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
