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The Acute Abdomen Jason E. Davis, MD. Abdominal Pain A leading cause for hospital admissions Most self-limited and of little consequence Subset of serious.

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Presentation on theme: "The Acute Abdomen Jason E. Davis, MD. Abdominal Pain A leading cause for hospital admissions Most self-limited and of little consequence Subset of serious."— Presentation transcript:

1 The Acute Abdomen Jason E. Davis, MD

2 Abdominal Pain A leading cause for hospital admissions Most self-limited and of little consequence Subset of serious acute pathology may require acute medical and/or surgical intervention – This latter group referred to as ‘acute abdomen’ Not all acute abdomens = surgical abdomen – Renal colic, gastroenteritis, infectious colitis*, PID – Mesenteric ischemia, ruptured AAA, appendicitis, perforated bowel, perf’d peptic ulcer, inc’d hernia

3 Broad Differential Dx

4 Anatomic Considerations Embryonic origin & Blood supply – Foregut: esophagus, stomach, proximal duodenum, pancreas, liver, biliary tract, spleen Celiac artery – Midgut: distal duodenum, jejunem, ileum, cecum, appendix, proximal 2/3 transverse colon Superior mesenteric artery – Hindgut: remaining colon and rectum Inferior mesenteric artery

5 Anatomic Considerations Innervation – Visceral pain: autonomic, dull, cramping, poorly localized, often assoc with nausea and diaphoresis Often midline secondary to embryonic origin – Parietal pain: somatic, sharp, severe, persistent, loc Referred visceral sensation – Foregut pain: Epigastric – Midgut pain: Peri-umbilical – Hindgut pain: Hypogastrium

6 Anatomic Considerations


8 Approach to Acute Abdomen Age Location and character of pain Pain duration and progression Associated symptoms – Nausea – Emesis – Anorexia – Constipation/Diarrhea

9 Approach to Acute Abdomen Most important symptom is PAIN. Accordingly, history should include all of the following: 1. Onset 2. Severity 3. Type of pain 4. Radiation of pain 5. Change in nature of pain 6. Associated bowel or urinary symptoms 7. Aggravating or relieving factors

10 Approach to Acute Abdomen Diagnosis according to onset of pain: – Sudden – Rapid – Gradual – Chronic (exacerbation) Sudden onset (full pain in seconds) Perforated ulcer Mesenteric infarction Ruptured AAA Ruptured ectopic pregnancy Ovarian torsion or ruptured cyst Pulmonary embolism Acute myocardial infarction Rapid onset (initial sensation to full pain over minutes or hours) Strangulated hernia Volvulus Intussusception Acute pancreatitis Biliary colic Diverticulitis Ureteral and renal colic Gradual onset (hours) Appendicitis Strangulated hernia Chronic pancreatitis Peptic ulcer disease Inflammatory bowel disease Mesenteric lymphadenitis Cystitis and urinary retention Salpingitis and prostatitis Stereotypes of Pain Onset and Associated Pathology Position of patient (motionless vs. writhing in pain vs. rolling restlessly  appendicitis/peritonitis vs. mesentary ischemia vs. ureteral/intestinal colic)

11 Approach to Acute Abdomen DiaphragmaticSupraclavicular area (Kehr’s sign) UreteralHypogastrium, groin, inner thigh Cardiac painEpigastrium, jaw, shoulder AppendixPeriumbilical via T10 nerve DuodenumUmbilical region via greater thoracic splanchnic nerve Hiatal herniaEpigastrium via T7 and T8 nerves Pancreas or gallbladderEpigastrium Gallbladder and bile ductEpigastric pain, wraps around scapula Structure irritated Location of referred pain

12 Named Exam Findings 12 Cullen's signBluish periumbilical discoloration Retroperitoneal hemorrhage (hemorrhagic pancreatitis, abdominal aortic aneurysm rupture) Kehr's signSevere left shoulder painSplenic rupture Ectopic pregnancy rupture McBurney's signTenderness located 2/3 distance from anterior iliac spine to umbilicus on right side Appendicitis Murphy's signAbrupt interruption of inspiration on palpation of right upper quadrant Acute cholecystitis Iliopsoas signHyperextension of right hip causing abdominal pain Appendicitis Obturator's signInternal rotation of flexed right hip causing abdominal pain Appendicitis Grey-Turner's signDiscoloration of the flankRetroperitoneal hemorrhage (hemorrhagic pancreatitis, abdominal aortic aneurysm rupture) Chandelier signManipulation of cervix causes patient to lift buttocks off table Pelvic inflammatory disease Rovsing's signRight lower quadrant pain with palpation of the left lower quadrant Appendicitis Sign Finding Association

13 Imaging and Laboratory Studies 13 Laboratory examinations – CBC with differential, type & screen – Chem-10, amylase, LFT’s, urinanalysis X-rays of the chest and abdomen (upright/supine) – Distended loops of bowel, kidney stones, perf  free gas Ultrasound: cholelithiasis, bile duct obstruction, AAA Abdominal CT: AAA, abdominal abscess, severe diverticulitis Endoscopy: perforated peptic ulcer, SBO, gastric cancer Colonoscopy: carcinoma of the colon Angiography: mesenteric ischemia Radionuclide scans

14 Appendiceal Disease Appendicitis – 7% lifetime risk of appendicitis – Most common cause of acute abdominal surgery in the U.S. Though living in Lehigh Valley appears to be risk for gallbladder disease – Must be considered in every patient with acute abdomen – Especially common during pregnancy (also important to consider ectopic pregnancy in women of reproductive age) Constipation: “the great imitator” Less common among differential diagnoses – Mucocele, carcinoid, appendiceal carcinoma

15 Special Considerations Elderly patients – May not mount febrile response – Atypical pain presentation (severity/location) Immunosuppressed patients – Opportunistic infections, lymphomas – Corticosteroids may mask pain Obese patients – May be more difficult to palpate Patients taking pain medications – Opioids may cause constipation and mask/distort pain Pregnant women – Distorted abdomen & pregnancy may mimic Sx’s

16 Beyond Appendicitis

17 Appendiceal Neoplasms – Carcinoid Marjority of appendiceal neoplasms Derived from neural crest cells <2cm (90%)  appendectomy >2cm (10%)  right hemicolectomy Slow mets, 5 yr survival >50% w/ mets Primary Adenocarcinoma – Mucinous more favorable than Colonic – Assoc with colon and ovarian CA (15 – 30%) Lymphoma (often AIDS-associated)

18 Acute Abdomen Algorhithm adopted from Vanderbilt Medical Center

19 RLQ Pain Adopted from Vanderbilt Medical Center

20 Case 1: Ms. Jones 27 years old, pregnant female ED presentation – Crampy peri-umbilical pain – Nausea, emesis and anorexia x 12 hours – Pain has ‘migrated’ to RLQ over past several hours, becoming constant and intense Urinanalysis: mild hematuria and pyuria CT scan – deferred for preg

21 Case 1: Ms. Jones revisited Appendicitis – Classic chronologic presentation – Especially common during pregnancy 1 out of every 1750 pregnancies! May be in RUQ due to enlarged uterus – Mild hematuria and pyuria are common in appendicitis with pelvic inflammation – Radiopaque fecalith present only 5% x’s Open or Laparoscopic appendectomy

22 Case 2: Mr. Smith 42 year-old male ED presentation – Fever, vomiting and diarrhea – Constant abdominal pain 4hrs, radiates to back Last bowel movement yesterday, flatus unsure FUA: non-specific bowel gas pattern

23 Case 2: Mr. Smith revisited Gastroenteritis – Classic presentation – Pain often follows N/V Non-surgical, medical management

24 Summary Differential diagnosis for acute abdomen is lengthy Many presentations will not require admission or surgery Ischemic colitis, ruptured AAA, intestinal or ulcer perforation, and ectopic pregnancy are important causes not to be missed Common differentials include appendicitis, cholecystitis, obstruction, and ischemia, but will vary per population

25 Thank you

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