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