Beruflich Dokumente
Kultur Dokumente
It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with
commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for
potential conflicts of interest. If conflicts are identified, they are resolved prior to confirmation of participation.
Only participants who have no conflict of interest or who agree to an identified resolution process prior to their
participation were involved in this CME activity.
Learning Objectives
1. Recognize the signs and symptoms of intra-
abdominal conditions requiring surgical intervention.
2. Perform specialized maneuvers to narrow the
differential diagnosis of acute abdominal pain.
3. Appropriately utilize labs and radiology tests in the
evaluation of acute abdominal pain.
4. Appreciate that acute abdominal pain in children
could be due to different etiologies than adult
patients.
Abdominal Pain
Non-surgical Surgical acute abdomen
Peritonitis Obstruction
Blood
Pus
Foreign material
Location, Location, Location
RUQ Hepatitis/GB
LUQ Gastric/spleen
Periumbilical Pancreatitis/early appy
RLQ Appy/GYN
Torsion
Cysts
PID
Ectopic
LLQ Diverticulitis/GYN
General/ill-defined Ischemia, obstruction
Location, Location, Location
with Visceral Pain Ill-Defined Location
RUQ Hepatitis/GB
LUQ Gastric/spleen
Periumbilical Pancreatitis/early appy
RLQ Appy/GYN
Torsion
Cysts
PID
Ectopic
LLQ Diverticulitis/GYN
General/ill-defined Ischemia, obstruction
Location, Location, Location
when Parietal Peritoneum Involved - Localizes
RUQ Hepatitis/GB
LUQ Gastric/spleen
Periumbilical Pancreatitis/early appy
RLQ Appy/GYN
Torsion
Cysts
PID
Ectopic
LLQ Diverticulitis/GYN
General/ill-defined Ischemia, obstruction
Abdominal Pain and Analgesia:
Give It!!
Pain relief does not increase the risk of diagnostic
and management errors
Terminology:
Reducible:
Incarcerated: ie, Stuck! (despite gentle firm
pressure)
Strangulated: vascular compromise (surgical
emergency)
Abdominal Wall and Hernias
Indirect inguinal hernia: 75% of all hernias!!!
Most common hernia in both sexes!!!
Men are 5x more common
More likely to incarcerate/strangulate than direct
Direct inguinal hernia: 2nd most common
Note: You can NOT differentiate between
direct and indirect hernias on exam!!!
Femoral hernias: more common in women
Located below inguinal ligament, medial to femoral pulse
Abdominal Hernias:
Do You Remember These?
Spigelian hernia: rare, located along lateral border
of rectus muscle, below umbilicus, at junction of
arcuate line
A. Acute cholecystitis
B. Ascending cholangitis
C. Gallstone pancreatitis
D. Gallstone ileus
3. The 60 y/o male presents to the ED/office with 3
days of worsening RUQ pain. The pain radiates to the
right scapula. (+) nausea and vomiting.
He is febrile (temp = 39 C, 102.2 F), P = 122,
BP = 90/45
He is jaundiced (total bilirubin = 7.8), RUQ is tender.
Liver
GB
. . -----------Cystic duct
Pancreas
Duodenum--
Complications of Gallstone Disease
1. Cholecystitis: in 10% of patients with biliary colic
Occluded cystic duct
RUQ pain and tender, +/-fever, WBC
(+) Murphy sign: cessation of inspiration
2. Ascending (acute) cholangitis: occluded CBD
(choledocholithiasis)
50-70%-Charcots triad: fever, abd pain, and jaundice
Reynolds' pentad---Charcots + confusion + shock
3. Gallstone pancreatitis: obstructed ampulla of Vater
reflux of bile
4. Gallstone ileus: biliary-enteric fistula, 6/1000 SBO
Gallstone Disease: Evaluation
Clinical Suspicion: Classic history
Ultrasound - 99% specific
If high degree of suspicion, but negative US.
Think dyskinesia!!!
Dyskinesia: gallbladder ejection fraction < 50%
(using a cholecystokinin cholecystoscintigraphy scan
in conjunction with typical clinical symptoms)
A. Abdominal x-ray
B. Abdominal ultrasound
C. CT scan of abdomen and pelvis
D. MRI of abdomen and pelvis
5. You are evaluating a 6 year old for abdominal
pain. You have a moderate degree of suspicion
that the patient may have appendicitis. What
would you do to confirm?
4% A. Abdominal x-ray
66% B. Abdominal ultrasound
28% C. CT scan of abdomen and pelvis
1% D. MRI of abdomen and pelvis
Table is American College of Radiology
Appendicitis: Diagnostic Imaging
X-ray: rarely useful
Unless appendicolith seen
US: first choice: age < 14yrs and pregnancy
26 studies (as of 2006) of US in pediatrics
Sensitivity: 88%; specificity of 94%1
CT: study of choice in adults
No advantage to using contrast
MRI: good sensitivity and specificity
greater cost, longer acquisition time, and less
clinical availability 1
Doria AS, et al. Radiology. 2006;241(1):83-94
6. The most common cause of intestinal
obstruction is:
dilates
At risk patients:
Neuropsychiatric disorders
Institutionalized/NH patients
Parkinson disease
Multiple sclerosis
Image reprinted with permission from
Spinal cord injury Medscape Reference(http://emedicine.medscape
Excessive laxatives, enemas .com/), 2014, available at: http://emedicine
.medscape.com/article/2048554-overview.
Sigmoid Volvulus
Average age: 8th decade
recurrence
12-15% mortality rate