The Acute Abdomen

David C. Evans, MD

Assistant Professor of Surgery

david.evans@osumc.edu

LSI Part 2Understanding Patients with Reproductive and Surgical Needs

Acute Abdomen Learning Objectives

Primary Objectives

• Evaluate and determine initial treatment of patients presenting with surgical diseases in all patients as well as medical diseases in pregnant patients.

• Evaluate and formulate a management plan for a patient with acute abdominal pain.

Secondary Objectives

• Recognize medical or surgical emergencies in the pregnant and non-pregnant female patients.

• Evaluate and formulate a management plan for a patient with perforation of the GI tract.

• Develop a differential diagnosis for abdominal pain.

• Describe the initial evaluation, diagnostic studies management of a patient with an acute abdomen

• Decide if a patient with an acute abdomen needs an operation, and justify your decision.

• Describe the signs, symptoms and clinical findings associated with acute abdomen.

• Recognize patients with extra-abdominal causes of abdominal pain.

Acute Abdomen Learning Resources

Click to link directly to Sabiston:Chapter 47, “Acute Abdomen” (on-campus / proxy server only)

Foundational Science – Physiology“How sick is this patient?” Systemic Inflammatory Response Syndrome (SIRS)

Criteria Temp >38°C (100.4°F) or < 36°C (96.8°F) Heart Rate > 90 Respiratory Rate > 20 or PaCO2 < 32 mm Hg WBC > 12,000/mm>3, < 4,000/mm>3, or > 10% bands

Acute Abdomen Alert Signs + Findings

Likely Need Surgery

“Free Air”

Sepsis / SIRS

Peritonitis

Peritonitis-Irritation of the Peritoneal LiningTypical signs (most patients have some, not all)

Pain with movement or stretching of the peritoneum. Often keep knees and hips flexed

Hypersensitive to touch, mild bumps (car rides / hospital cart)

Rigid abdomen “Rebound tenderness” Can be focal or diffuse

Usually Requires

Surgery

ObesityChemo

SteroidsLimited Mental Capacity

Don’t always trust a benign exam

Pneumoperitoneum

Pneumoperitoneum

AlgorithmAcute

Abdominal Pain with Peritonitis

SIRS / Sepsis

Operate

Stable /

No SIRS

Pneumo-peritoneum On

X-ray

Operate

No Pneumo-peritoneum On

X-ray

Contrast Study (Typically CT)

Free Air or Contrast

Extravasation -> Operate

Contained Collection /

Perforation -> Operate vs.

Drain

Normal Study -> Monitor Closely

“Safe Strategies”

N.B. Exceptions do exist

AlgorithmAcute Abdominal

Pain Without Peritoneal Signs

Generalized Pain

CT with PO and IV contrast

Normal

Evaluate for “Non-Surgical Causes”

Arterial Ischemia

Operate

Venous Thrombosis

Anticoagulate

Focal Pain

Selective Imaging (History / Exam

Dependent)

Positive

Operate / Drain

Negative

Continue to Evaluate- Urgent

Surgery Not Required

Foundational Science – Anatomy“Where does it hurt?” – Referred Pain

Common Causes of the Acute Abdomen

Bowel Perforation or Ischemia

Infection (Appendicitis / Cholecystitis, etc)

Hemoperitoneum (trauma, ruptured ectopic, etc)

Hernias (Incarcerated / Strangulated)

Always Check for Hernias

Sudden Severe Abdominal Pain

Kidney Stone (Hematuria, flank pain) Ruptured AAA (Shock, Back Pain, H/O vascular dz) Perforated Ulcer Patients know exactly

when these symptoms

started!

Non-abdominal causes of pain

Endocrine and Metabolic Causes

• Uremia• Diabetic crisis• Addisonian crisis• Acute

intermittent porphyria

• Hereditary Mediterranean fever

Hematologic Causes

• Sickle cell crisis• Acute leukemia• Other blood

dyscrasias

Toxins and Drugs

• Lead poisoning• Other heavy

metal poisoning• Narcotic

withdrawal• Black widow

spider poisoning

Case 1 - A Hypotensive Pt

Case 2

58 yo male 2 day history of left lower quadrant abdominal pain. Pain started L>R, Attempted to take some pepto-bismol but that did not help. He report some associated nausea, he denies any

vomiting Some subjective fevers at home. The pain was unrelenting therefore he came to the ED for

further evaluation. He reports his abdomen feels more distended and the pain is worse with movement. He has been unable to tolerate much PO.

Case 2- order of events

Physical Exam / Vitals Labs Imaging

ConfirmationTreatment

Plan

Abdomen: Tender, distended. Peritonitis

14.8 (87% granulocytes)

12.8 243

44.3

Does he need a CT scan?

Case 2 Findings

Case 2 – CT Probably not needed but here it is Free air Inflammation Diverticuli

-> perforated

diveriticulitis

Case 2 Treatment Surgery!

Summary

Physical Exam, Patient Status (sepsis, etc.) drives algorithm

Differential Diagnosis based on exam, confirmed with imaging

Take every opportunity to examine patients with pathology now as a student

Timing can be crucial to good outcomes

Acute Abdomen Quiz

Thank you for completing this module

Questions? Contact me at:

david.evans@osumc.edu

640 Faculty Office Tower (395 W 12th Ave.)

Image Credits

Slide 1 photo- http://www.enfermeriablog.com/tag/cuidados-peritonitis/ Slide 3- cover images from amazon.com Slide 4- “Know the signs, know sepsis”- Boston Medical Center;

http://www.coloribus.com/adsarchive/prints/land-rover-defender-fireball-1965105/ Slide 5-6 photos- OSUMC images Slide 7 photo- http://onemomsbattle.com/TheLiesofaNarcissist Slide 8 image- http://prep-pg.blogspot.com/2012/04/radiological-signs-of-bowel-perforation.html Slide 9 image- OSUMC Slide 12 image from Sabiston, Ch. 47. Slide 14 image from

http://www.celebritydiagnosis.com/2013/04/dwayne-the-rock-johnson-undergoes-hernia-surgery/ Slide 15 image- http://www.hongkiat.com/blog/extraordinary-clocks/ Slide 16 table- adapted from Sabiston, Ch. 47. Slide 18 images- http://www.fairview.org/healthlibrary/Article/89315 and cancer.osu.edu Slide 19 image- http://www.pinterest.com/carolinagirl525/x-ray/ Slide 20 image- Van Wagoner ZD, Evans DC, Askegard-Giesmann JR, Kenney BD. Perforated

peptic ulcer in a child with a vagus nerve stimulator for seizure control. Brain Stimul. 2013 Nov;6(6):972-3.

Slide 24- OSU clinical image Slide 25 image- http://5minuteconsult.com/ViewImage/2027820

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