The acute abdomen - a process-based approach

Dr Arjun Rajagopalan

The acute abdomen

A process-based approach

Dr Arjun Rajagopalan FRCSC, FACS

Sundaram Medical Foundation

Chennai


Approach to the acute abdomen

DEFINITION

PainReferred to the abdomenRecent onset - 48 - 72 hrs

De novo

Change in chronic

abdominal pain



Points of departure

Process not organ

4 quadrants, not 9+1



DRILL - 4 Rs

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral



RECOGNITION

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

1

23

4

5

Women



PROCESSES

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Catastrophes Hemodynamic collapseHoles PerforationBlocks ObstructionInflammation“-itis”I don’t knowNonspecific abdominal pain - NSAPCross border “Medical” disorders



PROCESSES

Catastrophe

Hole

Block

Itis

NSAP

A 22 yr old female presents with a 2 hour history of sudden, severe lower abdominal pain and collapse. O/E: P=140/mt. and thready, BP = 60/40 mm. The abdomen is distended and diffusely tender. You would recognize this as:

A 22 yr old female presents with a 2 hour history of sudden, severe lower abdominal pain and collapse. O/E: P=140/mt. and thready, BP = 60/40 mm. The abdomen is distended and diffusely tender. You would recognize this as:



PROCESSES

Catastrophe

Hole

Block

Itis

NSAP

A 38 year old male presents with a 6hr h/o sudden, severe, epigastric pain with nausea and vomiting. He is a smoker. O/E: Pulse = 120/mt, BP = 100/60 mm, T = 101.6F. There is guarding with rigidity of the upper abdomen You would recognize this as:

A 38 year old male presents with a 6hr h/o sudden, severe, epigastric pain with nausea and vomiting. He is a smoker. O/E: Pulse = 120/mt, BP = 100/60 mm, T = 101.6F. There is guarding with rigidity of the upper abdomen You would recognize this as:



PROCESSES

Catastrophe

Hole

Block

Itis

NSAP

A 63 year old female presents with a 36hr h/o bilious vomiting, colicky abdominal pain, abdominal distension and inability to pass flatus. She has had a hysterectomy 12 yrs ago. O/E: Pulse = 120/mt, BP = 90/60 mm, T = 99.6F. The abdomen is distended and diffusely tender. You would recognize this as:

A 63 year old female presents with a 36hr h/o bilious vomiting, colicky abdominal pain, abdominal distension and inability to pass flatus. She has had a hysterectomy 12 yrs ago. O/E: Pulse = 120/mt, BP = 90/60 mm, T = 99.6F. The abdomen is distended and diffusely tender. You would recognize this as:



PROCESSES

Catastrophe

Hole

Block

Itis

NSAP

A 48 year old female presents with 36hr h/o right upper quadrant abdominal pain, nausea, vomiting and low grade fever. There is tenderness with guarding in the right upper quadrant. You would recognize this as:

A 48 year old female presents with 36hr h/o right upper quadrant abdominal pain, nausea, vomiting and low grade fever. There is tenderness with guarding in the right upper quadrant. You would recognize this as:



PROCESSES

Catastrophe

Hole

Block

Itis

NSAP

Tenderness

Guarding

Rigidity



PROCESSES

Catastrophe

Hole

Block

Itis

NSAP

An 18 year old girl is admitted with a 24 hour history of vague, lower abdominal pain and nausea. Her periods are irregular. Her vital signs are normal. O/E: The abdomen is mildly distended with minimal localising signs.

An 18 year old girl is admitted with a 24 hour history of vague, lower abdominal pain and nausea. Her periods are irregular. Her vital signs are normal. O/E: The abdomen is mildly distended with minimal localising signs.



PROCESSES Quadrant-wise

Catastrophe

Hole

Block

Itis

NSAP


Catastrophes Hemodynamic collapseHoles PerforationBlocks ObstructionInflammation“-itis”I don’t knowNonspecific abdominal pain - NSAP


PROCESSES

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral



3 tubes

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

iv line= crystalloids = blood - seldomnasogastric tube = conservativebladder catheter



THE MENU

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

HemogramUrinalysisUrine pregnancy testSerum amylasePlain filmsBarium contrast studyIVU UltrasoundCT scan



PLAIN X-RAY

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Upright chest

KUBUpright abdomen

Supine abdomenLeft-lateral decubitus



UPRIGHT CHEST

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral



ABDOMINAL FILMS

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Multiple air-fluid levels

Step laddering

J - loops



ABDOMINAL FILMS

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Valvulae coniventes



ABDOMINAL FILMS

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Ileus



ULTRASOUND

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Gall stone



ULTRASOUND

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Appendicitis

Probe directed tenderness



ULTRASOUND

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Ectopic gestation

Unruptured ectopic



ULTRASOUND

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral Ureteric calculus


Ischemic bowel


ULTRASOUND

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Bowel obstruction



CT SCAN

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral Appendicitis



CT SCAN

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

ReferralPancreatitis



CT SCAN

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

ReferralDiverticulitis



NARCOTIC ANALGESIARecognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

No contraindicationAdminister with monitoring



NSAID

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Diclofenac

Colic Ureteric Biliary



OPTIONS

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Discharge & follow upAdmit for observationExpectant watchingAdmit for urgent surgeryAdmit for elective surgery



INDIAN PERSPECTIVE

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Delays Chronic infections

TBTyphoidAscariasis



INDIAN PERSPECTIVE

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral


Appendicitis

Cholecystitis


IN PREGNANCY 1 in 500-650

pregnancies



IN PREGNANCYRecognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

SymptomsPregnancy or disease?

Guarding etc - absentDisplacement of organsWBC/ amylase - raisedDelays

Perforated appendicitis - 45%



X-RAY IN PREGNANCYRecognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

The risk [of abnormality] is considered to be negligible at 5 rad

(0.05 Gy – 5 mG) or less when compared to the other risks of

pregnancy, and the risk of malformations is significantly

increased above control levels only at doses above 15 rad (0.15 Gy – 15

mG).

Mean foetal absorbed dose



IN PREGNANCYRecognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

ULTRASOUND



MRI IN PREGNANCYRecognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Appendicitis

Safe at < 1.5T



MRI IN PREGNANCYRecognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Biliary tract



FETAL LOSS

Weeks Spont. abortion Preterm labour1 - 12 12% -

13 - 26 0 - 5% 5%

27 - 40 - 30 - 40%



DRILL - 4 Rs

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral



PROCESSES

Recognition

Resuscitation

Response

Diagnostic

Therapeutic

Referral

Catastrophes Hemodynamic collapseHoles PerforationBlocks ObstructionInflammation“-itis”I don’t knowNonspecific abdominal pain - NSAPCross border “Medical” disorders


THANK YOU

The acute abdomen - a process-based approach

Health & Medicine

Transcript of The acute abdomen - a process-based approach