7AppendicitisPain usually (70%) starts centrally (umbilical region) and moves to Mcburney’s PointThe RLQ becomes tender in 65%-95% of casesMost common acute surgical condition of the abdomenOccurs in about 7% of population, between age yrs old
8Appendicitis: Pathogenesis Long finger-like process that extends from the inferior tip of the cecumObstruction of the narrow lumen initiates the clinical illnessD/T viral illness or fecal obstruction (fecaliths)
9AppendicitisS/S: Periumbilical abdominal pain, nausea, fever, pain with motion, advanced stage sepsis due to bowel perforation.Tests: inspection normal to immobile patient, can look quite ill. Labs abnormal elevated CRP, WBCs, abnormal palpationTx/Complications: Immediate surgical referral, if septic life threatening.
12Irritable Bowel Syndrome Common disorder, cause unknown, diagnosis of exclusionS/S: intermittent loose stools, intermittent constipation, relation to foods, relation to stress (anxiety and depression), distention of bowel causing pain.GI Bleeding, fever, weight loss, and persistent severe pain are NOT s/s of IBS
13IBS – cont.Diagnosis: Again of exclusion, Rome III diagnostic criteria* for irritable bowel syndromeRecurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with 2 or more of the following(1) Improvement with defecation(2) Onset associated with a change in frequency of stool(3) Onset associated with a change in form (appearance) of stoolCriteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. Discomfort means an uncomfortable sensation not described as pain. In pathophysiology research and clinical trials, a pain/discomfort frequency of at least 2 days a week during screening evaluation for subject eligibility.Reproduced with permission from Longstreth, GF, et al. Gastroenterology 2006; 130:1480.TX: Treatment is directed at symptoms not cause. Diarrhea- antidiarrheal, Constipation- Fiber, Miralax, MOM, Anxiety- Ativan etc. Depression –SSRIs, Tricylcics, Pain-Antispasmodics, Anitcholanergics, Physical Therapy, muscle release. Avoid Narcotics.BRAT Diet: Bananas, Rice, Applesauce and Toast
15Inguinal HerniaDefinition: A hernia is the protrusion of a portion of an organ or tissue through an abnormal opening in the wall that normally contains it. In this case the Inguinal area. Can be direct or indirect.s/s: painless to painful bulge in RLQ,LLQ, worse with motion, lifting. If no bowel movements worrisome for incarcerated bowel (surgical emergency).Tx: referral to surgeonCan be difficult to diagnose. Common when born
16UlcersExcessive secretion of gastric acids, inadequate protection of mucus membrane, stress, heredity, medicationss/s: mid epigastric, gnawing abdominal pain radiating to back, improved with eating, tarry stools, anemiaDx: Exam, UGI x-ray, CBC, EGDTx: Hold offending meds (NSAIDS), twice daily PPI. Treat h. Pylori if present. Reevaluate
17Esophageal Reflux Heartburn Cause: Transient relaxation of the lower esophageal sphincter intrinsic pressure, angle of cardioesphygeal junction, action of diaphragm, gravity.s/s: Retro sternal, non exertional chest pain, with or without episodes of regurgitation.Dx: Based on symptoms, sometimes seen on UGI.Tx: If no alarm symptoms then PPI and re-evaluate. If alarm sxs: dysphagia, GI bleeding or weight loss then EGD needed.
18DiarrheaCauses: infection, drug-induced, food related, post-surgical, psychological, exercise (runner’s trot)s/s: Three or more bowel movements per day are considered to be abnormal, and the upper limit of stool weight is generally agreed to be 200 g per day in Western countries.Dx: Multiple studies, stool o&p, stool culture, stool c.diff toxin, stool fecal fat and if no cause and chronic then colonoscopy and blood work, watch electrolytes.Tx: Aim at underlying cause, mostly supportive with low glucose electrolyte solution, watered down Gatorade.BRAT diet: Avoid lactose, bland diet. No ETOH.
19Runners Diarrhea Incidence Runners Diarrhea affects 35% of runners in 10k raceMechanismIncreased intestinal motility with intense RunningCaused by gastrointestinal peptidePossibly related to bowel ischemiaSymptoms and SignsWatery DiarrheaIncreased stool frequencyLarge volumesBloody stool in 12% of patientsDiffuse nonlocalized low Abdominal PainTenesmusRecommendationsEstablish pre-run ritualAvoid eating 2 to 3 hours before RunningDecrease dietary sugarsLactoseFructoseAspartame (Nutri-sweet)SorbitolDecrease Dietary Fiber or use liquid meals before raceDecrease caffeine intakeAvoid mints or gum containing SorbitolAvoid large Vitamin Doses (especially Vitamin C)Switch training time of day to eveningStay conditionedConsider anti-Diarrheal drugsConsider temporary decrease in miles or intensityInitially decrease program by 20-25%Slowly re-increase Exercise programConsider rice-based electrolyte solution (CeraSport)Anecdotal evidence only
20Constipation Definition: Three or less bowel movement weekly S/S: bloating, early satiety, bulging abdomen, painful defecation, nausea, abdominal painDx: History, KUB with sitz marker studyTx: Fiber, water, exercise, Miralax, Amitiza, MOM, think about pelvic floor dysfunction, biofeedback
21GastroenteritisDefinition: Literally inflammation of gastrointestinal system resulting in a plethora of symptoms from N/V to diarrhea. Usually attributed to viral or bacterial cause.Cause: E. Coli infection, staphylococcal food poisoning, botulism, viral, chemical or drug relatedS/S: N/V, steatorrhea, bloody stools, dehydration, weakness, abdominal pain relieved by bowel movements.Dx: Stool studies, O&P, Stool cultures, stool for fat, c.diff toxin, stool for fat. BMPTx: Usually supportive, fluids, water down Gatorade, let run it’s course avoid anti diarrheals, consider pepto, if longer than two weeks further investigation. Bland diet (BRAT) avoid milk products.
22Ulcerative Colitis Cause: Unknown, ?autoimmune S/S: Loose stools w/ w/o blood, nocturnal stools, iron deficiency anemia, LLQ abdominal pain.Dx: Usually on colonoscopy, some IBD serologyTx: prednisone, asacol
23Crohn’s DiseaseS/S: Will present with diarrhea, blood in stool, pain nonspecific to generalized.Dx: Labs, colonoscopyTx: Immunosuppressive medications. Last resort surgical removal of ulcerated portion
24Abdominal Trauma Common sports Key is immediate recognition, monitoring & management
25Abdominal TraumaScreening tools: exam and History observe for abdominal distention or falling BP rising pulse without explanationUltrasound: +/-Diagnostic Peritoneal Lavage: +/-Computed Tomography: +/-
26Splenic Injuries Most commonly injured organ in abdomen Deceleration causes a shearing force on vessels and capsuleBlunt trauma to LUQ
27Splenic InjuriesS/S: LUQ pain radiating to back, severe, sharp unrelenting to dull ache after trauma, some ecchymosisTx: avoid surgery if possibleReturn to play: 6-8 weeks depending on recovery and sport activity.Al Harris- DB Green Bay
28Liver Injuries 2nd most common injured Blunt trauma to RUQ, lower chest from front or backs/s: RUQ ache radiating to back, usually contusion of ribs, achy in character.Tx: Usually supportive with monitoring.
29Still more options Are you pregnant?, reproductive diseases Ovarian Cysts, PID, EndometriosisUTI or bladder infection, Kidney stonesCan be secondary to appendicitisPylonephritis
30SummaryIf fever, bloody stool/urine, pallor, distress, no body movement, unexplained weight loss or severe pain are present, something serious is wrong!!