPancreas

• Pancreatitis, acutePancreatitis, acute

Urinary TractUrinary Tract

• Cystitis, acuteCystitis, acutePyelonephritis, acutePyelonephritis, acuteRenal infarctRenal infarctUreteral or renal colicUreteral or renal colic

Female Reproductive Female Reproductive SystemSystem

• Ruptured ectopic pregnancy*Ruptured ectopic pregnancy*Ruptured ovarian follicular cyst*Ruptured ovarian follicular cyst*Twisted ovarian tumor*Twisted ovarian tumor*DysmenorrheaDysmenorrheaEndometriosisEndometriosisSalpingitis, acuteSalpingitis, acute

Vascular SystemVascular System

• Ischemic colitis, acute*Ischemic colitis, acute*Mesenteric thrombosis*Mesenteric thrombosis*Ruptured arterial aneurysm Ruptured arterial aneurysm

RetroperitoneumRetroperitoneum

• Retroperitoneal hemorrhage Retroperitoneal hemorrhage

MiscellaneousMiscellaneous

• Precompetition anxiety Precompetition anxiety TraumaTrauma

Appendicitis, acuteAppendicitis, acute

• Constant pain, progressively more severConstant pain, progressively more severe; begins in periumbilical region, moves e; begins in periumbilical region, moves to right lower quadrant; nausea, vomitinto right lower quadrant; nausea, vomiting, and anorexia follow pain; low-grade feg, and anorexia follow pain; low-grade fever; patient appears illver; patient appears ill

Cholecystitis, acute Cholecystitis, acute

• Constant pain in right upper Constant pain in right upper quadrant, onset often postprandial; quadrant, onset often postprandial; nausea and vomiting; tenderness in nausea and vomiting; tenderness in right upper quadrant and right right upper quadrant and right shoulder; splinting on right sideshoulder; splinting on right side

Perforated peptic ulcer Perforated peptic ulcer

• Sudden onset of pain in midepigastrium Sudden onset of pain in midepigastrium that spreads and is aggravated by movethat spreads and is aggravated by movement; patient appears acutely ill and is rment; patient appears acutely ill and is reluctant to move; rigid abdomen; gruntieluctant to move; rigid abdomen; grunting respiration; bowel sounds absent ng respiration; bowel sounds absent

Ectopic pregnancyEctopic pregnancy

• Pain sudden, severe, and persistent, genPain sudden, severe, and persistent, generally following a missed or abnormal peerally following a missed or abnormal period, typically epigastric; often associateriod, typically epigastric; often associated with hypotension and tachycardia d with hypotension and tachycardia

Ovarian cystOvarian cyst

• Pain constant with sharp, sudden onset; Pain constant with sharp, sudden onset; usually in ipsilateral hypogastrium; may usually in ipsilateral hypogastrium; may have nausea and vomiting following the have nausea and vomiting following the pain pain

Pelvic inflammatory diseasePelvic inflammatory disease

• Pain at end of or shortly after normal Pain at end of or shortly after normal menstrual period; bilateral lower menstrual period; bilateral lower quadrant pain aggravated by cervical quadrant pain aggravated by cervical manipulation; anorexia, nausea, and manipulation; anorexia, nausea, and vomiting rare; possible cervical vomiting rare; possible cervical discharge; feverdischarge; fever

Urinary calculus Urinary calculus

• Pain location changes with Pain location changes with movement of stone, may radiate to movement of stone, may radiate to testicle, groin of involved side; pain testicle, groin of involved side; pain very severe; patient cannot get very severe; patient cannot get comfortablecomfortable

History and PEHistory and PE

Mode of onset, Mode of onset, progression, character, and progression, character, and severity of painseverity of pain • surgical etiology: sudden in onset, seversurgical etiology: sudden in onset, sever

e or explosive, progressive, continuous, e or explosive, progressive, continuous, and lasts more than 6 hours generally. and lasts more than 6 hours generally.

• nonsurgical diagnosis: gradual in onset, nonsurgical diagnosis: gradual in onset, mild to moderate in intensity, intermittemild to moderate in intensity, intermittent, recurrent, or resolves partially or cont, recurrent, or resolves partially or completely in less than 6 hours. mpletely in less than 6 hours.

Colic painColic pain

• Pain arising in a hollow, tubular structurPain arising in a hollow, tubular structure, such as the ureter, intestine, biliary rae, such as the ureter, intestine, biliary radicles, or fallopian tubes, may be contindicles, or fallopian tubes, may be continuous or intermittent uous or intermittent

Activity during which pain Activity during which pain was first notedwas first noted

• Surgical etiology: awakens the patient oSurgical etiology: awakens the patient or begins during relative inactivity r begins during relative inactivity

• Nonsurgical diagnosis: during or closely Nonsurgical diagnosis: during or closely following strenuous activity--or after eatfollowing strenuous activity--or after eatinging

Initial location of painInitial location of pain

• the farther from the umbilicus the pain localizes, the gthe farther from the umbilicus the pain localizes, the greater the chance that a surgical condition exists. reater the chance that a surgical condition exists.

• Epigastrium: foregut derivatives (stomach, duodenum,Epigastrium: foregut derivatives (stomach, duodenum, biliary tract, and pancreas) or the spleen presents. biliary tract, and pancreas) or the spleen presents.

• periumbilical area: midgut derivatives (jejunum, ileum,periumbilical area: midgut derivatives (jejunum, ileum, proximal third of the colon, and appendix). proximal third of the colon, and appendix).

• Hypogastrium: embryonic hindgut (distal two-thirds oHypogastrium: embryonic hindgut (distal two-thirds of the colon), internal reproductive organs (ovaries, fallf the colon), internal reproductive organs (ovaries, fallopian tubes, uterus, seminal vesicles, and prostate), aopian tubes, uterus, seminal vesicles, and prostate), and the urinary bladder. nd the urinary bladder.

Shifting painShifting pain

• When the original inflammation extends When the original inflammation extends to the parietal peritoneum.to the parietal peritoneum.

• Appendicitis initially causes pain in the pAppendicitis initially causes pain in the periumbilical area. Then, after 4 to 6 houreriumbilical area. Then, after 4 to 6 hours, the inflammation extends to the regios, the inflammation extends to the regional peritoneal surface and is perceived inal peritoneal surface and is perceived in the right lower quadrant.n the right lower quadrant.

Associated symptomsAssociated symptoms

• In surgical conditions, pain may be folloIn surgical conditions, pain may be followed by nausea, vomiting, and anorexia.wed by nausea, vomiting, and anorexia.

• In nonsurgical conditions nausea, vomitiIn nonsurgical conditions nausea, vomiting, and anorexia typically precede pain.ng, and anorexia typically precede pain.

• Clinical experience: vomiting in the obesClinical experience: vomiting in the obese patient is an ominous symptom and sue patient is an ominous symptom and suggests serious abnormalities. ggests serious abnormalities.

• Fever is a common finding in patients Fever is a common finding in patients who have abdominal pain.who have abdominal pain.

• However, fever and chills is rarely However, fever and chills is rarely seen in surgical processes. This seen in surgical processes. This combination suggests infection in the combination suggests infection in the urinary tract, respiratory system, etc. urinary tract, respiratory system, etc.

• Obstipation--nonpassage of both stool aObstipation--nonpassage of both stool and gas--however, always suggests a surgnd gas--however, always suggests a surgical problem. ical problem.

• Diarrhea, especially with cramps, indicatDiarrhea, especially with cramps, indicates gastroenteritis and other nonsurgical es gastroenteritis and other nonsurgical conditions like inflammatory bowel diseconditions like inflammatory bowel disease. ase.

What aggravates the What aggravates the painpain • Always ask first about which activities aggravate Always ask first about which activities aggravate

the pain. (One can generally assume that the the pain. (One can generally assume that the opposite will ease the pain.) opposite will ease the pain.)

• If the patient hears questions about what eases If the patient hears questions about what eases the pain, he or she may perceive it as minimizing the pain, he or she may perceive it as minimizing the problem and become defensive.the problem and become defensive.

• Coughing, sneezing, rapid movements, and Coughing, sneezing, rapid movements, and walking, especially down stairs, can cause walking, especially down stairs, can cause peritoneal irritation. Musculoskeletal pain is often peritoneal irritation. Musculoskeletal pain is often relieved by changing position. A bowel movement relieved by changing position. A bowel movement often eases the pain of gastroenteritis, but the often eases the pain of gastroenteritis, but the pain may promptly recur.pain may promptly recur.

• Men who do experience abdominal Men who do experience abdominal pain have a higher incidence of pain have a higher incidence of surgical disease.surgical disease.

Medications and supplementsMedications and supplements

• Aspirin and other nonsteroidal anti-inflaAspirin and other nonsteroidal anti-inflammatory drugs, erythromycin, potassiummatory drugs, erythromycin, potassium, and salt tablets commonly cause gasm, and salt tablets commonly cause gastric irritation and abdominal pain.tric irritation and abdominal pain.

nonsurgical diagnosis nonsurgical diagnosis

• Previous episodes, family history of siPrevious episodes, family history of similar problems, peers with the same smilar problems, peers with the same symptoms, food intolerance, allergies, ymptoms, food intolerance, allergies, sudden changes in training or diet, ansudden changes in training or diet, and travel to regions with endemic disead travel to regions with endemic disease.se.

Physical Exam PointersPhysical Exam Pointers

• vital signs, inspection, auscultation, lighvital signs, inspection, auscultation, light touch, palpation, percussion, and rectot touch, palpation, percussion, and rectovaginal exam vaginal exam

keys to the physical exam keys to the physical exam

• tell the patient tell the patient • Auscultation should precede other modalities Auscultation should precede other modalities • farthest from the site of maximal pain farthest from the site of maximal pain • ask the patient questions and have him or her ask the patient questions and have him or her

answer during palpation answer during palpation • rebound tenderness rebound tenderness • Any pain elicited in the obese patient is significAny pain elicited in the obese patient is signific

ant ant