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The Cute Abdomen

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					The (a)Cute Abdomen
              Objectives
• Know the common causes of abdominal
  pain
• Be able to diagnose them
• Recognize & manage appendicitis
• Explain inguinal hernias & their repair
• Diagnose & recommend rx for
  cholelithiasis
         The Acute Abdomen
           (Complicated?)
11 organ systems

3 kinds of abdominal pain

Infants, children, adults, & geriatric pt.s
  have different common problems &
  different presentations for the same
  conditions
   The Approach to Abdominal
             Pain
• Location of pain

• Referred pain

• 7 Elements of H.P.I.

• Type of pain
      The Acute Abdomen
• Knowledge of anatomy is
  crucial
• Location of
  pain is vital
  to determine
  etiology
       Abdominal Pain Types
               **
• Visceral: within walls of organs; often
  ______ in nature

• Somatic: parietal peritoneum; often
  ______ in nature

• Neuropathic :

• Referred: Away from site of pathology
       Areas of Referred Pain
                 **
•   Trapezius ?
•   Scapula ?
•   Flank ?
•   Midback ?

•   Diaphragm or Duodenum
•   Biliary
•   Renal
•   Pancreatitis or Duodenum
• Do not forget the RECTAL
  & PELVIC exams !!
• Pregnancy test
THE ACUTE ABDOMEN
                **

• US is ordered for
  –Cholelithiasis
  –Abscesses
  –Palpable masses
  –AAA
  –Pelvic Pain in women
• CT Scan should be considered
  early when the diagnosis is not
  obvious
When to order which imaging
          study?
• Location of Pain Imaging Study
•   RUQ              Ultrasound
•   LUQ              CT Scan
•   RLQ              CT Scan with IV
                         contrast
•   LLQ              CT with oral & IV
                         contrast
• Suprapubic         Ultrasound
      THE USUAL CULPRITS
•   Non-Surgical:        34%
•   Appendicitis         28%
•   Cholecystitis        10%
•   Small Bowel Obstr.   4%
•   GYN                  4%
•   Pancreatitis         3%
•   Renal                3%
•   Cancer               3%
•   Diverticulitis       3%
      Classical Clinical Course
• Anorexia, nausea & peri-umbilical pain

• Vomiting

• Pain moves to Right lower quadrant

• Peritoneal signs

• Fever
           Sign/Sx Prevalence
•   SX                Frequency   L.R.
•   Pain              99+ %
•   RLQ Pain*         96%         8.4
•   Pain Migration*   54          3.6
•   Anorexia          24-99       1.1
•   Nausea            62-99
•   Fever             67-69       3.2
•   Psoas             50          3.2
•   Emesis            32-75
•   Rebound           26          2
•   Guarding          21
   Use of Diagnostic Scales
• Not validated
• Can be useful with inexperienced
  clinicians to sort pt.s into Low,
  Moderate, or High risk categories
• Low risk : follow
• Moderate risk : Further studies
• High risk : Call a surgeon
            Diagnosing
                **

• PE accuracy is 80%

• CT Scan accuracy is 93-98%: Do
  when diagnosis is uncertain

• DX harder in extremes of age
      Management of Appy
• SURGERY (Board answer)
  – Lap may be preferred over open. ‘B’ Rec
    Cochrane


• Antibiotic prophylaxis is effective in
  preventing post-op comps in
  appendectomies. (pre-, peri- or post-)
  – ‘B’ REC.   Cochrane
CHOLECYSTITIS
     Classical Clinical Course
                 **
• Women age 30-60 with prior
  pregnancy
• After fatty meal
• Dull RUQ pain*, 75% are colicky;
  L.R. = 2.5
• Murphy’s Sign*; 65% + & L.R. = 5.0
• N&V
• Pain subsides over hours
    Classical Clinical Course
• If progresses, Severe RUQ pain with
  radiation to right scapula or shoulder
• Fever
• With stone, pain may be epigastric
• RUQ tenderness
• Possible RUQ mass
• Elevated bili
                 DX
                 **
• Sonography is 1st choice

• Sans RX, perf can occur in 28-72
  hrs.

• In diabetics, perf can occur earlier
                      RX
                      **
• ACUTE: Surgery unless very high risk

• Chronic: Surgery usually; definitely if stones
  are calcified or GB is non-functioning (by
  OCG)
  ASX: Not rx’d unless kids, DM, sickle cell,
  calcified GB wall
  Lap vs open: Lap, only for recovery time
  ‘B’ Rec. Cochrane
               Hernia
• Protrusion of the peritoneum or
  preperitoneal fat through an abnormal
  opening in the abdominal wall

• Presents as a bulge
                Groin Hernia

• Men : Women 25 : 1

• Right : Left 2 : 1

• Femoral
  – Women > Men
  – Strangulation risk > inguinal
• Inguinal
  – Indirect : Direct 2 : 1
  – Most common in men and women
                Groin Hernia

• Inguinal: relationship of sac to inguinal
  canal determines external bulge

  – Movement from internal ring to scrotum
  – Indirect vs. direct hernia is intraoperative
    diagnosis, not clinical diagnosis

• Femoral: relationship of sac to inguinal
  ligament determines external bulge
             Inguinal Anatomy
                       inferior epigastric
                             vessels
                                             shelving edge
                                               internal oblique
                                               transversus abdominus

                                                    rectus abdominis
                            transversalis fascia
shelving edge


                transversalis fascia                    pubic tubercle
    internal ring        external ring
            Hernia Pathology
• Incarceration: contents of hernia sac not
  reducible into peritoneal cavity
  – Acute: fascial margins trap contents
  – Chronic: contents adhesed in sac

• Strangulation: incarceration with
  compromise of blood supply
  – Narrow neck at greatest risk: indirect inguinal,
    femoral, and umbilical
      Hernia Repair Indications
                **
• Asymptomatic
  – prevent visceral incarceration and/or
    strangulation

• Symptomatic, non-obstructed
  – Treat discomfort from bulge
  – Prevent incarceration/strangulation

• Visceral obstruction/strangulation
  – Release obstruction/manage viscera
  – Prevent recurrence
  Groin Hernia Management

• Most hernias: ambulatory OR

  – Local/regional/general anesthesia

  – Prohibitive operative risk: truss
    Groin Hernia Management
• Acute incarceration
  – Reduction
     • Distal traction and gentle milking
     • Caution: reduction en masse
     • Successful reduction shows visually

  – Urgent elective repair if reduced
Groin Hernia Management

• Emergent repair
  – Irreducible acute incarceration
  – Strangulation

• Fluid, electrolyte resuscitation
        Groin Hernia Repair
          Complications
• Recurrence
  –Tissue repair: 1.3—25%
  –Tension-free mesh: 0.5—5%
  –Mesh is best : ‘B’ Rec. Cochrane
  –Lap vs. Open ? ‘I’ Rec. Cochrane
  –Antibiotic prophylaxis doesn’t help. ‘B’ Rec

• Greatest risk is repair of previous hernia
  at same location
                 Summary
•   Know anatomy
•   Know presentations
•   Know the P.E.
•   Know appropriate diagnostic studies
•   Involve surgeons early
           Bibliography
• Cartwright S & Knudson M. AFP.
  2008;77:971-8.
• Ebell M. Point of Care Guides.
  Diagnosis of Appendicitis. AFP.
  2008;77:828-30.

				
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posted:11/30/2011
language:English
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