Beruflich Dokumente
Kultur Dokumente
OF
PATIENTS WITH
AN ABDOMINAL DISORDER
DESIGNED FOR:
PROBLEM-BASED LEARNING
COMPETENCY-BASED LEARNING
IN- AND OFF- CAMPUS LEARNING
Author:
DEAD
IS SATISTFIED
STRATEGIES
IN THE TASKS OF
Content
Title
Goals and Strategies
Content ..................................................................................................................................... A
Preface ..................................................................................................................................... C
A
About the Author
Dr. Reynaldo O. Joson is presently a permanent professor at the Department of Surgery of the
University of the Philippines, College of Medicine.
He is at the same time an affiliate associate professor of the University of the Philippines Open
University as well as a faculty in the University of the Philippines College of Public Health.
He is currently the Chief of the Division of Head and Neck, Breast, Esophagus, and Soft Tissue
Surgery at the Philippine General Hospital.
Academic Degrees
He obtained his Doctor of Medicine from the University of the Philippines College of Medicine in
1974; his Master in Hospital Administration from the UP College of Public Health in 1991; his Master in
Health Profession Education from the UP National Teachers Training Center for Health Profession in 1993;
his Master of Science in Clinical Medicine (General Surgery) from the UP College of Medicine in 1998.
His finished his residency in General Surgery at the Philippine General Hospital in 1981 after
which he became a Diplomate of the Philippine Board of Surgery.
One of his missions in life is to contribute to the health development in the Philippines through
education. This mission started in 1990 when, as Director of the UPCM Postgraduate Institute of
Medicine, he designed a structured Department of Health-UPCM Postgraduate Circuit Courses in four
provincial hospitals in the Philippines (Ilagan, Isabela in Luzon; Aklan in the Visayas; and Koronadal,
South Cotobato and Oroquieta, Misamis Occidental in Mindanao).
He then went on to develop a structured general surgery training program using a distance
education mode from 1991 to 1994 in Zamboanga City Medical Center. With this program, he added 7
trained general surgeons to the pool of 2 that served the 3 million population of Western Mindanao.
In 1994, he helped established the Zamboanga Medical School Foundation. He helped designed a
community-oriented, competency-based, and problem-based learning medical curriculum for the school.
This curriculum was adopted by a medical school in Legazpi, Albay in 1995 and by another medical school
in Cebu in 1996.
He is presently preoccupied with the full development of this curriculum as well as designing a
telehealth program.
Hospital Administration
He is currently an assistant medical director at the Manila Doctors Hospital in charge of its
quality assurance program.
B1
Writings
He started writing books, primers, self-instructional programs, and course packs in medicine,
surgery, hospital administration, and medical education in 1985. As of December of 1999, he has about 30
finished products.
Contact Numbers
http://web.pacific.net.ph/~rjoson
B2
Preface
Dear Learner,
Mabuhay!
This program has been especially designed with you, the learner, and the principles of effective
teaching and learning in mind.
As you go through this learning program, please bear in mind the following:
1.1 Assumes you have learning aspirations and expectations and therefore, are
motivated;
1.2 Gives you the privilege to use other learning strategies in achieving the objectives in
this program;
1.3 Welcomes you to go beyond the learning package as you so desire; and
1.4 Expects discipline, honesty, and maturity in fulfilling your learning activities.
2. We shall define learning as a positive observable change (for the better or improvement) in
human behavior, disposition, attitude, performance, or capability which persists over a
period of time.
4. The program will contain learning materials which I think will be relevant to your being an
effective, efficient, and humane health professional.
5. The ultimate goal of the learning program is to produce health professionals who will
contribute to the health development in the Philippines.
6. When I made this program, I tried my best to facilitate your learning. Bear in mind, however,
that I am not infallible. Thus, analyze carefully everything in this program. Dont
hesitate to offer disagreements and constructive criticisms for own learning and for
the improvement of the program.
Best wishes for a fruitful learning with the help of this program.
C
The Course Pack
Content and How to Use
Content
Folder 6: Evaluation
This folder contains test blueprint and pretest examinations.
D1
The Course Pack
How to Use
Initial Steps:
Subsequent Steps:
Overall Advice:
During the study proper, be constantly guided by the instructional design, especially the learning
objectives, which shall serve as the steering wheel in whatever that should be done in the course. This
includes the evaluation.
D2
CLINICAL DIAGNOSIS
OF PATIENTS WITH
AN ABDOMINAL DISORDER
FOLDER 1
INSTRUCTIONAL DESIGN
Clinical Diagnosis of Patients with an Abdominal Disorder
Dear Learner,
Mabuhay!
ABDOMINAL HEALTH PROBLEM is any problem that affects the abdomen which in turn
affects the health of the individual.
The ABDOMINAL HEALTH PROBLEM affects the biopsychosocial well-being of any person
who has it. It frequently leads to disability and may even cause death.
The common causes of the various types of ABDOMINAL HEALTH PROBLEM can be
conveniently categorized by kinds of disorders and factors involved. These are as follows:
IA1
The ABDOMINAL HEALTH PROBLEM is a universal phenomenon. It involves the young and
the old and both the female and the male gender.
In the newborn, the problem consists primarily of congenital anomalies (notably inguinal hernias).
In the young adult and middle age, metabolic/nutritional (notably stones in the biliary tree and
urinary tract and obesity) and inflammatory/infectious (notably acid peptic diseases and gastroenteritis)
disorders are most common.
In the elderly people, cancer is the primary concern. It can involve all the kinds of structures and
systems found within the abdominal domain.
Trauma to the abdomen is also a primary concern for everybody primarily because of high-speed
and modern transportation system, high-impact sports, and significant crime rate.
Every primary health care physician should know how to manage any patient with or with possible
ABDOMINAL HEALTH PROBLEM. He should also know how to handle ABDOMINAL HEALTH
PROBLEM in the community as well as to deal with issues associated with the problem, such as bioethical,
psychosocial, medicolegal and research issues.
Clinical Diagnosis
Trauma
Pain (nontrauma)
Lump
Difficulty in eating
Vomiting
Difficulty in defecation
Diarrhea
Difficulty in urination
Polyuria
Abdominal Distention
Hematemesis
Hematochezia
Jaundice
Obesity
Loss of weight
IA2
Recognize
Acute surgical abdomen
Traumatic
Nontraumatic
Intestinal obstruction
Abdominal tumor
Gastrointestinal bleeding
Acute gastroenteritis
Acute appendicitis
Acute cholecystitis
Hepatitis
Pancreatitis
Acid peptic disease
Gastritis
Abdominal cancer
Esophageal problem
Inguinal hernia
Urinary tract infection
Ureteral stone
Reproductive tract infection
Malnutrition (under and over)
Intestinal parasitism
Hyperspleenism
Others
Algorithm for
Abdominal pain (nontraumatic and traumatic)
Abdominal mass
Jaundice
Gastrointestinal bleeding
Referral
Indications
When
To whom
IA3
Advice
Clinical Diagnosis
Paraclinical Diagnostic Process
Blood tests
Urine tests
Stool tests
Plain Abdomen
KUB-IVP
Ultrasound
CT scan
Endoscopy
Biopsy
COURSE FOCUS:
CLINICAL DIAGNOSIS OF PATIENTS WITH AN ABDOMINAL DISORDER
At the end of the course, given a patient with any abdominal disorder, the student should be able
to:
1. Establish a good rapport with any patient presented to him for management (up to clinical
diagnosis only).
2. Demonstrate skills in gathering relevant data using interview (history) and fundamental
methods of physical examination.
3. Analyze and correlate history and physical examination findings in an attempt to arrive at a
clinical diagnosis.
4. Demonstrate skills in medical recording of data gotten from interview and physical
examination as well as the clinical diagnosis.
Given a hypothetical and/or actual patient with an abdominal disorder, the student must be able to:
IA4
3. Define the concept of the main health problem in terms of:
4. Identify reliable clinical cues of the more common causes of the health problem.
5. Gather relevant data using interview and fundamental methods of physical examination.
6. Analyze and correlate history and physical examination finding in an attempt ot arrive at a
clinical diagnosis using the processes of pattern recognition and prevalence.
7. Do medical recording.
CONTENT
Biological Foundation and Basis of Clinical Evaluation of Patients with Abdominal Disorder
Anatomy of the abdomen (wall, contents of peritoneal cavity and retroperitoneal space)
Physiology of the abdomen
Pathology of the abdomen
Clinical cues (pathophysiology) of abdominal disorders
IA5
TEACHING-LEARNING STRATEGY
Problem-based Learning
Hypothetical Patient Management (at least 6 patients)
Trauma
Nontraumatic Abdominal Pain
Abdominal Mass
Jaundice
Gastrointestinal Bleeding
Diarrhea
Actual Patient Management (at least 3 patients)
Demonstration-Return Demonstration
Self-instructional Programs and Hand-outs
SKILLS EXPECTED
Rapport
Interview
Physical Examination
Clinical Diagnostic Process
Advice
Medical Recording
END-OF-COUSE EVALUATION
Practical Examination
Rapport
Interview
Physical Examination
Clinical Diagnostic Process
Advice
Medical Recording
IA6
BEST WISHES ON YOUR LEARNING JOURNEY!
IA7
Clinical Diagnosis of Patients with an Abdominal Disorder
Rating Scale
Key:
1= excellent, exceptional, present (if parameter is a choice between present or absent)
2= good, demonstrated at all times, complete
3= fair, demonstrated most of the time
4 = poor, demonstrated some time
NO (5) = not observed, absent (if parameter is a choice between present or absent)
Passing Grade: A grade of at least three (3) overall and in each of the six (6) standards.
Standard: The student used adequate and proper verbal and behavioral means to establish rapport
with the patient.
Standard: During the interview, the student systematically gathered relevantly complete data.
Standard: During the physical examination, the student systematically and gently performed
relevantly complete manuevers and concisely interpreted data obtained.
1of 2 pages
Clinical Diagnosis of Patients with an Abdominal Disorder
Rating Scale
Key:
1= excellent, exceptional, present (if parameter is a choice between present or absent)
2= good, demonstrated at all times, complete
3= fair, demonstrated most of the time
4 = poor, demonstrated some time
NO (5) = not observed, absent (if parameter is a choice between present or absent)
Passing Grade: A grade of at least three (3) overall and in each of the six (6) standards.
Standard: During the formulation of clinical diagnosis, the student systematically and concisely
used the processes of pattern recognition and prevalence to come out with the
primary and secondary clinical diagnoses.
Standard: During the advice on clinical diagnosis, the student was systematic and clear and
complete.
Standard: In the medical recording, the student wrote down relevant data clearly and
completely; line-drew physical finding data clearly; and wrote down the primary
and secondary clinical diagnosis.
2/2 pages
Clinical Diagnosis of Patients with an Abdominal Disorder
Case Presentation and Discussion Up to Clinical Diagnosis Only
I. Case Presentation
Present Database
General Data
Minimum: Initials of patient, age, sex
As needed: Occupation, residence, religion
Chief Complaint
History of Present Illness/Condition
As needed:
Past Medical History
Personal Social History
Obstetrical and Gynecological History
Physical Examination
1. Identify data from database which can serve as cues for a clinical diagnosis.
Age/Sex
Symptoms
Signs
2. Based on pattern recognition and prevalence, decide on the primary and
secondary diagnoses. Primary diagnosis is what you think is the most likely
diagnosis and secondary diagnosis is the closest second.
Primary Clinical Diagnosis:
Secondary Clinical Diagnosis:
3. Illustrate/explain how you arrive to the primary and secondary clinical
diagnoses.
Use the clinical diagnostic processes of pattern recognition and prevalence.
Use algorithm as much as possible.
Use pathophysiology to support your primary and secondary clinical
diagnoses.
III. References Used in Discussion of Pathophysiology, Clinical Cues, and Algorithm (at least 2
references)
Evaluation:
Evaluation Parameters 1 (excellent) 2 (good) 3 (fair) 4 (poor)
need to revise
1. Concise in use of pattern recognition
and prevalence processes
2. Clear in written communication and legible
Final Grade: Average of 1 and 2
Complete (3 parts, follow format, with REVISED IF INCOMPLETE
at least 2 references)
CLINICAL DIAGNOSIS
OF PATIENTS WITH
AN ABDOMINAL DISORDER
FOLDER 2
Blueprint
1. Trauma
2. Pain (nontrauma)
3. Lump
4. Difficulty in eating
5. Vomiting
6. Difficulty in defecation
7. Diarrhea
8. Difficulty in urination
9. Polyuria
10. Abdominal Distention
11. Hematemesis
12. Hematochezia
13. Jaundice
14. Obesity
15. Loss of weight
Trauma
Pain (nontraumatic cause)
Lump
Jaundice
Difficulty in Defecation
IIA1
Chief Complaints Clinical Entities
7. Diarrhea Gastroenteritis
IIA2
Clinical Diagnosis Of Patients With an Abdominal Disorder
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the abdomen
Actual patient experience
IIB1
Clinical Diagnosis Of Patients With an Abdominal Disorder
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the abdomen
Actual patient experience
Learning issues/plan
Anatomy/Physiology/Pathology
Pathophysiology and Clinical Cues
Algorithm
Physical examination of the abdomen
Actual patient experience
IIB2
Clinical Diagnosis Of Patients With an Abdominal Disorder
Triggers for Problem-based Learning Sessions
Trigger 5: Patient with difficulty in eating
1. Identify the main health problem.
2. Define the concept of the main health problem in terms of:
2.1 Anatomy of the system, organs, tissues, and cells involved (draw)
2.2 Physiology of the system, organs, tissues, and cells involved
2.3 Common types
2.4 Common causes
2.5 Pathophysiology of the more common causes
3. Identify reliable clinical cues of the more common causes of the health problem.
IIB8
HYPOTHETICAL PATIENT MANAGEMENT
Trigger 1
Questions:
3. What do you think are the more common/least common general and specific
condition causing Trauma to the Abdomen?
4. Select one common general or specific condition and diagram the pathophysiology
leading to the Trauma to the Abdomen.
IIC1
TRAUMA TO THE ABDOMEN
Trigger 2
Pertinent history
30 years old, male
Chief complaint: Trauma to the abdomen
3 hours ago, shot by a male assailant.
Physical examination:
Normal vital signs
A gunshot wound on the left periumbilical area
No other injuries
Questions:
2. What are the bases for your primary and secondary diagnoses?
Demonstrate use of pattern recognition with pathophysiology and
prevalence.
Signs/Symptoms/Pathophysiology Prevalence data
Primary diagnosis
Secondary diagnosis
3. Do you need more data (sign/symptom) to firm up your primary and secondary
diagnoses?
If yes, what? How will it firm up your diagnosis?
[ Data asked for either not available or normal. Facilitator may supply other data.]
Trigger 3
The diagnosis of the patients health problem is
Questions:
Advice the patient and relatives on the pathophysiology of the disease. Use diagram.
IIC2
HYPOTHETICAL PATIENT MANAGEMENT
Trigger 1
Questions:
3. What do you think are the more common/least common general and specific
condition causing Nontraumatic Abdominal Pain?
4. Select one common general or specific condition and diagram the pathophysiology
leading to the Nontraumatic Abdominal Pain.
IID1
NONTRAUMATIC ABDOMINAL PAIN
Trigger 2
Pertinent history
30 years old, male
Chief complaint: Nontraumatic Abdominal Pain
12 hours ago, periumbilical pain. 4 hours after, pain localized at right lower
quadrant. No other associated symptoms.
Physical examination:
Normal vital signs
Abdomen: direct right lower quadrant tenderness with guarding, no mass
Questions:
2. What are the bases for your primary and secondary diagnoses?
Demonstrate use of pattern recognition with pathophysiology and
prevalence.
Signs/Symptoms/Pathophysiology Prevalence data
Primary diagnosis
Secondary diagnosis
3. Do you need more data (sign/symptom) to firm up your primary and secondary
diagnoses?
If yes, what? How will it firm up your diagnosis?
[ Data asked for either not available or normal. Facilitator may supply other data.]
Trigger 3
The diagnosis of the patients health problem is
ACUTE APPENDICITIS
Questions:
Advice the patient and relatives on the pathophysiology of the disease. Use diagram.
IID2
ABDOMINAL MASS
Trigger 1
Questions:
3. What do you think are the more common/least common general and specific
condition causing an abdominal mass?
4. Select one common general or specific condition and diagram the pathophysiology
leading to the abdominal mass.
IIE1
ABDOMINAL MASS
Trigger 2
Pertinent history
40 years old, female
Chief complaint: Abdominal mass
Noted 3 months ago
No associated symptoms
Physical examination:
Mass at epigastrium, 4 cm, nontender, movable, firm
No jaundice
No neck nodes
No associated distant mass
Questions:
2. What are the bases for your primary and secondary diagnoses?
Demonstrate use of pattern recognition with pathophysiology and prevalence.
Signs/Symptoms/Pathophysiology Prevalence data
Primary diagnosis
Secondary diagnosis
3. Do you need more data (sign/symptom) to firm up your primary and secondary
diagnoses?
If yes, what? How will it firm up your diagnosis?
[ Data asked for either not available or normal. Facilitator may supply other data.]
ABDOMINAL MASS
Trigger 3
The diagnosis of the patients health problem is
COLONIC CANCER
Questions:
1. Advice the patient and relatives on the pathophysiology of the disease. Use diagram.
2. Advice the patient and relatives on screening of the disease.
3. Advice the patient and relatives on early detection of the disease.
IIE2
HYPOTHETICAL PATIENT MANAGEMENT
JAUNDICE
Trigger 1
Questions:
1. What is Jaundice?
3. What do you think are the more common/least common general and specific
condition causing a jaundice?
4. Select one common general or specific condition and diagram the pathophysiology
leading to the jaundice.
IIF1
HYPOTHETICAL PATIENT MANAGEMENT
JAUNDICE
Trigger 2
Pertinent history
40 years old, female
Chief complaint: Jaundice
Noted 3 months ago
No associated symptoms
Physical examination:
Jaundice
No tenderness or mass on the abdomen
Questions:
2. What are the bases for your primary and secondary diagnoses?
Demonstrate use of pattern recognition with pathophysiology and prevalence.
Signs/Symptoms/Pathophysiology Prevalence data
Primary diagnosis
Secondary diagnosis
3. Do you need more data (sign/symptom) to firm up your primary and secondary
diagnoses?
If yes, what? How will it firm up your diagnosis?
[ Data asked for either not available or normal. Facilitator may supply other data.]
JAUNDICE
Trigger 3
The diagnosis of the patients health problem is
Questions:
1. Advice the patient and relatives on the pathophysiology of the disease. Use diagram.
2. Advice the patient and relatives on screening of the disease.
3. Advice the patient and relatives on early detection of the disease.
IIF2
CLINICAL DIAGNOSIS
OF PATIENTS WITH
AN ABDOMINAL DISORDER
FOLDER 3
PROBLEM-BASED
LEARNING ISSUES
Problem-based Learning Issues
Instructions
Given hypothetical and actual patients, pretest questions and any kind of
ABDOMINAL DISORDER to solve, list down deficiencies and uncertainties in
competences as learning issues and decide on a specific learning plan. Use the form
below.
FOLDER 4
LEARNING OBJECTIVES
Clinical Diagnosis of Patients with an Abdominal Disorder
At the end of the course, given a patient with an abdominal disorder, the student should be able to:
1. Establish a good rapport with any patient presented to him for management (up to clinical
diagnosis only).
2. Demonstrate skills in gathering relevant data using interview (history) and fundamental
methods of physical examination.
3. Analyze and correlate history and physical examination findings in an attempt to arrive at a
clinical diagnosis.
4. Demonstrate skills in medical recording of data gotten from interview and physical
examination as well as the clinical diagnosis.
Given a hypothetical and/or actual patient with an abdominal disorder, the student must be able to:
1. Establish a good rapport.
4. Identify reliable clinical cues of the more common causes of the health problem.
5. Gather relevant data using interview and fundamental methods of physical examination.
6. Analyze and correlate history and physical examination finding in an attempt ot arrive at a
clinical diagnosis using the processes of pattern recognition and prevalence.
7. Do medical recording.
1. Establish a good rapport with any patient presented to him for management (up to clinical
diagnosis only).
2. Demonstrate skills in gathering relevant data using interview (history) and fundamental
methods of physical examination.
3. Analyze and correlate history and physical examination findings in an attempt to arrive at a
clinical diagnosis.
4. Demonstrate skills in medical recording of data gotten from interview and physical
examination as well as the clinical diagnosis.
IV2
Specific Learning Objectives (Enabling Competencies)
4. Identify reliable clinical cues of the more common causes of the health problem.
5. Gather relevant data using interview and fundamental methods of physical examination.
6. Analyze and correlate history and physical examination finding in an attempt ot arrive at a
clinical diagnosis using the processes of pattern recognition and prevalence.
7. Do medical recording.
IV3
Physical Examination of the Abdomen
Learning Objectives:
2. Enumerate the two situations or purposes where physical examination of the abdomen is
being done.
6. Enumerate the core areas that should be included in screening physical examination of the
abdomen.
7. Enumerate the two most common methods of physical examination of the abdomen.
10. State the basic parameters for a quality inspection and palpation of the abdomen.
12. Process data derived from physical examination of the abdomen to come out with a
physical diagnosis.
IV4
CLINICAL DIAGNOSIS
OF PATIENTS WITH
AN ABDOMINAL DISORDER
FOLDER 5
LEARNING RESOURCES
MATERIALS AND
REFERENCES
Clinical Diagnosis of Patients with an Abdominal Disorder
Textbooks of
Anatomy
Physiology
Pathology
Physical Diagnosis
Internal Medicine
Pediatrics
General Surgery
Gastroenterology
Learning Objectives:
1/2 pages
11. Make a written record of findings of a physical examination of the abdomen.
Line drawing of abdomen, whole or involved areas
Illustrate findings with description and explanation
12. Process data derived from physical examination of the abdomen to come out with a
physical diagnosis.
Data from physical examination
|
Usual -Unusual
Nothing unusual - normal
Unusual - normal variant
Unusual - abnormal
|
Diagnostic Label
Name of disorder,
involved area, organ, or tissue
Descriptive label of unsual finding,
if name of disorder is not known,
involved area, organ, or tissue
2/2 pages
CLINICAL DIAGNOSIS
OF PATIENTS WITH
AN ABDOMINAL DISORDER
FOLDER 6
EVALUATION
Clinical Diagnosis on Patients with an Abdominal Disorder
Comprehensive Exam
(Pretest/Posttest)
Content Blueprint
Content
Breakdown
Anatomy
Physiology
Pathology
Microbiology
Clinical Diagnosis
Epidemiology and Miscellany
Written Examination
Instructions:
A B C D E A B C D E
6. O O O O O 31. O O O O O
7. O O O O O 32. O O O O O
8. O O O O O 33. O O O O O
9. O O O O O 34. O O O O O
10. O O O O O 35. O O O O O
A B C D E A B C D E
11. O O O O O 36. O O O O O
12. O O O O O 37. O O O O O
13. O O O O O 38. O O O O O
14. O O O O O 39. O O O O O
15. O O O O O 40. O O O O O
A B C D E A B C D E
16. O O O O O 41. O O O O O
17. O O O O O 42. O O O O O
18. O O O O O 43. O O O O O
19. O O O O O 44. O O O O O
20. O O O O O 45. O O O O O
A B C D E A B C D E
21. O O O O O 46. O O O O O
22. O O O O O 47. O O O O O
23. O O O O O 48. O O O O O
24. O O O O O 49. O O O O O
25. O O O O O 50. O O O O O
Student ID: ________________________________ Score: __________________
A B C D E A B C D E
56. O O O O O 81. O O O O O
57. O O O O O 82. O O O O O
58. O O O O O 83. O O O O O
59. O O O O O 84. O O O O O
60. O O O O O 85. O O O O O
A B C D E A B C D E
61. O O O O O 86. O O O O O
62. O O O O O 87. O O O O O
63. O O O O O 88. O O O O O
64. O O O O O 89. O O O O O
65. O O O O O 90. O O O O O
A B C D E A B C D E
66. O O O O O 91. O O O O O
67. O O O O O 92. O O O O O
68. O O O O O 93. O O O O O
69. O O O O O 94. O O O O O
70. O O O O O 95. O O O O O
A B C D E A B C D E
71. O O O O O 96. O O O O O
72. O O O O O 97. O O O O O
73. O O O O O 98. O O O O O
74. O O O O O 99. O O O O O
75. O O O O O 100. O O O O O
A B C D E A B C D E
101. O O O O O 126. O O O O O
102. O O O O O 127. O O O O O
103. O O O O O 128. O O O O O
104. O O O O O 129. O O O O O
105. O O O O O 130. O O O O O
A B C D E A B C D E
106. O O O O O 131. O O O O O
107. O O O O O 132. O O O O O
108. O O O O O 133. O O O O O
109. O O O O O 134. O O O O O
110. O O O O O 135. O O O O O
A B C D E A B C D E
111. O O O O O 136. O O O O O
112. O O O O O 137. O O O O O
113. O O O O O 138. O O O O O
114. O O O O O 139. O O O O O
115. O O O O O 140. O O O O O
A B C D E A B C D E
116. O O O O O 141. O O O O O
117. O O O O O 142. O O O O O
118. O O O O O 143. O O O O O
119. O O O O O 144. O O O O O
120. O O O O O 145. O O O O O
A B C D E A B C D E
121. O O O O O 146. O O O O O
122. O O O O O 147. O O O O O
123. O O O O O 148. O O O O O
124. O O O O O 149. O O O O O
125. O O O O O 150. O O O O O
Student ID: ________________________________ Score: __________________
Subject: Clinical Diagnosis of Abdominal Disorders
A B C D E A B C D E
151. O O O O O 176. O O O O O
152. O O O O O 177. O O O O O
153. O O O O O 178. O O O O O
154. O O O O O 179. O O O O O
155. O O O O O 180. O O O O O
A B C D E A B C D E
156. O O O O O 181. O O O O O
157. O O O O O 182. O O O O O
158. O O O O O 183. O O O O O
159. O O O O O 184. O O O O O
160. O O O O O 185. O O O O O
A B C D E A B C D E
161. O O O O O 186. O O O O O
162. O O O O O 187. O O O O O
163. O O O O O 188. O O O O O
164. O O O O O 189. O O O O O
165. O O O O O 190. O O O O O
A B C D E A B C D E
166. O O O O O 191. O O O O O
167. O O O O O 192. O O O O O
168. O O O O O 193. O O O O O
169. O O O O O 194. O O O O O
170. O O O O O 195. O O O O O
A B C D E A B C D E
171. O O O O O 196. O O O O O
172. O O O O O 197. O O O O O
173. O O O O O 198. O O O O O
174. O O O O O 199. O O O O O
175. O O O O O 200. O O O O O
AN APPROACH TO PATIENTS WITH AN ABDOMINAL PROBLEM
A student of medicine will encounter the phrase "acute abdomen" in his readings and in conferences.
"Acute abdomen" is a phrase that is very commonly used in medicine. Inspite of its common usage,
there exists confusion as to what the phrase actually means and as to how it should be used. The main
reason for this confusion is the absence of a universally accepted definition.
Dorland's Illustrated Medical Dictionary (1981) defines acute abdomen as an abdominal condition of
abrupt onset, usually associated with abdominal pain due to inflammation, perforation, obstruction,
infarction, or rupture of intraabdominal organs. Emergency surgical intervention is usually required. It is
also called surgical abdomen.
Others define it as an abdominal condition of abrupt onset wherein prompt and immediate diagnosis is
required so that an appropriate early treatment may be instituted.
Still others define it as an abdominal condition if left undiagnosed and untreated can lead to a
catastrophy.
With such a variety of definitions comes a variety of interpretations and usages. Some physicians use
the phrase to mean an acute surgical abdomen. Some think that not all cases of acute abdomen end up
with surgery. In other words, some acute abdomen may be nonsurgical.
Some physicians use the phrase just to stress the urgency of treatment of the abdominal condition, such
as an immediate operation.
Some physicians use it to mean only those presenting with acute severe abdominal pain. Some use it
to include other abdominal manifestations beside pain, such as gastrointestinal bleeding, distention, and
vomiting. Some physicians confine it to nontraumatic abdomen whereas some extend it to traumatic
abdomen.
With such a variety of interpretations and usages, misunderstanding and confusion tend to ensue,
especially when it is used as an assessment label in a patient with an abdominal problem. The phrase
"acute abdomen" should only be used as a label for a book or for a symposium in which all kinds of
acute abdominal problems will be discussed. It should not be used as an assessment label for a particular
patient. A more specific and more informative assessment label should be used, such as acute surgical
abdomen, or simply, surgical abdomen; acute nonsurgical abdomen or simply, nonsurgical abdomen;
nontraumatic nonsurgical abdomen; nontraumatic surgical abdomen; traumatic nonsurgical abdomen; or
traumatic surgical abdomen, whichever is applicable.
All patients with an abdominal problem, whatever its clinical presentation, no matter how mild or
severe it is, no matter how sudden or insidious it is, are potential candidates for having a surgical
abdomen. An abdominal problem may be an abdominal pain or tenderness; an abdominal distention;
vomiting; diarrhea; constipation; bleeding; jaundice; mass; or any symptoms and signs referable to the
abdomen or which are considered manifestations of abdominal disorders. In the evaluation of
patients with an abdominal problem, the most important question to answer is whether a surgical abdomen
is present or not.
There are two types of diagnosis that a physician can make after evaluation of a patient with an
abdominal problem. These are, namely: 1) diagnosis of surgical abdomen or nonsurgical abdomen and
2) diagnosis of a specific abdominal disorder, such as acute appendicitis and acute cholecystitis.
Although it is a good practice to make a diagnosis of a specific abdominal disorder, realistically
speaking, more often than not, it is difficult. At times, it is impossible to get to a specific diagnosis. If
one will always go for a specific diagnosis, one may unnecessarily be consuming a lot of time,
effort, and money that the whole process may turn out not to be practical and cost-effective. Sometimes,
it may be detrimental.
If one cannot get to a specific diagnosis of an abdominal disorder with history, physical examination, and
some diagnostic procedures, then, it is sufficient to just decide whether a surgical abdomen is present
or not. A surgical abdomen is one that needs an operation. With a diagnosis of a surgical abdomen,
the physician can proceed right away to the next step in the management, which is surgery. The
operation not only provides treatment for the surgical disorder that may be present, it also provides
specific diagnosis of the abdominal disorder on operation. If the diagnosis, however, is a nonsurgical
abdomen, then the physician can institute nonsurgical forms of management.
Initial evaluation of any abdominal problem relies on history and physical examination. Subsequent
and further evaluation may consist of additional interview, repeat examinations, and diagnostic
procedures. Active observation, especially with serial monitoring of the abdomen, also forms part
of the subsequent evaluation. In fact, it is the most important among all the diagnostic tools. For serial
monitoring of the abdomen to be useful and reliable, it must be accurate and it must be done by the
same examiner at closed intervals.
In examining the abdomen, the physician must look for any abnormalities that may be present and which
may give clue to a diagnosis of the abdominal disorder.
Laboratory examinations and diagnostic procedures should be done only when indicated and not for
reasons of routine. They should be selected rationally. For example, one should not order for an
abdominal X-ray simply because one is dealing with an abdominal problem. A plain abdominal x-ray
is often not informative if ordered on the above basis.
If one is suspecting intestinal obstruction, it is enough to order for a supine abdominal x-ray. An upright
abdominal x-ray is not necessary.
In the evaluation of patients for possible acute appendicitis, complete blood count (CBC) and urinalysis
should not be routinely ordered. In fact, they are not necessary in ruling in or ruling out acute
appendicitis.
"When in doubt, operate" is a commonly heard saying. In fact, it has become a teaching and it has
frequently been used as a justification for operation. This saying should be qualified because it is
dangerous and it can be abused. As it is, it has led to a significant number of unnecessary operations.
The saying should be changed to "When in doubt, do not operate. Continue to observe and monitor
very closely. Operate only when surgical abdomen is strongly suspected. Let conscience and 'if I
were the patient' be the guide in the decision-making on whether to operate or not".
A surgical abdomen is one that needs an exploratory laparotomy procedure. An evaluation of surgical
abdomen is made based primarily on signs of surgical abdomen and secondarily on a diagnosis of a
specific surgical abdominal disease.
The timing of the operation can either be now or as soon as possible. Surgery is done right away in those
cases suspected of having bleeding actively going on, which if not controlled will soon lead to shock and
subsequent death. For other cases, the timing of surgery is done on an as soon as possible basis, that
means, as soon as all necessary preparations for surgery are through and without undue and
unnecessary delay due to whatever reason. As soon as possible may be within one hour, within 4 to
6 hours, or longer, depending on the situation.
In general, the timing of operation is such that an operation is done on a stat basis for active bleeding
that is life-threatening and on an as soon as possible basis for peritonitis, obstruction, abscess, and
intraabdominal mass.
Operations for peritonitis and obstruction are done sooner than those for abscess and intraabdominal mass.
The general preparations for patients with surgical abdomen consist of the following:
In summary, the approach to the management of patients with an abdominal problem consists essentially
and initially of evaluation to determine whether a surgical abdomen is present or not. If a surgical
abdomen is present, the patient is prepared for an operation. If a nonsurgical abdomen is decided upon,
the patient is managed accordingly. In equivocal cases, laboratory examinations, diagnostic procedures,
and closed monitoring are utilized as indicated.
APPROACH TO PATIENTS WITH AN ABDOMINAL TRAUMA
An overview of the management approach to patients with an abdominal trauma is shown in the diagram
below:
EVALUATION
INITIAL TREATMENT
INITIAL TREATMENT
POSTOP CARE
An abdominal trauma is said to be present if an injury is inflicted on the abdominal torso with
possible or actual afflictions of the peritoneal and retroperitoneal organs. The peritoneal and
retroperitoneal organs may also be injured with the point of entry or point of initial impact being away
from the abdominal torso. Examples are impalement through the anus and missile injuries entering
through the shoulder reaching the peritoneal cavity. Such cases are also considered abdominal
trauma.
An abdominal trauma is usually caused by either blunt or penetrating injury. Blunt abdominal trauma
are usually those associated with vehicular accidents, falls, and punches. Penetrating abdominal
trauma are usually those caused by stab wounds, missile injuries, and hacking wounds.
The first step in the management approach of patients with abdominal trauma is evaluation. There are
several things to emphasize regarding evaluation.
The evaluation should be fast. Patients with abdominal trauma may be at any of the following stages
when first seen by a surgeon:
The first four situations require a fast evaluation to ensure a well-timed treatment. The last situation
also demands a fast evaluation in order to check its presence and to make sure that the other four
situations are not present.
The results of the evaluation should be concise and complete so that proper (accurate and adequate)
treatment may be instituted.
There is such a thing as initial evaluation and subsequent (including repeat or repeated) evaluation.
These contribute to the making of a fast, concise, and complete evaluation.
The diagnostic tools consist of interview, physical examination, laboratory examinations, diagnostic
procedures, and monitoring. These are done as indicated and as available.
The initial evaluation relies on physical examination with or without interview, depending on the latter's
availability. The most important question to answer when evaluating a traumatized abdomen is
whether a surgical abdomen is present or not. By surgical abdomen is meant an abdomen needing an
exploratory laparotomy. The following are the more common signs of surgical abdomen:
1. Signs of peritoneal irritation (definite, persistent, and increasing direct tenderness with or without
muscle guarding)
2. Penetrating missile injuries
3. Hypotension with blood loss as a suspect
4. Frank bleeding from the peritoneal cavity or from the gastrointestinal tract
5. Evisceration
Subsequent evaluation may consist of more interview, repeat physical examinations, some laboratory
examinations, some diagnostic procedures, and close monitoring. The subsequent evaluation is done
to make more certain and more complete the initial assessment. Below are some pointers in the evaluation.
Serial monitoring of the abdomen by palpation must be done by the same examiner and at close intervals.
X-ray examinations are done only when indicated, tolerable, and when they do not cause undue delay in
treatment.
A chest x-ray upright is the appropriate view to look for pneumoperitoneum. Anteroposterior-lateral
supine plain abdominal x-rays are used to evaluate patients with penetrating foreign bodies, such as
bullets and darts.
The serum amylase may be evaluated in patients suspected to have isolated pancreatic injuries.
Probing of a stab wound may be done aseptically when feasible to check for transgression of the
peritoneal lining. Ice-pick stab wounds cannot and should not be probed.
A nasogastric tube may be inserted to check for gastrointestinal bleeding. A urinary bladder
catheterization may be done to check for bleeding in the excretory system.
A peritoneal tap or a peritoneal lavage may be done in unconscious patients with a history of blunt
trauma and suspected of having intraperitoneal bleeding or rupture of viscus.
As mentioned, the most important question that a surgeon has to decide when evaluating a traumatized
abdomen is whether a surgical abdomen is present or not. If the evaluation is that the patient has no
or equivocal surgical abdomen, then no exploratory laparotomy is instituted. Monitoring should be
continued until such a time that the patient is finally cleared of a surgical abdomen.
If the evaluation is that the patient has a surgical abdomen, then the patient is prepared for exploratory
laparotomy. Preparations include the following as indicated:
The timing of operation for patients with traumatic surgical abdomen is usually on a "right away" basis.
In patients with hypovolemic shock secondary to blood loss, the operation should be considered part of
the resuscitative measures and should be done right away even without waiting for the blood to arrive.
The exploratory laparotomy is done under general anesthesia usually using a liberal vertical midline
incision. Just like the preoperative evaluation, the intraoperative evaluation or exploration should also
be fast, concise, and complete. There is also such a thing as initial and subsequent evaluation.
For whatever injuries that may be seen on exploration, the topmost priority in terms of treatment is to
control bleeding. The second priority is to control soilage of the peritoneal cavity from perforated and
leaking hollow viscera.
In patients with abdominal trauma, all the intraperitoneal and the retroperitoneal organs may be
injured in varying combinations and severity. Essentially, the injuries consist of contamination, necrosis,
bleeding, rupture of organs, and soilage of the peritoneal cavity and retroperitoneal area. With such
kinds of injuries that may occur in abdominal trauma, treatment, therefore, can be categorized into five
general procedures. These are, namely: 1) control of bleeding; 2) control of soilage; 3) debridement; 4)
repair; and 5) cleansing or lavage.
Bleeding can be controlled by various techniques or methods such as ligation, hemostatic suturing, repair
of vascular tear, excision of bleeding organs, compression and packing.
Soilage can be controlled also by various techniques or methods, such as repair of ruptured hollow
viscera, resection-anastomosis, excision, and exteriorization.
After exploration, the specific types of surgical procedures that will be performed by the surgeon will be
dependent on a lot of factors, among which are the type of organs injured, the nature and severity of
the injuries in a particular organ, the general condition of the peritoneal cavity, the overall condition
of the patient, the availability of blood, and the surgeon's preference and decision-making. Whatever
will be the surgeon's decision as to the type of intraoperative treatment to be instituted, the ultimate
aims are to control bleeding successfully, to control peritoneal and retroperitoneal soilage
adequately, to repair properly, and to avoid intraoperative and postoperative morbidity and mortality.
Below are some pointers on the use of drains, controlling bleeding, and antibiotics.
Regarding the use of peritoneal and retroperitoneal drains, either Penrose, sump or tube drains may be
used. The two most important things to remember regarding a drain are that, one, if placed, it should
serve a purpose and two, it should serve its purpose adequately. For Penrose drains, the exit wound on
the abdominal wall should be big enough to allow free drainage.
Regarding intraoperative bleeding, the surgeon should control profused bleeders as soon as possible
and as skillfully as possible. The patient should not be allowed to bleed to death. Compression,
packing, or clamping should be used as necessary to control bleeding while waiting for blood to arrive,
while trying to place proximal and distal vascular controls, or while deciding on a maneuver that will
completely stop the bleeding.
Lastly, to prevent infection within the abdomen and on the abdominal wound, reliance should be placed
more on the surgical techniques of debridement, copious lavage, and drainage than on antibiotics. The
antibiotics that may be given are the broad spectrum ones that can cover for gram-positive, gram-negative,
and anaerobic organisms.
APPROACH TO PATIENTS WITH ACUTE NONTRAUMATIC ABDOMEN
A nontraumatic abdomen is an abdomen with disorders that are not due to trauma. A
nontraumatic abdominal problem may be any symptom or sign experienced by the patient himself or
sign observed by an onlooker (relative, friend, or physician) on a patient that is referable to the abdomen.
Examples of symptoms that may be manifestations of an abdominal disorder are abdominal pain,
discomfort, feeling of bloatedness, and nausea. Examples of signs that may be manifestations of an
abdominal disorder are vomiting, distention, tenderness, jaundice, obstipation, diarrhea,
hematemesis, and hematochezia.
The word "acute" as an adjective describing the nontraumatic abdomen will be used here from the
point of view of the patients. Whatever be the nature of the abdominal complaint of the patients, whatever
be the severity or the duration, if the patients think it is acute, then it is acute.
The word "acute" has various meanings, usages, and interpretations. For practical purposes,
the physician should just accept whatever be the interpretations of the patients and then decide whether
there is an acute nontraumatic surgical abdomen or not. After this decision, he then manages the patient
accordingly.
The first step in the management approach of patients with acute nontraumatic abdomen is
evaluation.
The diagnostic tools that are and may be used in the evaluation consist of interview, physical
examination, laboratory examinations, diagnostic procedures, and monitoring. These are done as
indicated and as available.
Initial evaluation of any nontraumatic abdominal problem relies on interview and physical
examination. Interview is done on conscious, communicable, and coherent patients to get clue as
to the nature of the abdominal problem. For unconscious, uncommunicable, and incoherent patients,
interview may be done with the relatives and watchers.
The physical examination is done also to get clue as to the nature of the abdominal problem as
well as to clarify, confirm, or dispel suspicions derived during the interview.
In examining the abdomen, the physician looks for any abnormalities that may be present.
Specifically, he looks for abdominal distention; palpates for guarding, rigidity, direct tenderness,
abnormal mass, and organomegaly; and auscultates for frequency of bowel sounds.
It is important to emphasize that there should be repeated physical examinations of the abdomen.
There should be at least two, with significant intervals in between. Another point to emphasize is that
the repeated examinations must be done by the same physician and this goes without saying that the
physician must be well-versed and accurate in his examination of the abdomen.
Laboratory examinations and diagnostic procedures should be done only when indicated and not
for reasons of routine. They should be selected rationally and on a cost-effective basis.
For example, one should not order for an abdominal X-ray simply because one is dealing with
an abdominal problem. A plain abdominal X-ray is often not informative if ordered on the above
basis.
If one is suspecting intestinal obstruction, it is enough to order for a supine abdominal X-ray. An
upright abdominal X-ray is not necessary as it does not add significant information on top of the physical
findings and plain supine abdominal X-ray.
If one wants to look for pneumoperitoneum, one orders for an upright chest X-ray and not an
upright abdominal X-ray. Pneumoperitoneum is best seen on an upright chest X-ray.
In the evaluation of patients with possible acute appendicitis, complete blood count (CBC) and
urinalysis should not be routinely ordered. In fact, they are not necessary in ruling in or ruling out acute
appendicitis.
Monitoring is another diagnostic tool and it includes additional interview, repeated physical
examinations, and serial laboratory examinations. Monitoring is important because it tends to get
information and valuable and accurate information at that, when one diagnostic tool and one doing are
unable to produce.
There are two types of diagnosis that a physician can make after evaluation of a patient with
an acute nontraumatic abdominal problem. These are, namely: 1) diagnosis of surgical abdomen or
nonsurgical abdomen and 2) diagnosis of a specific abdominal disorder, such as acute appendicitis
and acute cholecystitis.
If one cannot get to a specific diagnosis of an abdominal disorder with history, physical
examination, and some diagnostic procedures, then, it is sufficient to just decide whether a surgical
abdomen is present or not. A surgical abdomen is one that needs an exploratory laparotomy. With a
diagnosis of a surgical abdomen, the physician can proceed right away to the next step in the
management, which is surgery. The operation not only provides treatment for the surgical disorder that
may be present, it also provides a specific diagnosis of the abdominal disorder on exploratory
laparotomy. If the diagnosis, however, is a nonsurgical abdomen, then the physician can institute more
diagnostic work-ups, if needed, and nonsurgical forms of treatment.
Acute nontraumatic abdominal disorders that are surgical or potentially surgical in nature can be
classified as follows: (Note: This is only a practical classification.)
For one reason or another, a patient may be a poor operative risk. The surgeon has to decide what
to do with this problem of poor operative risk. It should not be that simply because the patient is a poor
operative risk that the surgeon decides against operating when an operation is really needed. The surgeon
should face the challenge and should as much as possible come up with a live patient after the operation.
He can achieve this by properly deciding on the timing of the operation, properly preparing the
patient for the operation, and properly performing the operation. He should not hesitate to call in
colleagues and other subspecialists to help. If possible, he should try to improve the operative risk
before operating. He should not forget to inform the patient and his relatives of the risks involved..
The timing of the operation for patients with acute nontraumatic surgical abdomen can be
either now or as soon as possible. Surgery is done right away in those cases suspected of having active
bleeding, which if not controlled will soon lead to shock and subsequent death. For other cases, the
timing of surgery is done on an as soon as possible basis, that means, as soon as all necessary
preparations for surgery are through and without undue and unnecessary delay due to whatever reason.
As soon as possible may be within one hour, within 4 to 6 hours, or longer, depending on the situation.
In general, the timing of operation is such that an operation is done on a stat basis for active
bleeding that is life-threatening and on as soon as possible basis for peritonitis, obstruction, and
abscess. Operations for peritonitis and obstruction are done sooner than those for abscess.
The general preparations for patients with acute nontraumatic surgical abdomen consist of
the following:
l. No oral intake
2. Hydration, if dehydrated
3. Replacement of electrolyte losses, if present
4. Preoperative laboratory examinations, as indicated
5. Preoperative medications, as indicated
5.1 Analgesics
5.2 Antibiotics
5.3 Drugs for co-existing medical problems
5.4 Supportive drugs
5.5 Drugs prescribed by the anesthesiologists
6. Preoperative preparatoty procedures, as indicated, such as insertion of nasogastric tube and
urinary catheter
All patients with acute nontraumatic surgical abdomen are scheduled for an initial exploratory
laparotomy. Exploratory laparotomy simply means the peritoneal cavity is opened and the inside of the
cavity is explored and examined.
Any type of incision can be used for an exploratory laparotomy. The incision may be
vertical, transverse, or oblique. The incision may be at the midline, at the paramedian, at the subcostal
area, below or above the umbilicus, or at any quadrant of the abdomen. The incision may be short or
long.
The exploration may be total or limited. Whether it be total or limited, the exploration must
fulfil the following requirements:
1. It must come out with a complete and accurate evaluation of the abdominal problem.
2. It must not be associated with a missed diagnosis.
3. It must not be associated with iatrogenic injuries and complications.
After the intraoperative evaluation, operative procedures are carried out as dictated by the
specific diagnosis and as decided by the surgeon. In patients with acute nontraumatic surgical
abdomen, the operative procedures that may be possibly performed can be classified under three big
categories. These are, namely: 1) to control peritonitis; 2) to relieve obstruction; and 3) to control
bleeding.
The operative procedures that are usually performed under control of peritonitis are:
1. Excision or resection
Appendectomy
Cholecystectomy
Gastrointestinal resection
2. Repair
Repair of perforation
3. Debridement
4. Lavage
5. Drainage
The operative procedures that are usually performed under relief of obstruction are:
1. Adhesiolysis and release of bands
2. Resection and anastomosis
3. Bypass or internal drainage
4. External drainage
Colostomy
T-tube choledochostomy
5. Removal of stone
The operative procedures that are usually performed under control of bleeding are:
1. Suture ligation of bleeders
2. Resection and anastomosis
3. Decongestion of portal hypertension with or without esophageal transection and
anastomosis
4. Excision of ruptured ectopic pregnancy
5. Prosthetic graft replacement for ruptured aortic aneurysm
After the operation comes the postoperative care. This includes consideration of the following:
1. Postoperative medications
Analgesics, antibiotics, etc.
2. Care of tubes and drains
3. Care of wounds
4. Blood replacement
5. Nutrition
6. Fluid and electrolytes
7. Monitoring for the appearance of complications and, if they do occur, treating them
accordingly
8. Support of other systems of the body
EVALUATION
INITIAL TREATMENT
INITIAL TREATMENT
MONITOR DIAGNOSTIC
CONTROL PERITONITIS
RELIEVE OBSTRUCTION
CONTROL BLEEDING
POSTOP CARE
APPROACH TO PATIENTS WITH NON-ACUTE SURGICAL ABDOMEN
Reynaldo O. Joson, MD, DPBS
1991;2000
NONTRAUMATIC ABDOMEN
ACUTE NON-ACUTE
The word "acute" implies a problem of sudden onset and of a severity that must be urgently managed by a
physician. "Non-acute", on the other hand, connotes a problem that has no obvious urgency. The problem
may be tolerated by the patient who has it; insiduous in onset; and non-life threatening.
Just as an acute abdominal problem may either be surgical or nonsurgical, a non-acute abdominal
problem may likewise be categorized as such.
The first step in the management approach of patients with non-acute nontraumatic abdomen is
evaluation. The essential question to answer during evaluation is whether a surgical abdomen is
present or not. A surgical abdomen is ruled out first before a nonsurgical abdomen is accepted as a
diagnosis.
The following are conditions that are usually classified as non-acute surgical abdomen, especially when
they are in the early stage of their natural history and they have not caused complications that would
classify them as acute surgical abdomen (Note: all non-acute surgical abdomen are potential acute
surgical abdomen):
1. Gallbladder Stones
2. Splenomegaly
3. Abdominal Tumors
The diagnostic tools that may be used in the evaluation of patients with non-acute surgical abdominal
conditions consist of interview, physical examination, laboratory examinations, diagnostic
procedures, and monitoring. These are done as indicated and as available.
I. GALLBLADDER STONES
Gallbladder stones may be detected through a plain abdomen (if the stones are opaque); oral
cholecystogram; and ultrasound.
Patients with gallbladder stone may present with acute surgical abdomen; non-acute surgical
abdomen; or they can be completely asymptomatic, the stone detected only incidentally in
the process of an investigation for other problem.
Asymptomatic gallbladder stones may not have to be removed. The patients are advised the following:
II. SPLENOMEGALY
Though rare, splenomegaly may be done to palliate patients with massive spleen secondary to
leukemia, lymphoma, and myeloproliferative disorders.
At present, the most common indications for splenomegaly in patients with non-acute surgical abdomen
are still idiopathic thrombocytopenic purpura and hemolytic anemia. The surgeon doing splenectomy in
such hemotologic disorders must closely work hand in hand with a hematologist.
Any organ or tissue in the abdomen can give rise to a tumor. Thus, tumors can originate in the following
abdominal organs and tissues:
1. Liver
2. Pancreas
3. Stomach
4. Small Intestines
5. Large Intestines
6. Mesentery and Omentum
7. Retroperitoneum
In general, if a tumor is palpable, its location on the abdomen is the first clue to its diagnosis. All
organs and tissues situated at the particular location of the tumor should be suspected to be a possible
source. For example, a tumor in the epigastric area can be a gastric, a transverse colonic, or a pancreatic
tumor. A tumor in the right lower quadrant can be an ileocecal, appendiceal, or an ovarian tumor.
The second clue to the diagnosis of a palpable abdominal mass is its mobility. If it is very mobile, then
it may be arising from structures which are mobile such as the omentum, transverse colon, and small
intestine.
The third clue to the diagnosis of a palpable abdominal mass is the accompanying symptomatology or
sign. The presence of gastrointestinal disturbance such as vomiting, constipation, and bleeding will
suggest an origin in the gastrointestinal tract. The presence of jaundice will suggest hepatobiliary
and pancreatic origin of the mass.
For nonpalpable abdominal tumors, the thing that will make a physician suspect their possible presence is
symptomatology of the patient. For example, an obstructive type of jaundice without a palpable mass
should lead to the suspicion of a mass obstructing the hepatobiliary tract.
After the history and physical examination, one should have a primary suspect as to the possible origin
of the abdominal tumor. This primary suspect should be one that is logically arrived at based on the
signs and symptoms of the patient.
An exploratory laparotomy can be selected as the next step after history and physical examination if the
surgeon is certain that there is an intra-abdominal mass and that this mass has to be surgically treated
regardless of what it will turn out to be on further examinations. Selecting an exploratory laparotomy as
the next step after history and physical examination presupposes that the surgeon will utilize the
intraoperative exploration as the diagnostic procedure and that he will make a decision on the
specific treatment procedure thereafter.
If the surgeon is not certain of the presence of an intra-abdominal surgical mass, he must perform
diagnostic procedures to ascertain at least its presence before deciding on exploratory laparotomy.
Diagnostic procedure may be done to get an idea where the mass is originating from.
At times, diagnostic procedures prior to exploratory laparotomy must be done. For example, a rectal
mass needs a confirmation of its malignancy before an abdominoperineal resection is done. A
tumor involving one kidney and which requires a total nephrectomy for its treatment requires a prior
excretory urography to evaluate the status of the contralateral kidney.
Depending on the primary suspect of where the mass is originating from, the following diagnostic
procedures may be done:
1. Gastrointestinal endoscopy.
2. Barium study of the gastrointestinal tract.
3. Ultrasound
4. Excretory urogram
Gastrointestinal endoscopy and barium study are best used to evaluate tumor that may possibly arise from
the gastrointestinal tract.
Ultrasound is best used to evaluate tumors that may possibly be arising from the liver, pancreas, uterus,
ovaries, and kidneys.
Excretory urogram is the best used when tumor is suspected to be coming from the kidneys and urinary
bladder.
The types of treatment that can be done on the various tumors in the abdomen depend on a lot of
factors:
1. Is it resectable or not ?
2. Is it benign or malignancy ?
3. Is it involving a solid organ ?
3.1 Is it involving the whole organ ?
3.2 Is a partial resection of the organ enough ?
3.3 Is a reconstruction needed ?
4. Is it involving a hollow organ ?
4.1 Is a partial resection of the organ enough ?
4.2 Is a reconstruction needed ?
The basic form of surgical treatment of intraabdominal mass is excision. If the mass is benign, simple
excision is sufficient. If the mass is malignant, a wide excision is called for.
After excision, a form of reconstruction may have to be done. In the abdomen, after an excision,
especially one that involves a hollow organ, the reconstruction is usually a re-establishment of the
gastrointestinal continuity.
PRINCIPLES OF ABDOMINAL SURGICAL ONCOLOGY
Surgical oncology is the study of management of tumors needing surgical intervention of some kind.
Abdominal surgical oncology is the study of management of abdominal tumors needing surgical
intervention of some kind.
A surgical oncologist is a surgeon who specializes in the treatment of tumors. He must possess
knowledge related to tumors needing surgery. He must also possess knowledge beyond cancer
surgery.
1. Detection
2. Diagnosis
3. Staging
4. Alternative options for therapy
5. Adjuvant therapies
6. Follow-up care
7. Detection and treatment of recurrence and metastasis
Abdominal tumors may be benign or malignant. The basic surgical treatment of malignant abdominal
tumors is a wide resection. Another definitive surgical treatment for abdominal cancers is a radical en
bloc resection.
The goals of surgical treatment of abdominal cancers may be curative or palliative. As much as
possible, the abdominal surgeon should always aim for cure. In unresectable tumors, palliative
procedures may be performed such as an exteriorization and bypass to relieve gastrointestinal obstruction
and resection to control gastrointestinal bleeding.
Below is a list of definitive surgical procedures that may be done for the different abdominal cancers:
Liver cancers
Subtotal hepatectomy
Right hepatectomy
Left hepatectomy
Extended right hepatectomy
Wide excision
Pancreatic cancers
Subtotal pancreatectomy
Total pancreatectomy
Stomach cancers
Subtotal gastrectomy
Total gastrectomy
Retroperitoneal cancers
Wide excision
MANAGEMENT OF PATIENTS WITH PERITONEAL IRRITATION
One manner of presentation of patients with acute nontraumatic surgical abdomen is with signs
and symptoms of peritoneal irritation. For conscious patients, the most notable symptom of peritoneal
irritation is abdominal pain. On physical examination, signs of peritoneal irritation include direct
tenderness and guarding or rigidity of the abdominal wall. The earliest sign of peritoneal irritation is
direct tenderness. It is to be emphasized here that not all direct tenderness are signs of peritoneal
irritation. Serial monitoring of the direct tenderness is important. If the direct tenderness is definite,
progressive and associated with persistent guarding or rigidity of the abdominal wall, then there is
peritoneal irritation.
Peritoneal irritation is usually a sign of peritonitis or inflammation of the peritoneum. A patient with
purulent materials in the peritoneal cavity will manifest the signs of peritoneal irritation. A patient
with hemoperitoneum will likewise manifest the same signs of peritoneal irritation. A patient with an
intraabdominal abscess, expanding aortic aneurysm, and hydrops of the gallbladder may likewise
present with definite, progressive, direct tenderness and even guarding. The tenderness of the latter three
conditions, especially when they are in the earlier stages of the diseases, may not be due to peritonitis. It
may be due to the pressure produced by the palpation on a progressively distending hollow structure.
Although peritoneal irritation is not always synonymous with peritonitis, this phrase is used to indicate the
presence of a surgical or potentially surgical abdomen. Thus, in the presence of a definite and
progressive direct tenderness, a physician should strongly suspect surgical abdomen. The suspicion
should be more so if guarding or rigidity of the abdominal wall is present.
Usually, patients with peritoneal irritation requires exploratory laparotomy. There are exceptions. If a
specific diagnosis of amebic liver abscess, a non-necrotizing pancreatitis, a noncalculous
cholecystitis, and a colonic diverticulitis without perforation can be made, then exploratory
laparotomy is not needed. The patients with such conditions are treated with nonsurgical means. Surgery
is done only when these nonsurgical means fail and there is progression of the diseases to a situation in
which an operation is needed.
If a specific diagnosis of the diseases mentioned in the preceding paragraph and other diseases of the
same category cannot be made, then an exploratory laparotomy is indicated. The exploration will spell
out the specific diagnosis, the cause of the peritoneal irritation. This will be followed by a
definitive operative procedure for the specific condition that is present.
Another situation in which an operation is indicated in patients with peritoneal irritation is when the
physician strongly suspects a surgical condition as the cause. Examples are acute appendicitis,
perforated peptic ulcer, perforated typhoid ileitis, and abscess. Surgery is needed to control the
peritonitis.
Below is a list of categorizations and common conditions that fall under peritoneal irritation as the
presenting manifestation of acute nontraumatic surgical or potentially surgical abdomen.
I. Inflammatory bowels
A. Acute appendicitis
B. Diverticulitis
C. Necrotizing enterocolitis
II. Perforated bowels
A. Perforated peptic ulcer
B. Perforated typhoid ileitis
III. Cholecystitis
IV. Pancreatitis
V. Intraabdominal abscess
A. ACUTE APPENDICITIS
There are at least three forms of clinical presentation of acute appendicitis. These are,namely:
1. Acute appendicitis with nongeneralized peritonitis
2. Acute appendicitis with generalized peritonitis
3. Appendiceal abscess
In acute appendicitis with nongeneralized peritonitis, the peritoneal irritation is usually limited to the
right lower quadrant of the abdomen. It may extend to the hypogastrium or to the right upper quadrant.
The peritoneal irritation is not present in the whole abdomen. The appendix may be suppurative,
gangrenous , or with frank perforation but still with nongeneralized peritonitis.
In acute appendicitis with generalized peritonitis, the appendix has perforated and there is peritoneal
irritation all over the abdomen.
In appendiceal abscess there is a tender right lower quadrant abdominal mass. The appendix has
ruptured and the peritonitis has been contained through some defense mechanisms in the form of abscess
formation.
The diagnostic tools for acute appendicitis are usually limited to interview, physical examination, and
monitoring (repeated interview and physical examination). Complete blood count, urinalysis, X-rays,
and ultrasound cannot give out a definite diagnosis of acute appendicitis. Thus, they are not needed
and should not be used in evaluating patients with possible acute appendicitis.
The only ways in which a definitive diagnosis of acute appendicitis can be gotten are through 1) a
laparoscope, if this is available; 2) inspection on laparotomy; and 3) microscopic examination of the
appendix ( the presence of polymorphonuclear leukocytosis in the submuscularis layer).
Even the interview and the physical examination cannot give out a definite diagnosis of acute
appendicitis. However, especially with repeated interview and physical examination, they offer a reliable
basis for suspecting the possible presence of acute appendicitis. An advice is to first look for signs of
peritoneal irritation through palpation. If these signs are present and if there are no data to suggest
other pathologies, such as ectopic pregnancy and perforated typhoid ileitis, acute appendicitis is placed
as the primary consideration for the cause of the surgical abdomen. With such a diagnostic approach,
the accuracy rate for suspecting acute appendicitis is high. There can be errors in the specific diagnosis
of the abdominal disorder. The diagnosis may be an ectopic pregnancy or something other than acute
appendicitis. However, the decision to operate based on the presence of peritoneal irritation is still
correct. So, such an approach, even if there is an error in the specific diagnosis, will not be all in vain.
Here are some other practical tips in the evaluation of patients with possible acute appendicitis.
1. In all patients presenting with right lower quadrant pain and tenderness, always rule in or rule out
acute appendicitis.
2. In all patients presenting with a recent epigastric pain, watch out, for this may be the first symptom
of acute appendicitis.
3. An epigastric pain that later transfers to the right lower quadrant is not pathognomonic of acute
appendicitis.
4. During the interview, inquire at least on the following essential points: a) urinary disturbance; b)
bowel disturbance; c) vaginal discharge; d) time of most recent mense; and e) possible pregnancy.
5. In the absence of data that will suggest other diagnosis, strongly consider acute appendicitis.
6. In the presence of data that will suggest the possibility of another disease, weigh this disease against
acute appendicitis, which one has the higher probability of being the case. Bear in mind that two diseases
may be present at the same time, though this is rare.
7. There are times in which it is difficult to differentiate between acute appendicitis and pelvic
inflammatory diseases. Monitor and decide. With increasing tenderness and guarding, operate.
8. There is no need to elicit rebound tenderness, Rovsing's sign, psoas sign, and obturator sign. They
are not reliable signs of acute appendicitis. If they are elicited, know how to interpret them.
9. Do not make a diagnosis of chronic appendicitis and use this as a justification for operation.
10. It is possible to come out with such diagnoses based on repeated interview and physical examinations:
a. Acute surgical abdomen most probably acute appendicitis with nongeneralized peritonitis
b. Acute surgical abdomen, most probably acute appendicitis with generalized peritonitis
c. Acute surgical abdomen, most probably appendiceal abscess
11. In cases of equivocal evaluation in that one cannot yet rule in or rule out acute appendicitis, the thing
to do is to monitor. Repeated interview, checking for any change in the intensity of the pain, and
repeated physical examination, especially of the abdomen ,looking for signs of peritoneal
irritation, must be done at closed intervals and by the same physician.
12. Do not operate on the basis of "if in doubt, operate. Morbidity is lower if an error of commission is
committed as compared to an error of omission." Proper monitoring should not lead to an error of
commission. Corollary to this, it reduces errors of commission. Morbidity is not increased with a delay in
the timing of the operation as a result of closed and proper monitoring.
Once a decision is made that the patient has an acute surgical abdomen most probably secondary to
acute appendicitis, the patient should be informed of the assessment and a formal consent gotten for the
operation. The contemplated operative procedure should be stated as "exploratory laparotomy (or right
lower quadrant abdominal exploration) and appendectomy," and not simply, "appendectomy". This is so
because the exploration may give a finding other than an appendicitis. If this is so, the surgeon has the
leeway to do other operative procedures as dictated by the exploratory laparotomy findings as well
as appendectomy, that is, if he decides to do an incidental appendectomy.
For patients suspected of having an appendiceal abscess, the consent will be for "exploratory laparotomy,
drainage of abscess, and appendectomy."
Once acute appendicitis and appendiceal abscess are strongly suspected, the treatment is a surgical
operation. The operation should be done as soon as possible to prevent the progression of the peritonitis
and to remove its source, which is the appendix.
To emphasize, a patient strongly suspected to have a right lower quadrant intraabdominal abscess,
which could be an appendiceal abscess, should be subjected to an operation as soon as possible and not
to an initial medical treatment followed by the so-called interval appendectomy. An early surgical
operation is not only safe, it is also cost-effective. It establishes the definitive diagnosis and cures the
condition at the earliest and shortest time possible and with lesser expense. There is no delay in
diagnosis and treatment if the abdominal disorder turns out to be something other than an appendiceal
abscess and a surgical condition at that.
Preoperative preparations for patients suspected to have acute appendicitis and appendiceal abscess
include the following:
1. No oral intake
2. Intravenous fluids
3. Preop antibiotics
4. Other preop preparations, checking and support
The essential operative steps in patients with acute appendicitis with nongeneralized peritonitis
consist of the following:
Incision
Transverse right lower quadrant incision
Intraoperative evaluation
Appendectomy
Secured ligation of appendiceal stump with or without cecal burial
Cleansing and diluting of exudates
Sponging
Irrigating
Wound closure
Leaving subcutaneous and skin layers unsutured in the presence of heavy contamination, gangrenous, and
perforated appendicitis
The essential operative steps in patients with acute appendicitis with generalized peritonitis consist
of the following:
Incision
Long transverse incision, initially at the right lower quadrant extending towards the left as necessary
Intraoperative evaluation
Appendectomy
Copious peritoneal lavage
Wound closure
Leave subcutaneous and skin layers unsutured
The essential operative steps in patients with appendiceal abscess consist of the following:
Incision
Transverse right lower quadrant incision over the palpable mass
Intraoperative evaluation
Evacuation of purulent content of the abscess
Appendectomy
Look for the appendix by palpation
Copious lavage of the abscess cavity
Leaving of wound open, all layers
The incision is a transverse one in all patients suspected of having acute appendicitis. In such patients
because of unavoidable contamination of the wounds created on the abdominal wall to get to the inflamed
appendix, the wounds are usually best left open. Transverse incisional wounds left open are faster to heal
and their scars are more superior than vertical incisional wounds left to heal by secondary intention.
The intraoperative evaluation in patients suspected to have acute appendicitis consists initially of
confirming or disproving the preoperative suspicion.
An inspection of the appendix can lead to a definitive diagnosis of acute appendicitis. The presence
of suppurative fibrin on the wall of the appendix, gangrene, and perforation are diagnostic of suppurative
appendicitis, gangrenous appendicitis, and perforated appendicitis respectively. The presence of an
abscess around the appendix is diagnostic of appendiceal abscess. The presence of omentum enveloping
the appendix is diagnostic of appendicitis.
"Congestion" of the appendix is not diagnostic of appendicitis, although acute appendicitis may be
really present. The only way to establish whether a "congested appendix" is acute appendicitis is to
subject it to a microscopic examination. The presence of polymorphonuclear leukocytosis in the
submuscularis layer is diagnostic of acute appendicitis.
In the absence of obvious signs of acute appendicitis, the surgeon should look for an explanation of the
abdominal pain. Looking for an explanation of the abdominal pain does not always mean the surgeon
has to enlarge the incision to explore the entire abdominal cavity.
If a right lower quadrant incision has been utilized, if after examining the appendix, there are no obvious
signs of acute appendicitis, the surgeon should determine whether abnormal peritoneal fluids are
present or not. Abnormal peritoneal fluids are more often suppurative exudates and blood. If these
abnormal fluids are present, the surgeon should go all out to look for their source. He may have to
lengthen the incision if necessary.
If there are no abnormal peritoneal fluids, then the surgeon should evaluate at least the distal ileum to look
for a rare Meckel's diverticulitis; the mesentery of the distal ileum to look for abnormally enlarged
lymph nodes or masses; the uterus; the ovaries and the fallopian tubes, especially on the right side; the
cecum; and other structures located in the right lower quadrant area where there was tenderness
preoperatively.
If there is a surgical condition other than acute appendicitis, then it is treated accordingly. If the
abdomen turns out to be nonsurgical, an incidental appendectomy can be done if there is an informed
consent.
An abdominal wound created to take out an inflamed appendix may or may not be closed completely.
However, the best preventive measure against wound infection in such a situation is to leave the
subcutaneous and skin layers unsutured (NOT ANTIBIOTICS). This is strongly recommended for
gangrenous and perforated appendicitis, appendiceal abscess, and wounds that are heavily contaminated.
For suppurative appendicitis, the best protective measure against wound infection is still leaving the
subcutaneous and skin layers unsutured. However some patients may not like to see an open wound and
the incidence of wound infection with complete closure is not very common. The wound can be closed
completely but loosely, if there is minimal suppuration and minimal contamination of the wound.
Appendicitis is an example of inflammatory bowel disease. Other inflammatory bowel diseases consist
of the diverticulitis ( Meckel's and colonic). the enteritis, and the colitis.
Among the four inflammatory bowel diseases mentioned above, appendicitis is the most common and it is
one that once suspected clinically, calls for an exploratory laparotomy. Diverticulitis, enteritis, and colitis,
on the other hand, are not as common, are usually initially treated medically, and are treated only
surgically when with complications such as perforation and gangrene.
A specific diagnosis of complicated diverticulitis, enteritis, and colitis is difficult to make, short
of a laparoscopy or laparotomy. One usually starts off with a diagnosis of acute nontraumatic
surgical abdomen which leads to an exploratory laparotomy. The latter is the one that provides the
specific diagnosis of a complicated diverticulitis, enteritis, and colitis.
Clinically, however, there are clues to suspect some of the conditions. A right lower quadrant tenderness
will make one suspect acute appendicitis. A left lower quadrant tenderness will make one suspect left
colonic diverticulitis.
Meckel's diverticulitis will usually present with right lower quadrant problem. However, since it is
rare and since acute appendicitis is very common, one does not usually give out an impression of
Meckel's diverticulitis.
Complicated enteritis and colitis usually present with generalized abdominal tenderness that a specific
diagnosis based on abdominal findings is difficult. One has to rely on other data such as diarrhea,
dysentery, fever prior to onset of abdominal pain, and age. A newborn is more susceptible to
necrotizing enterocolitis.
As far as operative treatment of complicated diverticulitis, enteritis, and colitis (necrotizing, perforated,
and bleeding), the essential treatment is a resection. If a resection cannot be performed, then a diverting
enterostomy or colostomy is done. The primary objective of an operative procedure for complicated
inflammatory bowel diseases is to control the peritonitis.
The primary bases for suspecting a perforated peptic ulcer are the following:
1. Antibiotics
2. Analgesics
3. Diet
4. Watching out for complications
5. Antipeptic ulcer medications
The primary bases for suspecting a perforated typhoid ileitis are the following:
1. No oral intake
2. Analgesics
3. Antibiotics
1. Antibiotics
2. Analgesics
3. Diet
4. Watching out for complications
E. PERFORATED LARGE BOWELS OF WHATEVER ETIOLOGY
The primary bases for suspecting a perforated large bowel are the following:
1. No oral intake
2. Analgesics
3. Antibiotics
1. Antibiotics
2. Analgesics
3. Diet
4. Watching out for complications
5. Closure of colostomy
F. ACUTE CHOLECYSTITIS
The primary basis for suspecting acute cholecystitis is a direct right upper quadrant abdominal
tenderness in an adult patient. This suspect of acute cholecystitis has to be confirmed before an
operation is undertaken. This can be done through an ultrasound of the gallbladder. The finding of
gallstone(s) is a go-signal for operation on patients with a right upper quadrant tenderness that is suspected
to be due to acute cholecystitis. If ultrasound is not available, the following are used as bases to suspect a
surgical cholecystitis:
1. No oral intake
2. Analgesics
3. Antibiotics
1. Analgesics
2. Antibiotics
3. Diet
4. Watching out for complications
G. ACUTE PANCREATITIS
The primary basis for suspecting acute pancreatitis is a sudden severe epigastric pain and tenderness in
an adult patient. The suspect of acute pancreatitis may be confirmed through a serum amylase
determination. A marked elevation of the serum amylase is highly suspicious of acute pancreatitis.
Acute pancreatitis may be treated nonsurgically. Indications for exploratory laparotomy are signs
of peritoneal irritation and a tender mass suspicious of pancreatic abscess.
1. No oral intake
2. Analgesics
3. Antibiotics
4. Nasogastric tube decompression of stomach
5. Fluid and electrolyte maintenance
6. Monitoring for surgical pancreatitis
The essential steps in the operation of surgical pancreatitits are the following:
1. Analgesics
2. Antibiotics
3. Nutrition
3.1 Intravenous alimentation
3.2 Enteral alimentation
4. Fluid and electrolyte maintenance
5. Watching out for complications
H. INTRAABDOMINAL ABSCESS
1. Appendiceal abscess
2. Colonic diverticular abscess
3. Pelvic inflammatory disease with abscess formation
4. Pancreatic abscess
5. Liver abscess
5.1 Pyogenic
5.2 Amebic
A suspected intraabdominal abscess in the right lower quadrant is most likely an appendiceal abscess.
A suspected intraabdominal abscess in the left lower quadrant is most likely a left colonic diverticular
abscess.
A suspected pelvic abscess in a female is most likely part and parcel of a pelvic inflammatory disease.
A suspected intraabdominal abscess in the left upper quadrant is most likely a pancreatic abscess.
A suspected intraabdominal abscess in the right upper quadrant is most likely a liver abscess.
To firm up the clinical suspicion of an intraabdominal abscess, an ultrasound, an upright abdominal x-ray,
and even a needle aspiration can be done.
Except for an amebic liver abscess, the primary treatment of all intraabdominal abscesses is an operation.
A medical therapy is the initial treatment for amebic liver abscess. If this fails, then an operation is
needed.
The operation consists of an open drainage of the abscess and controlling the source of the abscess.
For diverticular abscess, open drainage and colonic resection are done with protective colostomy.
For pelvic abscess in females, open drainage may have to be done if conservative measures fail. A total
hysterectomy and bilateral salpingo-oophorectomy may be indicated.
For pyogenic liver abscess, open drainage and removal of the stones in the common bile duct, which is the
culprit, are done.
MANAGEMENT OF PATIENTS WITH HOLLOW VISCERAL OBSTRUCTION
One manner of presentation of patients with acute nontraumatic surgical abdomen is with signs
and symptoms of mechanical hollow visceral obstruction. For conscious patients, the most notable
symptom of a hollow visceral obstruction is a colicky abdominal pain.
There are two categories of hollow visceral obstruction. These are, namely:
The primary bases for suspecting mechanical gastrointestinal tract obstruction are the following:
Numbers 1 to 6 are clinical signs of mechanical gastrointestinal tract obstruction while numbers 7
and 8 are radiologic signs. A plain supine abdominal X-ray is usually done to firm up the clinical
suspicion of gastrointestinal tract obstruction. An upright film of the abdomen in patients with
suspected gastrointestinal tract obstruction is not needed because it does not add more significant
information than what can be obtained from the plain supine abdominal X-ray correlated with the clinical
findings. The only information that is looked for in upright abdominal X-ray in patients with
suspected intestinal obstruction is an air-fluid level. By the time the air-fluid level is present in the
upright film, the diagnosis of mechanical gastrointestinal tract obstruction is already obvious just from the
clinical findings and the findings from the supine film. Besides, air-fluid level is not pathognomonic
of mechanical gastrointestinal tract obstruction. It can also be seen in ileus.
There are a lot of information that can be gotten from the plain supine film. The following may be present:
The presence of distention and a cut-off sign together with the clinical signs are diagnostic of mechanical
gastrointestinal tract obstruction. Beside suggesting the presence of mechanical intestinal obstruction, the
plain supine film can also suggest the possible etiology. This is suggested through the level of
obstruction correlated with the most common cause of obstruction at that level and correlated with the age
of the patient. In the newborn, the presence of obstruction at the jejunal level will suggest jejunal atresia
and at the ileal level, ileal atresia. In the adults, in a young Filipino patient, the presence of
obstruction at the ileocecal level will suggest the tuberculosis as the cause.
Barium instillation of the gastrointestinal tract may be done if necessary. It is done in situations in
which the diagnosis of obstruction is still equivocal despite monitoring of the clinical signs and serial plain
abdominal X-rays. It is done in the newborn and pediatric patients for early diagnosis of
intussusception, Hirchsprung's disease, and other causes of gastrointestinal tract obstruction. The
barium may be instilled antegradely or retrogradely through the gastrointestinal tract. It is
contraindicated in patients with frank signs of peritonitis. If the procedure is done, the surgeon should
be at hand ready to operate when complication of the procedure arises.
An entity which has to be differentiated from mechanical intestinal obstruction is ileus. Ileus is
suspected if the following are present:
1. Presence of gas throughout the length of the gastrointestinal tract on plain supine film of the
abdomen without a cut-off distension sign
2. Ballooned rectal vault
3. Hypoactive bowel sounds
Patients with mechanical intestinal obstruction will present with signs and symptoms corresponding to
the degree of the mechanical obstruction, either incomplete or complete. They will also present with
signs and symptoms corresponding to whether strangulation and rupture have occurred or not.
As a rule, early, incomplete, nonstrangulated mechanical gastrointestinal tract obstructions are harder to
diagnose than complete, nonstrangulated and strangulated obstructions. Thus, for the early,
incomplete, nonstrangulated obstructions, monitoring is very important. A maneuver which can be
done is bring out the diagnosis during the monitoring. In patients in which the diagnosis of intestinal
obstruction is equivocal, oral feeding may be continued. This maneuver will rule in or rule out
intestinal obstruction in the shortest time possible. The insertion of a nasogastric tube in such patients
will not help in bringing out the true diagnosis.
Once a diagnosis of mechanical gastrointestinal tract obstruction is made, efforts must be made to
determine the following:
1. Is there frank strangulation? The earliest sign of strangulation is definite direct tenderness. The late
signs are the signs of generalized peritonitis. If signs of strangulation are present, the operation is done as
soon as possible. If there are no signs yet of peritoneal irritation, if the diagnosis of mechanical
gastrointestinal obstruction is made, operation is also done as soon as possible before strangulation
and malnutrition set in.
2. What is the possible etiology? Hernia, if present, can be a cause. Adhesions as a cause is
considered if the patient has a previous abdominal operation. If there is no previous abdominal
operation, the suspected level of obstruction as gotten from the plain supine film of the abdomen, the age
of the patient, and other data from the history and physical examination may give a clue. Knowing
the possible etiology preoperatively is very important because it may influence the decision-making on
the type of treatment and what incision to use. For example, there is a tendency toward conservatism in
patients with adhesions. If an inguinal hernia is the cause of the obstruction, treating the hernia
through an inguinal incision can be performed. If the obstruction is due to a left-sided colonic cancer,
a loop transverse colostomy may be performed through an incision at the upper quadrants rather than
an outright formal exploratory laparotomy.
If the etiology is not known and if there are signs of strangulation and generalized peritonitis,
regardless of the cause, known or unknown, a formal exploratory laparotomy is done.
The preoperative preparations in patients with mechanical gastrointestinal tract obstruction consist of and
should consider the following:
1. No oral intake
2. Fluid and electrolyte maintenance
3. Antibiotics
4. Analgesics
5. Nasogastric tube insertion
The essential steps in the formal exploratory laparotomy for patients with mechanical gastrointestinal
tract obstruction consist of the following:
1. Analgesics
2. Antibiotics
3. Fluid and electrolyte maintenance
4. Diet
5. Watching out for complications
6. Closure of colostomy
7. Definitive operation
The cystic duct of the gallbladder can be obstructed by stones to cause cholecystitis. The common
bile duct can be obstructed by stones to cause cholangitis.
The primary bases for suspecting biliary tract obstruction consist of the following:
The essential steps of the operation in patients with biliary tract obstruction consist of the following:
1. Analgesics
2. Antibiotics
3. Diet
4. Watching out for complication
5. Decision of reoperation in patients with residual stones
MANAGEMENT OF PATIENTS WITH GASTROINTESTINAL BLEEDING
Reynaldo O. Joson, MD, DPBS
1991;2000
One manner of presentation of patients with acute nontraumatic abdomen is with signs of gastrointestinal
bleeding. The patients may present with hematemesis or hematochezia.
The approach to patients with hematemesis and hematochezia consists of deciding on the following issues:
Hematemesis is present if there is a vomitus of fresh blood. Hematochezia is present if there is a passage of
bloody stools. At the first encounter between the physician and the patient, there may be no frank
evidence of hematemesis or hematochezia. A nasogastric tube may be inserted and a rectal
examination performed to investigate the complaint of hematemesis or hematochezia. The finding of
fresh blood within the nasogastric tube supports the presence of hematemesis while the presence of
fresh blood on rectal examination, hematochezia.
On the initial evaluation, the presence of signs of hypovolemic shock (hypotension and tachycardia)
suggests that massive bleeding had taken place. So is the presence of pallor.
Monitoring can also answer the question whether the bleeding is profused and continuous. The drainage
through the nasogastric tube and the anus can be monitored. So are the vital signs.
The presence of profuse and continuous bleeding dictates that the physician has to act fast in the
management of the patient.
Hematemesis, fresh blood in the nasogastric tube, and melena point to a bleeding in the upper
gastrointestinal tract. The more common causes are bleeding esophageal varices, bleeding
peptic ulcer, gastritis, and gastric cancer.
Hematochezia points to a bleeding in the lower gastrointestinal tract. The more common causes are
bleeding from a colitis, rectal cancer, and hemorrhoids.
Bleeding can originate at any level of the gastrointestinal tract and it can be due to a myriad of causes.
To make the evaluation a little easier, the bleeding is first classified into upper and lower gastrointestinal
bleeding. Under each category is a list of all the possible and the more common causes. Using the data
in the interview and physical examination of a particular patient, the most probable diagnosis is
arrived at.
Aside from interview and physical examination, laboratory examinations, diagnostic procedures, and
monitoring are utilized as indicated in the evaluation of patients with gastrointestinal bleeding.
Endoscopy, barium studies, angiography, and scanning are used as indicated and as available.
The causes of gastrointestinal bleeding can be categorized into two big groups in terms of treatment. One
group consists of those conditions which are outright surgical disorders upon diagnosis. This means,
that for these disorders, surgery is the treatment of choice. Examples under this group are the bleeding
tumors, the bleeding esophageal varices, the bleeding hemorrhoids, and the bleeding arteriovenous
malformations.
The second group consists of those conditions which are considered bleeding complications of medical
disorders. Examples are bleeding gastritis, bleeding peptic ulcer, and bleeding colitis. These medical
disorders can become surgical disorders because of the bleeding problem. In these cases, nonsurgical
measures are tried out first. If these measures fail, surgery is inidcated, especially if the bleeding is
continuous and massive to the point that the life of the patient is threatened.
1. No oral intake
2. Insertion of nasogastric tube for gastric lavage
3. Antibiotics
4. Blood transfusion
5. Blood for use during surgery
1. Analgesics
2. Antibiotics
3. Diet
4. Fluid and electrolyte maintenance
5. Blood volume maintenance
6. Watching out for rebleeding
7. Watching out for complications of the surgical procedures performed