The Acute Abdomen
LSI Part 2
Understanding Patients with Reproductive and Surgical Needs
David C. Evans, MD
Assistant Professor of Surgery
david.evans@osumc.edu
Acute Abdomen Learning Objectives
Primary Objectives
Secondary Objectives
• Evaluate and determine initial
treatment of patients presenting with
surgical diseases in all patients as well
as medical diseases in pregnant
patients.
• Evaluate and formulate a management
plan for a patient with acute abdominal
pain.
• Recognize medical or surgical
emergencies in the pregnant and nonpregnant female patients.
• Evaluate and formulate a management
plan for a patient with perforation of
the GI tract.
• Develop a differential diagnosis for
abdominal pain.
• Describe the initial evaluation,
diagnostic studies management of a
patient with an acute abdomen
• Decide if a patient with an acute
abdomen needs an operation, and
justify your decision.
• Describe the signs, symptoms and
clinical findings associated with acute
abdomen.
• Recognize patients with extraabdominal causes of abdominal pain.
Acute Abdomen Learning Resources
Click to link directly to Sabiston:
Chapter 47, “Acute Abdomen”
(on-campus / proxy server only)
Foundational Science – Physiology
“How sick is this patient?”
 Systemic Inflammatory Response Syndrome (SIRS)
Criteria
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Temp >38°C (100.4°F) or < 36°C (96.8°F)
Heart Rate > 90
Respiratory Rate > 20 or PaCO2 < 32 mm Hg
WBC > 12,000/mm>3, < 4,000/mm>3, or > 10% bands
Acute Abdomen Alert Signs + Findings
Peritonitis
Sepsis /
SIRS
“Free Air”
Likely Need Surgery
Peritonitis-Irritation of the Peritoneal Lining
Typical signs (most patients have some, not all)
 Pain with movement or stretching of the peritoneum.
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Often keep knees and hips flexed
 Hypersensitive to touch, mild bumps (car rides / hospital
cart)
 Rigid abdomen
 “Rebound tenderness”
 Can be focal or diffuse
Usually Requires
Surgery
Don’t always trust a benign exam
Steroids
Chemo
Obesity
Limited
Mental
Capacity
Pneumoperitoneum
Pneumoperitoneum
Algorithm
Acute
Abdominal Pain
with Peritonitis
Stable /
No SIRS
SIRS / Sepsis
Operate
“Safe Strategies”
N.B. Exceptions
do exist
Pneumoperitoneum On
X-ray
No Pneumoperitoneum On
X-ray
Operate
Contrast Study
(Typically CT)
Free Air or
Contrast
Extravasation ->
Operate
Contained
Collection /
Perforation ->
Operate vs.
Drain
Normal Study ->
Monitor Closely
Algorithm
Normal
Evaluate for “NonSurgical Causes”
Acute Abdominal
Pain Without
Peritoneal Signs
Generalized Pain
Focal Pain
CT with PO and IV
contrast
Selective Imaging
(History / Exam
Dependent)
Arterial Ischemia
Operate
Venous
Thrombosis
Anticoagulate
Positive
Negative
Operate / Drain
Continue to
Evaluate- Urgent
Surgery Not
Required
Foundational Science – Anatomy
“Where does it hurt?” – Referred Pain
Common Causes of the Acute Abdomen
Bowel Perforation or Ischemia
Infection (Appendicitis / Cholecystitis, etc)
Hemoperitoneum (trauma, ruptured ectopic, etc)
Hernias (Incarcerated / Strangulated)
Always Check for Hernias
Sudden Severe Abdominal Pain
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Kidney Stone (Hematuria, flank pain)
Ruptured AAA (Shock, Back Pain, H/O vascular dz)
Perforated Ulcer
Patients know exactly
when these symptoms
started!
Non-abdominal causes of pain
Endocrine and
Metabolic
Causes
•
•
•
•
Uremia
Diabetic crisis
Addisonian crisis
Acute
intermittent
porphyria
• Hereditary
Mediterranean
fever
Hematologic
Causes
• Sickle cell crisis
• Acute leukemia
• Other blood
dyscrasias
Toxins and
Drugs
• Lead poisoning
• Other heavy
metal poisoning
• Narcotic
withdrawal
• Black widow
spider poisoning
Case 2
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58 yo male
2 day history of left lower quadrant abdominal pain.
Pain started L>R,
Attempted to take some pepto-bismol but that did not help.
He report some associated nausea, he denies any
vomiting
 Some subjective fevers at home.
 The pain was unrelenting therefore he came to the ED for
further evaluation. He reports his abdomen feels more
distended and the pain is worse with movement. He has
been unable to tolerate much PO.
Case 2- order of events
Physical
Exam / Vitals
Labs
Imaging
Confirmation
Treatment
Plan
Case 2 Findings
 Abdomen: Tender, distended. Peritonitis
14.8
12.8
44.3
 Does he need a CT scan?
(87% granulocytes)
243
Case 2 – CT Probably not needed but here
it is



Free air
Inflammation
Diverticuli
-> perforated
diveriticulitis
Case 2 Treatment
 Surgery!
Summary
 Physical Exam, Patient Status (sepsis, etc.) drives
algorithm
 Differential Diagnosis based on exam, confirmed with
imaging
 Take every opportunity to examine patients with
pathology now as a student
 Timing can be crucial to good outcomes
Thank you for completing this module
Questions? Contact me at:
david.evans@osumc.edu
640 Faculty Office Tower (395 W 12th Ave.)
Image Credits
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Slide 1 photo- http://www.enfermeriablog.com/tag/cuidados-peritonitis/
Slide 3- cover images from amazon.com
Slide 4- “Know the signs, know sepsis”- Boston Medical Center;
http://www.coloribus.com/adsarchive/prints/land-rover-defender-fireball-1965105/
Slide 5-6 photos- OSUMC images
Slide 7 photo- http://onemomsbattle.com/TheLiesofaNarcissist
Slide 8 image- http://prep-pg.blogspot.com/2012/04/radiological-signs-of-bowel-perforation.html
Slide 9 image- OSUMC
Slide 12 image from Sabiston, Ch. 47.
Slide 14 image from http://www.celebritydiagnosis.com/2013/04/dwayne-the-rock-johnsonundergoes-hernia-surgery/
Slide 15 image- http://www.hongkiat.com/blog/extraordinary-clocks/
Slide 16 table- adapted from Sabiston, Ch. 47.
Slide 18 images- http://www.fairview.org/healthlibrary/Article/89315 and cancer.osu.edu
Slide 19 image- http://www.pinterest.com/carolinagirl525/x-ray/
Slide 20 image- Van Wagoner ZD, Evans DC, Askegard-Giesmann JR, Kenney BD. Perforated
peptic ulcer in a child with a vagus nerve stimulator for seizure control. Brain Stimul. 2013
Nov;6(6):972-3.
Slide 24- OSU clinical image
Slide 25 image- http://5minuteconsult.com/ViewImage/2027820
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