The acute abdomen - a process-based approach
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Dr Arjun Rajagopalan
The acute abdomen
A process-based approach
Dr Arjun Rajagopalan FRCSC, FACS
Sundaram Medical Foundation
Chennai
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Dr Arjun Rajagopalan
Approach to the acute abdomen
DEFINITION
PainReferred to the abdomenRecent onset - 48 - 72 hrs
De novo
Change in chronic
abdominal pain
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Dr Arjun Rajagopalan
Approach to the acute abdomen
Points of departure
Process not organ
4 quadrants, not 9+1
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Dr Arjun Rajagopalan
Approach to the acute abdomen
DRILL - 4 Rs
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
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Dr Arjun Rajagopalan
Approach to the acute abdomen
RECOGNITION
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
1
23
4
5
Women
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Dr Arjun Rajagopalan
Approach to the acute abdomen
PROCESSES
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Catastrophes Hemodynamic collapseHoles PerforationBlocks ObstructionInflammation“-itis”I don’t knowNonspecific abdominal pain - NSAPCross border “Medical” disorders
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Dr Arjun Rajagopalan
Approach to the acute abdomen
PROCESSES
Catastrophe
Hole
Block
Itis
NSAP
A 22 yr old female presents with a 2 hour history of sudden, severe lower abdominal pain and collapse. O/E: P=140/mt. and thready, BP = 60/40 mm. The abdomen is distended and diffusely tender. You would recognize this as:
A 22 yr old female presents with a 2 hour history of sudden, severe lower abdominal pain and collapse. O/E: P=140/mt. and thready, BP = 60/40 mm. The abdomen is distended and diffusely tender. You would recognize this as:
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Dr Arjun Rajagopalan
Approach to the acute abdomen
PROCESSES
Catastrophe
Hole
Block
Itis
NSAP
A 38 year old male presents with a 6hr h/o sudden, severe, epigastric pain with nausea and vomiting. He is a smoker. O/E: Pulse = 120/mt, BP = 100/60 mm, T = 101.6F. There is guarding with rigidity of the upper abdomen You would recognize this as:
A 38 year old male presents with a 6hr h/o sudden, severe, epigastric pain with nausea and vomiting. He is a smoker. O/E: Pulse = 120/mt, BP = 100/60 mm, T = 101.6F. There is guarding with rigidity of the upper abdomen You would recognize this as:
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Dr Arjun Rajagopalan
Approach to the acute abdomen
PROCESSES
Catastrophe
Hole
Block
Itis
NSAP
A 63 year old female presents with a 36hr h/o bilious vomiting, colicky abdominal pain, abdominal distension and inability to pass flatus. She has had a hysterectomy 12 yrs ago. O/E: Pulse = 120/mt, BP = 90/60 mm, T = 99.6F. The abdomen is distended and diffusely tender. You would recognize this as:
A 63 year old female presents with a 36hr h/o bilious vomiting, colicky abdominal pain, abdominal distension and inability to pass flatus. She has had a hysterectomy 12 yrs ago. O/E: Pulse = 120/mt, BP = 90/60 mm, T = 99.6F. The abdomen is distended and diffusely tender. You would recognize this as:
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Dr Arjun Rajagopalan
Approach to the acute abdomen
PROCESSES
Catastrophe
Hole
Block
Itis
NSAP
A 48 year old female presents with 36hr h/o right upper quadrant abdominal pain, nausea, vomiting and low grade fever. There is tenderness with guarding in the right upper quadrant. You would recognize this as:
A 48 year old female presents with 36hr h/o right upper quadrant abdominal pain, nausea, vomiting and low grade fever. There is tenderness with guarding in the right upper quadrant. You would recognize this as:
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Dr Arjun Rajagopalan
Approach to the acute abdomen
PROCESSES
Catastrophe
Hole
Block
Itis
NSAP
Tenderness
Guarding
Rigidity
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Dr Arjun Rajagopalan
Approach to the acute abdomen
PROCESSES
Catastrophe
Hole
Block
Itis
NSAP
An 18 year old girl is admitted with a 24 hour history of vague, lower abdominal pain and nausea. Her periods are irregular. Her vital signs are normal. O/E: The abdomen is mildly distended with minimal localising signs.
An 18 year old girl is admitted with a 24 hour history of vague, lower abdominal pain and nausea. Her periods are irregular. Her vital signs are normal. O/E: The abdomen is mildly distended with minimal localising signs.
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Dr Arjun Rajagopalan
Approach to the acute abdomen
PROCESSES Quadrant-wise
Catastrophe
Hole
Block
Itis
NSAP
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Dr Arjun Rajagopalan
Catastrophes Hemodynamic collapseHoles PerforationBlocks ObstructionInflammation“-itis”I don’t knowNonspecific abdominal pain - NSAP
Approach to the acute abdomen
PROCESSES
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
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Dr Arjun Rajagopalan
Approach to the acute abdomen
3 tubes
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
iv line= crystalloids = blood - seldomnasogastric tube = conservativebladder catheter
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Dr Arjun Rajagopalan
Approach to the acute abdomen
THE MENU
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
HemogramUrinalysisUrine pregnancy testSerum amylasePlain filmsBarium contrast studyIVU UltrasoundCT scan
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Dr Arjun Rajagopalan
Approach to the acute abdomen
PLAIN X-RAY
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Upright chest
KUBUpright abdomen
Supine abdomenLeft-lateral decubitus
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Dr Arjun Rajagopalan
Approach to the acute abdomen
UPRIGHT CHEST
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
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Dr Arjun Rajagopalan
Approach to the acute abdomen
ABDOMINAL FILMS
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Multiple air-fluid levels
Step laddering
J - loops
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Dr Arjun Rajagopalan
Approach to the acute abdomen
ABDOMINAL FILMS
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Valvulae coniventes
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Dr Arjun Rajagopalan
Approach to the acute abdomen
ABDOMINAL FILMS
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Ileus
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Dr Arjun Rajagopalan
Approach to the acute abdomen
ULTRASOUND
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Gall stone
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Dr Arjun Rajagopalan
Approach to the acute abdomen
ULTRASOUND
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Appendicitis
Probe directed tenderness
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Dr Arjun Rajagopalan
Approach to the acute abdomen
ULTRASOUND
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Ectopic gestation
Unruptured ectopic
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Dr Arjun Rajagopalan
Approach to the acute abdomen
ULTRASOUND
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral Ureteric calculus
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Dr Arjun Rajagopalan
Ischemic bowel
Approach to the acute abdomen
ULTRASOUND
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Bowel obstruction
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Dr Arjun Rajagopalan
Approach to the acute abdomen
CT SCAN
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral Appendicitis
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Dr Arjun Rajagopalan
Approach to the acute abdomen
CT SCAN
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
ReferralPancreatitis
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Dr Arjun Rajagopalan
Approach to the acute abdomen
CT SCAN
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
ReferralDiverticulitis
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Dr Arjun Rajagopalan
Approach to the acute abdomen
NARCOTIC ANALGESIARecognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
No contraindicationAdminister with monitoring
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Dr Arjun Rajagopalan
Approach to the acute abdomen
NSAID
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Diclofenac
Colic Ureteric Biliary
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Dr Arjun Rajagopalan
Approach to the acute abdomen
OPTIONS
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Discharge & follow upAdmit for observationExpectant watchingAdmit for urgent surgeryAdmit for elective surgery
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Dr Arjun Rajagopalan
Approach to the acute abdomen
INDIAN PERSPECTIVE
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Delays Chronic infections
TBTyphoidAscariasis
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Dr Arjun Rajagopalan
Approach to the acute abdomen
INDIAN PERSPECTIVE
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
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Dr Arjun Rajagopalan
Appendicitis
Cholecystitis
Approach to the acute abdomen
IN PREGNANCY 1 in 500-650
pregnancies
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Dr Arjun Rajagopalan
Approach to the acute abdomen
IN PREGNANCYRecognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
SymptomsPregnancy or disease?
Guarding etc - absentDisplacement of organsWBC/ amylase - raisedDelays
Perforated appendicitis - 45%
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Dr Arjun Rajagopalan
Approach to the acute abdomen
X-RAY IN PREGNANCYRecognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
The risk [of abnormality] is considered to be negligible at 5 rad
(0.05 Gy – 5 mG) or less when compared to the other risks of
pregnancy, and the risk of malformations is significantly
increased above control levels only at doses above 15 rad (0.15 Gy – 15
mG).
Mean foetal absorbed dose
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Dr Arjun Rajagopalan
Approach to the acute abdomen
IN PREGNANCYRecognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
ULTRASOUND
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Dr Arjun Rajagopalan
Approach to the acute abdomen
MRI IN PREGNANCYRecognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Appendicitis
Safe at < 1.5T
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Dr Arjun Rajagopalan
Approach to the acute abdomen
MRI IN PREGNANCYRecognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Biliary tract
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Dr Arjun Rajagopalan
Approach to the acute abdomen
FETAL LOSS
Weeks Spont. abortion Preterm labour1 - 12 12% -
13 - 26 0 - 5% 5%
27 - 40 - 30 - 40%
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Dr Arjun Rajagopalan
Approach to the acute abdomen
DRILL - 4 Rs
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
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Dr Arjun Rajagopalan
Approach to the acute abdomen
PROCESSES
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Catastrophes Hemodynamic collapseHoles PerforationBlocks ObstructionInflammation“-itis”I don’t knowNonspecific abdominal pain - NSAPCross border “Medical” disorders
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Dr Arjun Rajagopalan
THANK YOU