Acute abdomen

1. Acute abdomen Primary symptom is abdominal pain Duration of pain <7 days Medical or Surgical causes(non-traumatic) Etiology can be trivial or life threatening Requires an intervention

2. Differential Diagnosis Large List of Potential Diagnoses Any List Will Inevitably Be Missing Diagnoses Customary to Categorize By Quadrants

3. Quadrants of Abdomen

4. Differential Diagnosis

5. Differential by Location Epigastrium Acid/Peptic Disease Ulcer, GERD, Gastritis ACS (Angina, MI) Aortic Aneurism Cholelithiasis, Choledocholithiasis Diaphragmatic Defect Related Paraesophageal Hernia, Gastric Volvulus, Congenital Diaphragmatic Hernias Gastroenteritis Pancreatitis Gastric Cancer, Pancreatic Cancer, etc.

6. Differential by Location Right Upper Quadrant Appendicitis (Retrocecal or Malrotated) Cholelithiasis, Choledocholithiasis Liver Related Hepatitis, Abscess, Malignancy Renal Related Pyelonephritis, Nephrolithiasis/Ureterolithiasis Subdiaphragmatic Process Abscess

7. Differential by Location Left Upper Quadrant Colonic Ischemia Pancreatic Pancreatitis, Tumor Renal Pyelonephritis, Nephrolithiasis/Ureterolithiasis Splenic Infarct, Abscess Subdiaphragmatic Process Abscess.

8. Differential by Location Mid-Abdomen/ Periumbilical Aortic Aneurism Appendicitis Small Bowel Obstruction Ischemia (“Intestinal Angina”) Gangrene

9. Differential by Location Right lower quadrant Appendicitis Colon Related Colitis (Especially Pseudo membranous), Right- orLeft-Sided Diverticulitis, Cancer Crohn’s Disease Gynaecological Tubal Pregnancy, Ovarian Torsion, Cyst, PID,Tuboovarian Abscess,Tumor, Endometriosis, etc. Hernia Inguinal, Femoral Meckel’s Diverticulitis

10. Differential by Location Right Lower Quadrant (Continued) Renal Pyelonephritis, Nephrolithiasis/Ureterolithiasis Typhlitis Rectus/Retroperitoneal Hematoma Left Lower Quadrant Colon Related Colitis (Especially Pseudomembranous), Diverticulitis, Cancer, Colonic Ischemia Diverticulitis+ Same as RLQ-Appendicitis

11. Differential by Location Suprapubic Colon Cancer Diverticulitis Gynecological Endometritis, Endometriosis, PID Prostatitis UTI More …

12. Medical causes of acute abdomen Endocrine and Metabolic Causes UremiaDiabetic crisisAddisonian crisisAcute intermittent porphyriaHereditary Mediterranean fever Hematologic Causes Sickle cell crisisAcute leukemiaOther blood dyscrasias Toxins and Drugs Lead poisoningOther heavy metal poisoningNarcotic withdrawalBlack widow spider poisoning

13. Symptoms SYMPTOMS reflect a subjective change from normal function Pain Appetite: anorexia, nausea, vomiting, dysphagia, weight loss Bowel habits: bloating, diarrhea, constipation, flatulence

14. Signs SIGNS are objective and reproducible findings Tenderness Rigidity Masses Altered bowel sounds Evidence of malnutrition Bleeding Jaundice

15. The Physiology of Abdominal Pain Abdominal pain from any cause is mediated by either visceral or somatic afferent nerves Several factors can modify expression of pain Age extremes Vascular compromise (pain ‘out of proportion’) Pregnancy CNS pathology Neutropenia

16. Visceral Pain Stimuli Distension 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

17. Somatic Pain Stimuli Irritation of the peritoneum Sensation Sharp, localized pain Easily described Cardinal signs Pain Guarding Rebound Absent bowel sounds

18. Patterns of Referred Pain

19. History Pain When? Where? How? Abrupt, gradual Character Sharp, burning, steady, intermittent Referral? Previous occurrence? Vomiting Relationship to pain How often? How much?

20. History Nausea? Anorexia? Bowel movements Number Character Bloody? Past Medical and Surgical History Travel History Last meal Systemic Review

21. Physical Examination Appearance and position of patient Vital signs Appearance of abdomen Distention Hernia Scars

22. Physical Examination Tenderness Rigidity Masses Bowel sounds Rectal and Pelvic Examination Careful exam of heart, lungs and skin

23. Diagnosis Investigations X-Ray Upright chest Upright and supine abdominal Complete Blood count Urinalysis (pregnancy test in females) Amylase, Creatinine, BUN, Electrolytes USG CT Scan

24. Specialised Tests Two Mainstays Ultrasound (U/S) Better for Specific Inquiries (Biliary Tract, Appendicitis, or Acute Female Pelvic Pathology) CT Scan Better as a More Generalized Abdominal Survey Especially Useful for Certain Diagnoses Appendicitis, Diverticulitis, Bowel Obstruction, Colitis Abdominal Sepsis, Tumor Useful for Occult Diagnosis (“Fishing Expedition”)

25. Other specialised testing Other Radiographic Studies Nuclear Medicine, Angiography, etc. Endoscopy Used Judiciously Laparoscopy Exploratory Laparotomy

26. Immediate Treatment of the Acute Abdomen 1. Start large bore IV with either saline or lactated Ringer’s solution 2. IV pain medication 3. Nasogastric tube if vomiting or concerned about obstruction 4. Foley catheter to follow hydration status and to obtain urinalysis 5. Antibiotic administration if suspicious of inflammation or perforation 6. Definitive therapy or procedure will vary with diagnosis Remember to reassess patient on a regular basis.

27. Physical Exam of the patient(What you see) Organ rupture Characterized by shock, clammy patient, pallor, fainting. Hypotension Tachycardia 1. Spleen 2. Aortic rupture 3. Ectopic pregnancy 4. Ruptured ovarian cyst *These conditions usually require immediate surgery!

28. Peritonitis Primary Caused by spontaneous bacterial seeding from states such as cirrhosis. No GI leak Secondary Casued by GI/GU leak (PID, ulcer rupture, etc) Tertiary 2nd turning into chronic infection, after closures of the leak.