The Acute Abdomen - physicianeducation.org

1 The Acute AbdomenDr. Ed SnyderDr. Melanie WalkerHuntington Memorial HospitalCauses of the Acute AbdomenXHemorrhage in GI tract Blood vessel GU tractYPerforation of GI tract Ulcer Infection Parasites cancer GU tractCauses of the Acute AbdomenZInflammation [Obstruction of the .. GI tract Adhesions Hernia Volvulus Tumor Intussusception Parasites GU tract Stone Tumor Vascular System Thrombus, EmbolusSigns SIGNSare objective and reproducible findings Tenderness Rigidity Masses Altered bowel sounds Evidence of malnutrition Bleeding JaundiceSymptoms SYMPTOMS reflect a subjective change from normal function pain Appetite:anorexia, nausea, vomiting, dysphagia, weight loss Bowel habits:bloating, diarrhea, constipation, flatulenceThe Physiology of Abdominal pain Abdominal pain from any cause is mediated by either visceral or somaticafferent nerves Several factors can modify expression of pain Age extremes Vascular compromise ( pain out of proportion ) Pregnancy CNS pathology NeutropeniaVisceral pain Stimuli Distention 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)foregutmidguthindgutSomatic pain Stimuli Irritation of the peritoneum Sensation Sharp, localized pain Easily described Cardinal signs pain Guarding Rebound Absent bowel soundsExample.]

2 McBurney s point in late appendicitisPatterns of Referred PainGastric painLiver and biliary painBiliary colicDiaphragmatic irritationUreteral or kidney painColonic painUterine and rectal painPancreatic and renal painHistory 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 ReviewPhysical Examination Appearance and position of patient Vital signs Appearance of Abdomen Distention Hernia ScarsPhysical Examination Tenderness Rigidity Masses Bowel sounds Rectal and Pelvic Examination Careful exam of heart, lungs and skinPhysical Examination: The QuadrantsDiagnosis: Right Upper Quadrant (RUQ) pain Investigations XRay Upright chest Upright and supine abdominal Complete Blood count Urinalysis Amylase, Creatinine, BUN, ElectrolytesDifferential diagnosis .

3 RUQ PainCLUESCONDITIONF ever, tachypnea, bronchial breathingRight lower lobe pneumoniaShift of pain , tendernessRetrocecal appendicitisEdema, dyspnea, elevated JVPC ongestive heart failureDysuria, fever, costovertebral angle tendernessRight pyelonephritisAlcohol history, jaundice, medicationsAcute hepatitisRecurrent attacks, tender over gall bladder areaBiliary colic, Acute cholecystitisDiagnosis: Left Upper Quadrant (LUQ) and Epigastric pain Investigations Upright chest XR Upright and supine abdominal XR CBC Amylase and lipase (if available) differential diagnosis : LUQ and Epigastric PainCLUESCONDITIONF ever, XR findings, bronchial breathingPneumoniaRecurrent, relationship to meals, relationship to postureGastritis / Peptic ulcer diseaseHistory of alcohol consumption, history of similar event, elevated labsPancreatitisHistory of trauma, gross deformity, extreme tenderness on palpationFractured ribsHistory of trauma or splenic diseaseSplenic ruptureDiagnosis: Right Lower Quadrant (RLQ) pain Investigations Urinalysis (to exclude obvious urinary causes) Pregnancy test Ultrasound Complete blood countDifferential diagnosis .

4 RLQ nextGynecologic causesRecurrent, several days historyCrohn s diseaseTender swollen testis, usually young ageTorsed right testisColicky pain , hematuriaRight renal colicFever, inconstant signsMesenteric adenitisShift of pain , anorexia, localized tendernessAcute appendicitisGynecologic Causes of RLQ PainCLUESCONDITIONS udden onset, amenorrhea, shockPelvic inflammatory diseaseSevere pain , vomitingRuptured ectopic pregnancyMidcycle, sudden onsetTorsion of ovaryFever, cervical excitation, dischargeRuptured follicleDiagnosis: Left Lower Quadrant (LLQ) pain Pregnancy test Urinalysis to exclude unsuspected urinary source Ultrasound Complete blood count Upright and supine abdominal XR CT scan if diverticular disease is suspectedDifferential diagnosis : LLQ PainGynecologic causes as for RLQ painTender, swollen testis, young ageTorsion of testisCLUESCONDITIONC olicky pain , hematuriaLeft renal colicColicky pain , obstipationLarge bowel obstructionRecurrent attacks, diarrhea (+/- mucus, blood)Inflammatory bowel diseaseDysuria, frequencyUrinary tract infectionPalpable bladder, difficulty passing urineAcute urinary retentionElderly patient, recurrentDiverticular diseaseDiagnosis.

5 Periumbilical pain Investigations CBC Amylase and lipase, if available If severe, unrelenting pain urgent surgical referral If pain colicky and no flatus erect and supine abdominal XR If diarrhea and vomiting stool testsDifferential diagnosis : Periumbilical PainCLUESCONDITIONS evere pain , tenderness less marked, rectal bleedingIschemic bowelColicky pain , vomiting, no flatusSmall bowel obstructionNausea, short historyEarly appendicitisRecurrent diarrhea, +/- mucus and bloodInflammatory bowel diseaseColicky pain , hard stoolConstipationVomiting and diarrheaGastroenteritisCommon Gastrointestinal Causes of the Acute Abdomen Appendicitis Perforated peptic ulcer Intestinal perforation Meckel s diverticulum Diverticulitis Chronic irritable bowel disease GastroenteritisCommon Visceral Causes of the Acute Abdomen Acute pancreatitis Acute calculous cholecystitis Acalculous cholecystitis Hepatic abscess Ruptured hepatic tumor Acute hepatitis Splenic ruptureCommon Gynecologic Causes of the Acute Abdomen Ruptured ovarian cyst Ovarian torsion Ectopic pregnancy Acute salpingitis Pyosalpinx Endometritis Uterine ruptureExtra-Abdominal Causes of the Acute Abdomen Supradiaphragmatic Myocardial infarction Pericarditis Left lower lobe

6 Pneumonia Pneumothorax Pulmonary infarction Hematologic Sickle cell disease Acute leukemia Drugs Metabolic Nervous System Herpes Zoster Tabes dorsalis Nerve root compression Endocrine Diabetic ketoacidosis Addisonian crisisImmediate Treatment of the Acute large bore IV with either saline or lactated Ringer s pain tube if vomiting or concerned about catheter to follow hydration status and to obtain administration if suspicious of inflammation or therapy or procedure will vary with diagnosisRemember to reassess patient on a regular basis.