09 Acute Med Abd

8/7/2019 09 Acute Med Abd

http://slidepdf.com/reader/full/09-acute-med-abd 1/42

Acute medical abdomen



Features:

severe abdominal pain, with brutal onset

local and general signs

EMERGENCY:

- establish immediate diagnosis

- take immediate action

- prevent fatal event



Two forms:

- the medical acute abdomen- the surgical acute abdomen

It is necessary for the practitioner to

know the etiopathogenic classification

in order to formulate a correct diagnosis

an soon as possible and to establish the

appropriate therapeutic attitude.



DIAGNOSIS

History

Physical examination

Limited lab tests



IS THE PAIN ACUTE OR

CH

RONIC?Did the pain recently start or has it occured for

weeks,months or years?

Chronic: mild chronic discomfort localized to

one area (perforated duodenal ulcer or perforated

diverticulum)

Acute: recurrent attacks of severe colic

(gallstones, kidney stones, mild intestinalobstruction caused by a benign tumor, such as a

carcinoid).



WAS THE ONSET SUDDEN?

Pain that is sudden in onset, severe or explosive,

progressive, continuous, and lasts more than 6hours generally indicates surgical etiology

Pain that is gradual in onset, mild to moderate in

intensity, intermittent, recurrent, or resolvespartially or completely in less than 6 hours favors

a nonsurgical diagnosis.



HOW WAS THE ONSET?

Persistent pain that awakensthe patient or

begins during relative inactivity

Pain that occurs during

Strenuous activity

or after eating

surgical

solution

nonsurgical

diagnosis



WHERE IS THE PAIN?

Epigastric pain:

stomach, duodenum, intestine, gallbladder, or

pancreas

Appendicitis: usually it is the initial site before the

pain shifts to the right lower quadrant.

Pain in periumbilical area arising from midgutderivatives:

jejunum, ileum, proximal third of the colon, and

appendix.

Pain in the hypogastrium arising from the embryonichindgut

distal two-thirds of the colon

internal reproductive organs (ovaries, fallopian tubes,

uterus, seminal vesicles, and prostate) the urinary bladder



Location of Abdominal Pain

Four quadrants:

oRight Upper Quadrant

oRight Lower Quadrant

oLeft Upper QuadrantoLeft Lower Quadrant

Three central areas:

oEpigastric

oPeriumbilicaloSuprapubic



Digestive system



DOES THE PAIN RADIATE?

Gallbladder pain beneath the right scapula

Left diaphragmatic irritation the left shoulder

Renal pain the region of pubis or vagina

Ruptured aortic aneurysm: severe pain beginning in themidback rapidly spreading to the abdomen



Radiation of Abdominal Pain

Perforated Ulcer

Biliary Colic

Renal Colic

Dysmenorrhea/Labor

Renal Colic (Groin)



HOW IS THE PAIN DESCRIBED?

Severe, knifelike pain: ± associated with shock EMERGENCY!

Burning pains:

± Peptic ulcers

Acute waves of sharp constricting pain (³take the breath away´):

± Renal or biliary colic

Tearing pain:

± Dissecting aneurysm

Ache:

± Appendicitis Dull ache in the region of the kidney:

± Pyelonephritis

Colicky pain that becomes steady:

± Appendicitis, strangulating intestinal obstruction, or a veryserious vascular accident.



WHAT GIVES RELIEF?

Antacids:

± Peptic ulcer

During the acute attack:

± Walking the floor biliary colic ± The patient lies as quietly as possible peritonitis



ARE OTHER SYMPTOMS ASSOCIATED WITH THE

PAIN?

Vomiting: ± If it precedes pain and esp. if it is followed shortly by diarrhea

gastroenteritis

± 3 mechanisms:

Severe irritation of local peritoneum or mesentery

Obstruction of a muscular tube (bile duct, intestine, ureter)

Absorbed toxin or drug stimulation of CNS centers controlling the

vomiting reflex

± Severe vomiting that precedes an intense epigastric, left chest, or

shoulder pain emetic perforation of intra-abdominal esophagus. ± 1 or 2 times/hour after the onset of pain appendicitis

± Acute intestinal obstruction: the lower the site of obstruction, the more

delayed is the vomiting

Shock, pallor, sweating, fainting



nausea

anorexia

fever

chills

constipation

diarrhea.

In surgical conditions: pain may be followed by nausea,vomiting, and anorexia.

In nonsurgical conditions nausea, vomiting, and anorexia

typically precede pain.


PAIN?



Anorexia is uncommon in:

athletes

especially in obese individuals

Fever is a common finding

This combination suggests infection in the urinary

tract, respiratory system, etc.


PAIN?



Constipation may accompany any abdominal condition

that causes an illness

Obstipation-nonpassage of both stool and gas--

however, always suggests a surgical problem

Diarrhea, especially with cramps:

gastroenteritis

other non-surgical conditions (inflammatory bowel

disease).


PAIN?



Coughing, sneezing,

rapid movements,

walking, especially down stairs

Musculoskeletal pain is often relieved by changing

position.

A bowel movement often eases the pain of gastroenteritis, but the pain may promptly recur.

WHAT AGGRAVATES THE PAIN?

peritoneal irritation



HISTORY OF PRECEDING SYMPTOMS

Previous symptoms and history of:

± Ulcer disease

± Gallstone colic

± Diverticular disease

± Esophageal reflux

± Diarrhea

± Constipation

± Jaundice

± Melena ± Hematuria

± Hematemesis

± Weight loss

± Mucus or blood in stool

Can help establish

the diagnosis



DRUG HISTORY

Details concerning drugs, both therapeutic and addictive: ± K tablets: highly irritating to the intestin perforation and peritonitis

± Prednisone or immunosuppresive increase the chance of perforation

of some portion of the GI tract

± Anticoagulants bleedings.

FAMILY HISTORY OF CERTAIN DISEASES

Pain

Vomiting

Diarrhea

In other family members gastroenteritis



GENERAL PH YSICAL EXAMINATION

Must not be neglected

BP, pulse, state of consciousness, degree of shock

PERISTALSIS:

± Active peristalsis of normal pitch nonsurgical disease

(gastroenteritis)

± High-pitched peristalsis or borborygmi in rushes intestinal

obstruction

± Severe pain and absolutely silent abdomen IMMEDIATE

EXPLORATION!



Tenderness

Rebound tenderness

Degree of distention

Palpable masses

Operative scars adhesions and intestinal

obstructions

Orifices external hernias




Pain arising in a hollow, tubular

structure, such as the ureter, intestine,

biliary tract, or fallopian tubes, may be

continuous or intermittent

The severity of such pain is inversely

proportional to the diameter of thetubular structure involved

Tip to remember



Rectal and pelvic examinations

Jaundice or evidence of bleeding in subcutaneous

tissues ± Retroperitoneal bleeding from

hemorrhagic pancreatitis

Dissecting bluish discoloration

Frank ecchymoses of the costovertebral angles (Grey

Turner¶s sign) or around the umbilicus (Cullen¶s sign)




Murphy¶s Sign

Technique

A.Maneuver: Deep subcostal palpation of right

upper quadrant on inspirationB.Positive: Worsened pain

Suggests

Acute Cholecystitis



Carnett's Sign

I nterpretation of abdominal muscle wall pain

1. I ntra-abdominal pain source = Negative Carnett's Sign (abdominal

pain decreases with tensing abdomen)

2. Abdominal Muscle Wall Pain = Positive Carnett's Sign (pain

increases or remains unchanged)

Technique

A. Patient lies supine

B. Patient tenses abdominal wall by

1. Lifting head off table

2. Lifting shoulder off table



Laboratory studies

Confirmation only

CBC, UA, Blood chemistries

Serum and urinary amylase

Use lab only as needed, not as a ³Shotgun´



Radiographic and Endoscopic

studies

Confirmation onlyStart with simple and inexpensive studies

- x-rays

- IVU

- US- CT



Common Causes of Acute Abdominal

Pain

Gastrointestinal TractAppendicitis, acute*

Meckel's diverticulitis*Perforated bowel*

Perforated peptic ulcer*

Small and large bowel obstruction*

Strangulated hernia*

DiverticulitisGastritis

Gastroenteritis

Inflammatory bowel disease

Mesenteric lymphadenitis

*Condition requires urgent surgery



Liver, Spleen, and Biliary Tract

Cholangitis, acute*

Cholecystitis, acute*

Hepatic abscess*Ruptured hepatic tumor*

Ruptured spleen*

Biliary colic

Hepatitis, acuteSplenic infarct



PeritoneumIntra-abdominal abscess*

Primary peritonitisTuberculous peritonitis

PancreasAcute pancreatitis

Urinary TractC

ystitis, acutePyelonephritis, acute

Renal infarct

Ureteral or renal colic



Female Reproductive SystemRuptured ectopic pregnancy*

Ruptured ovarian follicular cyst*Twisted ovarian tumor*

Dysmenorrhea

Endometriosis

Salpingitis, acute

Vascular SystemIschemia, acute*

Mesenteric thrombosis*

Ruptured arterial aneurysm*

RetroperitoneumRetroperitoneal hemorrhage



Generalized Abdominal Pain Causes

Peritonitis

Pancreatitis

Leukemia

Sickle Cell Crisis

Early Appendicitis

Mesenteric Adenitis

Mesenteric

Thrombosis

Gastroenteritis

Abdominal Aortic

aneurysm

Splenic arteryaneurysm

Mesenteric Artery

aneurysm

Colitis Intestinal obstruction



Left Lower Quadrant Pain Causes

Appendicitis

I ntestinal obstruction

Constipation

Diverticulitis

Leaking aneurysm

Abdominal wall hematoma

O varian cyst or torsion

U reteral calculus (Nephrolitiasis)

R enal pain

Seminal vesiculitis

Psoas abscess



Left U pper Quadrant Abdominal Pain Causes

GastritisPancreatitis

Splenic enlargement, rupture, infarction, aneurysm

R enal pain

Herpes Zoster

Myocardial I schemia

PneumoniaEmpyema



Right Lower Quadrant Pain Causes

Appendicitis

I ntestinal obstruction

R egional enteritis

Diverticulitis

CholecystitisPerforated U lcer

Leaking aneurysm

Abdominal wall hematoma

O varian cyst or torsion

U reteral calculus (Nephrolithiasis)

R enal pain

Seminal vesiculitis

Psoas abscess



Right Upper Quadrant Pain Causes

Gall Bladder or Billiary Tract Disease

Hepatitis

Hepatic abscess

Hepatomegaly due to Congestive heart failure

Peptic U lcer

Pancreatitis

R etrocecal Appendicitis

R enal pain

Herpes Zoster Myocardial I schemia

Pericarditis

Pneumonia

Empyema



Extraperitoneal Abdominal Pain Causes

I .Cardiopulmonary Causes

A.Cardiopulmonary Causes

B.PneumoniaC.Empyema

D.Myocardial I nfarction

E.Active R heumatic Heart Disease

F. Aortic Dissection

II .Hematologic Causes A.Leukemia

B.Sickle Cell Crisis



III . Neurologic Causes

A.Spinal cord tunor B.Spinal O steomyelitis

C.Tabes dorsalis

D.Herpes Zoster

E.Abdominal Epilepsy

F.Abdominal MigraineIV . Genitourinary and R enal Causes

A.Pyelonephritis

B.Perinephric abscess

C.Nephrolithiasis or other U reteral obstruction

D.Prostatitis

E.Seminal vesiculitis

F.Epididymitis



V . Metabolic Causes A.U remia

B.Diabetic acidosis

C.Porphyria

D.Addison's Disease in crisisVI . Toxins

A.Bacterial I nfection

B.I nsect Bites

C.Snake Bite V enoms

D.Spider Bite V enoms (e.g. Black Widow Spider Bite)E.Drugs

F.Lead poisoning



Things to Remember

Consider inguinal/rectal examination in males

Consider pelvic/rectal examination in females

Inflammatory bowel disease can mimic acute

apendicitis

Herpes zoster ± confusing pain if located in right lower

quadrant

Pneumonia-diffuse radiated abdominal pain, no

tenderness

Acute MI ± diffuse abdominal pain

Drug addicts ± severe colicky pain

Spinal/CNS disease ± radiculitis, reffered pain

Psychogenic somatoform disorders

09 Acute Med Abd

Documents

Transcript of 09 Acute Med Abd