The Acute Abdomen

Acute Abdomen Definition

• Intraabdominal process causing severe pain and often requiring surgical intervention.

• 2 considerations– Surgical or non surgical causes

General Causes

• Divided into 6 broad categories– Inflammatory - ie appendicitis– Mechanical - ie acute small bowel obstruction– Neoplastic - ie cancer– Vascular - ie mesenteric vascular occulsion– Congenital defects - ie Intussusception– Traumatic - ie mesenteric bleeds due to

trauma

Red Flags in Acute Abdomens• › Signs of impending shock• › Hypotension, tachycardia, tachypnea• › Septic appearance• › Confusion• › Signs of dehydration• › Rigid abdomen• › Absent bowel sounds• › Patient lying still or writhing• › Involuntary guarding• › Tenderness to percussion• › Hematemesis, hematochezia• › Abdominal pain prior to vomiting• › Abdominal pain localized to the periphery • of the abdomen or pelvis

Pathophysiology

• Visceral– From abdominal viscera– innervated by autonomic nerve fibers– Responds to sensation of distention &

muscular contraction– Poorly localized

Pathophysiology con’t

• Parietal– From parietal peritoneum– Innervated by somatic nerves– Responds to irritation from infectious,

chemical or other inflammatory processes.– Sharp and well localized

Pathophysiology con’t

• Referred– Perceived distant from source– Results from convergence of nerve fibers at

spinal cord– Eg. Scapular pain due to biliary colic or groin

pain due to renal colic

Abdominal P/E

• Inspection• Auscultation• Percussion• Palpation

Abdominal P/E

• Looking for– Distension– Rigidity– Guarding– Eviseration/Ecchymosis– Rebound tenderness– Rebound tenderness– Masses

Acute Abdominal Pain

Acute Abdomen Non-Rigid

Acute Upper Abdomen

Acute Lower Abdomen

Review

• Right lower quadrant pain, fever, leukocytosis, McBurney’s point localization of pain is most associated with:A. Diverticulitis.

B. Ulcerative colitis.

C. Appendicitis.

D. Tubo-ovarian abscess.

E. Cholecystitis.

Review - ANSWER

• Right lower quadrant pain, fever, leukocytosis, McBurney’s point localization of pain is most associated with:A. Diverticulitis.

B. Ulcerative colitis.

C. Appendicitis.

D. Tubo-ovarian abscess.

E. Cholecystitis.

Review

• A complete small bowel obstruction might be suspected in a patient with:A. Hypoactive bowel sounds.

B. Pain out of proportion to physical exam findings.

C. Crampy abdominal pain that waxes and wanes.

D. Diarrhea.

E. A flat, rigid abdomen.

Review - ANSWER

• A complete small bowel obstruction might be suspected in a patient with:A. Hypoactive bowel sounds.

B. Pain out of proportion to physical exam findings.

C. Crampy abdominal pain that waxes and wanes.

D. Diarrhea.

E. A flat, rigid abdomen.

Liver Infections

Hepatic Abscess• uncommon• 3 major forms

- pyogenic, aerobes & anaerobes (80%)

- amebic, Entamoeba histolytica (10%)

- fungal, Candida species (10%)

Liver Infections

1. Pyogenic Liver Abscess• usually gram (-) aerobic bacteria• from appendicitis or diverticulitis• ascension in biliary tree• systemic source from dental procedures• trauma• biliary instrumentation (iatrogenic)

Liver Infections

1. Pyogenic Liver Abscess• fever, chills, pain, weight loss• tender liver, jaundice, hepatomegaly• Ultrasound• CT scan• percutaneous drainage• antibiotics

Liver Infections

2. Amebic Liver Abscess• parasitic Entamoeba histolytica• tropical climates• young men account for 90% of cases• RUQ abdominal pain• fever, chills, nausea, vomiting, anorexia,

weight loss

Liver Infections

2. Amebic Liver Abscess• percutaneous drainage• amebicidal agents-paromomycin-luminal

agent.• metronidazole-tissue agent• chloroquine and emetine

Liver Infections

3. Fungal Liver Abscess-Hepatosplenic Candidiasis or Chronic Disseminated Candidiasis

• Candida albicans• multiple abscesses• immunocompromised• leukemia, HIV• systemic antifungal therapy (Amphotericin

B)

Abdominal Wall Hernias

Classification:• inguinal hernia (direct or indirect)• femoral hernia• umbilical hernia• epigastric hernia• Spigelian hernia (lateral ventral hernia)• ventral / incisional hernia

Groin Hernias

Inguinal Hernia (96%)• more common in men than women• indirect (80%) [Internal inguinal ring]• direct (20%) [Hesselbach’s triangle]Femoral Hernia (4%)[medial femoral canal]• Lifetime risk of developing a groin

hernia is- 25% for men- 5% for women

Inguinal Hernia Presentation

• Soft non-tender mass in the groin.• Local burning or aching.• Enlargement of the mass by coughing

(any maneouver that increase intra-abdominal pressure).

Inguinal Hernia RepairIndications for Elective Surgery• pain / discomfort• limits / restrictions on activity• increasing size of hernia• small risk of incarceration &

strangulation• cosmetic

Indications for Emergency Surgery• incarceration & strangulation

Ventral Hernia

• 11 – 20% of laparotomies• incarceration 5 – 15%• risk of strangulation 2%• recurrence rates = 50% with tension

repair• 50% of incisional hernias appear in the

first

6 months following laparotomy• most occur within 2 years

Appendicitis

Clinical Presentation• intermittent, crampy, periumbilical pain• obstruction of appendiceal lumen with

a fecalith• nausea follows the pain• anorexia• low grade fever• pain migrates to RLQ within 24 hrs and

changes to constant & sharp pain

AppendicitisPhysical Examination• RLQ tenderness & localized peritonitis• Rovsing’s sign (RLQ pain with LLQ

palpation)• obturator sign suggests a pelvic

appendix• psoas sign suggests a retrocecal

appendix• in females, must do pelvic exam to rule

out adnexal mass or tenderness.

Possible Positionsof the Appendix

P/E• McBurney's point tenderness:1.5 to 2

inches from ASIS to the umbilicus.• Rovsing's sign: pain in the RLQ w/

palpation of LLQ (rt-sided local peritoneal irritation).

• Psoas sign: (retrocecal appendix) RLQ pain with passive right hip extension.

• Obturator sign: (pelvic appendix) RLQ pain with rt hip/knee flexion and internal rotation.

Appendicitis

Laboratory Examination• WBC count• urinalysis• urine β-HCG to rule out pregnancy

AppendicitisImaging Studies• Ultrasound

- may be useful (sensitivity 80%, spec 90%)

- highly operator dependent

- useful to rule out gynecologic pathology

• CT scan

- more accurate than U/S for appendicitis, sens and spec 95%.

Appendicitis

Treatment of Nonperforated Appendicitis• laparoscopic vs open appendectomy

ASAP• fluid & electrolyte imbalance usually

minor• prophylactic IV antibiotics to prevent

wound infection.• post-op hospital discharge 24-48 hrs

Appendicitis

Treatment of Perforated Appendicitis• may be acutely ill• significant dehydration & electrolyte

disturbance• CT scan – appendiceal abscess or

phlegmon• percutaneous drainage of abscess• may choose to delay surgery for months• interval appendectomy

BREAK

VASCULAR EMERGENCIES

Vascular Emergencies

Mesenteric Ischemia• low blood flow to bowel• embolic event to SMA (atrial fibrillation)• thrombosis of SMA• nonocclusive mesenteric ischemia (low

flow

states in critically ill patients) - vasoconstriction

Vascular Emergencies

Mesenteric IschemiaDiagnosis• angiography• CT scan with contrastTreatment• operative attempts to restore mesenteric

flow• need to resect any nonviable bowel• thrombolytic therapy an option

Vascular Emergencies

Ruptured Abdominal Aortic Aneurysm (AAA)

• common surgical emergency• many pts do not know they have an

aneurysm until it ruptures• risk factors include smoking, >60 yrs,

HTN, CAD, dyslipidemia, FmHx.

AAA

Vascular EmergenciesClinical Presentation Ruptured AAA• acute abdominal or back pain• usually sudden onset• lightheadedness or collapse due to

sudden hypotension• immediate CT scan if pt

hemodynamically stable.• if unstable, diagnosis with Hx, P/E,

ultrasound

Vascular Emergencies

Ruptured Abdominal Aortic Aneurysm (AAA)

Treatment• immediate OR• laparotomy with X-clamp proximal aorta &

repair aneurysm with interposition tube graft

• fluid & blood resuscitation• ICU post-op

Bifurcated TubeGraft forAAA Repair

Abdominal Trauma

Principles of the Initial Assessment

• ATLS®

• Airway, Breathing, Circulation

• prioritizing life-threatening injuries• assessment & resuscitation simultaneous

Abdominal Trauma

Purpose of Diagnostic Work-up

• most important decision is to determine

whether or not the patient requires an

emergent laparotomy

Diagnosis of Abdominal Trauma

• history & physical exam• FAST (Focused Assessment with

Sonography for Trauma)• CT scan• DPL (diagnostic peritoneal lavage)

Diagnostic Test of Choice ?

• ALL PATIENTS FAST

If FAST is not available, then in general:• unstable patients DPL• stable patients CT scan

FAST ( Trauma Ultrasound )Advantages• portable• inexpensive• rapid assessment• can be easily repeated during work-up• accurate for the presence of

intraperitoneal free fluid• can be performed by trained non-

radiologist

Look for free fluid

in 4 places:• perihepatic• perisplenic• pelvis• pericardium

FAST Technique

CT Scan

• hemodynamically stable patients only• very specific and sensitive for solid

organs• quantify / grade severity of organ injury• contrast extravasation (implications)• CT scan not needed if indication for

laparotomy exists• may miss bowel injury, ruptured

diaphragm

DPL

• sensitive for presence of intraperitoneal

blood• open or closed technique• positive = gross blood

red cell count > 100,000/mm3

• rarely used in blunt trauma if FAST available

Approach to Penetrating Abdominal Trauma

Categorization of the anatomical site of injury:

• stab wound to anterior abdomen• GSW to anterior abdomen• thoracoabdominal penetrating trauma• tangential GSW• back & flank penetrating trauma• transpelvic GSW

Stab Wound to Abdomen

Anatomy (anterior abdomen)• costal margin• anterior axillary line• inguinal ligament

Stab Wound to Abdomen

Indications for laparotomy• hemodynamic instability• peritonitis• blood in NG, foley, rectal exam• evisceration• retained stabbing implement• positive FAST or DPL (100,000 RBCs)

Management of GSW abdomen

• ABC• IV lines above & below diaphragm• log roll early to find all bullet wounds• plain film X-rays to localize bullets• determine need for surgery• tetanus / antibiotics• communicate with blood bank

GSW Abdomen - Indications for Laparotomy

• hemodynamic instability• peritonitis• path of bullet• blood in foley, NG, rectal exam• pneumoperitoneum• evisceration• positive FAST or DPL (RBC count >

5,000)

Summary

• history & physical exam of acute abdominal

conditions• diagnostic tests• resuscitation• surgical treatment

Red Herrings

• Nerve root impingement

Red Herrings

• Herpes Zoster