dr.ramate wongwilairat. md somdejphajaotaksin hospital
TRANSCRIPT
DR.RAMATE WONGWILAIRAT. MD
SOMDEJPHAJAOTAKSIN HOSPITAL
OUTLINE
DIFINITION ACUTE ABDOMENANATOMY AND PATHOPHYSIOLOGY
ABDOMINAL PAINETIOLOGY OF ACUTE ABDOMENCLINICAL ASSESSMENT HISTORY TAKING PHYSICAL EXAMINATION LABORATORY INVESTIGATION IMAGING STUDYKEY FEATURES OF COMMON CAUSES
OF ACUTE ABDOMINAL PAINQUESTION
DIFINITION diagnosis and treatment immediately
medical or surgical condition
timimg 1-4 wk
Anatomy relate t o abdominal pain
Peritoneum visceral and parietal peritoneum
abdominal organ intraabdominal and retroperitoneal organ
Abdominal wall
pathophysiology
Intraabdominal organ
NERVE1.Parietal peritoneum Abdominal wall inferior epigastric a. somatic sipinal nerve T7-L2
2.Intraabdominal organ Visceral peritoneum celiac trunk , SMA , IMA
autonomous system
Type of abdominal pain
Visceral painSomatic painRefered painMigratory pain
Viscera l pain
abdominal organ parasympathetic and sympathetic
C-fiber ,slow transmitter dull and crampy not localized
midline pain (bilaterallity) Stretching , compression , torsion, distention
Viscera l pain foregut epigastium
midgut periumbilical
hindgut suprapubic
Somati c pain
Irritate to Parietal peritoneum
A-delta fiber , spinal nerve
fast transmitters sharp and exquisite localized
peritoneal sign : localized tender , guarding
MigratorypainAcute appendicitis
Migratory pain
Peptic ulcer perforate
Refere d pain
pain felt at a site distant from a disease
processPathophysiology multiple pain afferents in the posterior horn of spinal cord
Common nerve root
Spinal nerve r 4ootC
Right shoulder diaphragm
gall bladder
liver capsule
peumoperitomeun
•Left shoulder diaphragm spleen tail of pancrease stomach splenic flexure of colon
The thoracic a - ffernt T6 T8
Right scapular gall bladder
biliary treeLeft scapular spleen tail of pancrease
Refere d pain
Groin/genitalia ureter kidney Back- midline pancrease duodenum aorta
ETIOLOGY OF ACUTE ABDOMINAL PAIN
1. INFLAMMATION /INFECTION
A. PERITONEUM PRIMARY PERITONITIS ; ASCITES SCONDARY PERITONITIS: HOLLOW VICUS ORGAN PERFORATE TERTIALY PERITONITIS : TB
B. HOLLOW VICUS ORGAN APPENDICITIS , CHOLECYSTITIS , GASTROENTERITIS DIVERTICULITIS, PEPTIC ULCER
C. SOLID VISCERA PANCREATITIS , HEPATITIS
D. MESENTERY LYMPADINITIS
E. PELVIC ORGAN PID , ENDOMETRIOSIS , TUBOOVARIAN ABSCESS
2. MECHANICAL ( OBSTRUCTION /ACUTE DISTENTION)
A.HOLLOW VISCUS ORGAN GUT OBSTRUCTION ; HERNIA ,TUMOR INTUSSUSCEPTION BILIARY TRACT OBSTRUCTION: CALCULI TUMOR
B.SOLID ORGAN ACUTE HEPATOMEGALY , SPLENOMAGALY
C.MESENTERY OMENTAL TORSION
D.PELVIC ORGAN OVARIAN CYST , ECTOPIC PREGNANCY
3. VASCULAR
A.INTRAPERITONEAL BLEEDING RUPTURE LIVER AND SPLEEN RUPTURE AORTA , SPLENIC ANEURYSM RUPTURE ECTOPIC PREGNANCY
B.INTRAPERITONEAL ISCHEMIA MESENTERY THOMBOSIS HEPATIC INFRACION : TOXIMIA , PURPURA SPLENIC INFRACTION OMENATAL INFRACTION
Abdominal pain pathway
InflammationInfectionObstructionDistentionBleedinginfarction
Intraabdominal organParietal peritoneum
Spinothalamic tract
vagus
Spinal nervesympathetic
Somatic painVisceral painRefer pain
History takingPEinvestigation
HISTORY TAKING
CLINICAL ASSESSMENT
duration Site of pain 1. maximum point of pain
2. initial location of pain
Nature in o nset of pain
Sudden onset hollow viscus organ perforate
ischemic process passage stoneGradual onset inflammmation process
Progressi on of pain
Intermittent pain Colicky seconds( bowel)
minutes (ureteric)
tens of minutes (biliary)
Constant pain peptic ulcer,
pancreatitis
Subside early colicMore severe late colic
Characteri stic of pain
Burning peptic ulcer
Sharp or stabbing ureteric colic
Crampy gut ostruction
gastroenteritis
Aggravate or r elieve of pain
Posture lying still
rolling around
GI function type of food
Associatedsymptom
Vomitting type of vomitus
timing frequentAnorexiaBowel habitsfever
HISTORY TAKING
age menstruation past illness familial history
organ systemic review
medication
Physical examination
CLINICAL ASSESSMENT
BASIC CONSIDERATIONA large number of different
structures Small abdominal cavityPelvic cavity and dome of
diaphargmAbdominal wall muscleThe brain cannot distinguish depend on tecnique
of examination
preparation
The environment warm and private good daylight and oblique
The bed hard bed with a backrest
rest head on pillow and flex hip
preparation
Exposure uncover the patients from nipple to knees
genitalia and hernia orifices
Get the patients to relax rest his arm on his side breathe regularly and slowly
preparation
The position of the examination
right side , hand and forearm horizontal position
clean and warm hand short nail
The routine of examination
InspectionAuscultation
Percussionpalpation
INSPECTATION
Look at the whole abdomen symmetry buldging : organomegaly , mass distended : gas , ascitis, fat , mass scaphoid abdomen: malnutrition
inspectation
ScarSpider nevi , superficial vien dilate
Visible peristalsisGrey tunner and cullen sign
Herniaumbilicus
Spider nevi
Bowels sound (all quadrants)
peritalsis ; gurgling noise…mixture gas and air
low pitched , every few seconds
no bowel sound over a 15-30 seconds
paralytic ileus intestinal obtruction : high pitch , freqent
Systolic bruit aortic or iliac aneurysm
Splashing sounds gastric outlet obstruction
percussion
Percussion
Tympanic or hypotympanic (dullness) on percussion liver or spleen dullness (span) loss of liver dullness????? shifting dullness (ascites ) hypertympanic ( gut obstruction or ileus)Determining the extent of the tender area
Liver span
Shifting dullness
Fist test (tender on percussion)
palpation
Pressing gently and lightly
Symmetrical over all the abdomen
Begin palpation on nontender area
principle
Light palpationfor tenderness
Assess the degree
mild tenderness
moderate tenderness guarding
severe tenderness rebound
Localized or generallized
• Subcutaneous mass
Deep palpation
Masses position tenderness shape fluctuation size , surface, edge , consistency
pulsatile
deep palpation(bimanual)
Deep Palpate the normal solid organ
liverHand on the right side
transvesely of abdomenStart at umbilicusPatient takes a deep breatheThe inferior edge of enlarged
liver bumpThe index finger .. Irregular or
smoothWhen cannot palpate the liver, please move up the hand to the
costal margin
Spleen normal spleen is not palpable
palpate with the finger tips on
the left and below the umbillicus
the patients takes deep breathe
move the right hand toward
the left costal margin left hand lift the lower cage forwards
Kidneys puts left hand behind the right loin
, between the 12th rib and iliac crest
lift the loin and kidney forwards
puts the right hand on the right side
of abdomen just above the level of
the anterior superior iliac spine
the patients take deep breathe
Palpation donot forget
Supraclavicular fossa
Hernial orificeFemoral pulseExternal genitalia
Special examination
Murphy sign
OBTURATOR SIGN
Pitfall in physic al examinationElderly , childrenMask factor; analgesic , steroid
Immuno-compromised host
Repeatly in PE ReliabilityAs a whole
DIFFERENTIAL DIAGNOSIS
Differentialdiagnosis
Differentialdiagnosis
notice
Medical causeSiteSolid or hollow viscusCongenital , trauma , tumor
Infectionincidence
INVESTIAGATION
CLINICAL ASSESSMENT
Diagnosis investigation
Confirm diagnosisExclusion diagnosis Pre op evaluation depend on facility and policy
Always required history taking
physical examination
CBC
Hct or Hb GI loss dehydrate
leukocytosis infective condition
ischemic process
LFT bilirubin alkaline phosphatase
liver enzymeUrianalysis KUB stone infectionAmylase pancreatitisBUN Cr e renal, e imbalance
Blood sugar DM., acute pancreatitis
Urine pregnancy test ectopic pregnancy
Hemoculture sepsis, cholangitis
pyogenic liver abcess
Diagnosis imaging
plain film abdomen; supine , CxR , upright
free air PUP
bowel gas pattern gut obstruct
abnormal calcification gall stone KUB stone chro.pancreatitis
Ultra sound hepatobiliary system , solid organ
gynecologic condition KUB systemCT scan acute diverticulitis complication severe pancreatitis
Contrast media unnessary barium enema
colonic obstruction
pseudo obstruction
intussusception
Laparoscope diagnosis treatment unidentify diag pelvic pain
PID. Acute appendicitis endometriosis
KEY FEATURE COMMON CAUSE OF ACUTE ABDOMINAL PAIN
ACUTE APPENDICITISCilnical assesment
HISTORY Gradual onset , fever ,anorexia(90%) , nuasea vomitting(70%) migratory pain, pelvic pain, dysuria, diaarhea, testicular painTypical sequence : anorexia –abdominal pain – vomitting (95%)
PE. Depend on antomical site fever ,tenderness, guarding at RLQ guarding (Mac Burney) and rebound PR. Tenderness at right side rousing , obturator sign
Lab investigation film acute abdomen is not helpful minimal WBC in urine leukocytosis
PEPTIC ULCER PERFORATEClinical assessment
HISTORY sudden onset ,severe pain generalized abominal pain ,migratory pain , risk factor to peptic ulcer PE abdominal distention decrease bowel sound, generalized guarding rebound tenderness ( broad like rigidity)
Lab investigation film acute abdomne free air (70 %)
ACUTE PANCREATITISClinical assesssment
HISTORY haevy alcohol drinking one of exlusion : same , PUP , acute cholecystitis gradual onset ,severe pain after meal usually epigastric pain , dullness and radiate to the back relieved by the patient leaning forward
PE mark tender , voluntary or involuntary guarding rebound tenderness positive Grey tunner and Cullen sign
Investigate film acute abdomen. Colon cut off sign , Sentineal loop rising serum amylase(30 %), urine amylase rising lipase
DIVERTICULITISClinical assessment
History : old age with chronic constipation, pain in left lower abdominalrefer suprapubic and goin or back dysuria (irritate bladder)
PE : terderness , guarding , rebound at LLQ. mass palpable(phlegmon or abscess) pelvic peritonitis PR: trnderness at Cul de sac
INVESTIGATE : clinical diagnosis CT (investigate of choice) and ultrasound
INTESTINAL OBSTRUCTION CLINICAL ASSESSMENT
HISTORY intermittent onset , colicky abdominal pain frequent vomtting , constipation hernia , previous surgery
PE abdominal distention ,visible peritalsis, hyperactive bowel sound , hypertympanic on percussion localized tenderness , mass ? , surgical scar , incarcerated hernia
Investigation film acute abdomen . Dilate bowel , air fluid level
MESENTERIC ISCHEMIACLINICAL ASSESSMENT
HISTORY hyperlipidemia, CVA , MI , AF intestinal angina , acute onset and constant Extrem pain unresponsive to narcotic
PE abdominal distention , hypoactive bowel sound generalized tenderness , guarding , rebound (pain is out of porportion to PE )
INVESTIGATION leukocytosis film acute abdomen: non specific , bowel dilate
A 69-year-old woman presents with 3 day history of constipation and constant pain in left lower abdomen.The pain has suddenly become much worse and she has collapsed and been admitted to casualty. On examination she has a tachycardia and is hypotensive. There is severe lower abdominal pain with guarding throughout the mid-and lower abdomen
A. 42 –year-old woman with a history of biliary colic and intermittent faundice is admitted as an emergency with a 2-day history of more severe abdominal pain radiating into her back, associated with profuse vomiting. On examination she is morbidly obese, is dehydrated, has a tachycardia and generalized vague abdominal tenderness.
A.78-year-old man presents with a 3 – day history of vomiting faeculent fluid, He has a grossly distended abdomen and a palpable mass in the right groin.The mass is firm,slightly tender and lies below and lateral to the pubic tubercle
A. 60 year-old man presents with a 48-hour history of sudden onset epigastric pain radiating through to the back after an alcoholic binge. Examination reveals the patient to be apyrexial,tachycardic and normotensive.The patient is diffusely tender with guarding in the epigastrium.An erect chest x – ray is normal,but the blood gas analysis reveals hypoxia
A 22-year-old woman presents with pain in the right iliac fossa. The patient is anorexic,has not vomited,but had some dysuria and frequency.Her temperature is 37.5 co The patient is flushed and has localized guarding in the right iliac fossa and suprapubic region.
A 50-year-old obese woman presents with epigastric pain. On examination her temperature is 38.5 co She is tender in the upper abdomen and Murphy’s sign is positive.
CONCLUSION
ABDOMINAL PAIN DIFFERENTIAL DIAG PROVISIONL DIAG
CLINICAL ASSESSMENTHISTORY TAKINGLAB INVESTIGATION
PATHOPHYSIOLOGYANATOMYKNOWLAGE
หนั�งสื�ออางอ�ง• จุ ตพล วิ�ลาสืรั�ศมี� ในั : สื�โรัจุนั� กาญจุนัพ�ญจุพล , บรัรัณาธิ�การั .
ศ�ลยศาสืตรั� ทั่� วิไป กรั งเทั่พฯ : กรั งเทั่พเวิชสืารั 2548 . หนัา 100 – 108• ชวินัรั�ฐ สื วิ�ภะบภรัณ�ก ล . ในั : สื�โรัจุนั� กาญจุนัป)ญจุพล , บรัรัณาธิ�การั . ศ�ลยศาสืตรั�ทั่� วิไป. กรั งเทั่พ : กรั งเทั่พเวิชสืารั -109119 1989 : 1061-1067• รั�งสืรัรัค์� ก ภพ�นั�มี�ตรั . การัดู-แลผู้-ป0วิยทั่� มีาดูวิยเรั� องปวิดูทั่องเฉี�ยบพล�นั ในั : สื เทั่พ กลชาญ วิ�ทั่ธิ�2 , บรัรัณาธิ�การั โรัค์ทั่างเดู�นัอาหารัและการัรั�กษา กรั งเทั่พ ซ โรังพ�มีพ�จุ ฬาลงกรัณ�
มีหาวิ�ทั่ยาล�ย, 2548 หนัา -19•Norman L.Browse. The abdomen In : Introduction to
the symptom and sign of surgical disease second edition 1991:363-403•Helen Sweetland. Kevin Conway. Acute abdominal
pain in Crush Course Surgery second edition 2004:1-7 •Seymour I. Schwartz. Manifestations of gastrointestinal disease In ; Seymour IS, editor . Principle of
surgery 5 th edition New York 1989:1061-1067