The$Acute$Abdomen$ - jjsjjs.me.uk/images/docs/Acute abdomen.pdf · Si Distended resonant abdomen ‘tinkling’ bowel sounds shock Ix CT Mx Fluid balance Conservative vs Operative

Mr Jason Smith - Consultant Surgeon

The Acute Abdomen

Jason Smith MD DMI FRCS(Gen.Surg) Consultant Surgeon


Acute Abdomen

General name for presence of signs, symptoms of inflamma4on of peritoneum


The problems of a surgeon   If I operate and the problem is not surgical, pa4ent exposed to unnecessary risk, anesthe4c, etc.   Risks greater with concomitant illness, older age

  If I do not operate and problem is surgical, pa4ent at risk because of wrong therapy.   Again the older pa4ent is under greater burden.

  Risk-‐Predic4on Algorithms


Probably needs an operation   Acute pain   Sep4c & toxic   Board-‐like abdomen

  Absent bowel sounds   WBC 25,000   Free air under diaphragm


Probably doesn’t need an operation   Trivial pain   Robust appearance   SoM abdomen with no guarding

  Normal bowel sounds   Normal WBC/CRP


Abdominal Anatomy   Organs can be classified as:

  Hollow

  Solid   Major vascular


Solid Organs   Liver   Spleen   Kidney

  Pancreas

When solid organs are injured, they bleed heavily

and cause shock


Patient Assessment – Initial Views   Does the pa4ent look ill, sep4c or shocked?

  Call for help!

  Are they lying s4ll   (peritoni4s, shock),

  or rolling around in agony   (colic)?

  Assess and manage Airway, Breathing and Circula4on as a priority (as per ALS/ATLS).


Patient Assessment – Initial Views   As per ATLS, Mx occurs at the same 4me as assessment & diagnosis   Large bore venflon – large vein

  Oxygen

  Analgesia (limited)

  “Am I out of my depth?”   “Do I have enough help?”

  Documenta4on!!   Safety -‐ you


Patient Assessment -‐ History   Where do you hurt?

  Know loca4ons of major organs

  But realize abdominal pain loca4ons do not correlate well with source


Patient Assessment -‐ History   What does pain feel like?

  Steady pain -‐ inflammatory process

  Crampy pain -‐ obstruc4ve process

  Sharp – peritoneal irrita4on

  Dull – peritoneal stretching


Patient Assessment -‐ History   Was onset of pain gradual or sudden?   Sudden = perfora4on, hemorrhage, infarct

  Gradual = peritoneal irriga4on, hollow organ distension


Patient Assessment -‐ History   Does pain radiate (travel) anywhere?

  Right shoulder, angle of right scapula = gall bladder

  Around flank to groin = kidney, ureter   Into middle of back = pancreas, duodenum


Patient Assessment -‐ History

  Dura4on?   <6 hour dura4on = ? surgical significance

  Nausea, vomi4ng? Bloody? “Coffee Grounds”?

Any blood in GI tract = Emergency until proven otherwise



  Change in urinary habits? Urine appearance?   Change in bowel habits? Appearance of bowel movements? Melena?


Patient Assessment -‐ History   Regardless of underlying cause vomi4ng or diarrhea can be a problem because of associated volume loss

Everybody has pancreatitis until proven otherwise



  Females   Last menstrual period?

  Abnormal bleeding?

In females, abdominal pain = Gynaeproblemuntil proven otherwise

In females, abdominal pain = Pregnant until proven otherwise


Physical Exam   General Appearance

  Lies perfectly s4ll inflamma4on, peritoni4s

  Restless, writhing obstruc4on

  Abdominal distension?

  Ecchymosis around umbilicus, flanks?


Physical Exam

  Vital signs   Tachycardia ? Early shock (more important than BP)

  Rapid shallow breathing peritoni4s

Young / Old patients have different responses to fluid loss


Physical Exam   Palpate each quadrant

  Work toward area of pain

  Warmhands, gentle approach!   Pa4ent on back, knee bent (helps relax)

  Use child’s own hand

  Note tenderness, rigidity, involuntary guarding, voluntary guarding (steth-‐test), masses


Physical Exam   Bowel Sounds

  Listen 1 minute in each quadrant

  Listen before feeling   Absent bowel sounds ileus, peritoni4s, shock

Auscultating bowel sounds has no value in trauma patients

Auscultating bowel sounds in reality is a waste of time in the acute phase


Management   Airway   High flow O2

  An4cipate vomi4ng, appropriate clothing, bowel

  An4cipate hypovolemia – hence large bore cannulae   Nothing by mouth, un4l DDx established   Limited analgesics


Management   In adults > 30, consider possibility of referred cardiac pain.

  In females, consider possible gynaeproblem, especially tubal ectopic pregnancy


Acute Abdomen -‐ Investigations   Urinalysis   FBC, U&E   Plain AXR

  (CT)


The WCC in 570 patients Diagnosis Sensi+vity % Specificity %

Appendici4s (↑) 91 21

Cholecys44s (↑) 78 11 Obstruc4on (↑) 56 8

Gastroenteri4s (N) 49 11

Other Non-‐surgical (N) 62 82

Predic4ve value of ↑ WCC for surgical condi4on 29% Predic4ve value of ↓ WCC for non-‐surgical cond 93%


Sensitivity of plain AXR-‐ 249 Patients % Abnormal

Appendici4s 48 Cholecys44s 64

Pancrea44s 60 Intes4nal Obstruc4on 98 Perforated Ulcer 60


Frequency of Diagnoses in 1000 Patients

Unknown 41% Cholecys4s 4% Urinary Tract 9% Intes4nal Obst 2.5%

Gastroenteri4s 7% Cons4pa4on 2%

PID 7% Misc 7%

80%!!


Appendiscitis

Age Young > old Dx correct in 50% Several episodes

Sx Central dull to RIF sharp N&V Off food

Si Pain, foetor WCC, CRP – waste of time

Ix Exclude gynae problems

Mx Fluid balance Antibiotics Laparoscopy or open


Stomach/duodenum – Perforation

Age Young men & alcohol Older anyone & drugs

Sx Pain, generalised, sharp, upper Rigidity

Si Peritonism Shock +/- sepsis

Ix Air under diaphragm CT better

Mx Fluid resus – most important Laparotomy & oversew / patch Conservative?


Age Young men & alcohol Older anyone & drugs

Sx Haematemesis +/- Melena

Si Shock Rockall score Wilson Index

Ix OGD (mesenteric angiogram)

Mx Fluid resus – most important OGD inject Laparotomy & underun


Age Fat, female, forty, fertile Common in Asians

Sx Colicky upper abdo pain (stools/urine), Courvoisier's sign N&V

Si Palpable GB Jaundice

Ix USS +/- CT (Must exclude Ca Pancreas)

Mx Conservative Lifestyle adjustment / lipids Lap Chole


Age Overweight, women > men Hx Gallstones

Sx Acute sharp RUQ pain rad to back, shoulder N&V

Si Pyrexia +/- Rigors, tachcardia Jaundice

Ix Bloods USS +/- CT

Mx Antibiotics (met) – 20% are infected Analgesia Lap Chole (acutely)


Cholangitis

Age As for previous

Sx Acute sharp RUQ pain rad to back, shoulder N&V

Si Pyrexia +/- Rigors Jaundice (Charcot’s Triad)

Ix Bloods USS +/- CT (medical emergency)

Mx Antibiotics (inc met) ERCP / PTC Lap Chole


Acute Pancreatitis

Age Any age, predom younger with alcohol & older with gallstones

Sx Constant pain, N&V++ Shock

Si Pyrexia (Peritonism) (Jaundice)

Ix Bloods (amylase & CRP) USS +/- CT (medical emergency)

Mx Supportive & complex (surgery)


Meckel’s Diverticulum

Age Rare, often found incidently

Sx Rectal bleeding Sx similar to appendiscitis

Si

Ix Radioisotope scan

Mx Remove only if symptomatic


Small bowel obstruction

Age All ages, depends on underlying cause 5-10% of all admissions

Sx Colicky general pain Vomiting early/late ‘constipation’

Si Distended resonant abdomen ‘tinkling’ bowel sounds shock

Ix CT

Mx Fluid balance Conservative vs Operative


Mesenteric Ischaemia

Age 50% embolic, 25% atheroma, 10% venous 90% mortality

Sx Incredibly difficult to diagnose Severe central pain Pain out of proportion to findings

Si WCC, acidosis, lactate

Ix Laparotomy

Mx Embolectomy, grafting, resection Open & close


Acute Diverticulitis

Age 10% at 40yrs 60% by 80yrs Sx common in middle age/elderly

Sx Usually LIF pain +/- constipation +/- rectal bleeding

Si Tenderness Fever, tachycardia Raised WCC & CRP

Ix Ba enema / flexi CT

Mx Antibiotics, lifestyle 2 strikes and its out!


Lower GI Bleed

Age Age determines likely cause

Sx BR / DR rectal bleeding

Si Shock Wilson Index

Ix Flexi / colonoscopy / angiogram

Mx Fluid balance & Mx of shock then underlying cause


Perforated colon

Age Age determines likely cause Don’t overlook iatrogenic & self induced causes

Sx Peritonism Tachycardia

Si Shock Generalised tenderness, boardlike

Ix WCC, CRP CT

Mx Resuscitate Laparotomy +/- stoma


Acute Severe Colitis

Age Young 20-35, women > men

Sx Bloody diarrhoea , mucus urgency ++ Generalised abdo pain

Si Shock Anaemic, WCC up

Ix Flexi / colonoscopy Plain films

Mx Fluid balance & Mx of shock Steroids, cyclosporin Joint Mx with physicians

Mr Jason Smith - Consultant Surgeon 11/98 medslides.com 44

Acute Abdominal Pain Non-‐surgical Emergencies   Mesenteric Adeni4s   Acute Enteric Infec4ons   Acute Enteric Poisonings

  Inflammatory Bowel Disease   Pancrea44s (usually)

Mr Jason Smith - Consultant Surgeon 11/98 medslides.com 45

Acute Abdominal Pain Metabolic Causes   Diabe4c Ketoacidosis   Heavy Metal Poisoning   Acute Porphyria

  Sickle Cell Crisis

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The$Acute$Abdomen$ - jjsjjs.me.uk/images/docs/Acute abdomen.pdf · Si Distended resonant abdomen ‘tinkling’ bowel sounds shock Ix CT Mx Fluid balance Conservative vs Operative