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ACUTE ABDOMEN

Pain and tenderness


May or may not require surgical intervention
AGE AND GENDER
- Appendicitis (young)
- Biliary disease, bowel obstruction,
ischemia, infarction and diverticulitis (old)
NON SURGICAL CAUSES
1.)Endocrine and metabolic (HAMPUD)
- uremia, diabetes, addisons, porphyria,
hyperlipoproteinemia, Meditteranean
fever
2.)Hematologic (BLS)
- sickle cell, leukemia, blood dyscrasias
3.)Drug toxins (poisons)
- lead, heavy metal, narcotics, black
widow poisons
HISTORY* PE* LAB TEST IMAGING
STUDIES *most important
HISTORY TAKING
- past and present
- open ended questions
- medical and gynecologic (women)
Take note of the following:
VOMITING
- preceded OR proceeded by abdominal pain
- in Acute abdomen, pain(1st) vomiting (2nd)
OBSTRUCTION
- caused by ischemia or perforation
DIARRHEA
- caused by enteritis, inflammation, parasite
NARCOTICS
- Oddi spasm, exacerbate biliary/pancreatic
pain
- mask pain thus difficult to diagnose
NSAIDs
- inflammation and perforation
STEROIDS
- block mucus secretion
- reduce inflammatory reaction
ANTICOAGULANTS
- bleeding, hemorrhage, hematomas

PHYSICAL EXAMINATION
INSPECTION
- inspect patient (1st) then inspect abdomen
(2nd)
- peritonitis Px avoids movements
- flexed hip reduce abs pressure
- check for scars, cyanosis, pallor, diaphoresis
- check for hernias upon palpation
- erythema or edema cellulitis
- Ecchymosis deep necrosis
AUSCULTATION
- quiet ileus
- hyperactive enteritis
- high pitch mechanical obstruction
- echoes lumen distention
- bruits turbulent blood flow (present in
fistula and stenosis)
PERCUSSION
- hyper resonance/ tympany gas filled
Ileus tympany in all except RUQ
- dull abdominal mass
- lateral pressure ascites waves to other
side
false(+) to obese px by using
ulnar surface of examiners hand
in the midline then make wave
- pressure peritonitis excruciating pain
PALPATION (final major step)
- begin gently and away from the pain
- guarding is obvious even before palpation
- involuntary guarding by peritonitis
To assess vol and invol guarding,
apply a constant pressure in the
area away from pain then ask the
patient to take a slow deep
breath. Voluntary will relax,
involuntary will remain rigid.
AAron
Chandelier
Cruveihier
Edward
(vampire)

McBurneys
Acute
pressure epigastricAppendicitis
pain
Cervix mvt lower Pelvic inflam Dse
abs
and pelvic pain
Caput medusa
Portal HPN
Periumbilical
Hemoperitoneum

- e-,BUN, crea vomit, 3rd space fluid,


Rectus
endometab
hematoma
- amylase, lipase pancreatitis, infarction,
Grey Turner Umbilicus and flank Acute
perforation
discoloration
pancreatitis
- bilirubin, Alk PO4ase, serum
Iliopsoas
Leg Extension with appendicitis
aminotransferasebile
resistance pain
- lactate, ABG ischemia and infarction
Kehr
L shoulder pain
Splenic
- UA bacteria, DM, renal dse.
hemoperitoneum
- UHCG pregnancy
Murphy
RUQ pressure
Acute
- parasite, C.difficile diarrhea
Inspiration pain
cholecystits
IMAGING STUDIES
Obturator
Flex ext rotation
Pelvic abcess
- HISTORY & PE >>> CT SCAN
right thigh
- PLAIN RG(1st) CT SCAN (2nd)
hypogastric
Cullen
Fothergill

bruising
Abdominal mass

pain
LLQ pressure
Mcburneys pain

- plain radiographs Acute abdomen


- upright chest RG detects 1mL air in
peritoneum
* if the pain is:
- Lateral decubitus Abs RG 5-10mL air, for
solid viscera quadrant pain
Px who
cannot stand, for
small bowel periumbilical
perforated duodenal ulcer
colon pain pubic-umbilicus
- plain films abnormal calcifications
- pointed by one finger means localized, palm - upright and supine abs RG obstruction
means generalized pain
- colon has haustra markings unlike Small
- sudden (perforation & ischemia)
intestines
- progressive (inflammation)
- cecal volvulus comma shaped loop
- sigmoid volvulus bent tube, apex @ RUQ
Vvvisceral pain vvvvague, distention of
viscus
- ultrasoundgallbladder stone, wall, bile
e.g. Perforated duodenal ulcer
ducts, ovaries, adnexa, uterus,
generalized pain
INTRAPERITONEAL FLUID, intestinal air
Parietal pain sharper
disadvantage needs technician
e.g. Bacteria peritoneum
to interpret the result
inflammation fibrinous exudate
friction more localized pain
- CT SCAN almost ALL except
Referred pain distant
APPENDICITIS unless well performed using
Liver, gall bladder (right shoulder)
oral, rectal and IV contrast
Heart pancreas tail, spleen (left
Plain films and Barium enemas
shoulder)
better
Ureter (Scrotum, testicles)
Radiologist dependent readings
Advantage for traumatic injury
PERITONITIS
Rovsing

Acute
appendicitis

- Tenderness & guarding


- pneumococcus/streptococcus spp. (children)
- gram positive (adults w/ ESRD)
- e. coli, Klebsiella (adults w/ ascites &
cirrhosis)
LABORATORY STUDIES

INTRA ABDOMINAL PRESSURE (IAP)


- N= 5-7mmHg
- blood flow venous return stasis
- press diaphragm ventilation
- GERD, aspiration, obesity, head
elevationIAP

- CBC leukoctosis or bandemia

PERITONEAL LAVAGE

- anesthesized, 1L saline infusion (midline


adjacent to umbilicus) siphon back
analysis
IMMEDIATE LAPAROTOMY
- for emergency cases
- more harmful in delaying operations than
misdiagnosing a disease
ACUTE ABDOMEN IF:
a. >30 mmHg pressure
b. Distention, guarding and rebound
tenderness
c. >4U blood hemorrhage (unmanaged)
d. Sepsis
e. Hypoperfusion
f. Dilated instestine
g. Pneumoperitoneum
h. Extravasation of Contrast
i. Occlusion on angiography
j. Thickened wall with sepsis
k. >250 WBC/mL
l. >300,000 RBC/mL
m. Bilirubin & creatinine>plasma level
n. Particulate matter (stool)
PREPARATION FOR OPERATION
- IV e- infusions esp. hypokalemia
- prophylaxis for gram (-) & anaerobes
- Foley catheter bladder
- blood infusion
- acidosisbicarbonate and fluid repletion
ACUTE ONSET
No peritoneal sign acidosis,lactate CT
a. Ischemia OR or Angio
b. Normal Angio
c. Mesenteric venous thrombosis
anticoag
Peritoneal signXray
a. w/ air OR
b. w/o air PO contrast
a. leak OR
b. contained leak OR, NG
antibiotic
c. no leak CT
GRADUAL ONSET
Amylase, lipase, LFT
a. Pancreatitis

a. Mild supportive tx
b. ModerateCT
c. Severe
i. No shock CT
ii. Shock respiratory failure
peritoneal lavage
b. Fever, cholangitis antibiotics, ERCP
FEMALE
Gynecologic, UTI, appendicitis CT
a. Appendicitis laparotomy
b. No appendicitis CTDT
MALE
Consistent appendicitis OR laparotomy
Equivocal presentation CTCTDT
PERITONITISCT
a. Abscess AB, lavage resection
b. Perforation laparotomy
NO PERITONITIS
a. Diverticulitis AB
b. Equivocal CT CTDT
CASE 1
- 78 y.o. man, Hx of CABG, severe abdominal
pain began 6hrs ago, confused and disoriented,
pain is excruciating
- tenesmus
- digoxin, pindolol, ASA, Nitrate patch
- cool ashen skin, pulse rate = 120, BP = 85/50,
RR = 28, Temp = 36.5C, liquid stool (hematest
+), distended intestine, no bowel sound, no
guarding, no abdominal scar, tenderness difficult
to evaluate.
CASE 2
-18 y.o., M, periumbilical
pain, anorexia, &
***EVALUATION***
nausea
Generally irregular vital Stat
-later
the day
pain moved to RLQ
Bloodyinstool
bleeding
-Medications
unable to eat,
are vomiting
for atrial fibrillation
- Pain worsens
when
But (ASA,
NO)walking
bleeding
-BleedingO
RLQ tenderness,
involuntary
guarding, 38.3 C
(thats why!)
2 & BP
(fever),
Ischemia bleeding
WBC = 12,500 w/ 80% PMN lymphocytes
***MANAGEMENT***
***EVALUATION***
Resucitation STAT
Differentials:
Angiogram & thrombolytic therapy if there is no
Mesenteric
lymphadenitis,
UTI,
Gastritis,
peritonitis
Appendicitis
Blood transfusion
Appendicitis must be (+) Rovsings, Obturator
and Psoas signs and in rectal exam (precaution
with heart Px)
Visceral (vague) parietal (localized) pain
Pain is cresendo
***MANAGEMENT***
Appendectomy empty stomach <8hrs

CASE 3
- 59 y.o. M lower abdominal pain, fever, difficulty
when walking, intermittent cramps & changing
bowel habits over the past 2 months,
constipated with occasional diarrhea
- in the past 18 hrs, constant severe pain &
soreness in the LLQ, no apetite but thirsty
- 135/85 mmHg, pulse=100, 39 C
- lying supine, leg flexed at the hip and doesnt
want to move
-involuntary guarding & tenderness in LLQ, no
bowel sound
- tenderness on the left side of the upper rectum
- small brown bloody stools
***EVALUATION***
Inflammation
If female, consider gynecologic uterus ovary
problem
Consider tumor CA
Consider TB (GI manifestation)
Most likely, acute diverticulitis
***MANAGEMENT***
Needs further evaluation (SUBACUTE/OBSERVE)
CT scan for inflamed sigmoid
DONT USE!
colonoscopy perforate air sacs
barium enemabarium peritonitis
Antibiotic first,