How to cope with the patient

with an acute abdomen.

Mr Tim Campbell-Smith FRCS

Consultant general & colorectal surgeon, East Surrey Hospital

What is it?

Severe abdominal pain with signs and

symptoms suggestive of serious

underlying disease.

What are the signs & symptoms of

severe underlying pathology?

The problem

Abdominal pain is one of the commonest emergency

presentations.

It calls for prompt diagnosis and treatment.

Treatment of “the acute abdomen” is not invariably an

operation.

Delay in treatment of serious intra-abdominal pathology

increases morbidity and mortality.

How to diagnose the acute

abdomen?

History

Examination

Investigations

What can I do?

An approach…

Assessment

Intervention

Communication

Assessment

ABC

Take a history

The pain itself

Why are they in hospital?

What have they had done? (read the notes & operation notes if they’ve had surgery)

Examine the patient

Investigations

Blood tests

Imaging

What can I do?

Pain relief

Intervention (sepsis six: within the first hour)

Oxygen

Iv access & fluids

Blood cultures

lactate

Antibiotics

Catheter

Don’t forget βHCG

What can I do?

Communication

Who?

Ward staff

Medical team

Surgical registrar

Consultant surgeon

Critical care outreach

What can I do

Communication

What?

I need you here, I need advice. (esp late at night)

About the patient.

What has the patient had done?

What’s happened?

What you think is wrong?

What you’ve done?

What else would you like me to do?

When to worry/ask for help

Unwell patient. Early warning scores and obs

Severe pain not relieved by analgesia

Signs of peritonitis

Signs of obstruction

When you’re just worried!

A second set of eyes on a problem always helps.

Any questions at this point?

Case 1

Male 64 years old

Sudden onset of right loin pain & with vomiting

HR 128

BP 105/69

Pale

Sweaty

Thready radial pulse

A Nsaid’s, and arrange CT KUB

B Examine the abdomen

C pain relief then review with aim for o/p CT urogram

D iv access: urgent senior surgical review

Differential diagnosis

A Acute diverticulitis

B Ruptured AAA

C Right ureteric colic

D Large bowel obstruction

Case 2 28 year old

4 days post ileo-caecal resection and stricturoplasties

for Crohn’s disease.

Well until today, but progressing slowly.

Sudden onset of severe central abdominal pain with pain in

the shoulders, vomiting.

Temp 37.9

HR 116

BP 127/95

SaO2 93%

What would you do next?

History & examination

IV access

FBC, U&E, Clotting, G&S, ABG

IV fluids & pain relief

IV Antibiotics (sepsis 6)

Senior review

Xrays?

CT scan?

Prepare for theatre?

Case 3

43 year old female presents to SAU from her GP

Previously well

Occasional intolerance to fatty foods with RUQ

discomfort & dyspepsia

Sudden onset upper abdominal pain & vomiting this

morning

History

Severe constant pain

Pain eased slightly on sitting forwards

Worse when lying supine

Radiates through to the back

PHx: lap sterilisation

SHx: office worker, non-smoker, 17units alcohol a week

What would you do next?

Examination

Unwell, In pain

Sweaty

Tachycardic

Normotensive

Blood tests

X-rays/imaging

Differential diagnosis?

Gallstone disease: Cholecystitis, biliarycolic?

Acute pancreatitis?

Perforated duodenal ulcer?

Dissecting aortic aneurysm?

Quick Quiz

1.

A. What does this CXR show?

B. Give two possible causes

2.

A. What does this scan show?

B. What could be the cause?

C. Is it bad…?

3.

A. Give two abnormalities on the scan

B. Give two possible symptoms this patient may

present with.

4.

A. What phase has this scan performed in?

(arterial, venous, portal venous)

B. What does it show

C. What is the first thing to do?

6.

A. What is the diagnosis?

B. Where is the cause of this problem?

7.

A. What is the diagnosis?

B. What operation is this patient likely to have?

C. Name two thing you would do to prepare him for

theatre.

8.

A. What type of scan is this?

B. What views are these?

c. What does the scan show?

Any questions?