1. A Cute Abdomen

2. Goal  not exact diagnosis  but that a surgical condition exists

3. “The general rule can be laid down that the majority of severe abdominal pains that ensue in patients who have been previously fairly well, and that last as long as six hours, are caused by conditions of surgical import.” Silen W: Cope’s Early Diagnosis of the Acute Abdomen. 1996,p.6.

4. Diagnose Early Better outcomeBetter outcome Pain relief (narcotics)Pain relief (narcotics) AntibioticsAntibiotics

5. History AgeAge Onset - how long ago sudden or gradualOnset - how long ago sudden or gradual Distribution - area of maximal pain localization radiationDistribution - area of maximal pain localization radiation Character - sharp or dull, burning, steady or crampingCharacter - sharp or dull, burning, steady or cramping

6. History Nausea, vomiting, anorexiaNausea, vomiting, anorexia Diarrhea, constipation, flatus, blood, tenesmusDiarrhea, constipation, flatus, blood, tenesmus Menstruation - where in the cycle sexual activityMenstruation - where in the cycle sexual activity Previous episodes - relationship to meals:Previous episodes - relationship to meals: 2 - 2 1 / 2 hrs = duodenal worse with food = gastric fatty foods = gallstones weight loss?

7. Vomiting Relationship to pain appendicitis - pain precedes vomiting gastroenteritis - vomiting precedes painRelationship to pain appendicitis - pain precedes vomiting gastroenteritis - vomiting precedes pain Character - feculent vomiting pathognomonic of obstruction of distal small intestine, rare in colonic obstructionCharacter - feculent vomiting pathognomonic of obstruction of distal small intestine, rare in colonic obstruction

8. Physical Examination General appearance - restlessness = colic immobility with knees flexed = peritonitisGeneral appearance - restlessness = colic immobility with knees flexed = peritonitis Blood pressureBlood pressure Pulse - “too optimistic a friend to be relied upon…”Pulse - “too optimistic a friend to be relied upon…” Respiratory rate - may suggest a thoracic originRespiratory rate - may suggest a thoracic origin Temperature - could be normal, high or low > 104 o F (40 o C) suggests thorax or kidneyTemperature - could be normal, high or low > 104 o F (40 o C) suggests thorax or kidney Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996,p.32.

9. PE: Chest InspectionInspection PalpationPalpation PercussionPercussion AuscultationAuscultation

10. PE: Abdomen Inspection - distention, hernias DON”T FORGET THE FEMORAL CANALInspection - distention, hernias DON”T FORGET THE FEMORAL CANAL AuscultationAuscultation Palpation - rigidity area of greatest pain lastPalpation - rigidity area of greatest pain last Percussion - “rebound”, cough tenderness Rosving’s signPercussion - “rebound”, cough tenderness Rosving’s sign

11. Levien: Intro to Surg 1987, p.41.

12. PE: Abdomen “of all the modalities of physical diagnosis of the abdomen, auscultation is one of the least valuable and most misleading.” Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996,p.43.

13. PE: Pelvis Pelvic examination - bimanualPelvic examination - bimanual Rectal examination - mass, tenderness, bloodRectal examination - mass, tenderness, blood

14. “Overreliance on laboratory tests and radiological evaluations will very often mislead the clinician, especially if the history and physical examination are less than diligent and complete.” Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996,p.57.

15. Laboratory Tests CBC - leukocytosis, anemiaCBC - leukocytosis, anemia Urinalysis - infection, blood, pregnancyUrinalysis - infection, blood, pregnancy Electrolytes - renal function, dehydrationElectrolytes - renal function, dehydration Amylase, lipaseAmylase, lipase LFTsLFTs

16. Radiographic Studies Flat & upright abdomen - air-fluid levels, distended loops, edema in bowel wall, volvulus, fecolithFlat & upright abdomen - air-fluid levels, distended loops, edema in bowel wall, volvulus, fecolith CXR - free air, lower lobe pneumoniaCXR - free air, lower lobe pneumonia Contrast studies - H 2 O soluble if perforation disadvantage - aspiration, qualityContrast studies - H 2 O soluble if perforation disadvantage - aspiration, quality

17. Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996,p.64.

18. Appendicitis FecolithFecolith YoungYoung 1. Dull pain in midepigastrium 2. Nausea/vomiting follows pain 3. Localizes to RLQ * Anorexia + Fever LeukocytosisLeukocytosis Reginald H. Fitz 1843 - 1913

19. McBurney C: NY State Med J 1889;50,676-684. McBurney C: Ann Surg 1894;20,38-43. McBurney’s Incision

20. Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996.

21. Graham RR: Surg Gynecol Obstet 1937;64,235-238. Perforated Ulcer Sudden onsetSudden onset Previous episodes of pain ~ 2 hrs after eatingPrevious episodes of pain ~ 2 hrs after eating CXR - free airCXR - free air

22. Pancreatitis AlcoholAlcohol GallstonesGallstones TraumaTrauma HyperlipidemiaHyperlipidemia HyperparathyroidismHyperparathyroidism Drugs - thiazide diureticsDrugs - thiazide diuretics Unknown (10%)Unknown (10%)

23. Pancreatitis Excruciating painExcruciating pain Fever - almost alwaysFever - almost always Ranson’s criteriaRanson’s criteria Grey Turner signGrey Turner sign Cullen’s signCullen’s sign Cullen TS: Am J Obstet 1918;78(Sept),457. Turner GG: Brit J Surg 1920;7(Jan),394-395.

24. Ranson’s Criteria Admission 1. Age > 55 2. WBC > 16,000/mm 3 3. Glucose > 200 mg/100 ml 4. LDH > 350 I.U./L 5. SGOT > 250 Frankel units % During Initial 48 Hours 1. Hematocrit fall > 10% 2. BUN rise > 5%/mg/100 ml 3. Ca ++ < 8 mg/100 ml 4. Arterial pO2 < 60 mmHg 5. Base Deficit > 4 meq/L 6. Fluid sequestration > 6 L Ranson et al: Surg Gynecol Obstet 1974;139,69.

25. Amylase PancreatitisPancreatitis CholecystitisCholecystitis High intestinal obstructionHigh intestinal obstruction Acute renal insufficiencyAcute renal insufficiency Perforated ulcerPerforated ulcer & others& others

26. Cholecystitis Radiopaque gallstones (10-15%)Radiopaque gallstones (10-15%) Pain - RUQ, “colic”, radiates to the ipsalateral scapulaPain - RUQ, “colic”, radiates to the ipsalateral scapula Pain brought on with fatty foodsPain brought on with fatty foods US - stones, thickening, fluid, air in wallUS - stones, thickening, fluid, air in wall

27. Intestinal Obstruction pain - colicpain - colic Vomiting, distentionVomiting, distention ObstipationObstipation Auscultation - quiet to high-pitched, tinkling rushes to borborygmiAuscultation - quiet to high-pitched, tinkling rushes to borborygmi X-ray - air-fluid levels, fixed loopsX-ray - air-fluid levels, fixed loops

28. Small Bowel Obstruction 1. Adhesions (74%) 1 / 2 2 o to gynecologic or colonic operations 2. Neoplasm (8.6%) 3. Hernias (8.1%) most common cause in children Inflammatory bowel disease (5.2%)Inflammatory bowel disease (5.2%) Gallstone ileus, radiation enteritis, intussusceptionGallstone ileus, radiation enteritis, intussusception UnknownUnknown Bizer et al: Surgery 1981;89,407-413.

29. Adynamic Ileus 2 o to general peritonitis, severe chest injuries, after myocardial infarction, pneumonia, operations on the spine or abdomen, or narcotics2 o to general peritonitis, severe chest injuries, after myocardial infarction, pneumonia, operations on the spine or abdomen, or narcotics Auscultation - quiet, no borborygmiAuscultation - quiet, no borborygmi Involves both small & large bowelInvolves both small & large bowel Gaseous distention of both small & large bowelGaseous distention of both small & large bowel

30. Large Bowel Obstruction 1. Cancer (70%) 2. Volvulus (10%) 3. Diverticulitis (5%) Intussusception, uremiaIntussusception, uremia

31. Volvulus Sigmoid (most common)Sigmoid (most common) IleocecalIleocecal Transverse (rare)Transverse (rare) Barium enema is diagnostic & often therapeuticBarium enema is diagnostic & often therapeutic Sigmoidoscopy - alternative diagnostic & therapeutic modalitySigmoidoscopy - alternative diagnostic & therapeutic modality “bent inner tube sign”

32. Diverticulitis LLQ painLLQ pain Fever, leukocytosisFever, leukocytosis CT scan - pericolic abscessCT scan - pericolic abscess Antibiotics, NPO, NG decompressionAntibiotics, NPO, NG decompression Operation for persistent symptoms (7 days) or recurrent episodesOperation for persistent symptoms (7 days) or recurrent episodes

33. Hernias Indirect inguinal most common in both males & femalesIndirect inguinal most common in both males & females Femoral is more common in femalesFemoral is more common in females Direct inguinal, umbilical, ventral, incisional, Spigelian, Richter’s, lumbar, obturator, etc.Direct inguinal, umbilical, ventral, incisional, Spigelian, Richter’s, lumbar, obturator, etc.

34. Renal Colic Radiopaque ureteral calculus (85-90%)Radiopaque ureteral calculus (85-90%) Pain radiating to the testicle or vulvaPain radiating to the testicle or vulva VomitingVomiting Microscopic hematuriaMicroscopic hematuria

35. Female Disorders Ectopic pregnancy, PID, mittelschmerz, appendicitisEctopic pregnancy, PID, mittelschmerz, appendicitis Chandelier signChandelier sign UrinalysisUrinalysis UltrasoundUltrasound LaparoscopyLaparoscopy

36. Mesenteric Vascular Occlusion Pain out of proportion to physical examinationPain out of proportion to physical examination Risk factors - atrial fibrillation, digitalis, diuretics, cardiopulmonary bypassRisk factors - atrial fibrillation, digitalis, diuretics, cardiopulmonary bypass Barium enema may show “thumbprinting”Barium enema may show “thumbprinting” Angiography, MRIAngiography, MRI Mortality = 50%Mortality = 50%

37. Summary  not exact diagnosis  but that a surgical condition exists