D|agnos|s and Management of D|agnos|s and Management of

Acute Abdom|na| a|n Acute Abdom|na| a|n

Dr sh|rzad Nas|r|
Ass|stant professor of genera| surgery
Shar|at| nosp|ta|
"1he term "ocute obdomen" shou/d never be
equoted with the invoriob/e need for operotion
t |s |mportant to make a d|agnos|s ear|y
Lxc|ude med|ca| d|seases
1000 causes ex|st
NSA (34)
Acute append|c|t|s (28)
Acute ch|ecyst|t|s (10)
S8C (4)
erforated U (3)
ancreat|t|s (3)
D|vert|cu|ar d|sease (2)
Cthers (13)
2040 adm|ss|on rates
S06S |naccurate |n|t|a| d|agnos|s
Non operative
Discharge
Active observation
Emergent ('surgery now')
Urgent ('surgery today')
Semi-urgent ('surgery tomorrow')
istory 65 %
CIinicaI Examination 15 %
SpeciaI investigations 10%
ExpIoration, Post mortem 5-10%
24 yo hea|thy M w|th one day hx of abdom|na|
pa|n a|n was genera||zed at f|rst now worse
|n r|ght |ower abd rad|ates to h|s r|ght gro|n
ne has vom|ted tw|ce today Den|es any
d|arrhea fevers dysur|a or other comp|a|nts
No appet|te today kCS otherw|se negat|ve
Mnx negat|ve
Surgnx negat|ve
Meds none
Soc|a| hx no a|coho| tobacco or drug use
Iam||y hx noncontr|butory
Jhat e|se do you want to know?
Jhat |s on your d|fferent|a| d|agnos|s so far?
(healLhy male wlLh 8LC abd paln)
now do you approach the comp|a|nt of
abdom|na| pa|n |n genera|?
Let's rev|ew |n th|s |ecture
1ypes of pa|n
n|story and phys|ca| exam|nat|on
Labs and |mag|ng
C||n|ca| pear|s to he|p you |n the LD
#1e|| me more about your pa|n"
nave a rout|ne method of tak|ng a h|story
CkS1
Cnset
rovocat|on
ua||ty
kad|at|on
Sever|ty
1|m|ng
Ask about vom|t|ng bowe| funct|on b|eed|ng
anorex|a menstruat|on
Make sure to ask about
r|or ep|sodes of s|m||ar comp|a|nts
r|or abdom|na| surger|es
UD d|vert|cu|ar d|sease cho|e||th|as|s
nephro||th|as|s
Med|cat|ons stero|ds NSADS
I|scera|
nvolves hollow or solld organs mldllne paln due Lo bllaLeral
lnnvervaLlon
SLeady ache or vague dlscomforL Lo excruclaLlng or collcky paln
oorly locallzed
LplgasLrlc reglon sLomach duodenum blllary LracL
erlumblllcal small bowel appendlx cecum
Suprapublc colon slgmold Cu LracL
ar|eta|
nvolves parleLal perlLoneum
Locallzed paln
Causes Lenderness and guardlng whlch progress Lo rlgldlLy and
rebound as perlLonlLls develops
keferred
roduces sympLoms noL slgns
8ased on developmenLal embryology
ureLeral obsLrucLlon LesLlcular paln
SubdlaphragmaLlc lrrlLaLlon lpsllaLeral shoulder or
supraclavlcular paln
Cynecologlc paLhology back or proxlmal lower
exLremlLy
8lllary dlsease rlghL lnfrascapular paln
M eplgasLrlc neck [aw or upper exLremlLy paln
1ypes of a|n
I|scera|
nvolves hollow or solld organs mldllne paln due Lo bllaLeral
lnnvervaLlon
SLeady ache or vague dlscomforL Lo excruclaLlng or collcky paln
oorly locallzed
LplgasLrlc reglon sLomach duodenum blllary LracL
erlumblllcal small bowel appendlx cecum
Suprapublc colon slgmold Cu LracL
ar|eta|
nvolves parleLal perlLoneum
Locallzed paln
Causes Lenderness and guardlng whlch progress Lo rlgldlLy and rebound
as perlLonlLls develops
keferred
roduces sympLoms noL slgns
8ased on developmenLal embryology
ureLeral obsLrucLlon LesLlcular paln
SubdlaphragmaLlc lrrlLaLlon lpsllaLeral shoulder or
supraclavlcular paln
Cynecologlc paLhology back or proxlmal lower exLremlLy
8lllary dlsease rlghL lnfrascapular paln
M eplgasLrlc neck [aw or upper exLremlLy paln
Jhat k|nd of pa|n |s |t?
I|scera| pa|n
D|stent|on |nf|ammat|on
or |schaem|a |n ho||ow
v|scous so||d organs
Loca||sat|on depends on
the embryo|og|c or|g|n of
the organ
Iorgut to ep|gastr|um
M|dgut to umb|||cus
n|ndgut to the
hypogastr|c reg|on
ar|eta| pa|n
|s |oca||sed to the
dermatome above the s|te
of the st|mu|us
keferred pa|n
produces symptoms not
s|gns eg tenderness
Progression from:
DuII, aching, poorIy IocaIized character
To:
Sharp, constant & better IocaIized pain
indicates invoIvement of ParietaI peritoneum
Progression of Pain
Cho|ecyst|t|s k scapu|a
Append|c|t|s per|umb|||ca|
ancreat|t|s back
kecta| d|sease back
Nephro||th|as|s f|ank
D|aphragm |rr|tat|on shou|der
keferred a|n
1wo approaches to eva|uate pts w|th
acute abdom|na| pa|n
1 C|ass|f|cat|on of abd pa|n |nto
systems
2 Abdom|na| 1opography (4 quadrants)
enera||zed A
erforat|on
AAA
Acute pancreat|t|s
8||atera| p|eur|sy
Centra| A
Lar|y append|c|t|s
S8C
Acute gastr|t|s
Acute pancreat|t|s
kuptured AAA
Mesenter|c
thrombos|s
Lp|gastr|c pa|n
DU ] U
Cesophag|t|s
Acute pancreat|t|s
AAA
kU pa|n
a||b|adder d|sease
DU
Acute pancreat|t|s
neumon|a
Subphren|c abscess
LU pa|n
U
neumon|a
Acute pancreat|t|s
Spontaneous sp|en|c
rupture
Acute per|nephr|t|s
Subphren|c abscess
kI pa|n
Acute append|c|t|s
Mesenter|c aden|t|s (young)
erf DU
D|vert|cu||t|s
D
Sa|p|ng|t|s
Ureter|c co||c
Mecke|'s d|vert|cu|um
Lctop|c pregnancy
Crohn's d|sease
8|||ary co||c (|ow|y|ng ga||
b|adder)
Lo|n pa|n
Musc|e stra|n
U1s
kena| stones
ye|onephr|t|s
LI pa|n
D|vert|cu||t|s
Const|pat|on
8S
D
kecta| Ca
UC
Lctop|c
pregnancy
1 ntraabdom|na| (ar|s|ng from w|th|n the abd cav|ty ]
retroper|toneum) |nvo|ves
C (AppendlclLls ulverLlcullLls eLc)
Cu (8enal Collc eLc)
Cyn (AcuLe u regnancy eLc)
vascular sysLems (AAA MesenLerlc schemla eLc)
2 Lxtraabdom|na| (|ess common) |nvo|ves
Cardlopulmonary (AM eLc)
Abdomlnal wall (Pernla ZosLer eLc)
1oxlcmeLabollc (ukA lead eLc)
neurogenlc paln (ZosLer eLc)
sychlc (AnxleLy uepresslon eLc)
3 Nonspec|f|c Abd pa|n not we|| exp|a|ned or descr|bed
1hree ma|n categor|es of abdom|na|
pa|n
C|ass|f|cat|on by nature
Co||cky pa|n
8S
8owel obsLrucLlon
Stabb|ng
AAA
8urn|ng or bor|ng
uu
CesophaglLls
naw|ng
ancreaLlLls
ancreaLlc Ca
Aggravat|ng and ke||ev|ng factors
erlLonlLls lle moLlonless
8enal collc unable Lo flnd comforLable
poslLlon
laLLy foods blllary collc
aln lmproves wlLh eaLlng uu
Worse wlLh eaLlng Cu mesenLerlc
lschemla
CbLalnlng a hlsLory
Mn
bowel obsLrucLlon renal collc u Lend Lo recur
kCS
fever chllls lnfecLlous
nausea vomlLlng wlLh no flaLus bowel
obsLrucLlon
dysurla pregnancy mensLrual hlsLory
Ask about re|evant kCS
symptoms
nausea vomlLlng hemaLemesls anorexla
dlarrhea consLlpaLlon bloody sLools melena
sLools
U symptoms
uysurla frequency urgency hemaLurla
lnconLlnence
yn symptoms
vaglnal dlscharge vaglnal bleedlng
enera|
lever llghLheadedness
Pain first, foIIowed by Vomiting is
usuaIIy surgicaI.
The vomiting is due to 'refIex
pyIorospasm'
Nausea & vomiting first , foIIowed by
pain is usuaIIy due to a medicaI
condition
NAUSEA & VOMITING
hys|ca| exam|nat|on
Cbservat|on
8end|ng Iorward Chronlc
ancreaLlLls
Iaund|ced C8u obsLrucLlon
Dehydrated erlLonlLls Small 8owel
obsLrucLlon
Abdomen
nspect|on
Scaphold or flaL ln pepLlc ulcer
ulsLended ln asclLes or lnLesLlnal obsLrucLlon
vlslble perlsLalsls ln a Lhln or malnourlshed
paLlenL (wlLh obsLrucLlon)
Auscu|tat|on
8S
2mln Lo conflrm absenL
8rulL ln eplgasLrlum
a|pat|on
Check for Pernla slLes
1enderness
8ebound Lenderness
Cuardlng lnvolunLary spasm of
muscles durlng palpaLlon
8lgldlLy when abdomlnal muscles
are Lense boardllke ndlcaLes
perlLonlLls
Loca| k|ght ||ac Iossa tenderness
AcuLe appendlclLls
AcuLe SalplnglLls ln females
Low grade poor|y |oca||zed tenderness
nLesLlnal CbsLrucLlon
1enderness out of proport|on to
exam|nat|on
MesenLerlc schemla
AcuLe ancreaLlLls
I|ank 1enderness
erlnephrlc Abscess
8eLrocaecal AppendlclLls
Important Signs in Patients with AbdominaI Pain
Sign Finding Association
ullen's sign
Bluish periumbilical
discoloration
Retroperitoneal haemorrhage
Kehr's sign
Severe left shoulder pain Splenic rupture
Ectopic pregnancy rupture
McBurney's sign
Tenderness located 2/3 distance from
anterior iliac spine to umbilicus on right side Appendicitis
Murphy's sign
Abrupt interruption of inspiration on palpation
of right upper quadrant
Acute cholecystitis
liopsoas sign
Hyperextension of right hip causing abdominal pain Appendicitis
Obturator's sign
nternal rotation of flexed right hip causing
abdominal pain
Appendicitis
Grey-Turner's
sign
Discoloration of the flank Retroperitoneal haemorrhage
handelier sign
Manipulation of cervix causes patient to lift
buttocks off table
Pelvic inflammatory disease
Rovsing's sign
Right lower quadrant pain with palpation of
the left lower quadrant
Appendicitis
Psoas Sign
Psoas Sign
PassiveIy fIex
right hip and knee
then internaIIy
rotate the hip
Obturator Sign
1k Lxam|nat|on
tenderness
|ndurat|on
mass
frank b|ood
I Lxam|nat|on
8|eed|ng
D|scharge
Cerv|ca| mot|on tenderness
Adnexa| masses or
tenderness
Uter|ne S|ze or Contour
8ebound Lenderness consldered Lhe cllnlcal
lndlcaLor of perlLonlLls has a hlgh (23) false
neg 8aLe
8lgldlLy referred Lenderness cough paln are
sufflclenL evldence for perlLonlLls
AdmlnlsLraLlon of analgeslcs prlor Lo surglcal
consulLaLlon does noL obscure Lhe dlagnosls
notes
Labs mag|ng
Test Reason
B w diff
Left shift can be
very telling
BMP
N/V, lytes,
acidosis,
dehydration
Amylase
Pancreatitis,
perf DU, bowel
ischemia
LFT
Jaundice,hepati
tis
UA
GU- UT, stone,
hematuria
Beta-hG
Ectopic
Test Reason
KUB
Flat & Upright
SBO/LBO,
free air,
stones
Ultrasound
hol'y, jaundice
GYN pathology
CT scan
-Diagnostic
accuracy
Anatomic dx
ase not
straightforward
D|agnost|c mag|ng
|a|n I||m
Conslder erecL chesL xray
Conslder abdomen (wlll lL really make a dlfference? )
U|trasound
for paLlenLs wlLh blllary or pelvlc sympLoms
C1 Abdomen and e|v|s
evaluaLes vasculaLure lnflammaLlon and solld organs
Gastritis, ileitis, colitis, esophagitis
Ulcers: gastric, peptic, esophageal
Biliary disease: cholelithiasis, cholecystitis
Hepatitis, pancreatitis, holangitis
Splenic infarct, Splenic rupture
Pancreatic psuedocyst
Hollow viscous perforation
Bowel obstruction, volvulus
Diverticulitis
Appendicitis
Ovarian cyst
Ovarian torsion
Hernias: incarcerated, strangulated
Kidney stones
Pyelonephritis
Hydronephrosis
nflammatory bowel disease: crohns, U
Gastroenteritis, enterocolitis
pseudomembranous colitis, ischemia colitis
Tumors: carcinomas, lipomas
Meckels diverticulum
Testicular torsion
Epididymitis, prostatitis, orchitis, cystitis
onstipation
Abdominal aortic aneurysm, ruptures aneurysm
Aortic dissection
Mesenteric ischemia
Organomegaly
Hemilith infestation
Porphyrias
AS
Pneumonia
Abdominal wall syndromes: muscle strain, hematomas,
trauma,
Neuropathic causes: radicular pain
Non-specific abdominal pain
Group A beta-hemolytic streptococcal pharyngitis
Rocky Mountain Spotted Fever
Toxic Shock Syndrome
Black widow envenomation
Drugs: cocaine induced-ischemia, erythromycin,
tetracyclines, NSADs
Mercury salts
Acute inorganic lead poisoning
Electrical injury
Opioid withdrawal
Mushroom toxicity
AGA: DKA, AKA
Adrenal crisis
Thyroid storm
Hypo- and hypercalcemia
Sickle cell crisis
Vasculitis
rritable bowel syndrome
Ectopic pregnancy
PD
Urinary retention
leus, Ogilvie syndrome
DifferentiaI Diagnosis
Non-specific abd pain 34%
Appendicitis 28%
BiIiary tract 10%
SBO 4%
Gyn disease 4%
Pancreatitis 3%
RenaI coIic 3%
Perforated uIcer 3%
Cancer 2%
DiverticuIar 2%
Other 6%
Most Common Causes in the ED
Non-specific abdominaI pain
No source is identified
Vital signs are normal
Non specific abdominal exam,
no evidence of peritonitis or
severe pain
Patient improves during ED visit
Patient able to take fluids
Have patient return to ED in 12-
24 hours for re-examination if not
better or if they develop new
symptoms
System Disease System Disease
ardiac
Myocardial infarction
Acute pericarditis
Endocrine
Diab ketoacidosis
Addisonian crisis
Pulmonary
Pneumonia
Pulmonary infarction
PE
Metabolic
Acute porphyria
Mediterranean fever
Hyperlipidemia
G
Acute pancreatitis
Gastroenteritis
Acute hepatitis
Musculo-
skeletal
Rectus muscle
hematoma
GU
Pyelonephritis
NS
PNS
Tabes dorsalis (syph)
Nerve root
compression
Vascular
Aortic dissection
Heme
Sickle cell crisis
Non-SurgicaI Causes by Systems
Peritonitis
Tenderness w/ rebound, involuntary guarding
Severe / unreIenting pain
"UnstabIe" (hemodynamically, or septic)
Tachycardic, hypotensive, white count
IntestinaI ischemia, including strangulation
Pneumoperitoneum
CompIete or "high grade" obstruction
Decision to operate
peritonitis
Peritonitis
Infection, or rarely some other type of
inflammation, of the peritoneum.
Peritoneum is a membrane that covers the
surface of both the organs that lie in the
abdominal cavity and the inner surface of
the abdominal cavity itself.
Early or diffuse infection results in localized
or generalized peritonitis.
Late and localized infections produces an
intra-abdominal abscess.
Intra-abdominaI infections resuIt in 2
major cIinicaI manifestations
Primary the peritoneal infection is not directly
related to other intra-abdominal abnormalities.
Secondary an intra-abdominal process, such
as a ruptured appendix or a perforated peptic
ulcer, is evident.
Tertiary a later stage of the disease, when
clinical peritonitis and signs of sepsis persist
after treatment for secondary peritonitis, and no
pathogens or only low-grade pathogens are
isolated from the peritoneal exudate.
Infective peritonitis
Primary peritonitis, sometimes
referred to as spontaneous
bacteriaI peritonitis (SBP): infection
of the peritoneaI cavity without an
evident source.
Primary: aused by the spread of an
infection from the blood & lymph nodes to
the peritoneum. Very rare < 1%
Usually occurs in people who have an
accumulation of fluid in their abdomens
(ascites).
The fluid that accumulates creates a good
environment for the growth of bacteria.
Several decades ago, the organisms reported to
cause primary peritonitis in children were
Streptococcus Streptococcus pneumoniae pneumoniae and group A and group A
streptococci streptococci.
By the 1970s the number of nephrotic children with
streptococcal peritonitis had declined.
The relative frequency of peritonitis caused by gram gram- -
negative enteric bacilli negative enteric bacilli had increased.
n cirrhotic patients, microorganisms presumably of
enteric origin account for up to 69% enteric origin account for up to 69% of the
pathogens.
BacterioIogic Characteristics
E coli E coli is the most frequently recovered pathogen,
followed by Klebsiella Klebsiella pneumoniae, S.
pneumoniae, and other streptococcal species,
including enterococci enterococci..
Anaerobes Anaerobes and microaerophilic organisms are
infrequently infrequently reported.
n one series, sterile cultures occurred in 35% sterile cultures occurred in 35% of
patients with clinical findings consistent with
primary peritonitis.
Blood cultures Blood cultures were positive in one third one third of
these patients.
The frequency of culture-negative ascitic
fluid may be decreased by inoculating inoculating
blood blood- -cultured bottles with cultured bottles with ascitic ascitic fluid fluid at
the bedside.
Bacteremia Bacteremia is present in up to 75% is present in up to 75% of
patients with primary peritonitis caused by
aerobic bacteria.
The onset may be insidious, and findings
of peritoneal irritation may be absent in an
abdomen distended with ascites.
Fever (>37.8 [100F]) is the most
common presenting sign, 50 to 80%, and
may be present without without abdominal signs
or symptoms.
The ascitic fluid protein concentration may
be low because of
(1) hypoalbuminemia and
(2) dilution of ascitic fluid with
transudate from the portal system when
there is cirrhosis or the portal vein is
obstructed.
The WB in peritoneal fluid usually is greater
than 300 cells/mm3 300 cells/mm3 (in 85% of cases,
>1000/mm3), with PMN predominating in > 80%
of cases.
Ascitic fluid pH < 7.35 and a lactate > 25 pH < 7.35 and a lactate > 25 mg/dl
were more specific but less sensitive than a
WB> 500 cells/mm3
using all three parameters together
increased the diagnostic accuracy.
Gram staining Gram staining of the sediment, when
positive, is diagnostic, but it is negative in 60 negative in 60
to 80% to 80% of patients with cirrhosis and ascites.
Oral and intravenous contrast with T scanning
has greatly enhanced detection of intra-
abdominal sources of peritonitis.
Patients with primary peritonitis usually respond respond
within 48 to 72 hours within 48 to 72 hours to appropriate antimicrobial
therapy.
An exponential rate of decline in the number of decline in the number of
ascitic ascitic fluid leukocytes fluid leukocytes after the initiation of
antimicrobial therapy for primary peritonitis
differentiate primary from secondary bacterial differentiate primary from secondary bacterial
peritonitis peritonitis
Diagnosis
Paracentesis for smear and culture is
indicated in all cirrhotic patients with
ascites and in children with gross
proteinuria and abdominal pain.
However, paracentesis is not without
hazard.
Major complications include perforation of
the bowel with generalized peritonitis or
abdominal wall abscess and serious
hemorrhage.
Cover enteric bacteria (mainIy GNB) and
S pneumoniae.
3
rd
gen cephaIosporin
Carbapenem
%otal duration of 14 days
Treatment
Secondary: aused by the entry of
bacteria or enzymes into the peritoneum
from the gastrointestinal or biliary tract.
This can be caused due to an ulcer eating
its way through stomach wall or intestine
when there is a rupture of the appendix or
a ruptured diverticulum.
Also, it can occur due to an intestine to
burst or injury to an internal organ which
bleeds into the internal cavity.
Swelling &
tenderness in the
abdomen
Fever & hills
Loss of Appetite
Nausea &
Vomiting
^ Breathing & Heart Rates
Shallow Breaths
Low BP
Limited Urine Production
nability to pass gas or
feces
Signs & Symptoms
An acuteIy iII patient tends to Iie "very"
stiII because any movement causes
excruciating pain.
They wiII Iie with there knees bent to
decrease strain on the tender
peritoneum.
Hospitalization is common.
Surgery is often necessary to remove the
source of infection.
Antibiotics are prescribed to control the
infection & intravenous therapy (V) is used to
restore hydration.
Treatment
GeneraIized peritonitis +/-hypovoIemic
(non-hemorragic ) shock
CIinicaI presentation
Severe abdominal pain , 'looks sick'
Diffuse pertoneal signs: boardlike
rigidity, rebound tenderness, defens,guarding
Systemic inflammatory response,
septic, shock
DifferentiaI diagnosis
Perforated gastric/duodenal ulcer (tumor)
olonic perforation
Appendicitis
Acute mesenteric ischemia
Acute pancreatitis
Management
Preoperative preparation and operation
Except acute pancreatitis
PitfaIIs:
Acute pancreatitis ('the great mimicer')
Serum amylase
Mesenteric ischemia
The geriatric patient (no classical peritoneal signs)
ocaIized peritonitis
CIinicaI presentation
One quadrant peritonitis
Systemic inflammatory response +/- sepsis
DifferentiaI diagnosis:
RUQ: cholecystitis
RLQ: acute appendicitis
LLQ: acute divericulitis
LUQ: silent quadrant
LQ pain from gynecologic origin
Management:
Preoperative preparation and operation
onservative management(surgery tomorrow)
Except acute appendicitis (surgery today)