The Acute Abdomen

1. The Acute Abdomen Andrew Wright MD Department of Surgery

2. What is an acute abdomen?

3. What is an acute abdomen? • New onset abdominal pain • Usually abdominal pain as main symptom • Often seen by primary physician • Signifies need for prompt diagnosis • Does not necessarily imply need for surgical intervention

4. How do you diagnose an acute abdomen?

5. How do you diagnose an acute abdomen? History and Physical

6. History

7. Exact time and onset • Most slow • Can guide prognosis – i.e. timing of appendicitis • Acute • Colic • Bowel strangulation • Rupture of viscera • Torsion • Fainting • Abdominal apoplexy • Perforated ulcer, ruptured aortic aneurysm, ruptured ectopic • What was patient doing at time of onset? • i.e. “minor” trauma

8. Location • Initial location • Shifting of pain • Transition from visceral to parietal pain

9. What is visceral pain? • Intestines are: • Insensitive to touch • Sensitive to stretch, distension, or excessive contraction against resistance • Location: • Small intestine – umbilicus • Large intestine – hypogastrium • Biliary – RUQ, R subscapular • Kidney – Loin, occ radiates to ipsilateral testicle

10. What is visceral pain? • Character • Paroxysmal • Often excruciating • Patients will writhe, twist, attempt to find a comfortable position • In contrast to peritonitis – where patients will lie still to avoid further irritation

11. Character • Character • Burning – i.e. ulcer • Agony- i.e. pancreatitis • Sharp, constricting – i.e. biliary colic • Tearing – i.e. dissecting aneurysm • Gripping – i.e. obstruction • Aching – i.e. appendicitis • Dull, fixed – i.e. pyonephrosis

12. Radiation • Referred pain • Diaphragm – shoulder • Biliary tract – tip of shoulder • Pancreas – mid back • Kidney – mid back • Rectum- coccyx • Uterus – coccyx

13. Exacerbating factors • Relationship to food • Respiration • Pleuritic pain usually worse on deep inspiration • Micturation • UTI • Bladder obstruction • Nephrolithiasis • Peri-bladder abscess • Reclining • Often retroperitoneal origon

14. Vomiting • Cause • Obstruction • Severe irritation of nerves of peritoneum • i.e. pain, pancreatitis • Frequency • Relationship with pain • Character • Nausea and/or lack of appetite

15. Bowel Movements • Regularity • Diarrhea • True diarrhea vs. passage of several small loose stools • Blood • Mucus • i.e. intussusception

16. Menstruation • Regularity • Exact timing • Pain

17. History • Prior similar episodes • Prior illnesses that may relate • h/o peritonitis, appendicitis, pneumonia, etc. • Previous attacks of jaundice, melena, hematemesis, hematuria • Travel history • PMH • PSH

18. Examination

19. General appearance • General gestalt – is he (or she) sick?

20. Vitals • Pulse • Respiratory rate • Temp • Normal or mildly elevated typical • High fever unusual – suspect kidney or thorax • Hypothermic – suspect shock • Blood Pressure

21. Inspection • Determine exact location of pain first • Inspection • Distension • Bulge • Hernia • All potential orifices – including femoral • Movement • Rigidity with inspiration

22. Palpation • Keys to success • Gentleness • Thighs flexed • Thorough exam • Include back • Guarding • Rebound • Iliopsoas rigidity

23. Percussion • Liver dullness • Free-fluid

24. Rectal exam

25. Pelvic exam

26. Should pain meds be given prior to diagnosis?

27. Diagnostic Testing

28. Diagnostic Testing • CBC with dif • Electrolytes, BUN, creatinine, and glucose • Aminotransferases, alkaline phosphatase, and bilirubin • Lipase • Urinalysis • Pregnancy test in women of childbearing potential

29. Imaging

30. Imaging • Imaging • Plain XRays • Flat and Upright • Left Lateral Decubitus if not able to stand) • Chest • Ultrasound • CT • Additional Testing • Guide by Differential

31. Causes of Abdominal Pain

32. Extra-abdominal • Herpes Zoster • MI • Pneumonia

33. Biliary Disease • Cholelithiasis • Cholecystitis • Cholangitis • Pancreatitis • Biliary Dyskinesia

34. GI • GERD • Gastritis • Peptic Ulcer Disease • Irritable Bowel • Constipation • Diabetic Gastroparesis

35. Infectious • Appendicitis • Diverticulitis • Gastroenteritis • Viral • Eosinophilic • Yersinia • Hepatitis • Typhlitis • Tropical infectious diseases (helminthic) • Tuberculosis Typhlitis

36. Appendicitis Acute Appendicitis Normal

37. Appendicolith

38. Appendiceal Phlegmon

39. Peri-appendiceal Abscess

40. Diverticulosis

41. Diverticulitis

42. Diverticular Abscess

43. Bowel Obstruction • Hernia • Adhesion • Malignancy • Intussuception

44. Inflammatory • Crohn’s • Ulcerative Colitis • Malignancy • Epiploic appendagitis Epiploic appendagitis

45. Gynecologic • PID • Adnexal • Torsion • Cyst • Neoplasm • Endometriosis • Ectopic pregnancy • Endometritis • Leiomyomas

46. Urologic • UTI • Nephrolithiasis • Bladder distension

47. Vascular • Aneurysm • Dissection • Mesenteric Ischemia • Acute • Chronic • Sickle Cell Crisis Colonic Ischemia

48. Other • Psychiatric Disease • Spleen • Abscess • Infarct • Wandering Spleen • Musculoskeletal • Abdominal wall pain • Painful rib syndrome (chostochondritis) • Hernia

49. Other • Celiac artery compression • Abdominal Migraine • Fitz-Hugh-Curtis syndrome • Familial Mediterranean fever • Hereditary angioedema • Heavy Metal Poisoning • Metabolic • Diabetic Ketoacidosis • Porphyria • Lactose Intolerance

50. Pediatric • Henoch-Schönlein purpura • Intussuception • Malrotation with midgut volvulus • Recurrent Abdominal Pain – diagnosis of exclusion