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SETTING THE STAGE FOR DIAGNOSIS OF THE ACUTE ABDOMEN

SETTING THE STAGE FOR DIAGNOSIS OF THE ACUTE ABDOMEN. JENNIFER RODGERS, MSN, ARNP, ACNP WICHITA STATE UNIVERSITY. ACUTE ABDOMEN. By definition: Sudden, severe abdominal pain that is less than 24 hours in duration. It is in many cases a medical emergency.

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SETTING THE STAGE FOR DIAGNOSIS OF THE ACUTE ABDOMEN

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  1. SETTING THE STAGE FOR DIAGNOSIS OF THE ACUTE ABDOMEN JENNIFER RODGERS, MSN, ARNP, ACNP WICHITA STATE UNIVERSITY

  2. ACUTE ABDOMEN • By definition: Sudden, severe abdominal pain that is less than 24 hours in duration. It is in many cases a medical emergency. • Don’t want to miss the Acute Surgical Abdomen!!

  3. ACUTE ABDOMEN • Based on Natl. Hospital Ambulatory Medical Care Survey: • Abdominal Pain #3 most common presenting symptom to the ER for both men and women age 45-64 • #1 most common presenting symptom for women age 15-44 • Represents >5% of ED visits annually

  4. FINDINGS SUGGESTIVE OF SURGICAL ABDOMEN • Severe, sudden onset pain under 1 hour Think about Ruptured AAA (often accompanying back pain), Mesenteric Ischemia (often accompanying AFIB) , AMI (dyspnea/chest pain), Perforated Viscous, Nephrolithiasis (radiating to groin or back) • Pain precedes vomiting (Appendicitis, Cholecystitis, Small Bowel Obstruction) Graff, L.G 4th & Robinson D. (2001). Abdominal Pain and Emergency Department Evaluation. Emerg. Med Clinic North Am. 19(1):123-126.

  5. FINDINGS SUGGESTIVE OF SURGICAL ABDOMEN • Fever > 101 (with accompanying sx) *Fever lags behind sx in the elderly • Tachycardia • Leukocytosis with Left Shift • Peritoneal Signs • Age > 65 yrs Graff, L.G 4th & Robinson D. (2001). Abdominal Pain and Emergency Department Evaluation. Emerg. Med Clinic North Am. 19(1):123-126.

  6. ABDOMINAL ASSESSMENT • Have a systematic approach • Take a thorough history-the patient will tell you their story if you take time to listen • Always think about the cost & reason for a test and implications (i.e. IV contrast) • Thorough physical exam (review your abdominal assessment)

  7. ABDOMINAL ASSESSMENT • Think about age, gender of patient when considering differential • Think about where the pain is (i.e. RUQ versus Diffuse) and P.E. tests (i.e. Murphy’s sign) • Don’t miss the surgical abdomen (quiet & rigid is never good!!)

  8. WHAT DO YOU THINK? • WHAT ARE THE TWO MOST COMMONLY MISSED SURGICAL DIAGNOSIS? • APPENDICITIS • SMALL BOWEL OBSTRUCTION

  9. LET’S GET STARTED!!

  10. 76 YEAR OLD MALE • “Unable to void for the past 36 hours” • +constipation, no fever • No associated/aggravating factors • PMH: HTN, CKD (baseline Cr 1.5), mild Dementia, Hyperlipidemia, DM II • MEDS: HCTZ 25 mg Q day, Norvasc 5 mg Q day, Zocor 40 mg Q evening, Glipizide 5mg Q day, Aricept 10 mg Q day

  11. 76 YEAR OLD MALE • VS 99.4 110 128/76 • PE: + RLQ pain no rebound or guarding • Lab: Cr 8.6 K 5.0 WBC 13,000 Bands 12% Lymphs 34% Monos 4% Hgb 12 • UA +blood

  12. 76 YEAR OLD MALEWhat do you think? • WHAT IS YOUR DIFFERENTIAL? Acute Renal Failure, Pyleonephritis, Neprolithiasis, Diverticulitis, SBO • WHAT OTHER TESTS WOULD YOU LIKE? Urine C & S, CRP, Renal CT Scan, CXR

  13. 76 YEAR OLD MALE • Renal CT: Multiple Renal Calculi as well as stones in the bladder, diffuse constipation • CRP 8.0 (Elevated) • CXR-negative for infiltrate • Urine-negative for growth

  14. 76 YEAR OLD MALE • Dx: Acute Renal Failure (post renal), Multiple Renal Calculi & Bladder Calculi, Hyperkalemia, Constipation • Tx: NPO, Consult Urolology & Renal, Crystalloid Fluids, Foley to DD, Kayexelate, IV antibiotics (renal dose), frequent monitoring of Chemistry & U.O.

  15. 76 YEAR OLD MALE • 36 hours later…. • Lab Cr 2.3 K 4.0 WBC 9,000 Bands 7% +BM, eating and ambulating • Post Lithotripsy and Right Renal Stent Placement • Always think about cause Renal Failure Pre-Intra-Post>drives your Treatment Plan

  16. RLQ Differential • Think about age & sex of patient & organs in the region • Appendix-Appendicitis • Large Bowel-Diverticulitis, Abscess, Perforation • Small Bowel-SBO, Enteritis, Meckel’s Diverticulitis • Pelvic Organs-Ectopic Pregnancy, Ovarian cyst, PID, Ovarian Torsion

  17. RLQ Differential • Gallbladder-cholelithiasis, cholecystitis • Bladder-Prostatitis, Bladder stones, Torsion • Rectal Area-Hemorrhoids, prostatitis, perirectal abscess, STD • Aorta/illiac vessels-aneurysms

  18. LLQ PAIN DIFFERENTIAL • Same as RLQ • Appendicitis low probability • Descending colon-Diverticulitis, perforation, constipation, volvulus

  19. ABDOMINAL IMAGING • CT Scans-superior to MRI in abdominal area b/c looking at organ structures • Renal CT-no dye looks specifically for Renal Calculi & hydronephrosis • CT Appendix-Sensitivity near 100%, smaller bolus of contrast • CT Angiogram of Chest-R/O PE-gold standard *lots of contrast watch Cr!

  20. ABDOMINAL IMAGING • Ultrasound-not good for appendix, low yield, negative means didn’t visualize • Ultrasound-best first look for: gallbladder, pancreas, testicles, ovaries & adnexal structures, vascular structures (if bedside capabilities & patient stable) • Plain Films (Obstructive Series)-Flat/ upright abdomen + CXR- will show obstruction, constipation (FOS), free air under diaphragm

  21. 56 YEAR OLD MALE • CC: nausea “abdominal cramping, points to RUQ” x 3 days, intermittent chest pain • Worse after eating • PMH: CAD S/P CABG 3 weeks ago, ESRD on Dialysis, COPD, OSA, DMII, PVD • Meds: Cardizem CD 240 mg q day, Lantus/Humolog, Advair 50/250 BID, Renal Cap q day, Protonix 40 mg q am, Zocor 40 mg q day

  22. 56 YEAR OLD MALE • VS: 97.6 120/70 80 SpO2 94%-3L • PE: +RUQ tenderness, no chest wall tenderness, no CVA tenderness • Labs: Cr 5.6 (pre-dialysis) LFT’s-normal WBC 12,000 Bands 7%

  23. 56 YEAR OLD MALE WHAT DO YOU THINK? • WHAT IS YOUR DIFFERENTIAL? Cholelithiasis, Renal Stone, Pancreatitis, Pneumonia (RLL), PE, MI, PUD • WHAT OTHER TESTS DO YOU WANT? CXR, GB Ultrasound, Troponin, 12-Lead EKG, Amylase, Lipase, CRP

  24. 56 YEAR OLD MALE • WHAT OTHER PHYSICAL EXAM FINDING SHOULD YOU CHECK FOR IN RUQ PAIN? MURPHY’S SIGN-Slide finger tips up under right rib margin during exhalation. Then have pt take a deep breath. POSITIVE=any inspiratory arrest/pain • 56 year old male has +Murphy’s!!

  25. 56 YEAR OLD MALERESULTS • CXR-COPD, S/P CABG no acute infiltrate • GB Ultrasound-Sludge & GB thickening + stones • Troponin <0.04 (which is negative) • 12-Lead EKG-unchanged from previous • Amylase, Lipase WNL • CRP 4.2 (Elevated)

  26. 56 YEAR OLD MALE • HAS YOUR DIFFERENTIAL CHANGED? • WHAT DO WE DO FROM HERE? • HIDA SCAN-Nuclear Med scan that evaluates function of Gallbladder, after T99 injected, should see GB within 1 hr. If GB not visualized within 4 hrs >cholecystitis OR cystic duct obstruction

  27. 56 YEAR OLD MALE • HIDA Results-> 4 hrs GB not visualized • DX: Acute Cholecystitis • TX: NPO, Consult Surgery, Gentle IV Fluids, Pre-op Antiobiotics

  28. 56 YEAR OLD MALE • 36 hours later….S/P Open Chole>necrosed Gallbladder stable post op • Emergency cholecystectomy mortality rates 8-15% in the elderly

  29. RUQ DIFFERENTIALThink about organs in that area • Gallbladder-Cholecystitis, cholelithiasis, biliary colic • Renal-pyleonephritis, stone, hydronephrosis • Liver-Hepatitis, cirrhosis, CHF • Pancreas-pancreatitis

  30. RUQ DIFFERENTIALThink about organs in that area • Lung-Pneumonia, PE • Heart-MI, Pericarditis • Duodenum-PUD

  31. LUQ DIFFERENTIALThink about the organs in that area • Stomach-Gastritis, Gastric Ulcer • Pancreas-Pancreatitis • Kidney-Hydronephrosis, Calculi, pyleonephritis • Spleen-Trauma, Mono, occult rupture • Large bowel-Diverticulitis • Heart-MI, pericarditis • Lung-Pneumonia, PE

  32. Location of abdominal pain & possible causes. • Go to this link, scroll down to figure one. • http://www.merck.com/mmpe/sec02/ch011/ch011b.html • This is an excellent diagram which can be printed off for future reference.

  33. 66 YEAR OLD MALE • CC: Two day onset of “back pain” has gradually worsened, thought maybe he strained his back initially, this a.m. awakened with chest pain, diaphoresis, “feel weak” • PMH: HTN, Tobacco Addiction, Hyperlipidemia, PUD • Meds: Lisinopril/HCTZ 10/25 mg q day, Lipitor 40 mg q day, Zantac 150 mg BID

  34. 66 YEAR OLD MALE • VS 98.2 90/56 52 SpO2 88%-Room Air • P.E. Pulse-weak, thready, pale appearing • Labs: Cr 1.2 WBC 6,000 normal diff. • Hgb 12 INR 1.0

  35. 66 YEAR OLD MALEWHAT DO YOU THINK? • WHAT IS YOUR DIFFERENTIAL? Aneursym Dissection, AMI, Bowel Perforation • WHAT OTHER TESTS DO YOU WANT? STAT CT ABDOMEN R/O ANEURSYM OR STAT BEDSIDE ULTRASOUND IF U HAVE AVAILABLE 12-Lead EKG, Troponin

  36. 66 YEAR OLD MALE RESULTS • Abdominal CT-Dissecting AAA • Other results don’t matter at this point • STAT Surgery Consult, Fluids Wide Open, Type & Cross • You can’t get this patient to the OR fast enough!!!

  37. 66 YEAR OLD MALE • Review AAA photos on this site, also read Pearls/Pitfalls at bottom page of this site • http://www.erpocketbooks.com/er-ultrasounds/aortic-ed-ultrasounds/

  38. 66 YEAR OLD MALE • Ruptured AAA 13th leading cause of death in U.S. • 7 times more common in men than women • Most commonly occurs between ages 65-75, most common in male smokers • Presence of pulsatile mass present in < 30-50% of cases • Leading misdiagnosis is renal colic, as dissection of the renal artery may produce flank pain & hematuria Retrieved: http://emedicine.medscape.com/article/756735-overview 05/04/2010

  39. 67 YEAR OLD FEMALE • CC: Abdominal Pain and vomiting X 48 hours, nearly “passed out” on the way to the ER • PMH: Recently Diagnosed Lung Cancer, COPD, Tobacco Addition, HTN • MEDS: Chemotherapy, DuoNeb Via nebulizer TID, Lisinopril 10 mg Q Day

  40. 67 YEAR OLD FEMALE • VS: 101.4 80/54 120 Spo2 92%-5 liters • P.E. Ill appearing, abdomen rigid with absence of bowel sounds, diffuse abdominal pain with rebound & guarding • LABS: WBC 5.9 Bands 62%, Hgb 12.5 • Cr 1.6 Amylase 1112, Lipase 53

  41. 67 YEAR OLD FEMALEWHAT DO YOU THINK? • WHAT IS YOUR DIFFERENTIAL? Bowel Perforation, Ruptured/dissecting AAA, Small Bowel Obstruction, Esophageal rupture, perforated or ruptured abscess, Peptic ulcer perforation, Mesenteric Infarct, Pancreatitis, Splenic Infarct, Ischemic Colitis • WHAT TESTS DO YOU WANT? STAT ABDOMINAL CT

  42. 67 YEAR OLD FEMALETEST RESULTS • CT reveals Multiple distal enlarged bowel segments with distal decompression • Other results don’t matter at this point • STAT Surgery Consult, Fluids Wide Open, Type & Cross • You can’t get this patient to the OR fast enough!!!

  43. 67 YEAR OLD FEMALE • S/P Extensive Ischemic colitis with subtotal colectomy/ileostomy • Post operatively patient developed severe sepsis syndrome and persistent Resp. Failure requiring vent. support • 1 week later…extubated, TPN in place, up in chair Cr 0.6 Hgb 10.3 WBC 1.0 Bands 10%

  44. 24 YEAR OLD FEMALE • CC: “Increased pain with intercourse over past several weeks” over past 2 days onset of abdominal pain LLQ worsening, now rates as “9” Temp 102.8 • PMH: Tonsillectomy • Meds: None

  45. 24 YEAR OLD FEMALE • What else do you want to know? • History of STD’s? • Number of sexual partners? • IUD? • Sexual orientation? • Date of last menses? • Vaginal discharge?

  46. 24 YEAR OLD FEMALE • WHAT IS YOUR DIFFERENTIAL? Ruptured Uterine Cyst, Ecoptic Pregnancy, PID, Appendicitis (usually RLQ pain), UTI, Ovarian Torsion WHAT TEST DO YOU WANT TO ORDER? Urine Pregnancy Test, CBC, CRP, Wet mount & DNA probe for Gonorrhea &Chlamydia, Blood Cultures, Transvaginal pelvic ultrasound

  47. 24 YEAR OLD FEMALERESULTS • WBC 13,000 with 9% Bands • CRP 5.3 (elevated) • Cr 1.0 • Urine Preg. Negative • Blood cultures Negative • Vaginal Ultrasound- Positive for tubo-ovarian abscess

  48. 24 YEAR OLD FEMALE • Treatment: Hospitalize for IV antibiotics, gentle hydration, pain management, consult OB/GYN may need surgical intervention to drain abscess, remove IUD • PID affects 1 million women annually with ¼ requiring hospitalization • Women under the age of 25 & sexually active teens are at highest risk

  49. 24 YEAR OLD FEMALE • What are the two most common bacteria that cause PID? Chlamydia trachomatis & Niesseria gonorrhoeae

  50. 24 YEAR OLD FEMALE • 36 hours later…. • Afebrile with WBC 6,000 Bands 4% being discharged on PO antibiotics

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