Acute Abdomen

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What is an acute abdomen?

acute abdomen refers to a sudden, severe abdominal pain that is less than 24 hours in duration in previously well pts

Most common causes of acute abdomen (13)

AABCDE, GIM NPPP: Abscess (tubo-ovarian), Append, Bowel Obst, Bil colic, Cholecys, Divert (inc Meckel's), Ectopic preg, Gastroent, IBD, Mes ischemia, Nephrolith/Uterolith, Ov torsion, rupture/cyst, Pancr, Peritonitis, Perf (gastr/duod ulcer), Salpingitis

DDx for RUQ pain (17)

Abscess (subphrenic/perinephric most common), Cholangitis, Cholecystitis, Choledocholithiasis, Congestive Hepatopathy, Diverticulitis, Hepatitis, Herpes Zoster, IBD, Muscular strain, Neoplasm, Nephrolithiasis, PUD, PNA, Pneumothorax, PE, Pyelonephritis

DDx for RLQ pain (12)

DDx for LLQ pain (10)

Abscess, Diverticulitis, Ectopic pregnancy, Gastroenteritis, Hernia, IBD, Neoplasm, Ovarian torsion/cyst, PID, Pyelonephritis

DDx for LUQ pain (10)

Abscess (subphrenic/perinephric most common), Neoplasm (pancreatic, splenic, renal), Nephrolithiasis, Pancreatitis, PUD, PNA, Pneumothorax, PE, Pyelonephritis, Splenic infarct/rupture

What should you expect on physical exam of pt with acute abdomen?

1. peritoneal signs (irritation/pain with even slight jarring), 2. lie very still (to keep from irritation peritoneum), 3. Ask them to point to pain with one finger (helps in ddx)

Pain from stomach refers to where?

epigastric region/substernal

Pain from pancreas refers to where?

epigastric region

Pain from small intestine refers to where?

periumbilical

Pain from colon refers to where?

lower abdomen/suprapubic

Pain from gallbladder felt where?

RUQ

Characterization of pain - things you want to ask about when investigating acute abdomen

CLaSP: character, location, severity, pattern

Temporal sequence of pain - things you want to ask about when investigating acute abdomen

onset, frequency, progression, duration (ProDuFreOn)

alleviating/exacerbating factors - things you want to ask about when investigating acute abdomen

position, food, activity, medications

associated signs/symptoms - things you want to ask about when investigating acute abdomen

nausea vomiting, fever, chills, anorexia, wt. loss, cough, dysphagia, dysuria/frequency altered bowel function (diarrhea, constipation, obstipation, hematochezia, melena

PMH

prior surgery or illness, associated conditions (pregnancy, menstrual cycle, diabetes, atrial fibrillation or cardiovascular disease, immunosuppression)

Meds

anticoagulation, steroids

Visceral Pain: characterize, location, types of nerve fibers, nerve system, describe pt

diffuse, ill-defined, usually colicky; typically midline, frequently referred; carried on visceral efferent fibers; may cause para/sympathetic response, typically colicky or ischemic pain; pt writhing in pain

Parietal Pain: etiology, types of nerve fibers, Characterize, describe pts

secondary to peritoneal irritation, typically from inflammatory causes; carried on segmental somatic fibers; usually dull, steady ache though better localized; pts do not move or want to be moved

Peritoneal signs

1. extreme tenderness, 2. Rebound tenderness 3. Motion pain 4. Voluntary guarding 5. Involuntary guarding & rigidity

Places Where Fluid, Blood, or Pus can Collect

1. Pelvis 2. Paracolic gutters 3. Morrison’s pouch (subhepatic) 4. Interloop (between loops of bowel) 5. Subphrenic

Signs of Appendicitis

1. iliopsoas, 2. Rovsing’s, 3. Obturator, 4. McBurney's

Iliopsoas Sign

pain on passive extension of hip (retrocecal appendix)

Rovsing’s Sign

pain in RLQ when press on LLQ

Obturator Sign

pain on flexion & internal rotation of hip

McBurney’s Sign

pain at McBurney’s Point

Murphy’s Sign

inspiratory arrest when palpating under R costal margin (acute cholecystitis)

Boas’s Sign

referred R subscapular pain of biliary colic (cholelithiasis)

Signs of peritoneal irritation

a. Cough Tenderness b. Heel Tap: pain transmitted up muscles beneath peritoneal cavity

Cervical Motion Tenderness

classic sign of PID

Signs of Hemorrhagic Pancreatitis

a. Cullen’s Sign: bluish discoloration of periumbilical area b. Fox’s Sign: ecchymosis of inguinal ligament c. Grey Turner’s Sign: flank ecchymosis

Cullen’s Sign

bluish discoloration of periumbilical area, Sign of Hemorrhagic Pancreatitis

Fox’s Sign

ecchymosis of inguinal ligament, Sign of Hemorrhagic Pancreatitis

Grey Turner’s Sign

flank ecchymosis, Sign of Hemorrhagic Pancreatitis

Charcot’s Triad

fever, jaundice, RUQ pain (cholangitis)

Raynaud's pentad

fever, jaundice, RUQ pain + AMS and hypotension/sepsis/shock; harbinger of worsening, ascending cholangitis

Signs of Splenic Injury & Rupture

a. Kehr’s Sign: pain referred to tip of L shoulder b. Ballance’s Sign: dullness to percussion over the flanks (coag blood on L, fluid blood on R)

Kehr’s Sign

pain referred to tip of L shoulder

Ballance’s Sign

dullness to percussion in the left flank LUQ and shifting dullness to percussion in the right flank seen with splenic rupture/hematoma. The dullness in the left flank is due to coagulated blood, the shifting dullness on the right due to fluid blood.

Pt who is slightly febrile, with anorexia, N/V (pain before vomiting), pain is periumbilical then RLQ. What is the diagnosis? What do you diagnose with? What is the initial tx?

Acute Appendicitis, diagnose w CT, IVF rehydration, pre-op Abx (cefoxitin)

Pt with post-prandial biliary colic; N/V, fever, Murphy’s Sign; pain in RUQ, with referred pain to R subscapular area. What is the diagnosis? What do you diagnose with? What is the initial tx?

Gallbladder dz; diagnose w U/S; IVF, cholecystectomy. Abx, ERCP to decompress

Pt w N/V, absent bowel sounds, +/-fever, dehydration, shock; pain is epigastric/LUQ, radiates to back. What is the diagnosis? What do you diagnose with? What is the initial tx?

Pancreatitis; ddx w Amylase & lipase levels; AXR (sentinel loops), CT (fat stranding); NPO, NGT, IVF, TPN, H2 blocker, analgesia

what is the purpose of Ranson's criteria

11 prognostic Sx to identify high risk in pts w. pancreatitis

Ranson's criteria on admission

GA LAW: Glucose > 200 mg/dL, Age>55yr, LDH > 350 IU/dL, AST > 250 IU/dL, WBC > 16,000 cell/mm3

Ranson's criteria after 48h

C HOBBS: Ca++ < 8 mg/dL, Hematocrit decrease > 10%, arterial pO2 < 60 mmHg, BUN increase > 5 mg/dL, Base deficit > 4 mEq/L, fluid Sequestration > 6 L

Ranson's criteria mortality

1. If<3 signs, 1%; 2. 3-4 signs, 15%; 3. 5-6 signs, 50%; 4. 7+ signs, approximately 100%

Pt w Epigastric tenderness radiating to back, diffuse abd pain, N/V, dec bowel sounds, shock/dehydration, +/-fever

pancreatitis

Causes of pancreatitis

I GET SMASHED: Idiopathic, Gallstone, EtOH, Trauma, Steroids, Mumps and other viruses (EBV/CMV), Autoimmune (SLE, PAN), scorpion/snake, Hyper -ca -lipid Hypo-thermia, ERCP, Duod ulcer & Drugs (SAND - steroids/sulfonamides, azathioprine, NSAIDs, diuretics)

Pt w N/V, anorexia, blood in stool; Epigastric, radiates to back; What is the diagnosis? What do you diagnose with? What is the initial tx?

PUD; Guaiac+, EGD, UGI series; Abx vs. H. pylori, H2 blocker, antacids, sucralfate, omeprazole

Pt w dec Bowel sounds, tympany over liver; pain epigastric, radiates to back. What is the diagnosis? What do you diagnose with? What is the initial tx?

Perforated Ulcer; dx with CXR (free air); NGT, IVF, Foley, Abx, surgery

Pt w Heartburn, resp Sx from aspiration, regurgitation; epigastric pain. What is the diagnosis? What do you diagnose with? What is the initial tx?

GERD; dx with EGD, UGI contrast study, pH probe, manometry; H2 blockers, omeprazole, cisapride, elevate while sleeping

Pt with NGT blood; painless, or with epigastric pain. What is the diagnosis? What do you diagnose with? What is the initial tx?

Gastritis/Duodenitis, dx with EGD, initial tx with H2 blockers, antacids, sucralfate

pt with Fever, diarrhea, anorexia, mass, N/V, dysuria, LLQ or RLQ pain. What is the diagnosis? What do you diagnose with? What is the initial tx?

Diverticulitis; ddx with Abd CT, colonoscopy; tx w IVF, NPO, Abx, NG suction

Pt with Bloody Diarrhea, fever, weight loss; pain in hypogastric area. What is the diagnosis? What do you diagnose with? What is the initial tx?

Ulcerative colitis; Colonoscopy w. biopsy, barium enema, UGI, stool cultures; Sulfasalazine, steroids, metronidazole

Pt with Diarrhea, fever, weight loss; pain in hypogastric area; has anal disease. What is the diagnosis? What do you diagnose with? What is the initial tx?

Crohn's; Colonoscopy w. biopsy, barium enema, UGI, stool cultures; Sulfasalazine, steroids, metronidazole

N/V/D; pain after vomiting; diffuse abd pain. What is the diagnosis? What do you diagnose with? What is the initial tx?

Enterocolitis, Use hx to diagnose, abx and ivf to tx

Frequent vomiting, abd distention, high-pitched bowel sounds; pain is Hypogastric, Periumbilical. What is the diagnosis? What do you diagnose with? What is the initial tx?

SBO; AXR (air-fluid levels), CT; NGT, IVF, Foley

Abd distention, anorexia, obstipation, N/V, hypogastric pain. What is the diagnosis? What do you diagnose with? What is the initial tx?

Colon Obstruction; AXR, sigmoidoscopy, gastrografin enema; Colonoscopic reduction, enema, colonic tube

Hemoperitoneum, LUQ mass, pain in LUQ, referred to tip of L shoulder. What is the diagnosis? What do you diagnose with? What is the initial tx?

Splenic disease; Abd CT, DPL; Ex lap

Diffuse abd pain out of proportion to exam; N/V, hyperdefecation +/-heme stools, h/o AFib or heart dz. What is the diagnosis? What do you diagnose with? What is the initial tx?

Mesenteric Ischemia; Mesenteric A- gram, plain film shows “thumb- printing” ; Embolectomy, papaverine vasodilator; resect necrotic tissue

Hypotension w. pulsatile abd mass, diffuse epigastric pain. What is the diagnosis? What do you diagnose with? What is the initial tx?

Ruptured AAA; If not ruptured, U/S & CT; OR immediately

pain from any quadrant radiates from flank to testicles; What is the diagnosis? What do you diagnose with?

Nephrolithiasis; KUB, U/A, U/S.

What could thrombocytopenia indicate?

Sepsis

ABG showing metabolic acidosis

ischemia - possible bowel ischemia

Sentinel loop on KUB. What is it and what does it indicate?

pancreatitis; dilation of a segment of large or small intestine, indicative of localized ileus from nearby inflammation.

What study do you do for nonacute GI bleed or nonacute epigastric pain?

EGD

Describe acute appendicitis in elderly. What happens to the mortality rate?

more subtle Sx (less abd pain, fever & CBC unreliable); high rate of rupture --> high rate of mortality;

Describe acute appendicitis in infants.

high rate of rupture, faster progression of illness, inability to complain or give Hx, bowel wall inefficient at walling off perforation␣infection spreads

Describe acute appendicitis in pregnant women. Does it occur with increased frequency? What trimesters?

most common extrauterine surgical emergency in pregnant women – but occurs w. same frequency as nonpregnant women; usually in 1st 2 trimesters

Acute appendicitis in pregnant women. What about it makes the diagnosis more difficult?

appendix laterally & superiorly displaced - Dx more difficult; also “Sx of pregnancy” like N/V confused for appendicitis Sx; may compromise fetus

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Created by:

Christina Pham on 2009-11-06