Assessment and Management of the Acute Abdomen

Yingda LiNeurosurgery HMO23 September 2010

ObjectivesDevelop a rational approach to

assessing and managing the acute abdomen in adults

Identify red-flags on history and examination

Consolidate information previously learnt about specific pathologies

Have a set of rules to fall back onFamiliarise with the style of questions

commonly asked in exams

OverviewDefinitionHistoryExaminationInvestigationsManagementMulti-choice questions

DefinitionAbdominal painAcute onsetUsually severeRequiring urgent attention

Not always surgicalNot always intra-abdominal

source

Golden Rule 1Upper abdominal pain may be

from supra-diaphragmatic pathology

Acute myocardial infarct and lower lobe pneumonia should always be in your differential diagnosis

HistoryDemographicsTempoSite and radiationQualityAssociated symptomsAntecedent eventsPre-morbiditiesPrior episodesMenstrualPreoperative history

Golden Rule 2A woman of childbearing age is

pregnant till proved otherwiseA woman of childbearing age

who has acute abdominal pain is pregnant and has a ruptured ectopic till proved otherwise

Golden Rule 3Never dismiss or underestimate

acute abdominal pain in an elderly patient

They probably have mesenteric ischaemia, ruptured AAA, perforated diverticular abscess or a strangulated hernia

Golden rule 4Vomiting is the key associated

symptomPain before vomiting is usually

surgicalCombination of vomiting and

diarrhoea is usually gastroenteritis, but gastroenteritis must remain a diagnosis of exclusion

Examination

General appearance and vital signs

Inspection and palpation

Bedside tests

Rectal, testicular and pelvic

Auscultation

Golden Rule 5Vital signs are vitalYou can tell a lot just by looking

at a patient

InvestigationsDiagnostic

Pancreatic enzymes, cardiac enzymes

US, CT, MRCPAngiographyLaparoscopy

MSU

SupportiveX-rayLFTs

Lactate, PO4

WCC, neutrophilspH, ketones

AssociatedUEC, CMP

PreoperativeGrp and Hold

Severity and PrognosisCRP, platelets

Clotting, albuminCT

Criteria

ManagementResuscitative cascadeAirway, breathing, circulation

General measuresAnalgesia, antiemesisNBM, IV fluidsNGT, IDCSerial examinations

Specific measuresAntibiotics, image-guided drainageOpen surgery, laparoscopic-assistedERCPAngiographic interventionSigmoidoscopic decompression

What is the difference between an incarcerated vs. obstructed vs. strangulated hernia?

1. Hepatitis serology2. Upper abdominal

ultrasound3. Full blood examination4. ERCP5. Liver biopsy

What would be your clinical concern if he was febrile? What eponymous triad wouldthat constitute?

How would you explain the low serum bicarbonate?

A. Erect abdominal X-rayB. Full blood examinationC. Liver function testsD. Serum lipaseE. Upper G.I. endoscopy

A. CT kidney, ureter and bladderB. Ultrasound renal tractC. 24-hour urinary calcium excretionD. Plain X-ray kidney, ureter and bladderE. Mid-stream urine for phase microscopy

What is phase microscopy designed to look for?

What do you think is the most likely diagnosis?

Golden rules1. Upper abdominal pain may be from

supra-diaphragmatic pathology2. Woman of childbearing age is

pregnant till proved otherwise3. Acute abdominal pain in elderly

patients must not be dismissed or underestimated

4. Vomiting is the key associated symptom

5. Vital signs are vital