The Acute Abdomen
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The Acute Abdomen Jason Smith MD DMI FRCS(Gen.Surg) Consultant Surgeon Mr Jason Smith - Consultant Surgeon Acute Abdomen General name for presence of signs, symptoms of inflamma4on of peritoneum Mr Jason Smith - Consultant Surgeon The problems of a surgeon If I operate and the problem is not surgical, pa4ent exposed to unnecessary risk, anesthe4c, etc. If I do not operate and problem is surgical, pa4ent at risk because of wrong therapy. Risks greater with concomitant illness, older age Again the older pa4ent is under greater burden. Risk-­‐Predic4on Algorithms Mr Jason Smith - Consultant Surgeon Probably needs an operation Acute pain Sep4c & toxic Board-­‐like abdomen Absent bowel sounds WBC 25,000 Free air under diaphragm Mr Jason Smith - Consultant Surgeon Probably doesn’t need an operation Trivial pain Robust appearance SoM abdomen with no guarding Normal bowel sounds Normal WBC/CRP Mr Jason Smith - Consultant Surgeon Abdominal Anatomy Organs can be classified as: Hollow Solid Major vascular Mr Jason Smith - Consultant Surgeon Solid Organs Liver Spleen Kidney Pancreas When solid organs are injured, they bleed heavily and cause shock Mr Jason Smith - Consultant Surgeon Patient Assessment – Initial Views Does the pa4ent look ill, sep4c or shocked? Are they lying s4ll (peritoni4s, shock), or rolling around in agony Call for help! (colic)? Assess and manage Airway, Breathing and Circula4on as a priority (as per ALS/ATLS). Mr Jason Smith - Consultant Surgeon Patient Assessment – Initial Views As per ATLS, Mx occurs at the same 4me as assessment & diagnosis Large bore venflon – large vein Oxygen Analgesia (limited) “Am I out of my depth?” “Do I have enough help?” Documenta4on!! Safety -­‐ you Mr Jason Smith - Consultant Surgeon Patient Assessment -­‐ History Where do you hurt? Know loca4ons of major organs But realize abdominal pain loca4ons do not correlate well with source Mr Jason Smith - Consultant Surgeon Patient Assessment -­‐ History What does pain feel like? Steady pain -­‐ inflammatory process Crampy pain -­‐ obstruc4ve process Sharp – peritoneal irrita4on Dull – peritoneal stretching Mr Jason Smith - Consultant Surgeon Patient Assessment -­‐ History Was onset of pain gradual or sudden? Sudden = perfora4on, hemorrhage, infarct Gradual = peritoneal irriga4on, hollow organ distension Mr Jason Smith - Consultant Surgeon Patient Assessment -­‐ History Does pain radiate (travel) anywhere? Right shoulder, angle of right scapula = gall bladder Around flank to groin = kidney, ureter Into middle of back = pancreas, duodenum Mr Jason Smith - Consultant Surgeon Patient Assessment -­‐ History Dura4on? <6 hour dura4on = ? surgical significance Nausea, vomi4ng? Bloody? “Coffee Grounds”? Any blood in GI tract = Emergency until proven otherwise Mr Jason Smith - Consultant Surgeon Patient Assessment -­‐ History Change in urinary habits? Urine appearance? Change in bowel habits? Appearance of bowel movements? Melena? Mr Jason Smith - Consultant Surgeon Patient Assessment -­‐ History Regardless of underlying cause vomi4ng or diarrhea can be a problem because of associated volume loss Everybody has pancreatitis until proven otherwise Mr Jason Smith - Consultant Surgeon Patient Assessment -­‐ History Females Last menstrual period? Abnormal bleeding? In females, abdominal pain = Gynaeproblemuntil proven otherwise In females, abdominal pain = Pregnant until proven otherwise Mr Jason Smith - Consultant Surgeon Physical Exam General Appearance Lies perfectly s4ll inflamma4on, peritoni4s Restless, writhing obstruc4on Abdominal distension? Ecchymosis around umbilicus, flanks? Mr Jason Smith - Consultant Surgeon Physical Exam Vital signs Tachycardia ? Early shock (more important than BP) Rapid shallow breathing peritoni4s Young / Old patients have different responses to fluid loss Mr Jason Smith - Consultant Surgeon Physical Exam Palpate each quadrant Work toward area of pain Warmhands, gentle approach! Pa4ent on back, knee bent (helps relax) Use child’s own hand Note tenderness, rigidity, involuntary guarding, voluntary guarding (steth-­‐test), masses Mr Jason Smith - Consultant Surgeon Physical Exam Bowel Sounds Listen 1 minute in each quadrant Listen before feeling Absent bowel sounds ileus, peritoni4s, shock Auscultating bowel sounds has no value in trauma patients Auscultating bowel sounds in reality is a waste of time in the acute phase Mr Jason Smith - Consultant Surgeon Management Airway High flow O2 An4cipate vomi4ng, appropriate clothing, bowel An4cipate hypovolemia – hence large bore cannulae Nothing by mouth, un4l DDx established Limited analgesics Mr Jason Smith - Consultant Surgeon Management In adults > 30, consider possibility of referred cardiac pain. In females, consider possible gynaeproblem, especially tubal ectopic pregnancy Mr Jason Smith - Consultant Surgeon Acute Abdomen -­‐ Investigations Urinalysis FBC, U&E Plain AXR (CT) Mr Jason Smith - Consultant Surgeon The WCC in 570 patients Diagnosis Appendici4s (↑) Cholecys44s (↑) Obstruc4on (↑) Gastroenteri4s (N) Other Non-­‐surgical (N) Sensi+vity % Specificity % 91 21 78 11 56 8 49 11 62 82 Predic4ve value of ↑ WCC for surgical condi4on 29% Predic4ve value of ↓ WCC for non-­‐surgical cond 93% Mr Jason Smith - Consultant Surgeon Sensitivity of plain AXR-­‐ 249 Patients Appendici4s Cholecys44s Pancrea44s Intes4nal Obstruc4on Perforated Ulcer Mr Jason Smith - Consultant Surgeon % Abnormal 48 64 60 98 60 Frequency of Diagnoses in 1000 Patients Unknown Urinary Tract Gastroenteri4s PID 41% 9% 7% 7% Cholecys4s 4% Intes4nal Obst 2.5% Cons4pa4on 2% Misc 7% 80%!! Mr Jason Smith - Consultant Surgeon Appendiscitis Age Young > old Dx correct in 50% Several episodes Sx Central dull to RIF sharp N&V Off food Si Pain, foetor WCC, CRP – waste of time Ix Exclude gynae problems Mx Fluid balance Antibiotics Laparoscopy or open Mr Jason Smith - Consultant Surgeon Stomach/duodenum – Perforation Age Young men & alcohol Older anyone & drugs Sx Pain, generalised, sharp, upper Rigidity Si Peritonism Shock +/- sepsis Ix Air under diaphragm CT better Mx Fluid resus – most important Laparotomy & oversew / patch Conservative? Mr Jason Smith - Consultant Surgeon Age Young men & alcohol Older anyone & drugs Sx Haematemesis +/- Melena Si Shock Rockall score Wilson Index Ix OGD (mesenteric angiogram) Mx Fluid resus – most important OGD inject Laparotomy & underun Mr Jason Smith - Consultant Surgeon Age Fat, female, forty, fertile Common in Asians Sx Colicky upper abdo pain (stools/urine), Courvoisier's sign N&V Si Palpable GB Jaundice Ix USS +/- CT (Must exclude Ca Pancreas) Mx Conservative Lifestyle adjustment / lipids Lap Chole Mr Jason Smith - Consultant Surgeon Age Overweight, women > men Hx Gallstones Sx Acute sharp RUQ pain rad to back, shoulder N&V Si Pyrexia +/- Rigors, tachcardia Jaundice Ix Bloods USS +/- CT Mx Antibiotics (met) – 20% are infected Analgesia Lap Chole (acutely) Mr Jason Smith - Consultant Surgeon Cholangitis Age As for previous Sx Acute sharp RUQ pain rad to back, shoulder N&V Si Pyrexia +/- Rigors Jaundice (Charcot’s Triad) Ix Bloods USS +/- CT (medical emergency) Mx Antibiotics (inc met) ERCP / PTC Lap Chole Mr Jason Smith - Consultant Surgeon Acute Pancreatitis Age Any age, predom younger with alcohol & older with gallstones Sx Constant pain, N&V++ Shock Si Pyrexia (Peritonism) (Jaundice) Ix Bloods (amylase & CRP) USS +/- CT (medical emergency) Mx Supportive & complex (surgery) Mr Jason Smith - Consultant Surgeon Meckel’s Diverticulum Age Rare, often found incidently Sx Rectal bleeding Sx similar to appendiscitis Si Ix Radioisotope scan Mx Remove only if symptomatic Mr Jason Smith - Consultant Surgeon Small bowel obstruction Age All ages, depends on underlying cause 5-10% of all admissions Sx Colicky general pain Vomiting early/late ‘constipation’ Si Distended resonant abdomen ‘tinkling’ bowel sounds shock Ix CT Mx Fluid balance Conservative vs Operative Mr Jason Smith - Consultant Surgeon Mesenteric Ischaemia Age 50% embolic, 25% atheroma, 10% venous 90% mortality Sx Incredibly difficult to diagnose Severe central pain Pain out of proportion to findings Si WCC, acidosis, lactate Ix Laparotomy Mx Embolectomy, grafting, resection Open & close Mr Jason Smith - Consultant Surgeon Acute Diverticulitis Age 10% at 40yrs 60% by 80yrs Sx common in middle age/elderly Sx Usually LIF pain +/- constipation +/- rectal bleeding Si Tenderness Fever, tachycardia Raised WCC & CRP Ix Ba enema / flexi CT Mx Antibiotics, lifestyle 2 strikes and its out! Mr Jason Smith - Consultant Surgeon Lower GI Bleed Age Age determines likely cause Sx BR / DR rectal bleeding Si Shock Wilson Index Ix Flexi / colonoscopy / angiogram Mx Fluid balance & Mx of shock then underlying cause Mr Jason Smith - Consultant Surgeon Perforated colon Age Age determines likely cause Don’t overlook iatrogenic & self induced causes Sx Peritonism Tachycardia Si Shock Generalised tenderness, boardlike Ix WCC, CRP CT Mx Resuscitate Laparotomy +/- stoma Mr Jason Smith - Consultant Surgeon Acute Severe Colitis Age Young 20-35, women > men Sx Bloody diarrhoea , mucus urgency ++ Generalised abdo pain Si Shock Anaemic, WCC up Ix Flexi / colonoscopy Plain films Mx Fluid balance & Mx of shock Steroids, cyclosporin Joint Mx with physicians Mr Jason Smith - Consultant Surgeon Acute Abdominal Pain Non-­‐surgical Emergencies Mesenteric Adeni4s Acute Enteric Infec4ons Acute Enteric Poisonings Inflammatory Bowel Disease Pancrea44s (usually) 11/98 44 Mr Jason Smith - Consultant Surgeon medslides.com Acute Abdominal Pain Metabolic Causes Diabe4c Ketoacidosis Heavy Metal Poisoning Acute Porphyria Sickle Cell Crisis 11/98 45 Mr Jason Smith - Consultant Surgeon medslides.com
