MANAGEMENT OF ACUTE ABDOMEN BY SURGICAL SIDECURRENT PRYMARY APPROACH, DIAGNOSTIC, MANAGEMENT AND REFERRAL
Tomy Lesmana
Acute Abdomen
Abdominal pain of short duration that requires a decision regarding whether an urgent intervention is necessary (Moshe Schein 2005)
Doc, which of them has an ‘acute abdomen’?
Why Acute Abdomen is Special?
Abdominal pain is one of the most frequent reasons to visit physician offices and ERs
Early diagnosis is the key to improving outcomes
An accurate history and complete physical examination are more important than any diagnostic test
avoid further morbidity and mortality
Appproach to Abdominal Pain
Take Pain to Elicit Pain History
Location and character Onset Intensity Patterns of radiation and refferal of pain Duration and progression Profocative and palliating factors Previous episodes
Mc Namara. Emerg Med Clin N Am 2011Macaluso. Int J Gen Med 2012
Take Pain to Elicit Pain History
Location and character Onset Intensity Patterns of radiation and refferal of pain Duration and progression Profocative and palliating factors Previous episodes
Site of pain gives you some idea about site of pathology• Somatic?• Visceral?
Take Pain to Elicit Pain History
Location and character Onset Intensity Patterns of radiation and refferal of pain Duration and progression Profocative and palliating factors Previous episodes
• Sudden (several second/minutes)• Ruptured AAA, perforated ulcer,
torsion, ectopic pregnancy• Acute (1-2 hour)• Acute cholecystitis, pancreatitis,
strangulation, mesenterial infark, small bowel obstruction
• Gradual (several hours)• Appendicitis, inacarcerated hernia,
large bowel obstruction, peptic ulcer
Take Pain to Elicit Pain History
Location and character Onset Intensity Patterns of radiation and refferal of pain Duration and progression Profocative and palliating factors Previous episodes
Take Pain to Elicit Pain History
Location and character Onset Intensity Patterns of radiation and refferal of pain Duration and progression Profocative and palliating factors Previous episodes
Take Pain to Elicit Pain History
Location and character Onset Intensity Patterns of radiation and refferal of pain Duration and progression Profocative and palliating factors Previous episodes• Acute appendicitis• Perforated duodenal ulcer• Intestinal obstruction: colicky constant somatic pain (perforated)
Take Pain to Elicit Pain History
Location and character Onset Intensity Patterns of radiation and refferal of pain Duration and progression Profocative and palliating factors Previous episodes
•Peptic ulcer•Cholelithiasis•Peritoneal irritation (cough/walk)
Take Pain to Elicit Pain History
Location and character Onset Intensity Patterns of radiation and refferal of pain Duration and progression Profocative and palliating factors Previous episodes
• Cholelithiasis• Ureterolithiasis• Diverticulitis• Partial bowel
obstruction
PQRST mnemonic
P3 : positional, palliating, and provoking factors
Q : quality
R3 : region, radiation, referral
S : severity
T : temporal factors (time and mode of onset, progression, previous episodes).
Mc Namara. Emerg Med Clin N Am 2011Macaluso. Int J Gen Med 2012
Assessment of the Associated Symptoms
Anorexia Vomiting Constipation Diarrhea Other symptoms:
Jaundice Hematocezia Hematemesis Hematuria
Past Medical/Surgical History Medications Allergies Past Surgical History
Previous abdominal or pelvic operations Prior work up for abdominal pain
Past Medical History Diabetes Cardiovascular disease Gastrointestinal disease
Phisical Examination
General Appearance Lies perfectly still
Inflammation, peritonitis Restless, writhing
Obstruction colic Bending forward
Chronic pancreatitis Facial expression Vital Sign
Abdominal Examination
Art of Bed Side Assessment
Test for Peritoneal Irritation
Often innacurate Rebound tenderness
Muscle guarding and rigidity Voluntary VS involuntary Localized VS generalized Knees and hips flexed Work toward area of pain Warm hands Abdominal wall tension troughout the respiratory cycle
Abdominal Pain Exam – Don’t Forget
Cardiopulmonary examination MI, basal pneumonia, pleural effusion
Rectal exam for tenderness, mass, blood Vaginal/pelvic exam for discharge,
tenderness (PID)
Differential Diagnosis
the Clinical Patterns of Acute Abdomen
Abdominal pain and shock Ruptured Aneurisma/Ectopic/Hemorrhagic Pancreatitis
Generalized peritonitis Hollow organ perforation
Localized peritonitis Appendicitis/cholecystitis
Intestinal obstruction Mechanical/functional
“Medical” illness Inferior wall AMI/diabetic ketoacidosis
Schein’s Common Sense Emergency Abdominal Surgery 2005
Abdominal Pain and Shock
Ruptured abdominal aortic aneurism Ruptured ectopic pregnancy Surgical rescuscitation
3rd space fluid loss Intestinal obstruction Acute mesenteric ischemia Severe acute pancreatitis
Generalized Peritonitis
diffuse severe abdominal pain looks sick and toxic lies motionless extremely tender abdomen
with “peritoneal signs”
Perforated ulcerColonic perforationPerforated appendicitis
Generalized Peritonitis
Management: pre-operative preparation and operation (surgery tonight).
The patient should be taken to the operating room only after adequate pre-operative preparation
Pitfall: acute pancreatitis
Localized Peritonitis
Localized Peritonitis
Often not an indication for a surgery tonight policy
Uncertain diagnosis initially be treated conservatively admitted to the surgical floor intravenous antibiotics Hydration actively observed (serial physical exams)
Intestinal Obstruction
Simptoms Central, colicky abdominal pain Distension Constipation Vomiting.
Sign Distention Increased bowel sound
Intestinal obstruction
Useful Tips:1. Small bowel Vs Large bowel2. Scarred abdomen Vs Virgin abdomen3. Never forget to look for Femoral hernia4. Mechanical Vs Functional bowel
obstruction True/Pseudo obstruction
Small vs Large bowel
Symptoms Small Bowel Obstruction
Large Bowel Obstruction
Colicky Pain +++ +
Vomiting +++ +
Distension ++ ++++
Constipation + +++
Virgin Abdomen Vs Scarred Abdomen
Strangulated HerniaCrohn’s/TBIntussusceptionCancer
In cases of Acute abdomenNever forget to look for Femoral Hernia
Intestinal Obstruction
Management Intravenous fluid NGt decompression Antibiotics Conservative / Operative
Important Medical Causes
Acute myocard infark Diabetic ketoacidosis Porphyria Basal pneumonia
Know the Value & Limitation of Laboratory Test
Value Causes
HB/HCT Low Ruptured Ectopic
White cells
>10000>20000<4000/>10000
Acute abdomenIschemic bowelSevere Sepsis
Platelets Low Dengue fever
Serum amylase
> 1000 units Acute Pancreatitis
Urine Pus cells UTI
pregnancy test Ectopic Pregnancy
•Normal White cell count will not rule out Appendicitis
Role of Imaging in Acute Abdomen X ray Chest Abdomen Erect , Supine, KUB US abdomen CT abdomen MRI Visceral Angiogram
Etc…
Role of Xrays
X ray abdomen Erect
Multiple Fluid Levels
X ray abdomen Supine
Dilated loops
X ray Chest
Pneumoperitoneum
Role of US in Acute Abdomen
Gall Stones
Appendicitis
Normal US abdomen will notExclude acute appendicitis!
CT Abdomen
•Free gas•Fluid in the abdomen•Solid viscera• Liver/Spleen• Kidney
•Hollow viscus•Retroperitoneum• AAA• Pancreatitis
When to Call the Surgeon ?
Unstable vital sign (hypotension, sepsis) Obvious peritonitis Work up complete in stable patient, but
still without a definitive diagnosis
When the diagnosis is in question Serial examination in an observation
unit/ED When the patient is discharged home
Instruction to return if: Pain worsen New vomiting occurs Fever Pain persist beyond 8-12h
Conclusion
Clinical Decision Making is an ArtKnowledge, Experience & InstinctRely on your expertise and
instinctrather than Scans and tests!
THANKYOU
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