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Acute abdomen

Zahir Mughal

Core Surgical Trainee


Introduction

Common causes of acute abdomen.


To develop an approach to diagnose, investigate and
manage the acute abdomen.
Cases to contextualise clinical scenarios that you
may face as junior doctors.
The acute abdomen

Definition of acute abdomen:


Rapid onset of severe symptoms that may indicate
life-threatening intra-abdominal pathology.
There are surgical and non-surgical causes of acute
abdomen.
Task TIP: USE A
SYSTEMS or
PATHOLOGICAL
or ANATOMICAL
SIEVE!

Think about differential diagnoses for pain in the


following abdominal regions: (then see next slide)

1. RUQ
2. Epigastrium
3. LUQ
4. RLQ
5. LLQ
Approach to the acute abdomen

Initial impression
History
Examination
General and targeted investigations
General and targeted management
Initial impression

ABCDE
Does the patient look ill, septic or shocked?
Are they lying still (think peritonitis), or rolling
around in agony (think intestinal, biliary or renal
colic)?
History taking

Pain history
Systems review
Past medical/surgical history
Full clerking is important
Examination

Inspection
Palpation
Percussion
Auscultation
Palpate for hernias
Focus the examination to help rule in/out
differential diagnoses that you generated from the
history
Task

Think about diagnoses that are associated with the


following examination findings: (see notes for answers)

1. Rovsings sign

2. Psoas sign
Good
4. Cullens sign examination
technique is the
5. Grey-turners sign key to elicit
these signs
6. Murphys sign ACCURATELY
Investigations

Blood tests: FBC, U&Es, LFTs, amylase, glucose, clotting,


Ca2+, VBG.
'Group and save' or crossmatch.
Blood cultures if septic.
Pregnancy test in all child-bearing age women
Urine dipstix
Erect CXR
AXR
Consider CT scan, ultrasound scan, ECG and troponin.
Initial surgical management

General:
NBM
02 to maintain sats 94-98%
IV fluids
Analgesia
Targeted:
Depending on underlying condition e.g antibiotics for infective
cause, drip and suck for bowel obstruction, etc
Initial surgical management

Ask yourself does this patient need emergency


surgery?
E.g. you suspect ruptured appendix. You have
written in your management plan NBM, IV
fluids, analgesia, antiemetics.
Write down what would you do next in real-life
as the junior doctor clerking the patient. (See
next slide for answers)
The stuff that is the FY1s responsibility
but no one tells you
Resuscitation of the patient is first and foremost
Call senior to assess and then:
Book onto CEPOD list
Inform theatre co-ordinator
Discuss patient with on-call CEPOD anaesthetist
Inform blood bank to have group and save prepared urgently
Inform lab to process blood results urgently
Inform bed manager
Book ITU/HDU bed if needed
PATIENT CASES WORKSHOP

Junior doctor scenarios


Clinical problem solving
Application of knowledge
Case 1

You are the FY1 clerking a 25 years old woman


admitted with central to RIF pain since yesterday
with vomiting, low grade fever and loss of appetite.
Discuss:
What are your differential diagnoses?
What investigations would you do?
Possible treatments?
Acute appendicitis

Pathophysiology: infection and inflammation


obstruction venous congestion and oedema
arterial compression and ischaemia infarction and
perforation peritonitis
Clinical features: migration of pain, nausea, pyrexia,
vomiting, anorexia, McBurneys point tenderness.
Investigations: Bloods, CXR, AXR, urine dip, +- USS
abdomen +- CT
Management: Surgery is the gold standard Rx
Case 2

55 years old man admitted with Severe epigastric


pain and N&V OE feels cold to touch, severe
epigastric pain with guarding
Differentials
Investigation
Management
Acute pancreatitis

Aetiology: GETSMASHED
Pathophysiology
Clinical features
Scoring system: modified Glasgow
Treatment
Case 3

60 years old man admitted with collapse in the


community. Brought by ambulance to resus. Pt is
hypotensive with a pulsatile mass in the abdomen.
Differential
Assessment and initial management
Investigations in resus
Leaking/ruptured AAA

If pt reaches hospital with AAA has operative


mortality 50%, but only 50% patient reach
hospital alive
Get succinct history and examination
If suspected, access, bloods, G&S and cross
match at least 10 units
Slow IVI, Analgesia
Let your consultant and theatre know
immediately
Have consent form ready
Get ready to give the boss a hand for the next 3,
4, 5 hours.
Case 4

76 years old man admitted with LIF pain.


Define diverticulum, diverticulosis, diverticular
disease and diverticulitis.
Further history taking reveals several months
history of constipation and a 2 day history of
passage of mucus per rectum. O/E he has
tachycardia, abdominal distension, and localised
LIF tenderness.
Discuss investigations and treatment.
Diverticulitis

Diverticulum is an outpouching of the wall of a


luminal organ.
Congenital diverticulum involve all layers of the colonic wall.
Acquired diverticulum involve herniation of colonic mucosa
through muscular wall of the colon.
Diverticulosis: presence of diverticula
Diverticular disease: symptomatic diverticula
Diverticulitis: Acute inflammation of diverticula
Diverticulitis

Pathophysiology: Disease of the colon. Obstruction at neck of


diverticulum infection and inflammation abscess formation
fistula / perforation peritonitis.
Clinical presentation:
Diverticular disease change in bowel habit, abdominal discomfort,
bloating. PR bleeding.
Diverticulitis: low / LIF abdominal pain, change in bowel habit,
mucus discharge, urinary symptoms, anorexia. Signs of sepsis /
peritonitis.
Investigations:
Bloods, erect CXR, AXR, consider CT scan
Treatment:
Analgesia, antibiotics, ?NSAIDs.
Take home messages

If abdo pain, keep open mind


Think can it be chest, heart
If lower abdo pain, dont forget testicular torsion
and hernias
In women dont forget pregnancy test
Most diagnosis is made with history and
examination (open Qs and then focus it)
Make your own assessment when you get a referral
Remember steroids or other forms of
immunocompromise may mask symptoms and
signs of sepsis/peritonitis.
Conclusion

We have discussed
The clinical approach to the acute abdomen.
Clinical assessment, investigations and treatment of common
causes of acute abdomen
Acute appendicitis
Acute pancreatitis
Leaking/rupture AAA
Acute diverticulitis