ACUTE ABDOMEN

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ACUTE ABDOMEN Powered By Docstoc
					Acute abdomen
 Primary symptom is
  abdominal pain
 Duration of pain <7
  days
 Medical or Surgical
  causes(non-traumatic)
 Etiology can be trivial
  or life threatening
 Requires an
  intervention
Differential Diagnosis


 Large List of Potential Diagnoses
 Any List Will Inevitably Be Missing Diagnoses
 Customary to Categorize By Quadrants
Quadrants of Abdomen
Differential Diagnosis
     Differential by Location
Epigastrium

    Acid/Peptic Disease
   Ulcer, GERD, Gastritis
   ACS (Angina, MI)
   Aortic Aneurism
   Cholelithiasis, Choledocholithiasis
   Diaphragmatic Defect Related
   Paraesophageal Hernia, Gastric Volvulus, Congenital
    Diaphragmatic
   Hernias
   Gastroenteritis
   Pancreatitis
   Gastric Cancer, Pancreatic Cancer, etc.
Differential by Location

Right Upper Quadrant

 Appendicitis (Retrocecal or Malrotated)
 Cholelithiasis, Choledocholithiasis
 Liver Related
  Hepatitis, Abscess, Malignancy
 Renal Related
  Pyelonephritis, Nephrolithiasis/Ureterolithiasis
 Subdiaphragmatic Process
 Abscess
Differential by Location

Left Upper Quadrant
 Colonic Ischemia
 Pancreatic
   Pancreatitis, Tumor
 Renal
   Pyelonephritis, Nephrolithiasis/Ureterolithiasis
 Splenic
   Infarct, Abscess
 Subdiaphragmatic Process
   Abscess.
Differential by Location

Mid-Abdomen/ Periumbilical
 Aortic Aneurism
 Appendicitis
 Small Bowel Obstruction
 Ischemia (“Intestinal Angina”)
 Gangrene
    Differential by Location
Right lower quadrant
 Appendicitis
 Colon Related
 Colitis (Especially Pseudo membranous), Right-
  orLeft-Sided
 Diverticulitis, Cancer
 Crohn’s Disease
 Gynaecological
 Tubal Pregnancy, Ovarian Torsion, Cyst,
  PID,Tuboovarian
 Abscess,Tumor, Endometriosis, etc.
 Hernia
 Inguinal, Femoral
 Meckel’s Diverticulitis
      Differential by Location
Right Lower Quadrant (Continued)
 Renal
 Pyelonephritis, Nephrolithiasis/Ureterolithiasis
 Typhlitis
 Rectus/Retroperitoneal Hematoma
Left Lower Quadrant
 Colon Related
 Colitis (Especially Pseudomembranous), Diverticulitis,
  Cancer, Colonic
 Ischemia
 Diverticulitis+ Same as RLQ-Appendicitis
Differential by Location

Suprapubic
   Colon Cancer
   Diverticulitis
   Gynecological
   Endometritis, Endometriosis, PID
   Prostatitis
   UTI
 More   …
   Medical causes of acute abdomen
 Endocrine and Metabolic Causes
  Uremia
  Diabetic crisis
  Addisonian crisis
  Acute intermittent porphyria
  Hereditary Mediterranean fever
 Hematologic Causes
 Sickle cell crisis
  Acute leukemia
  Other blood dyscrasias
 Toxins and Drugs
  Lead poisoning
  Other heavy metal poisoning
  Narcotic withdrawal
  Black widow spider poisoning
Symptoms

 SYMPTOMS reflect a subjective change
 from
 normal function
 Pain
 Appetite: anorexia, nausea, vomiting,
      dysphagia,
 weight loss
 Bowel habits: bloating, diarrhea,
      constipation,
 flatulence
Signs


 SIGNS are objective and reproducible
  findings
 Tenderness
 Rigidity
 Masses
 Altered bowel sounds
 Evidence of malnutrition
 Bleeding
 Jaundice
The Physiology of Abdominal Pain

   Abdominal pain from any cause is mediated by
     either visceral or somatic afferent nerves
   Several factors can modify expression of pain
   Age extremes
   Vascular compromise (pain ‘out of proportion’)
   Pregnancy
   CNS pathology
   Neutropenia
Visceral Pain


Stimuli
 Distension of the gut or
  other
   hollow abdominal organ
 Traction on the bowel
   mesentery
 Inflammation
 Ischemia
 Sensation
  Corresponds to the
  embryologic origin of the
  diseased organ (foregut,
 midgut, hindgut
Somatic Pain


 Stimuli
Irritation of the
  peritoneum
 Sensation
    Sharp, localized pain
   Easily described
 Cardinal signs
   Pain
  Guarding
  Rebound
  Absent bowel sounds
  Patterns of Referred Pain

                              Diaphragmatic
                              irritation
              Gastric
              pain
Liver and biliary pain          Biliary colic
                               Pancreatic and
       Colonic pain
                               renal pain
  Ureteral or
                              Uterine and
  kidney pain
                              rectal pain
History


 Pain
  When? Where? How?
 Abrupt, gradual
 Character
   Sharp, burning, steady,
 intermittent
 Referral?
 Previous occurrence?
 Vomiting
  Relationship to pain
  How often? How much?
History

 Nausea? Anorexia?
 Bowel movements
  Number
  Character
  Bloody?
 Past Medical and Surgical History
 Travel History
 Last meal
 Systemic Review
Physical Examination

 Appearance and position of patient
 Vital signs
 Appearance of abdomen
  Distention
  Hernia
  Scars
Physical Examination


 Tenderness
  Rigidity
  Masses
 Bowel sounds
 Rectal and Pelvic Examination
 Careful exam of heart, lungs and skin
Diagnosis

Investigations
 X-Ray
      Upright chest
      Upright and supine abdominal
   Complete Blood count
   Urinalysis (pregnancy test in females)
   Amylase, Creatinine, BUN,        Electrolytes
   USG
   CT Scan
Specialised Tests
Two Mainstays
 Ultrasound (U/S)
     Better for Specific Inquiries (Biliary Tract,
      Appendicitis, or
     Acute Female Pelvic Pathology)
 CT Scan
    Better as a More Generalized Abdominal Survey
    Especially Useful for Certain Diagnoses
    Appendicitis, Diverticulitis, Bowel Obstruction,
    Colitis
    Abdominal Sepsis, Tumor
    Useful for Occult Diagnosis (“Fishing
      Expedition”)
Other specialised testing


 Other Radiographic Studies
    Nuclear Medicine, Angiography, etc.
 Endoscopy
   Used Judiciously
 Laparoscopy
 Exploratory Laparotomy
Immediate Treatment of the Acute
Abdomen


1. Start large bore IV with either saline or lactated
   Ringer’s
   solution
2. IV pain medication
3. Nasogastric tube if vomiting or concerned about
   obstruction
4. Foley catheter to follow hydration status and to obtain
   urinalysis
5. Antibiotic administration if suspicious of inflammation
   or
  perforation
6. Definitive therapy or procedure will vary with diagnosis
  Remember to reassess patient on a regular basis.
Physical Exam of the patient
(What you see) Organ rupture


 Characterized by shock, clammy patient,
  pallor, fainting.
 Hypotension Tachycardia
1. Spleen
2. Aortic rupture
3. Ectopic pregnancy
4. Ruptured ovarian cyst
*These conditions usually require immediate
  surgery!
Peritonitis
   Primary
       Caused by spontaneous bacterial
        seeding from states such as cirrhosis.
        No GI leak
   Secondary
       Casued by GI/GU leak (PID, ulcer
        rupture, etc)
   Tertiary
       2nd turning into chronic infection, after
        closures of the leak.

				
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posted:1/25/2013
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