Post on 04-Jun-2018
Acute AbdomenAcute Abdomen
Andreas M Andreas M KluftingerKluftinger MD FRCSCMD FRCSCggKelowna General HospitalKelowna General Hospital
DisclosureDisclosureDisclosureDisclosure
• Hernia Advisory Panele a d so y a e– Ethicon, Johnson & Johnson
• Fundingnil zilch zippo nada zero– nil, zilch, zippo, nada, zero
ObjectivesObjectivesObjectivesObjectives
• Understand the Pathophysiology andUnderstand the Pathophysiology and Etiology of the acute abdomen
• Approch to acute abdomen in rural tipractice
• Case presentations
Stedman's Medical DictionaryStedman's Medical DictionaryStedman s Medical Dictionary Stedman s Medical Dictionary 27th Edition27th Edition
“any serious acute intra-abdominal condition attended by pain tendernesscondition attended by pain, tenderness, and muscular rigidity, and for which emergency surgery must be considered "emergency surgery must be considered.
Acute Abdominal PainAcute Abdominal PainAcute Abdominal PainAcute Abdominal Pain
• 5-10 % of ER visits5 10 % of ER visits• Complex “black box”
D l i di i i bidit• Delays in diagnosis can increase morbidity• Excessive consultations (+/- transport) and
imaging can be costly and tax resources.• Primary assessment and triage are keyy g y
History & PhysicalHistory & PhysicalHistory & PhysicalHistory & Physical
• Onset nature duration location radiationOnset, nature, duration, location, radiation• Aggravating and relieving factors
A i t d GI GU t• Associated GI or GU symptoms• Past history (Surg and Med)• Review of Systems• Full physical examFull physical exam
Stereotypes of Pain Onset and Associated Pathology
S dd R id G d l•Sudden onset (full pain in seconds)
•Rapid onset(initial sensation to full pain over minutes or hours)
•Gradual onset(hours)
minutes or hours)
•Perforated ulcer •Mesenteric infarction
•Strangulated hernia •Volvulus
•Appendicitis •Strangulated herniaMesenteric infarction
•Ruptured abdominal aortic aneurysm •Ruptured ectopic
Volvulus•Intussusception•Acute pancreatitis •Biliary colic Di ti liti
Strangulated hernia •Chronic pancreatitis •Peptic ulcer disease •Inflammatory bowel disease M t i l h d itipregnancy
•Ovarian torsion or ruptured cyst •Pulmonary embolism
•Diverticulitis •Ureteral and renal colic
•Mesenteric lymphadenitis •Cystitis and urinary retention •Salpingitis and prostatitis
Pulmonary embolism •Acute myocardial infarction
Simplified in ThirdsSimplified in ThirdsSimplified in ThirdsSimplified in ThirdsEmbryologic Structures Nerves Arteries Pain Location
Foregut Esophagus, stomach,3/4
Thoracic splanchnics,
Coeliac Epigastrium,
duod,liver, gbpanc
p ,vagus
Midgut ¼ duod to Thoracic SMA PeriumbilicalMidgut ¼ duod to splenic flexure
Thoracic splanchnics,
vagus
SMA Periumbilical
Hindgut Left colon Pelvic IMA HypogastriumHindgut Left colon, rectum, GU
tract
Pelvic splanchnics,
lesser thoracic splanchnics
IMA Hypogastrium
p
Possible Causes of Pain by Location
Location of Pain Associated Diseases
Right upper quadrant(liver, kidney, gallbladder)
Acute cholecystitis, biliary colic, acute hepatitis, duodenal ulcer, right lower lobe pneumonia
Right lower quadrant Appendicitis, cecal diverticulitis, ectopic pregnancy, tubo-ovarian abcess,Right lower quadrant(ascending colon, appendix, ovary,
fallopian tube)
Appendicitis, cecal diverticulitis, ectopic pregnancy, tubo ovarian abcess, ruptured ovarian cyst, ovarian torsion
Left upper quadrant Gastritis, acute pancreatitis, splenic pathology, left lower lobe pneumonia pp q(pancreas, spleen, kidney)
p p p gy p
Left lower quadrant(sigmoid and descending colon,
f ll i t b )
Diverticulitis, ectopic pregnancy, tubo-ovarian abcess, ruptured ovarian cyst, ovarian torsion
ovary, fallopian tube)
Midline or periumbilical Appendicitis (early), gastroenteritis, mesenteric lymphadenitis, myocardial ischemia or infarction, pacreatitis
Flank Abdominal aortic aneurysm, renal colic, pyelonephritis
Front to back Acute pancreatitis, ruptured abdominal aortic aneurysm, retrocecalappendicitis posterior duodenal ulcerappendicitis, posterior duodenal ulcer
Suprapubic or lower abdominal Ectopic pregnancy, mittelschmerz, ruptured ovarian cyst, pelvic inflammatory disease, endometriosis, urinary tract infection
Sign Finding Association
Cullen's sign Bluish periumbilicaldiscoloration
Retroperitoneal hemorrhage
Grey Turner’s sign Bluish flank discoloration
gpancreatitis,
abdominal aortic aneurysm rupture)
Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy
McBurney's sign Tenderness located 2/3 distance from AppendicitisMcBurney s sign Tenderness located 2/3 distance fromASIS to umbilicus on right side
Appendicitis
Murphy's sign Abrupt interruption of inspiration onpalpation of right upper quadrant
Acute cholecystitispalpation of right upper quadrant
Iliopsoas sign Hyperextension of right hipcausing abdominal pain
Appendicitis
Obturator's sign Internal rotation of flexed right hip causing abdominal pain
Appendicitis
Chandelier sign Manipulation of cervix causes patient Pelvic inflammatoryChandelier sign Manipulation of cervix causes patient to lift buttocks off table
Pelvic inflammatory disease
Rovsing's sign Right lower quadrant pain with palpation of the left lower quadrant
Appendicitis
Referred Pain
Structure Irritated Location of Referred PainStructure Irritated Location of Referred Pain
Diaphragmatic Supraclavicular area (Kehr's sign)
Ureteral Hypogastrium, groin, inner thigh
Cardiac pain Epigastrum, jaw, shoulder
Appendix Periumbilical via T10 nerve
D d U bili l i i t th iDuodenum Umbilical region via greater thoracic splanchnic nerve
Hiatal hernia Epigastrum via T7 and T8 nervesHiatal hernia Epigastrum via T7 and T8 nerves
Pancreas or gallbladder Epigastrum
Gallbladder and bile duct Epigastric pain that wraps around to the scapula
Imaging AccuracyImaging Accuracyg g yg g yin in
A di itiA di itiAppendicitisAppendicitis
Modality Sensitivity Specificity Pos PredValue Neg Pred ValuePlain Film 10% 90%Plain Film 10% 90%Ultrasound 85-90% 92-96% 95% 80-90%
CT 95-97% 95% 97% 95-100%MRI 93% 91% 92% 100%MRI 93% 91% 92% 100%
Laboratory in AppendicitisLaboratory in AppendicitisLaboratory in AppendicitisLaboratory in AppendicitisTest Sensitivity Neg Pred Value
1. WBC >10.5 85%2. Neutrophils >75% 78% 94%3 C reactive protein 93-96%3. C reactive protein 93 96%
1+2 96%1+3 92.3%
1+2+3 99.2% (81% in children)
Urinalysis in AppendicitisUrinalysis in AppendicitisUrinalysis in AppendicitisUrinalysis in Appendicitis
• 30% of appendicitis patients have some30% of appendicitis patients have some urinary syptoms
• 14% have >10 WBC/hpf• 14% have >10 WBC/hpf• 18% have > 3 RBC/hpf
Imaging in PregnancyImaging in PregnancyImaging in PregnancyImaging in Pregnancy
• UltrasoundUltrasound– Safest
Useful for fetal assessment (dates viability– Useful for fetal assessment (dates, viability, placenta, amniotic fluid)
– NPV for appendicitis 80-90%– NPV for appendicitis 80-90%– PPV for appendicitis 95%
Imaging in PregnancyImaging in PregnancyImaging in PregnancyImaging in PregnancyProcedure Fetal ExposureChest radiograph (2 views) 0.02-0.07 mradAbdominal film (single view) 100 mradIntravenous pyelography >1 rad*Hip film (single view) 200 mradHip film (single view) 200 mradMammography 7-20 mradBarium enema or small bowel series 2-4 radCT (computed tomography) scan head or chest
<1 rad
CT scan abdomen and lumbar spine 3.5 radCT pelvimetry 250 mrad
No evidence of teratogenesis or fetal loss if cumulative dose < 5 rads
Acute AbdomenAcute AbdomenC d b PC d b PCaused by PregnancyCaused by Pregnancy
• Early pregnancy – Ruptured ectopic pregnancy– Septic abortion with peritonitis – Acute urinary retention due to retroverted gravid uterus– Torsion of the pregnant uterus
• Later pregnancy – Red degeneration of myomag y– Torsion of pedunculated myoma– Placental abruption, Placenta percreta– HELLP (hemolysis, elevated liver function, and low platelets) syndromeHELLP (hemolysis, elevated liver function, and low platelets) syndrome
– Spontaneous rupture of the liver – Uterine rupture – Chorioamnionitis
Conditions Associated with Conditions Associated with PPPregnancyPregnancy
• Acute pyelonephritisAcute pyelonephritis• Acute cystitis
A t h l titi• Acute cholecystitis• Acute fatty liver of pregnancy • Rupture of rectus abdominis muscle
Case #1Case #1Case #1Case #1
• 68 male 48 hrs RLQ pain68 male, 48 hrs RLQ pain• Quick onset, in RLQ
N i• No nausea or anorexia• No urinary syptoms• PHx: GERD, dyslipidemia• Tender RLQ and flank with peritonismTender RLQ and flank with peritonism• WBC 9.2 Urine clear
Case #2Case #2Case #2Case #2
• BW 41 yo electrician• collapsed at home with chest, abd paincollapsed at home with chest, abd pain• CPR by family, EHS to KGH
PHx: appe Meds: ASA• PHx: appe Meds: ASA• Exam: BP 60 sys, HR 100 RR 16
Chest clear Abdomen tender, acute
InvestigationsInvestigationsInvestigationsInvestigations
• Hb 108 WBC 8 9 Plts 256Hb 108 WBC 8.9 Plts 256• Hep panel – normal
Li 43• Lipase 43• ECG – normal• Trop < 0.1
LaparotomyLaparotomyLaparotomyLaparotomy
• 3 litres blood3 litres blood• intact liver, spleen, viscera
bl d f l• blood from lesser sac• rupured splenic artery aneurysm at hilum• splenectomy, distal pancreatectomy• 4 units FP 6 units RBC4 units FP, 6 units RBC• Recovery uneventful