Dr Arjun Rajagopalan
The acute abdomen
A process-based approach
Dr Arjun Rajagopalan FRCSC, FACS
Sundaram Medical Foundation
Chennai
Dr Arjun Rajagopalan
Approach to the acute abdomen
DEFINITION
PainReferred to the abdomenRecent onset - 48 - 72 hrs
De novo
Change in chronic
abdominal pain
Dr Arjun Rajagopalan
Approach to the acute abdomen
Points of departure
Process not organ
4 quadrants, not 9+1
Dr Arjun Rajagopalan
Approach to the acute abdomen
DRILL - 4 Rs
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Dr Arjun Rajagopalan
Approach to the acute abdomen
RECOGNITION
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
1
23
4
5
Women
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
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:
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:
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:
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:
Dr Arjun Rajagopalan
Approach to the acute abdomen
PROCESSES
Catastrophe
Hole
Block
Itis
NSAP
Tenderness
Guarding
Rigidity
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.
Dr Arjun Rajagopalan
Approach to the acute abdomen
PROCESSES Quadrant-wise
Catastrophe
Hole
Block
Itis
NSAP
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
Dr Arjun Rajagopalan
Approach to the acute abdomen
3 tubes
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
iv line= crystalloids = blood - seldomnasogastric tube = conservativebladder catheter
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
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
Dr Arjun Rajagopalan
Approach to the acute abdomen
UPRIGHT CHEST
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Dr Arjun Rajagopalan
Approach to the acute abdomen
ABDOMINAL FILMS
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Multiple air-fluid levels
Step laddering
J - loops
Dr Arjun Rajagopalan
Approach to the acute abdomen
ABDOMINAL FILMS
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Valvulae coniventes
Dr Arjun Rajagopalan
Approach to the acute abdomen
ABDOMINAL FILMS
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Ileus
Dr Arjun Rajagopalan
Approach to the acute abdomen
ULTRASOUND
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Gall stone
Dr Arjun Rajagopalan
Approach to the acute abdomen
ULTRASOUND
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Appendicitis
Probe directed tenderness
Dr Arjun Rajagopalan
Approach to the acute abdomen
ULTRASOUND
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Ectopic gestation
Unruptured ectopic
Dr Arjun Rajagopalan
Approach to the acute abdomen
ULTRASOUND
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral Ureteric calculus
Dr Arjun Rajagopalan
Ischemic bowel
Approach to the acute abdomen
ULTRASOUND
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Bowel obstruction
Dr Arjun Rajagopalan
Approach to the acute abdomen
CT SCAN
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral Appendicitis
Dr Arjun Rajagopalan
Approach to the acute abdomen
CT SCAN
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
ReferralPancreatitis
Dr Arjun Rajagopalan
Approach to the acute abdomen
CT SCAN
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
ReferralDiverticulitis
Dr Arjun Rajagopalan
Approach to the acute abdomen
NARCOTIC ANALGESIARecognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
No contraindicationAdminister with monitoring
Dr Arjun Rajagopalan
Approach to the acute abdomen
NSAID
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Diclofenac
Colic Ureteric Biliary
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
Dr Arjun Rajagopalan
Approach to the acute abdomen
INDIAN PERSPECTIVE
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Delays Chronic infections
TBTyphoidAscariasis
Dr Arjun Rajagopalan
Approach to the acute abdomen
INDIAN PERSPECTIVE
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Dr Arjun Rajagopalan
Appendicitis
Cholecystitis
Approach to the acute abdomen
IN PREGNANCY 1 in 500-650
pregnancies
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%
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
Dr Arjun Rajagopalan
Approach to the acute abdomen
IN PREGNANCYRecognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
ULTRASOUND
Dr Arjun Rajagopalan
Approach to the acute abdomen
MRI IN PREGNANCYRecognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Appendicitis
Safe at < 1.5T
Dr Arjun Rajagopalan
Approach to the acute abdomen
MRI IN PREGNANCYRecognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
Biliary tract
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%
Dr Arjun Rajagopalan
Approach to the acute abdomen
DRILL - 4 Rs
Recognition
Resuscitation
Response
Diagnostic
Therapeutic
Referral
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
Dr Arjun Rajagopalan
THANK YOU
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