Acute AbdomenAcute Abdomen

Andreas M Andreas M KluftingerKluftinger MD FRCSCMD FRCSCggKelowna General HospitalKelowna General Hospital

DisclosureDisclosureDisclosureDisclosure

• Hernia Advisory Panele a d so y a e– Ethicon, Johnson & Johnson

• Fundingnil zilch zippo nada zero– nil, zilch, zippo, nada, zero

ObjectivesObjectivesObjectivesObjectives

• Understand the Pathophysiology andUnderstand the Pathophysiology and Etiology of the acute abdomen

• Approch to acute abdomen in rural tipractice

• Case presentations

Stedman's Medical DictionaryStedman's Medical DictionaryStedman s Medical Dictionary Stedman s Medical Dictionary 27th Edition27th Edition

“any serious acute intra-abdominal condition attended by pain tendernesscondition attended by pain, tenderness, and muscular rigidity, and for which emergency surgery must be considered "emergency surgery must be considered.

Acute Abdominal PainAcute Abdominal PainAcute Abdominal PainAcute Abdominal Pain

• 5-10 % of ER visits5 10 % of ER visits• Complex “black box”

D l i di i i bidit• Delays in diagnosis can increase morbidity• Excessive consultations (+/- transport) and

imaging can be costly and tax resources.• Primary assessment and triage are keyy g y

History & PhysicalHistory & PhysicalHistory & PhysicalHistory & Physical

• Onset nature duration location radiationOnset, nature, duration, location, radiation• Aggravating and relieving factors

A i t d GI GU t• Associated GI or GU symptoms• Past history (Surg and Med)• Review of Systems• Full physical examFull physical exam

Stereotypes of Pain Onset and Associated Pathology

S dd R id G d l•Sudden onset (full pain in seconds)

•Rapid onset(initial sensation to full pain over minutes or hours)

•Gradual onset(hours)

minutes or hours)

•Perforated ulcer •Mesenteric infarction

•Strangulated hernia •Volvulus

•Appendicitis •Strangulated herniaMesenteric infarction

•Ruptured abdominal aortic aneurysm •Ruptured ectopic

Volvulus•Intussusception•Acute pancreatitis •Biliary colic Di ti liti

Strangulated hernia •Chronic pancreatitis •Peptic ulcer disease •Inflammatory bowel disease M t i l h d itipregnancy

•Ovarian torsion or ruptured cyst •Pulmonary embolism

•Diverticulitis •Ureteral and renal colic

•Mesenteric lymphadenitis •Cystitis and urinary retention •Salpingitis and prostatitis

Pulmonary embolism •Acute myocardial infarction

Abdominal Abdominal InnervationInnervation

Simplified in ThirdsSimplified in ThirdsSimplified in ThirdsSimplified in ThirdsEmbryologic Structures Nerves Arteries Pain Location

Foregut Esophagus, stomach,3/4

Thoracic splanchnics,

Coeliac Epigastrium,

duod,liver, gbpanc

p ,vagus

Midgut ¼ duod to Thoracic SMA PeriumbilicalMidgut ¼ duod to splenic flexure

Thoracic splanchnics,

vagus

SMA Periumbilical

Hindgut Left colon Pelvic IMA HypogastriumHindgut Left colon, rectum, GU

tract

Pelvic splanchnics,

lesser thoracic splanchnics

IMA Hypogastrium

p

Possible Causes of Pain by Location

Location of Pain Associated Diseases

Right upper quadrant(liver, kidney, gallbladder)

Acute cholecystitis, biliary colic, acute hepatitis, duodenal ulcer, right lower lobe pneumonia

Right lower quadrant Appendicitis, cecal diverticulitis, ectopic pregnancy, tubo-ovarian abcess,Right lower quadrant(ascending colon, appendix, ovary,

fallopian tube)

Appendicitis, cecal diverticulitis, ectopic pregnancy, tubo ovarian abcess, ruptured ovarian cyst, ovarian torsion

Left upper quadrant Gastritis, acute pancreatitis, splenic pathology, left lower lobe pneumonia pp q(pancreas, spleen, kidney)

p p p gy p

Left lower quadrant(sigmoid and descending colon,

f ll i t b )

Diverticulitis, ectopic pregnancy, tubo-ovarian abcess, ruptured ovarian cyst, ovarian torsion

ovary, fallopian tube)

Midline or periumbilical Appendicitis (early), gastroenteritis, mesenteric lymphadenitis, myocardial ischemia or infarction, pacreatitis

Flank Abdominal aortic aneurysm, renal colic, pyelonephritis

Front to back Acute pancreatitis, ruptured abdominal aortic aneurysm, retrocecalappendicitis posterior duodenal ulcerappendicitis, posterior duodenal ulcer

Suprapubic or lower abdominal Ectopic pregnancy, mittelschmerz, ruptured ovarian cyst, pelvic inflammatory disease, endometriosis, urinary tract infection

Sign Finding Association

Cullen's sign Bluish periumbilicaldiscoloration

Retroperitoneal hemorrhage

Grey Turner’s sign Bluish flank discoloration

gpancreatitis,

abdominal aortic aneurysm rupture)

Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy

McBurney's sign Tenderness located 2/3 distance from AppendicitisMcBurney s sign Tenderness located 2/3 distance fromASIS to umbilicus on right side

Appendicitis

Murphy's sign Abrupt interruption of inspiration onpalpation of right upper quadrant

Acute cholecystitispalpation of right upper quadrant

Iliopsoas sign Hyperextension of right hipcausing abdominal pain

Appendicitis

Obturator's sign Internal rotation of flexed right hip causing abdominal pain

Appendicitis

Chandelier sign Manipulation of cervix causes patient Pelvic inflammatoryChandelier sign Manipulation of cervix causes patient to lift buttocks off table

Pelvic inflammatory disease

Rovsing's sign Right lower quadrant pain with palpation of the left lower quadrant

Appendicitis

Referred Pain

Structure Irritated Location of Referred PainStructure Irritated Location of Referred Pain

Diaphragmatic Supraclavicular area (Kehr's sign)

Ureteral Hypogastrium, groin, inner thigh

Cardiac pain Epigastrum, jaw, shoulder

Appendix Periumbilical via T10 nerve

D d U bili l i i t th iDuodenum Umbilical region via greater thoracic splanchnic nerve

Hiatal hernia Epigastrum via T7 and T8 nervesHiatal hernia Epigastrum via T7 and T8 nerves

Pancreas or gallbladder Epigastrum

Gallbladder and bile duct Epigastric pain that wraps around to the scapula

Imaging for AppendicitisImaging for AppendicitisImaging for AppendicitisImaging for Appendicitis

Imaging AccuracyImaging Accuracyg g yg g yin in

A di itiA di itiAppendicitisAppendicitis

Modality Sensitivity Specificity Pos PredValue Neg Pred ValuePlain Film 10% 90%Plain Film 10% 90%Ultrasound 85-90% 92-96% 95% 80-90%

CT 95-97% 95% 97% 95-100%MRI 93% 91% 92% 100%MRI 93% 91% 92% 100%

Laboratory in AppendicitisLaboratory in AppendicitisLaboratory in AppendicitisLaboratory in AppendicitisTest Sensitivity Neg Pred Value

1. WBC >10.5 85%2. Neutrophils >75% 78% 94%3 C reactive protein 93-96%3. C reactive protein 93 96%

1+2 96%1+3 92.3%

1+2+3 99.2% (81% in children)

Urinalysis in AppendicitisUrinalysis in AppendicitisUrinalysis in AppendicitisUrinalysis in Appendicitis

• 30% of appendicitis patients have some30% of appendicitis patients have some urinary syptoms

• 14% have >10 WBC/hpf• 14% have >10 WBC/hpf• 18% have > 3 RBC/hpf

Imaging in PregnancyImaging in PregnancyImaging in PregnancyImaging in Pregnancy

• UltrasoundUltrasound– Safest

Useful for fetal assessment (dates viability– Useful for fetal assessment (dates, viability, placenta, amniotic fluid)

– NPV for appendicitis 80-90%– NPV for appendicitis 80-90%– PPV for appendicitis 95%

Imaging in PregnancyImaging in PregnancyImaging in PregnancyImaging in PregnancyProcedure Fetal ExposureChest radiograph (2 views) 0.02-0.07 mradAbdominal film (single view) 100 mradIntravenous pyelography >1 rad*Hip film (single view) 200 mradHip film (single view) 200 mradMammography 7-20 mradBarium enema or small bowel series 2-4 radCT (computed tomography) scan head or chest

<1 rad

CT scan abdomen and lumbar spine 3.5 radCT pelvimetry 250 mrad

No evidence of teratogenesis or fetal loss if cumulative dose < 5 rads

Acute AbdomenAcute AbdomenC d b PC d b PCaused by PregnancyCaused by Pregnancy

• Early pregnancy – Ruptured ectopic pregnancy– Septic abortion with peritonitis – Acute urinary retention due to retroverted gravid uterus– Torsion of the pregnant uterus

• Later pregnancy – Red degeneration of myomag y– Torsion of pedunculated myoma– Placental abruption, Placenta percreta– HELLP (hemolysis, elevated liver function, and low platelets) syndromeHELLP (hemolysis, elevated liver function, and low platelets) syndrome

– Spontaneous rupture of the liver – Uterine rupture – Chorioamnionitis

Conditions Associated with Conditions Associated with PPPregnancyPregnancy

• Acute pyelonephritisAcute pyelonephritis• Acute cystitis

A t h l titi• Acute cholecystitis• Acute fatty liver of pregnancy • Rupture of rectus abdominis muscle

Case #1Case #1Case #1Case #1

• 68 male 48 hrs RLQ pain68 male, 48 hrs RLQ pain• Quick onset, in RLQ

N i• No nausea or anorexia• No urinary syptoms• PHx: GERD, dyslipidemia• Tender RLQ and flank with peritonismTender RLQ and flank with peritonism• WBC 9.2 Urine clear

CT abdomenCT abdomenCT abdomenCT abdomen

Case #2Case #2Case #2Case #2

• BW 41 yo electrician• collapsed at home with chest, abd paincollapsed at home with chest, abd pain• CPR by family, EHS to KGH

PHx: appe Meds: ASA• PHx: appe Meds: ASA• Exam: BP 60 sys, HR 100 RR 16

Chest clear Abdomen tender, acute

InvestigationsInvestigationsInvestigationsInvestigations

• Hb 108 WBC 8 9 Plts 256Hb 108 WBC 8.9 Plts 256• Hep panel – normal

Li 43• Lipase 43• ECG – normal• Trop < 0.1

CT with Aorta ProtocolCT with Aorta ProtocolCT with Aorta ProtocolCT with Aorta Protocol

LaparotomyLaparotomyLaparotomyLaparotomy

• 3 litres blood3 litres blood• intact liver, spleen, viscera

bl d f l• blood from lesser sac• rupured splenic artery aneurysm at hilum• splenectomy, distal pancreatectomy• 4 units FP 6 units RBC4 units FP, 6 units RBC• Recovery uneventful