The Acute Abdomen - NCEMSF - acute... · The Acute Abdomen Benjamin Braslow, MD Department of...

The Acute AbdomenThe Acute Abdomen

Benjamin Braslow, MDBenjamin Braslow, MDDepartment of SurgeryDepartment of Surgery

Division of Trauma / Surgical Critical CareDivision of Trauma / Surgical Critical CareUniversity of Pennsylvania School of MedicineUniversity of Pennsylvania School of Medicine

Pain TypesPain Types

••

VisceralVisceral––

GeneralGeneral––

Distention of viscusDistention of viscus––

Mesenteric tractionMesenteric traction––

Irritation of Irritation of serosa/mucosaserosa/mucosa

––

Contraction of viscusContraction of viscus

••

SomaticSomatic––

WellWell--localized, sharplocalized, sharp––

Parietal irritationParietal irritation––

Abd wall receptorsAbd wall receptors

Abdominal PainAbdominal Pain••

The perception of abdominal pain is first The perception of abdominal pain is first visceral visceral and then becomes and then becomes somaticsomatic. .

••

The abdominal viscera and the visceral The abdominal viscera and the visceral peritoneum receive sensory fibers via the peritoneum receive sensory fibers via the sympathetic chain from T5 through L3. sympathetic chain from T5 through L3.

••

The sensory supply to the viscera is sparse The sensory supply to the viscera is sparse and and visceral painvisceral pain

is vague and poorly is vague and poorly

localized. localized. ••

The alimentary tract from the esophagus to The alimentary tract from the esophagus to the anal canal is insensitive to many stimuli the anal canal is insensitive to many stimuli which produce intense pain in other which produce intense pain in other structures. structures.

Abdominal PainAbdominal Pain

••

The gut can be biopsied, crushed or The gut can be biopsied, crushed or cauterized without pain. cauterized without pain.

••

If the bowel or any other hollow If the bowel or any other hollow viscusviscus

is is distended or if its muscle coat goes into distended or if its muscle coat goes into spasm, however, pain is felt. spasm, however, pain is felt.

••

The cause of visceral pain is tension in the The cause of visceral pain is tension in the muscle fibers produced by stretching of muscle fibers produced by stretching of the wall, spasm of the muscle or the wall, spasm of the muscle or stretching of the capsustretching of the capsule of the organ. le of the organ.

ColicColic

•• ��Violent peristaltic contractions Violent peristaltic contractions occur in an attempt to force luminal occur in an attempt to force luminal contents through an obstruction. contents through an obstruction.

••

Pain associated with obstruction is Pain associated with obstruction is severe and cramping in nature, but severe and cramping in nature, but intermittent, with painintermittent, with pain--free intervals free intervals and is called and is called coliccolic. .

Ischemic PainIschemic Pain

••

Ischemia of visceral muscle gives rise to pain Ischemia of visceral muscle gives rise to pain because the gut loses motility and becomes because the gut loses motility and becomes distended. distended.

••

Visceral pain of ischemic origin is caused Visceral pain of ischemic origin is caused most often by strangulation of the bowel in most often by strangulation of the bowel in hernia or hernia or volvulusvolvulus. .

••

A less frequent cause is acute mesenteric A less frequent cause is acute mesenteric throthrombosis.mbosis.

Somatic PainSomatic Pain

••

The parietal peritoneum which lines the The parietal peritoneum which lines the abdominal cavity and the interior surfaces abdominal cavity and the interior surfaces of the diaphragm derives sensory fibers of the diaphragm derives sensory fibers from the somatic nerves T6 through L1. from the somatic nerves T6 through L1.

••

When the parietal peritoneum is irritated, When the parietal peritoneum is irritated, somatic pain results. somatic pain results.

••

Somatic painSomatic pain

is with localized tenderness is with localized tenderness and spasm of the muscle groups supplied by and spasm of the muscle groups supplied by the dermatome of origin of the pain stimulus. the dermatome of origin of the pain stimulus.

Somatic Pain Somatic Pain examplesexamples

•• The right lower quadrant (RLQ) pain, The right lower quadrant (RLQ) pain, tenderness and muscle spasm associated tenderness and muscle spasm associated with appendicitis is caused by inflammation of with appendicitis is caused by inflammation of tthe contiguous RLQ parietal peritoneum. he contiguous RLQ parietal peritoneum.

••

The abdominal signs in perforated peptic The abdominal signs in perforated peptic ulcer, on the other hand, are generalized ulcer, on the other hand, are generalized because diffusion of highly acid fluid because diffusion of highly acid fluid throughout the peritoneal cavity causes throughout the peritoneal cavity causes intense irritation of all the parietal peritoneal intense irritation of all the parietal peritoneal surfasurfaces.ces.

Referred PainReferred Pain

•

Pain experienced at a site other than that stimulated but in somatic zones supplied by the same or adjacent segments of the spinal cord is called referred pain.

••

Visceral pain is referred to three zones Visceral pain is referred to three zones located in the midline of the abdomen.located in the midline of the abdomen.

Abdominal Pain DDXAbdominal Pain DDX

AppendicitisAppendicitis••

250,000 pts/yr in U.S.250,000 pts/yr in U.S.

••

1,000,000 hospital days /yr1,000,000 hospital days /yr••

Most common acute abdominal Most common acute abdominal emergency requiring surgeryemergency requiring surgery

••

Lifetime risk of developing appendicitis Lifetime risk of developing appendicitis for Americans:for Americans:––

8.6% for males 8.6% for males ––

6.7% for females6.7% for females

••

Lifetime risk of appendectomyLifetime risk of appendectomy––

12% for males12% for males––

23% for females23% for females

Presenter

Presentation Notes

Caring for patients with surgical emergencies is one of the cornerstones of our profession. The potential to promptly diagnose an acute surgical problem and intervene in a timely fashion presents the surgeon with a unique opportunity to immediately impact a critically ill patient. As the population ages, the patients with surgical emergencies tend to have considerably more co-morbid conditions and active medical problems. Unfortunately, these patients present at all hours of the day and night. They are challenging, time-consuming, and disruptive to the busy practicing surgeon. As a result, the surgeon’s well orchestrated and extremely efficient schedule of the day (outpatient office hours, elective surgical caseload, and for some, protected academic time) is often disrupted by an emergent consultation. When emergent surgery is necessary, identifying available time in a busy OR schedule which does not further impact the surgeon’s other responsibilities may be an additional challenge. Compounding this, many emergencies seem to occur on off hours and weekends, disrupting rest, family and personal times. The possibility of being up all night or all weekend has both explicit and implicit effects on surgeons scheduling full clinical loads the following day.

HistoryHistory••

Appendix 1Appendix 1stst

described by described by BerengarioBerengario

DaCarpiDaCarpi, , physicianphysician--anatomist, in 1521anatomist, in 1521

••

Appendicitis first reported in early 1700Appendicitis first reported in early 1700’’ss••

11stst

appendectomy performed in 1735 by Claudius appendectomy performed in 1735 by Claudius AmyandAmyand, Sergeant Surgeon to George II, Sergeant Surgeon to George II

••

1886 1886 ----

Clinical entity of Clinical entity of appendicealappendiceal

inflamationinflamation

→→ perforation perforation →→

abscess abscess →→

peritonitisperitonitis

»»

Reginald H. Fitz, Shattuck Prof of Pathological Anatomy @ HarvarReginald H. Fitz, Shattuck Prof of Pathological Anatomy @ Harvardd»»

Proposed early surgical removalProposed early surgical removal

History of History of McBurneyMcBurney’’ss PointPoint

••

Dr. Charles Heber Dr. Charles Heber McBurneyMcBurney••

Experience with early operative interference in cases Experience with early operative interference in cases of disease of the vermiform appendixof disease of the vermiform appendix

New York Medical Journal, 1889, 50:676New York Medical Journal, 1889, 50:676--684684

Pg 678: Pg 678: ““The seat of greatest pain, determined by The seat of greatest pain, determined by the pressure of one finger, has been very exactly the pressure of one finger, has been very exactly between an inch and a half and two inches from between an inch and a half and two inches from the anterior the anterior spinousspinous

process of the process of the iliumilium

on a on a

straight line drawn from that process to the straight line drawn from that process to the umbilicusumbilicus””

AppendicitisAppendicitis

AppendicitisAppendicitis

Cope’s Acute Abd

Anatomic Variations of Anatomic Variations of ““The The Great ImitatorGreat Imitator””

PathophysiologyPathophysiology••

Luminal ObstructionLuminal Obstruction––

Most common = fecal stasis & Most common = fecal stasis & fecalithsfecaliths

––

Lymphoid hyperplasiaLymphoid hyperplasia••

200 lymph follicles in 200 lymph follicles in submucosasubmucosa••

Highest number in adolescentsHighest number in adolescents••

Decline after 30 and absent after 60Decline after 30 and absent after 60

––

Vegetable matter / fruit seedsVegetable matter / fruit seeds––

InspissatedInspissated

barium from previous studybarium from previous study

––

Intestinal worms (Intestinal worms (ascaridsascarids))––

Tumors (Tumors (carcinoidcarcinoid))

PathophysiologyPathophysiology••

Ongoing mucus secretion of Ongoing mucus secretion of appendicealappendiceal

mucosa mucosa

into closed lumeninto closed lumen––

Rapid distention (ILP 50Rapid distention (ILP 50--60 mmHg)60 mmHg)••

Autonomic visceral pain afferent fibersAutonomic visceral pain afferent fibers••

MidabdominalMidabdominal

pain / pain / periumbilicalperiumbilical

acheache••

Unrelated to activity or positionUnrelated to activity or position••

Anorexia (90%)Anorexia (90%)

––

Venous pressure exceeded Venous pressure exceeded →→

mucosal ischemiamucosal ischemia––

Mucosal ulcerationMucosal ulceration→→invasion of invasion of appendicealappendiceal

wall by wall by intraluminalintraluminal

bacteria (bacteria (transmuraltransmural

inflamationinflamation))••

Migration of pain to RLQMigration of pain to RLQ

––

Perforation !!!Perforation !!!••

2020--30% of patients with appendicitis30% of patients with appendicitis••

50 % in Children <3, adults >5050 % in Children <3, adults >50••

Local or diffuse peritonitisLocal or diffuse peritonitis••

Temp > 38Temp > 3800C, WBCC, WBC↑↑↑↑↑↑

RadiologyRadiology

••

Obstruction seriesObstruction series••

UltrasoundUltrasound

••

CT scanCT scan

CAT ScanCAT Scan Appendicitis Appendicitis

••

Initial imaging study for ERInitial imaging study for ER••

98% sensitive98% sensitive

••

98% specific98% specific––

Rao et al N Eng J Med 338:141Rao et al N Eng J Med 338:141--146, 1998146, 1998

AppendectomyAppendectomy

••

OpenOpen––

Standard of careStandard of care––

Min morbidity/mortalityMin morbidity/mortality––

Wound complicationsWound complications

••

LaparoscopicLaparoscopic––

ExpensiveExpensive––

+/+/--

shorten recoveryshorten recovery––

Excellent diagnostic Excellent diagnostic tooltool

Laparoscopic AppeLaparoscopic Appe

Other Benign Disease of the Other Benign Disease of the Appendix (Horses)Appendix (Horses)

••

CrohnCrohn’’ss

DiseaseDisease••

Involves appendix in ~25% of pts with CD of terminal Involves appendix in ~25% of pts with CD of terminal ileumileum

••

50% of pts w/ colonic CD50% of pts w/ colonic CD••

? ? histologicallyhistologically

normal appendix in pt with active CDnormal appendix in pt with active CD••

If base of appendix not involvedIf base of appendix not involved……appyappy

recommendedrecommended

Other Benign Disease of the Other Benign Disease of the Appendix (Zebras)Appendix (Zebras)

••

AppendicealAppendiceal

Ulcerative ColitisUlcerative Colitis••

6161--87% of patients with pan colitis87% of patients with pan colitis

••


DiverticulitisDiverticulitis••

.004 .004 ––2.8% of surgical and autopsy material2.8% of surgical and autopsy material

••

AmyloidosisAmyloidosis••


EndometriosisEndometriosis

••

2.8% of patients with endometriosis2.8% of patients with endometriosis••

Usually asymptomaticUsually asymptomatic……found @ primary or incidental found @ primary or incidental appendectomyappendectomy

••

Pts with symptoms similar to acute Pts with symptoms similar to acute appyappy

or recurrent or recurrent appendicitisappendicitis

Gynecological PainGynecological Pain

••

Ovarian cystsOvarian cysts--

mid cycle painmid cycle pain••

Ovarian torsionOvarian torsion

••

PIDPID--

+CMT, high fever+CMT, high fever••

EndometriosisEndometriosis--

““chocolate cystschocolate cysts””

••

Ectopic pregnancy Ectopic pregnancy ––

1% pregnancies1% pregnancies

Ovarian TorsionOvarian Torsion

EndometriosisEndometriosis

TuboTubo--ovarian Abscessovarian Abscess

http://www.amersham-health.com/medcyclopaedia/Volume VII/

CrohnCrohn’’s Diseases Disease

••

Most common surgical dz of small Most common surgical dz of small bowelbowel

••

Peak incidence 20Peak incidence 20--30 yrs 30 yrs ••

Path Path ––

noncaseating granulomasnoncaseating granulomas

CrohnCrohn’’s Presentations Presentation

••

Pain Pain ––

most commonmost common••

DiarrheaDiarrhea--85% 85%

••

FistulaFistula••

ObstructionObstruction

CrohnCrohn’’s Txs Tx

••

Medical therapyMedical therapy••

Surgery for complications onlySurgery for complications only––


––

FistulaFistula––

PerforationPerforation

––

Intractable painIntractable pain

LLQ PainLLQ Pain

DiverticulitisDiverticulitis

••

25% of pop with Diverticulosis 25% of pop with Diverticulosis progress to diverticulitisprogress to diverticulitis

••

90% sigmoid colon90% sigmoid colon••

5% right colon5% right colon

Presentation DiverticulitisPresentation Diverticulitis

••

LLQ painLLQ pain 70%70%

••

Anorexia/n+vAnorexia/n+v

20%20%••

DiarrheaDiarrhea

30%30%

••

Urinary Urinary 15%15%

••

LeukocytosisLeukocytosis••

FeverFever

••

LLQ tenderLLQ tender••

LLQ palp massLLQ palp mass

Diverticulitis DXDiverticulitis DX

••

CT scan in CT scan in acuteacute

settingsetting

••

BE/ colonscopy when asymptomaticBE/ colonscopy when asymptomatic

Complications of Complications of DiverticulitisDiverticulitis

••

Abscess Abscess 40%40%••


10%10%

••

PerforationPerforation

10%10%••

FistulaFistula

4%4%


First Attack

30% symptom free

40% recurrent pain

30% recurrent diverticulitis

Renal/Ureteral StonesRenal/Ureteral Stones

••

Flank pain radiating to groin, Flank pain radiating to groin, scrotum,labiascrotum,labia

••

Abd cramping and nauseaAbd cramping and nausea••

U/AU/A--

microscopic hematuriamicroscopic hematuria

••

Plain films, IVP, CT scanPlain films, IVP, CT scan

Abdominal PainAbdominal Pain

Peptic Ulcer DZPeptic Ulcer DZ

••

DuodenalDuodenal––

Acid hypersecretionAcid hypersecretion––

Peak incidence 40sPeak incidence 40s––

Male>femaleMale>female

••

GastricGastric––

Mucosal breakdownMucosal breakdown––

Peak incidence 50sPeak incidence 50s––

Male>femaleMale>female

Peptic Ulcer DZ Peptic Ulcer DZ

••

DuodenalDuodenal––

Chronic burning painChronic burning pain––

Worse in post prandial Worse in post prandial periodperiod

––

H.pylori + 95%H.pylori + 95%

••

GastricGastric––

Chronic gnawing painChronic gnawing pain––

Esp during mealsEsp during meals––

H.pylori + 85%H.pylori + 85%

LUQ PainLUQ Pain

Gastric UlcerGastric Ulcer

Peptic Ulcer DZPeptic Ulcer DZ

Duodenal UlcerDuodenal Ulcer

Upper GI tract: gastric and Upper GI tract: gastric and duodenal ulcer perforationduodenal ulcer perforation

••

Incidence: 4 Incidence: 4 ––

10 per 10 per 100,000 per year100,000 per year

••

Affects 10% of all PUD Affects 10% of all PUD patientspatients

••

H. pylori positive: 50 H. pylori positive: 50 --

90%90%••

NSAID use: 30 NSAID use: 30 --

40%40%

HermanssonHermansson, , EurEur

J J SurgSurg

19991999RodriguezRodriguez--SanjuanSanjuan, World J , World J SurgSurg

20052005

Perforated peptic ulcer:Perforated peptic ulcer: Risk factors for mortalityRisk factors for mortality

••

Preoperative risk factorsPreoperative risk factors––

Age >75 yearsAge >75 years––

H/o cardiac or pulmonary diseaseH/o cardiac or pulmonary disease––

(ASA status)(ASA status)––

Shock on admissionShock on admission––

Gastric Gastric cardiacardia

or body perforation (vs DU)or body perforation (vs DU)––

Delay to OR > 12 hrDelay to OR > 12 hr

HermanssonHermansson, , EurEur

J J SurgSurg

19991999KujathKujath, , LangenbecksLangenbecks

Arch Arch SurgSurg

20022002TestiniTestini, World J , World J GastroenterolGastroenterol

20032003

CholecystitisCholecystitis


••

Approximately 1/3 of asymptomatic Approximately 1/3 of asymptomatic gallstones become symptomaticgallstones become symptomatic

••

Gallstone etiology >90%Gallstone etiology >90%

Cholecystitis PresentationCholecystitis Presentation

••

Epigastric/RUQ Epigastric/RUQ painpain

••

Radiation to back Radiation to back and shoulderand shoulder

••

Fatty food Fatty food intoleranceintolerance

••

Nighttime painNighttime pain

••

Associated nausea Associated nausea and vomitingand vomiting

••

FeverFever


••

RUQ tendernessRUQ tenderness••

RUQ guardingRUQ guarding

••

RUQ massRUQ mass••

MurphyMurphy’’s signs sign

--

inspiratory arrest inspiratory arrest with deep with deep palpationpalpation

••

LeukocytosisLeukocytosis--mildmild••

Alkphos,transaminAlkphos,transamin

ase,and amylase ase,and amylase may be elevatedmay be elevated

••

T.bili <4T.bili <4

Cholecystitis DXCholecystitis DX

••

UltrasoundUltrasound––

SensSens

85%85%

––

SpecSpec

95%95%

••

Plain film Plain film visible 15%visible 15%••

CT CT

••

HIDA scan HIDA scan + obs cystic duct 95% + obs cystic duct 95% S+SPS+SP

Laparoscopic CholeLaparoscopic Chole

PancreatitisPancreatitis

••

GallstoneGallstone••

ETOHETOH

••

DrugsDrugs••

Trauma Trauma

••

FamilialFamilial••

AnatomicAnatomic--p.divisump.divisum


••

Pain most common presentationPain most common presentation••

Midepigastric to backMidepigastric to back

••

Nausea and vomitingNausea and vomiting


••

Fever Fever ••

TachycardiaTachycardia

••

Epigastric Epigastric tendernesstenderness

••

Abd distentionAbd distention

••

TurnerTurner’’s signs sign

-- blue discoloration blue discoloration

of the flankof the flank••

CullenCullen’’ss

--blue blue

discoloration of discoloration of umbilicusumbilicus


••

LeukocytosisLeukocytosis••

Amylase and lipase elevatedAmylase and lipase elevated

••

Glucose elevationGlucose elevation

Bowel ObstructionBowel Obstruction

••

Accounts for 20% acute abdomen Accounts for 20% acute abdomen admissionsadmissions

••

EtiologyEtiology––

AdhesionsAdhesions

––

HerniaHernia––

NeoplasmNeoplasm


••

Pain Pain ••

DistentionDistention

••

ObstipationObstipation••

Nausea and vomitingNausea and vomiting


••

Fever Fever ••

TachycardiaTachycardia

••

PeritonitisPeritonitis••

Pain Pain ““out of proportion to physical out of proportion to physical findingsfindings””

RadiologyRadiology

••

Obstruction seriesObstruction series••

CTCT

••

UGI ?UGI ?

Acute Mesenteric IschemiaAcute Mesenteric Ischemia

Acute Mesenteric IschemiaAcute Mesenteric Ischemia

••

Acute interruption of blood flow to small Acute interruption of blood flow to small or large intestineor large intestine

••

Causes:Causes:––

Arterial embolismArterial embolism▪▪••

Superior mesenteric artery most commonly involvedSuperior mesenteric artery most commonly involved

––

Arterial thrombosisArterial thrombosis

––

NonocclusiveNonocclusive

mesenteric ischemiamesenteric ischemia▪▪••

Low cardiac output state with diffuse mesenteric vasoconstrictioLow cardiac output state with diffuse mesenteric vasoconstrictionn◦◦

––

Mesenteric venous thrombosis Mesenteric venous thrombosis

Acute Mesenteric IschemiaAcute Mesenteric Ischemia••

Risk FactorsRisk Factors––

AtrialAtrial

fibrillation/flutterfibrillation/flutter––

Recent acute MIRecent acute MI––

Ventricular aneurysmVentricular aneurysm––

CardiomyopathiesCardiomyopathies––

ValvularValvular

diseasedisease––

HypovolemiaHypovolemia

or hypotension (sepsis)or hypotension (sepsis)––

Coagulation disorders or malignancyCoagulation disorders or malignancy––

PancreatitisPancreatitis––

Portal hypertension/cirrhosisPortal hypertension/cirrhosis––

MedicationsMedications••

VasopressorVasopressor

medicationsmedications••

BetaBeta--blockersblockers••

DigoxinDigoxin••

Diuretics Diuretics

Acute Mesenteric IschemiaAcute Mesenteric Ischemia••

Clinical signs and symptomsClinical signs and symptoms

••

Severe abdominal pain out of proportion to Severe abdominal pain out of proportion to physical examphysical exam

••

Pain initially of a visceral nature and poorly Pain initially of a visceral nature and poorly localizedlocalized

••

NauseaNausea••

VomitingVomiting

••

DiarrheaDiarrhea••

GI bleeding may be present GI bleeding may be present

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