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56 Cards in this Set
- Front
- Back
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Acute Abdomen
Definition |
A severe, often life threatening disease of abdominal organs, the primary symptom of which is pain
Traditionally connotes surgically treated diseases, but not all are surgically treated |
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Acute Abdomen
Etiologies |
Inflammation (abscess, perforation)
- spilling of intestinal contents and bacteria Ischemia/Necrosis Obstrution/Distention - stretching of viscera causes pain Bleeding - Intraperitoneal... trauma causes initial pain, blood irritates causing diffuse pain - Intraluminal... crampy pain |
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Abdomen Visceral Pain
Characterization |
deep
dull crampy |
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Abdomen Visceral Pain
Etiology |
Stretch
- Of hollow organ, caused of distal obstruction Ischemia Contraction against obstruction |
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Abdomen Parietal Pain
Characterization |
sharp, focal
intense constant |
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Abdomen Parietal Pain
Etiology |
Trauma to peritoneum
Infection/Inflammation Irritants - Blood - Bile (even if uncomplicated, sterile bile) |
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Referred Pain
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Sensation of pain in a somatic distribution (dermatome or myotome) derived from the same spinal cord segments as the inflamed peritoneum (visceral or parietal)
Example: Small bowel pain perceived as diffuse discomfort in T10-12 dermatomes of back and anterior abdominal wall |
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What abdominal problem is associated with episodic pain?
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obstruction
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What abdominal problem is associated with steadily progressive pain?
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ischemia, peritoneal inflammation
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What abdominal problem is associated with colicky, changing to steady pain?
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intestinal strangulation
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What abdominal problem is associated with sudden relief of pain?
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relief of obstruction
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What should you do while you are making the diagnosis of acute abdomen?
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start fluid resuscitation
most of these patients are dehydrated |
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With what is instantaneous pain associated?
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Perforation of hollow viscus
- Duodenal or cecal perforation Rupture of solid organ - Splenic or hepatic rupture |
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With what is rapid onset (not instantaneous) pain associated?
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Hollow organ obstruction
- Small Bowel Obstruction, Ureteral colic, Sickle Cell Inflammatory process Toxic or metabolic - Leaking perforation, peritoneal blood, porphyria |
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With what is gradual onset pain associated?
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Chronic (non-surgical) processes
Progressive Inflammation - Appendicitis, cholecystitis, Pelvic Inflammatory Disease |
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What is involved in the history for Acute Abdomen?
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Standard HPI
Onset, progression of pain Associated symptoms Past Medical History Past Surgical History - Adhesive bowel obstruction |
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Obturator Sign
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Internally rotate hip
Will specifically hurt on the right side with appendicitis |
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Iliopsoas Sign
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Test specifically for RLQ inflammatory process
Lie on left side Extend the left leg and stretch the iliopsoas muscle |
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Physical Exam
Appearance |
Lie motionless in bed
Knees drawn to relax abdominal musculature Decreased abdominal wall movement with ventilation May walk with a limp |
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Physical Exam
Auscultation |
Chest auscultation to rule out pneumonia
Early bowel sounds variable Perforation may less to loss of bowel sounds (ileus) Stethoscope to distract during palpation |
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Physical Exam
Palpation |
Start gently in quadrant opposite pain if localized
Note rigidity will not relax with expiration Test rebound tenderness last (it will be the last thing they will let you do) For appendicitis: iliopsoas sign obturator sign |
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Appendix Anatomical Variations
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Retrocecal appendix
- Elevated in the right paracolic gutter, can even touch gallbladder Medial Lower down where you expect it |
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Cecum Anatomical Variations
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Elevated
- Can get higher and higher as a pregnancy progresses Lower |
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Colicky
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intermittent, sharp, intense pain
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What Labs should be ordered when considering acute abdomen?
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CBC
- WBC for inflammation Electrolytes - Cl-, K+ to determine if dehydrated Liver function - To determine if biliary in nature… alkaline phosphatases, transaminases Amylase/Lipase - Pancreatitis U/A - UTI, Pyelonephritis Serum BHCG (not an option) - Expect pregnancy in women up to 60 y/o |
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What is the importance of Clinical Course in acute abdomen?
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If significant uncertainty exists about diagnosis, detailed sequential exams by one person is highly accurate
Rapidly progressive disease mandates rapid treatment Slowly progressive disease allows equally deliberate workup |
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Most Common causes of Acute Abdomen
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Appendicitis
Small Bowel Obstruction Acute cholecystitis Acute Pancreatitis Diverticulitis PID Peptic Ulcer Disease |
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Female Pelvic Sources of Acute Abdomen
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Operative
- Ruptured ectopic pregnancy…. Urgent surgery because hemorrhagic - Ruptured cysts Non-operative - PID/Salpingitis - Endometriosis - Mittelsmerz (ovulation pain… self limited) - Tuboovarian abscess |
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Intra-abdominal causes of Acute Abdomen
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Primary peritonitis
Porphyria, sickle cell crisis, polyserositis (collagen vascular disease), uremia, DKA Neutropenic colitis - Associated with patients who are neutropenic from chemotherapy Rectus hematoma - Anticoagulated in 2 systems (heparin and antiplatelet therapy), minimal-to-no trauma causes blood collection within the rectus sheet Addison’s crisis |
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Extra-abdominal causes of Acute Abdomen
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Pneumonia, pleural inflammation
PE, MI, pericarditis, esophagitis Toxins Herpes zoster |
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Gastrointestinal causes of Acute Abdomen
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Appendicitis, intestinal or colonic obstruction, strangulated hernia
Peptic ulcer disease (perforation) Diverticulitis Acute gastritis/gastroenteritis Intestinal perforation |
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PID
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Pelvic Inflammatory Disease
Very common amongst women in reproductive years Bacterial infection in the tube spreads to cause parietal peritoneal inflammation |
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Peritoneal causes of Acute Abdomen
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abscess or primary peritoneal
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Retroperitoneal causes of Acute Abdomen
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Abscess, hemorrhage
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Liver/Spleen causes of Acute Abdomen
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Hepatitis, segmental or organ infarction
Abscess (local inflammation), splenic rupture |
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Pancrease/Biliary causes of Acute Abdomen
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Acute Pancreatitis
Biliary colic Acute cholecystitis Cholangitis |
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Vascular causes of Acute Abdomen
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Ruptured aortic, iliac or visceral aneurysm (pain radiates to back)
Acute mesenteric ischemia |
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Acute mesenteric ischemia
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common in patients with cardiovascular disease (or risk factors)
complaints out of proportion to the examination especially in the elderly patient |
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Cholangitis
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obstruction of bile duct as some point that causes stasis and bacteria
can cause jaundice, fever, severe pain, elevated WBC |
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Acute cholecystitis
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complete obstruction to outflow to the point where the gall bladder wall become edematous and you get invasions of the wall by bacteria because of ischemia
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Biliary colic
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caused by obstruction, intermittent
will completely resolve until the stone falls back to the same place |
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How good is our diagnostic accuracy of abdominal pain?
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47-76%
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What is the standard diagnostic tool for undifferentiated acute abdominal pain?
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CT
- Overall sensitivity = 86% - Overall specificity= 79% - Changed management in 40% |
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What is the best diagnostic tool for appendicitis?
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CT scan is the best initial evaluation of appendicitis
• 85% positive for appendicitis • 15% negative for appendicitis - Higher negative rate for lap appendectomy - 19% in laparoscopic surgery (acceptable because not too risky) - 15% in open |
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What do you look at on CT for appendicitis?
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edema around the appendix
diameter >7 mm target sign - concentric rings suggest inflammation |
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Compare CT and Ultrasound for acute abdominal pain?
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CT had a reduced admission rate by 28% in appendicitis (17% reduction overall)
CT changed surgical management in 40% of cases |
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What is the alvarado score?
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diagnosis of acute appendicitis
a score above 7 is sensitive a total of 10 points is possible better than physical exam |
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On what is the alvarado score based?
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Migration of pain (1)
Anorexia (1) Nause/vomiting (1) Tenderness in right iliac fossa (2) Rebound pain (1) Raised temperature (>37.3C) (1) Leukocyte count >10*10^9/L (2) Differential white cell count with neutrophils >75% (1) |
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Most common diagnoses for abdominal pain in elderly
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18% Diverticulitis
18% Bowel obstruction 10% Nephrolithiasis 10% Gallbladder disease |
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What is the overall accuracy of CT in geriatrics with abdominal pain?
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57%
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What is the accuracy of CT in geriatrics with acute surgical indications associated with abdominal pain?
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85%
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Statistics associated with Abdominal pain in the elderly
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60% of ED visits lead to hospitalization
20% underwent operation or invasive procedures 10% returned in 2 weeks 5% 2 week mortality Therefore, older patients with acute abdominal processes need to be treated with more urgency |
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Causes of Bowel Obstruction
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Adhesion from prior surgery or peritonitis (Number 1 cause in US)
Hernia (common in developing countries) Anatomic colonic obstruction - mass - volvulus |
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What are the complications of hernias?
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Incarceration
contents fixed or not reducible Strangulation contents with vascular compromise |
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Hernia
(what are the types?) |
Any defect in the abdominal wall that may allow peritoneal contents to protrude through the defect
Inguinal Umbilical Incisional Many are chronic and minimally symptomatic |
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Volvulus
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Any twisting of the bowel on its own mesentery (sigmoidal or cecal)
Causes vascular compromise with pain and obstruction Requires reduction - endoscopic approach (recurs frequently) - often requires surgical resection |
