the acute abdomen david c. evans, md assistant professor of surgery [email protected] lsi part 2...
TRANSCRIPT
The Acute Abdomen
David C. Evans, MD
Assistant Professor of Surgery
LSI Part 2Understanding Patients with Reproductive and Surgical Needs
Acute Abdomen Learning Objectives
Primary Objectives
• Evaluate and determine initial treatment of patients presenting with surgical diseases in all patients as well as medical diseases in pregnant patients.
• Evaluate and formulate a management plan for a patient with acute abdominal pain.
Secondary Objectives
• Recognize medical or surgical emergencies in the pregnant and non-pregnant female patients.
• Evaluate and formulate a management plan for a patient with perforation of the GI tract.
• Develop a differential diagnosis for abdominal pain.
• Describe the initial evaluation, diagnostic studies management of a patient with an acute abdomen
• Decide if a patient with an acute abdomen needs an operation, and justify your decision.
• Describe the signs, symptoms and clinical findings associated with acute abdomen.
• Recognize patients with extra-abdominal causes of abdominal pain.
Acute Abdomen Learning Resources
Click to link directly to Sabiston:Chapter 47, “Acute Abdomen” (on-campus / proxy server only)
Foundational Science – Physiology“How sick is this patient?” Systemic Inflammatory Response Syndrome (SIRS)
Criteria Temp >38°C (100.4°F) or < 36°C (96.8°F) Heart Rate > 90 Respiratory Rate > 20 or PaCO2 < 32 mm Hg WBC > 12,000/mm>3, < 4,000/mm>3, or > 10% bands
Acute Abdomen Alert Signs + Findings
Likely Need Surgery
“Free Air”
Sepsis / SIRS
Peritonitis
Peritonitis-Irritation of the Peritoneal LiningTypical signs (most patients have some, not all)
Pain with movement or stretching of the peritoneum. Often keep knees and hips flexed
Hypersensitive to touch, mild bumps (car rides / hospital cart)
Rigid abdomen “Rebound tenderness” Can be focal or diffuse
Usually Requires
Surgery
ObesityChemo
SteroidsLimited Mental Capacity
Don’t always trust a benign exam
Pneumoperitoneum
Pneumoperitoneum
AlgorithmAcute
Abdominal Pain with Peritonitis
SIRS / Sepsis
Operate
Stable /
No SIRS
Pneumo-peritoneum On
X-ray
Operate
No Pneumo-peritoneum On
X-ray
Contrast Study (Typically CT)
Free Air or Contrast
Extravasation -> Operate
Contained Collection /
Perforation -> Operate vs.
Drain
Normal Study -> Monitor Closely
“Safe Strategies”
N.B. Exceptions do exist
AlgorithmAcute Abdominal
Pain Without Peritoneal Signs
Generalized Pain
CT with PO and IV contrast
Normal
Evaluate for “Non-Surgical Causes”
Arterial Ischemia
Operate
Venous Thrombosis
Anticoagulate
Focal Pain
Selective Imaging (History / Exam
Dependent)
Positive
Operate / Drain
Negative
Continue to Evaluate- Urgent
Surgery Not Required
Foundational Science – Anatomy“Where does it hurt?” – Referred Pain
Common Causes of the Acute Abdomen
Bowel Perforation or Ischemia
Infection (Appendicitis / Cholecystitis, etc)
Hemoperitoneum (trauma, ruptured ectopic, etc)
Hernias (Incarcerated / Strangulated)
Sudden Severe Abdominal Pain
Kidney Stone (Hematuria, flank pain) Ruptured AAA (Shock, Back Pain, H/O vascular dz) Perforated Ulcer Patients know exactly
when these symptoms
started!
Non-abdominal causes of pain
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
Case 1 - A Hypotensive Pt
Case 2
58 yo male 2 day history of left lower quadrant abdominal pain. Pain started L>R, Attempted to take some pepto-bismol but that did not help. He report some associated nausea, he denies any
vomiting Some subjective fevers at home. The pain was unrelenting therefore he came to the ED for
further evaluation. He reports his abdomen feels more distended and the pain is worse with movement. He has been unable to tolerate much PO.
Case 2- order of events
Physical Exam / Vitals Labs Imaging
ConfirmationTreatment
Plan
Abdomen: Tender, distended. Peritonitis
14.8 (87% granulocytes)
12.8 243
44.3
Does he need a CT scan?
Case 2 Findings
Case 2 – CT Probably not needed but here it is Free air Inflammation Diverticuli
-> perforated
diveriticulitis
Summary
Physical Exam, Patient Status (sepsis, etc.) drives algorithm
Differential Diagnosis based on exam, confirmed with imaging
Take every opportunity to examine patients with pathology now as a student
Timing can be crucial to good outcomes
Acute Abdomen Quiz
Thank you for completing this module
Questions? Contact me at:
640 Faculty Office Tower (395 W 12th Ave.)
Image Credits
Slide 1 photo- http://www.enfermeriablog.com/tag/cuidados-peritonitis/ Slide 3- cover images from amazon.com Slide 4- “Know the signs, know sepsis”- Boston Medical Center;
http://www.coloribus.com/adsarchive/prints/land-rover-defender-fireball-1965105/ Slide 5-6 photos- OSUMC images Slide 7 photo- http://onemomsbattle.com/TheLiesofaNarcissist Slide 8 image- http://prep-pg.blogspot.com/2012/04/radiological-signs-of-bowel-perforation.html Slide 9 image- OSUMC Slide 12 image from Sabiston, Ch. 47. Slide 14 image from
http://www.celebritydiagnosis.com/2013/04/dwayne-the-rock-johnson-undergoes-hernia-surgery/ Slide 15 image- http://www.hongkiat.com/blog/extraordinary-clocks/ Slide 16 table- adapted from Sabiston, Ch. 47. Slide 18 images- http://www.fairview.org/healthlibrary/Article/89315 and cancer.osu.edu Slide 19 image- http://www.pinterest.com/carolinagirl525/x-ray/ Slide 20 image- Van Wagoner ZD, Evans DC, Askegard-Giesmann JR, Kenney BD. Perforated
peptic ulcer in a child with a vagus nerve stimulator for seizure control. Brain Stimul. 2013 Nov;6(6):972-3.
Slide 24- OSU clinical image Slide 25 image- http://5minuteconsult.com/ViewImage/2027820
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