Acute Abdomen PRESENTATION (Ingles)[1]

8/22/2019 Acute Abdomen PRESENTATION (Ingles)[1]

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American College of SurgeonsPrepared by

the Advisory Council for Surgery

and

Gayle Minard, MD, FACS

The Acute Abdomen

in the Adult


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American College of Surgeons

Overview

DefinitionPathophysiologySymptomsSigns

Work-upSpecific Diseases


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Definition ofAcute Abdomen

Sudden onset

Severe pain

Requires urgentdecision/diagnosis

Treatment often surgical


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Acute Abdomen

10% of ER visits or admitted patients 40% discharged from ER with pain of

unknown etiology

60% discharged from ER have wrongdiagnosis

The older the patient, the less accuratethe diagnosis


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Pathophysiology of

Abdominal Pain Referred painPain sensed at a considerable

distance from source Somatic painSegmental spinal nerves

Visceral painSympathetic, parasympathetic, or

somatic pathways


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History

Description of pain

Associated symptoms Gynecologic/GU history Past medical history

Family, social history


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Description of PainThe abdominal pain checklist

Onset and duration

Character and severity

Location and radiation

What makes it better

What makes it worse

Progression of pain

Associated symptoms


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Associated Symptoms

Nausea, vomiting Fever, chills

Anorexia, weight loss Food intolerance Pulmonary symptoms Change in bowel habits GU complaints


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Gynecologic / GU History

Last menses Contraception

Sexual history Obstetric history Vaginal discharge, bleeding Previous STDs Urinary symptoms


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Past Medical History

Cardiac or pulmonary disorders GI, vascular diseases

Diabetes, HIV Medications Recent invasive procedures Trauma Recent URI or strep throat


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Family & Social History

Inflammatory bowel disease Connective tissue disorders

Bleeding diatheses Cancer Recent travel

Environmental hazards Drugs, alcohol


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Physical Examination

General appearance ChestAbdomen Rectal

Pelvic GU


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General Examination

Distress

Acutely or chronically ill

Body position Color

Vital signs


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Chest Examination

Cardiac arrhythmias

Murmurs Mechanical heart valves Signs of pneumonia


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Abdominal Exam - LOOK

Distention Breathing pattern,

patient movement DiscolorationCullens sign

Grey Turners sign

Scars, hernia


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Abdominal Exam - LISTEN

Percussion

Auscultation


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Abdominal Exam - FEEL

Area of maximal tenderness CVA or flank tenderness

Masses Hernia Peritoneal signsinvoluntary guarding

pain on motion


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Abdominal ExamSpecial Signs

Rovsings sign

Murphys sign Psoas sign Obturator sign


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Method of eliciting psoas sign


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Method of performing obturator test


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Pelvic / Rectal / GU Exam

Tenderness

Masses Hernias Discharge, bleeding

Blood - occult or gross


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Work-up of Acute AbdomenBasic

UrinalysisAmylase, lipase

Pregnancy test Liver tests EKG Chest x-ray, abdominal films CBC


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Work-up of Acute Abdomen

Complex Ultrasound (US) Computed tomography (CT)

AngiographyBarium enema or endoscopy

never with peritonitis

Laparoscopy, especially inyoung women


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Common Causes

of Acute Abdomen

Appendicitis Diverticulitis

Cholecystitis Pancreatitis Bowel obstruction Perforated bowel Perforated ulcer

IBD Ectopic pregnancy

PID / TOA Gastroenteritis Mesenteric

ischemia

Nephrolithiasis


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Appendicitis

History: periumbilical cramping painmigrating to RLQ; anorexia

Exam: tenderness in RLQ and on rectal or

pelvic + Rovsings sign, Psoas sign, obturator

sign

US useful in young women

CT in doubtful cases Laparoscopy in young women and doubtful

cases


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Small Bowel Obstruction

History of previous abdominaloperation or hernia

Triad of diagnostic symptomscramping abdominal pain

vomitingobstipation


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Small Bowel Obstruction

Quartet of physical findings

Distention

Early: little or no tendernessLate: tenderness and guarding

Borborygmi

Radiographic findingsAir-fluid levels with J loops

Absence of air in colon


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Perforated Peptic Ulcer

History: PUD, NSAIDS,steroids, critical illness

Exam: generalized peritonitis Free air seen on plain

radiographs or CT


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Diverticulitis

History: constipation, LLQ pain,fever, diarrhea

Exam: LLQ tenderness, mass Laboratory tests

Pyuria, WBC elevatedCT - up to 93% sensitivity


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Pancreatitis

History: gallstones, alcohol, epigastricpain radiating to the back

Exam: generalized upper abdominaltenderness, most marked in epigastrium Increased amylase and lipase values

US - detects gallstones CT - 70-100% accuracy


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Cholecystitis

History: cramping epigastric and RUQpain, fatty food intolerance,

+ family history

Exam: RUQ tenderness, + Murphyssign, jaundice+

US - thickened GB wall,pericholecystic fluid


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Ureterolithiasis

History: flank pain, hematuria,radiation to groin, previous attacks

Exam: restless; no abdominaltenderness, flank tenderness

Urinalysis: RBCs, crystals CT, IVP and US useful


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Inflammatory BowelDisease

History: intermittent crampingabdominal pain, diarrhea, low

grade fever, weight loss Exam: localized abdominal

tenderness, + stool for blood

CT and Barium studies usuallydiagnostic


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Ectopic Pregnancy

History: menstrual irregularities,+ sexual history, symptoms of early

pregnancy Exam: adnexal mass on pelvic; may

have hypotension and tachycardia

Pregnancy test + US and laparoscopy diagnostic


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PID / TOA

History: premenopausal woman,midcycle, previous STD, vaginal

discharge, dysuria, Kehrs sign Exam: cervical motion

tenderness, adnexal mass

Pyuria US useful to diagnose


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Gastroenteritis

History: diarrhea, vomiting,crampy pain

Exam: no localizingperitoneal signs

Normal WBC


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Mesenteric Ischemia /

Infarction

History: intestinal angina, arrhythmias, lowflow, hypercoagulable state

Exam: pain out of proportion to findings WBC and amylase elevated Acidosis, stool + for blood

Thumb printing on plain film Angiography indicated - urgent!

Oth C f


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Other Causes ofAcute Abdomen

Volvulus Cholangitis

PneumoniaAcute M I Ovarian torsion / cyst

Hepatitis Sickle cell disease

Diabeticketoacidosis

Uremia Porphyria Intussusception Lupus HIV intestinal

disease


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Pitfalls

Old age Spinal cord injury

HIV Steroids

Very young? Very old? Very odd?

Be very careful.

F.T. de Dombal, MA , MD


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Summary

History and physical examinationmuch more important than

laboratory tests Making the management decision

is more important than making

the diagnosis

Treatment is often surgical

Acute Abdomen PRESENTATION (Ingles)[1]

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