ACUTE ABDOMEN

Download •Ruptured abdominal aortic aneurysm. •Ruptured ectopic. Volvulus. • Intussusception. •Acute pancreatitis. •Biliary colic. Di ti liti. Strang...

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Acute Abdomen Andreas M Kluftinger g MD FRCSC Kelowna General Hospital

Disclosure

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

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

Objectives • Understand the Pathophysiology and Etiology of the acute abdomen • Approch to acute abdomen in rural practice ti • Case presentations

Stedman's Stedman s Medical Dictionary 27th Edition “any serious acute intra-abdominal condition attended by pain pain, tenderness tenderness, and muscular rigidity, and for which emergency surgery must be considered considered."

Acute Abdominal Pain • • • •

5 10 % of ER visits 5-10 Complex “black box” D l Delays iin di diagnosis i can iincrease morbidity bidit Excessive consultations (+/- transport) and imaging can be costly and tax resources. • Primary y assessment and triage g are key y

History & Physical • • • • • •

Onset, nature Onset nature, duration duration, location location, radiation Aggravating and relieving factors A Associated i t d GI or GU symptoms t Past history (Surg and Med) Review of Systems Full physical exam

Stereotypes of Pain Onset and Associated Pathology •Sudden S dd onset •Rapid R id onset (full pain in seconds) (initial sensation to full pain over minutes or hours)

•Gradual G d l onset (hours)

•Perforated ulcer •Mesenteric Mesenteric infarction •Ruptured abdominal aortic aneurysm •Ruptured ectopic pregnancy •Ovarian torsion or ruptured cyst •Pulmonary Pulmonary embolism •Acute myocardial infarction

•Appendicitis •Strangulated Strangulated hernia •Chronic pancreatitis •Peptic ulcer disease •Inflammatory bowel disease •Mesenteric M t i llymphadenitis h d iti •Cystitis and urinary retention •Salpingitis and prostatitis

•Strangulated hernia •Volvulus Volvulus •Intussusception •Acute pancreatitis •Biliary colic •Diverticulitis Di ti liti •Ureteral and renal colic

Abdominal Innervation

Simplified in Thirds Embryologic

Structures

Nerves

Arteries

Pain Location

Foregut

Esophagus, , stomach,3/4 duod,liver, gb panc

Thoracic splanchnics, p , vagus

Coeliac

Epigastrium

Midgut

¼ duod to splenic flexure

Thoracic splanchnics, vagus

SMA

Periumbilical

Hindgut

Left colon, colon rectum, GU tract

Pelvic splanchnics, lesser thoracic p splanchnics

IMA

Hypogastrium

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 (ascending colon, appendix, ovary, fallopian tube)

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

pp q quadrant Left upper (pancreas, spleen, kidney)

Gastritis, acute p pancreatitis, splenic p pathology, p gy left lower lobe p pneumonia

Left lower quadrant (sigmoid and descending colon, ovary, fallopian f ll i ttube) b )

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

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, retrocecal appendicitis posterior duodenal ulcer appendicitis,

Suprapubic or lower abdominal

Ectopic pregnancy, mittelschmerz, ruptured ovarian cyst, pelvic inflammatory disease, endometriosis, urinary tract infection

Sign

Finding

Association

Cullen's sign

Bluish periumbilical discoloration

Grey Turner’s sign

Bluish flank discoloration

Retroperitoneal hemorrhage g pancreatitis, abdominal aortic aneurysm rupture)

Kehr's sign

Severe left shoulder pain

Splenic rupture Ectopic pregnancy

McBurney's McBurney s sign

Tenderness located 2/3 distance from ASIS to umbilicus on right side

Appendicitis

Murphy's sign

Abrupt interruption of inspiration on palpation of right upper quadrant

Acute cholecystitis

Iliopsoas sign

Hyperextension of right hip causing abdominal pain

Appendicitis

Obturator's sign

Internal rotation of flexed right hip causing abdominal pain

Appendicitis

Chandelier 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 Pain

Diaphragmatic

Supraclavicular area (Kehr's sign)

Ureteral

Hypogastrium, groin, inner thigh

Cardiac pain

Epigastrum, jaw, shoulder

Appendix

Periumbilical via T10 nerve

D d Duodenum

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

Hiatal 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 Appendicitis

Imaging g g Accuracy y in A Appendicitis di iti Modality

Sensitivity

Specificity

Pos PredValue

Neg Pred Value

Plain Film

10%

90%

Ultrasound

85-90%

92-96%

95%

80-90%

CT

95-97%

95%

97%

95-100%

MRI

93%

91%

92%

100%

Laboratory in Appendicitis Test

Sensitivity

1. WBC >10.5

85%

2. Neutrophils >75%

78%

3 C reactive protein 3.

93-96% 93 96%

Neg Pred Value 94%

1+2

96%

1+3

92.3%

1+2+3

99.2% (81% in children)

Urinalysis in Appendicitis • 30% of appendicitis patients have some urinary syptoms • 14% have >10 WBC/hpf • 18% have > 3 RBC/hpf

Imaging in Pregnancy • Ultrasound – Safest – Useful for fetal assessment (dates (dates, viability viability, placenta, amniotic fluid) – NPV for appendicitis 80-90% – PPV for appendicitis 95%

Imaging in Pregnancy Procedure

Fetal Exposure

Chest radiograph (2 views)

0.02-0.07 mrad

Abdominal film (single view)

100 mrad

Intravenous pyelography

>1 rad*

Hip film (single view)

200 mrad

Mammography

7-20 mrad

Barium enema or small bowel series

2-4 rad

CT (computed tomography) scan head <1 rad or chest CT scan abdomen and lumbar spine

3.5 rad

CT pelvimetry

250 mrad

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

Acute Abdomen C Caused db by P 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 g of myoma y Torsion of pedunculated myoma Placental abruption, Placenta percreta HELLP (hemolysis, elevated liver function, and low platelets) syndrome – Spontaneous rupture of the liver – Uterine rupture – Chorioamnionitis

Conditions Associated with Pregnancy Pregnancy • • • • •

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

Case #1 • • • • • • •

68 male male, 48 hrs RLQ pain Quick onset, in RLQ N nausea or anorexia No i No urinary syptoms PHx: GERD, dyslipidemia Tender RLQ and flank with peritonism WBC 9.2 Urine clear

CT abdomen

Case #2 • • • • •

BW 41 yo electrician collapsed at home with chest, abd pain CPR by family, EHS to KGH PHx: appe Meds: ASA Exam: BP 60 sys, HR 100 RR 16 Chest clear Abdomen tender, acute

Investigations • • • • •

Hb 108 WBC 8 8.9 9 Plts 256 Hep panel – normal Li Lipase 43 ECG – normal Trop < 0.1

CT with Aorta Protocol

Laparotomy • • • • • • •

3 litres blood intact liver, spleen, viscera bl d ffrom llesser sac blood rupured splenic artery aneurysm at hilum splenectomy, distal pancreatectomy 4 units FP, FP 6 units RBC Recovery uneventful