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Acute Abdomen

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  1. Acute Abdomen

  2. Acute Abdomen • Anatomy review • Non-hemorrhagic abdominal pain • Gastrointestinal hemorrhage • Assessment • Management

  3. Abdominal Anatomy Review

  4. Abdominal Cavity • Superior border = diaphragm • Inferior border = pelvis • Posterior border = lumbar spine • Anterior border = muscular abdominal wall

  5. Peritoneum • Abdominal cavity lining • Double-walled structure • Visceral peritoneum • Parietal peritoneum • Separates abdominal cavity into two parts • Peritoneal cavity • Retroperitoneal space

  6. Primary GI Structures • Mouth/oral cavity • Lips, cheeks, gums, teeth, tongue • Pharynx • Portion of airway between nasal cavity and larynx

  7. Primary GI Structures • Esophagus • Portion of digestive tract between pharynx and stomach • Stomach • Hollow digestive organ • Receives food from esophagus

  8. Primary GI Structures • Small intestine • Between stomach and cecum • Composed of duodenum, jejunum and ileum • Site of nutrient absorption into body • Large intestine • From ileocecal valve to anus • Composed of cecum, colon, rectum • Recovers water from GI tract secretions

  9. Accessory GI Structures • Salivary glands • Produce, secrete saliva • Connect to mouth by ducts

  10. Accessory GI Structures • Liver • Large solid organ in right upper quadrant • Produces, secretes bile • Produces essential proteins • Produces clotting factors • Detoxifies many substances • Stores glycogen • Gallbladder • Sac located beneath liver • Stores and concentrates bile

  11. Accessory GI Structures • Pancreas • Endocrine pancreas secretes insulin into bloodstream • Exocrine pancreas secretes digestive enzymes, bicarbonate into gut • Vermiform appendix • Hollow appendage • Attached to large intestine • No physiologic function

  12. Major Blood Vessels • Aorta • Inferior vena cava

  13. Solid Organs • Liver • Spleen • Pancreas • Kidneys • Ovaries (female)

  14. Hollow Organs • Stomach • Intestines • Gallbladder and bile ducts • Ureters • Urinary bladder • Uterus and Fallopian tubes (female)

  15. Right Upper Quadrant • Liver • Gallbladder • Duodenum • Transverse colon (part) • Ascending colon (part)

  16. Left Upper Quadrant: • Stomach • Liver (part) • Pancreas • Spleen • Transverse colon (part) • Descending colon (part)

  17. Right Lower Quadrant • Ascending colon • Vermiform appendix • Ovary (female) • Fallopian tube (female)

  18. Left Lower Quadrant • Descending colon • Sigmoid colon • Ovary (female) • Fallopian tube (female)

  19. Acute Abdomen

  20. Abdominal Pain • Visceral • Somatic • Referred

  21. Abdominal Pain • Visceral pain • Stretching of peritoneum or organ capsules by distension or edema • Diffuse • Poorly localized • May be perceived at remote locations related to organ’s sensory innervation

  22. Abdominal Pain • Somatic pain • Inflammation of parietal peritoneum or diaphragm • Sharp • Well-localized

  23. Abdominal Pain • Referred pain • Perceived at distance from diseased organ • Pneumonia • Acute MI • Male GU problems

  24. Non-hemorrhagic Abdominal Pain

  25. Esophagitis • Inflammation of distal esophagus • Usually from gastric reflux, hiatal hernia

  26. Esophagitis • Signs and Symptoms • Substernal burning pain, usually epigastric • Worsened by supine position • Usually without bleeding • Often temporarily relieved by nitroglycerin

  27. Acute Gastroenteritis • Inflammation of stomach, intestine • May lead to bleeding, ulcers • Causes •  acid secretion • Chronic EtOH abuse • Biliary reflux • Medications (ASA, NSAIDS) • Infection

  28. Acute Gastroenteritis • Signs and Symptoms • Epigastric pain, usually burning • Tenderness • Nausea, vomiting • Diarrhea • Possible bleeding

  29. Chronic Infectious Gastroenteritis • Long-term mucosal changes or permanent damage • Due primarily to microbial infections (bacterial, viral, protozoal) • Fecal-oral transmission • More common in underdeveloped countries • Nausea, vomiting, fever, diarrhea, abdominal pain, cramping, anorexia, lethargy • Handwashing, BSI

  30. Peptic Ulcer Disease • Craters in mucosa of stomach, duodenum • Males 4x > Females • Duodenal ulcers 2 to 3x > Gastric ulcers • Causes: • Infectious disease: Helicobacter pylori (80%) • NSAIDS • Pancreatic duct blockage • Zollinger-Ellison Syndrome

  31. Duodenal Ulcers 20 to 50 years old High stress occupations Genetic predisposition Pain when stomach is empty Pain at night Gastric Ulcers > 50 years old Work at jobs requiring physical activity Pain after eating or when stomach is full Usually no pain at night Peptic Ulcer Disease

  32. Peptic Ulcer Disease • Complications • Hemorrhage • Perforation, progressing to peritonitis • Scar tissue accumulation, progressing to obstruction

  33. Peptic Ulcer Disease • Signs and Symptoms • Steady, well-localized pain • “Burning”, “gnawing”, “hot rock” • Relieved by bland, alkaline food/antacids • Worsened by smoking, coffee, stress, spicy foods • Stool changes, pallor associated with bleeding

  34. Pancreatitis • Inflammation of pancreas in which enzymes auto-digest gland • Causes include: • EtOH (80% of cases) • Gallstones obstructing ducts • Elevated serum triglycerides • Trauma • Viral, bacterial infections

  35. Pancreatitis • May lead to: • Peritonitis • Pseudocyst formation • Hemorrhage • Necrosis • Secondary diabetes

  36. Pancreatitis • Signs and Symptoms • Mid-epigastric pain radiating to back • Often worsened by food, EtOH • Bluish flank discoloration (Grey-Turner Sign) • Bluish periumbilical discoloration (Cullen’s Sign) • Nausea, vomiting • Fever

  37. Cholecystitis • Gall bladder inflammation, usually 2o to gallstones (90% of cases) • Risk factors • Five Fs: Fat, Fertile, Febrile, Fortyish, Females • Heredity, diet, BCP use

  38. Cholecystitis • Acalculus cholecystitis • Burns • Sepsis • Diabetes • Multiple organ systems failure • Chronic cholecystitis (bacterial infection)

  39. Cholecystitis • Signs and Symptoms • Sudden pain, often severe, cramping • RUQ, radiating to right shoulder • Point tenderness under right costal margin (Murphy’s sign) • Nausea, vomiting • Often associated with fatty food intake • History of similar episodes in past • May be relieved by nitroglycerin

  40. Appendicitis • Inflammation of vermiform appendix • Usually secondary to obstruction by fecalith • May occur in older persons secondary to atherosclerosis of appendiceal artery andischemic necrosis

  41. Appendicitis • Signs and Symptoms • Classic: Periumbilical pain  RLQ pain/cramping • Nausea, vomiting, anorexia • Low-grade fever • Pain intensifies, localizes resulting in guarding • Patient on right side with right knee, hip flexed

  42. Appendicitis • Signs and Symptoms • McBurney’s Sign: Pain on palpation of RLQ • Aaron’s Sign: Epigastric pain on palpation of RLQ • Rovsing’s Sign: Pain in LLQ on palpation of RLQ • Psoas Sign: Pain when patient: • Extends right leg while lying on left side • Flexes legs while supine

  43. Appendicitis • Signs and Symptoms • Unusual appendix position may lead to atypical presentations • Back pain • LLQ pain • “Cystitis” • Rupture: Temporary pain relief followed by peritonitis

  44. Bowel Obstruction • Blockage of intestine • Common Causes • Adhesions (usually 2o to surgery) • Hernias • Neoplasms • Volvulus • Intussuception • Impaction

  45. Bowel Obstruction • Pathophysiology • Fluid, gas, air collect near obstruction site • Bowel distends, impeding blood flow/ halting absorption • Water, electrolytes collect in bowel lumen leading to hypovolemia • Bacteria form gas above obstruction further worsening distension • Distension extends proximally • Necrosis, perforation may occur

  46. Bowel Obstruction • Signs and Symptoms • Severe, intermittent, “crampy” pain • High-pitched, “tinkling” bowel sounds • Abdominal distension • History of decreased frequency of bowel movements, semi-liquid stool, pencil-thin stools • Nausea, vomiting • ? Feces in vomitus

  47. Hernia • Protrusion of abdominal contents into groin (inguinal) or through diaphragm (hiatal) • Often secondary to  intra-abdominal pressure (cough, lift, strain) • May progress to ischemic bowel (strangulated hernia)

  48. Hernia • Signs and Symptoms • Pain  by abdominal pressure • Past history • Inguinal hernia may be palpable as mass in groin or scrotum

  49. Crohn’s Disease • Idiopathic inflammatory bowel disease • Occurs anywhere from mouth to rectum • 35-45%: small intestine; 40%: colon • Runs in families • High risk groups • White females • Jews • Persons under frequent stress

  50. Crohn’s Disease • Pathophysiology • Mucosa of GI tract becomes inflamed • Granulomas form, invade submucosa • Muscular layer of bowel become fibrotic, hypertrophied • Increased risk develops for • Obstruction • Perforation • Hemorrhage