급성 복통 김 경 종 조선대학교 의과대학 외과학교실

acute abdomen (급성복증) : signs & Sx of abd. Pain and tenderness : a clinical presentation that often requires emergency surgical therapy : common incidence (7% in ER pts, 2% in primary pts)

흔한 복통의 원인 의료보험 자료(1995년) 대학병원 환자(1989년) 위염 위궤양 장관 감염성 질환 비감염성 위장관염 소화궤양 십이지장 궤양 기타 기능성 장질환 기능성 위장질환 국한성 장염 특정 감염성 장염 급성 충수염 대학병원 환자(1989년) 위장관염 급성 충수염 요로 결석 간 담도 질환 위염 소화궤양 자궁 외 임신 골반 내 감염 췌장염 분변 매복 장폐쇄

Etiology

Non-abdominal causes

Surgical acute abdominal conditions Infection Perforation Obstruction Ischemia Hemorrhage appendicitis ulcer perfo adhesion Buerger's disease solid organ trauma cholecystitis cancer perfo Volvulus (sigmoid or cecum) mesenteric thrombosis or embolism leak or ruptured a. aneurysm Meckel’s diverticulitis Boerhaave’s syndrome Incarcerated hernia strangulated hernias ruptured ectopic pregnancy hepatic abscess diverticular perfo IBD ischemic colitis bleeding GI diverticulum diverticulitis GI cancer testicular torsion A-V malformation Psoas abscess Intussusception ovarian torsion intestinal ulcer A-D fistula hemorrhagic pancreatitis spontaneous rupture of spleen

Abdominal region; 3 compartments abdominal cavity retroperitoneal cavity pelvic cavity

복막(peritoneum) 복통의 외과적 접근 Mesothelium (squamous epithelium) Visceral peritoneum vs parietal peritoneum

후복막(retroperitoneum) 복통의 외과적 접근 후복막(retroperitoneum)

골반강(pelvic cavity)

복막의 기능 복통의 외과적 접근 체액과 박테리아의 제거 (diaphragmatic stomata), 전신 순환계로 유입 (thoracic duct) 복막의 거식세포(macrophage)  cytokine 분비 백혈구의 복강 내 유입 복막의 비만세포(mast cell)  histamine  혈관확장 protein-rich fluid (Complement, Ig) opsonization of bacteria by protein-rich fluid abscess formation by sequestration of bacteria

Bacteria in peritoneal cavity ? Diaphragmatic stomata  thoracic duct early removal of bacteria from peritoneal cavity sepsis in relative early period

: foregut, midgut, hindgut Visceral pain : foregut, midgut, hindgut Parietal pain : localization Distension, stretching, ischemia, vigorous contraction,

Referred pain Right shoulder Liver, GB, Rt. diaphragm Left shoulder Heart, pancreas tail, spleen, lt diaphragm Scrotum & testicles Ureter

Approach to acute abd. pain

병력청취 복통의 외과적 접근 The PQRST P3: positional, palliating, & provoking factors Q: quality R3: region, radiation, referral S: severity T3: temporal factors (time & mode of onset, progression, previous episodes)

History taking Location; visceral vs parietal, retroperitoneum Character; colicky pain by smooth muscle contraction (d/t obstruction of GB, bowel, urinary tract) Onset; Intensity; acute onset, severe  serious or Cx pattern of radiation and referral pain duration and progression; persistent worsening Provocative and palliating factors Previous episodes

History taking Associated Symptoms Anorexia Vomiting (pain -> vomiting in surgical) Bowel symptoms (diarrhea, flatus, melena, blood) other symptoms (genitourinary tract Sx.) Medical and surgical History, current medication Hx of abd. Surgery medical condition (ex, AF or CHF  mesenteric ischemia) NSAIDs medication (aspirin) Social History (drug/alcohol)

신체검사 복통의 외과적 접근 전신외양 및 복부관찰: (ex. peritonitis vs renal colic) 2. Vital sign fever/hypotension/tachycardia 3. Inspection of abdomen scar/distension 4. Auscultation silent or high-pitched or metallic 5. Palpation tenderness/rebound tenderness/rigidity

Physical examination Rectal examination Other area (groin, ext. genitalia, back, chest)

Laboratory finding 복통의 외과적 접근 CBC with WBC diff (leukocytosis or bandemia) LFT/Amylase/lipase U/A electrolyte, BUN/Cr CRP/ESR serum lactate level/ procalcitonin

Imaging studies plain X-ray abd erect & KUB, chest P-A, lateral decubitus free air, calcification obstruction pattern volvulus Abdominal U/S bedside exam. In unstable pt other benefits

Abdominal (pelvic) CT scan Imaging studies Abdominal (pelvic) CT scan revolutionized Dx tool of acute abdomen almost all pts of acute abdomen esp, appendicitis in young women ischemic bowel in elderly patients

Diagnostic peritoneal lavage (DPL) 복통의 외과적 접근 Diagnostic peritoneal lavage (DPL) WBC >250/mL RBC >300,000/mL Bilirubin: more than plasma Particulate matter (stool) Creatinine: higher than plasma level

진단적 복강경 또는 개복술 (Diagnostic laparoscopy or laparotomy) 복통의 외과적 접근 진단적 복강경 또는 개복술 (Diagnostic laparoscopy or laparotomy)

ATYPICAL PATIENTS

Pregnancy Prone to delay in diagnosis 임신에 의한 증상으로 오인(복통, 오심, 구토, 식욕감퇴) 질병경과 또는 증상의 변화, 신체검사의 어려움(자궁확대) 검사결과의 변화 영상학적 검사의 부족 및 꺼림 더 보존적 치료의 경향

Appendicitis in pregnancy m/c d’s requiring op. False-positive Dx-> op: 15 ~ 35% ? Perforation  high risk of fetal death (20%)

Other surgical ds in pregnancy biliary tract disease, bowel obstruction timing of op. : second trimester or postpartum period

Acut abdomen in the critically ill cardiopulmonary bypass -> ischemic bowel, ileus, pseudoobstruction, stress ulcer, acalculous chole, acute pancreatitis vasoactive medication & ventilator support Sx. (obscure) abd. Pain (84%), abd. tenderness (95%), distension (73%) all diagnsotic method outcome: varied (MR; 31%-63%)

Immunocompromised pt with acute abdomen elderly, malnourished, DM, transplant recipient, cancer chemotherapy, HIV atypical fashion (inflammation?) in acute abdomen atypical infection: TB peritonitis, fungal infection, CMV, EBV

Acute abdomen in the morbidly obese challenge in acute Dx. severe abd. Pain: not common less specific finding: tachycardia, tachypnea, pleural effusion, or fever

Treatment algorithms for acute abdomen

Treatment of acute-onset severe generalized abd. pain Sabiston: Textbook of Surgery 2008

Treatment of gradual-onset severe generalized abd. pain Sabiston: Textbook of Surgery 2008

우상복부 통증의 치료 Sabiston: Textbook of Surgery 2008

우하복부 통증의 치료 Sabiston: Textbook of Surgery 2008

좌상복부 통증의 치료 Sabiston: Textbook of Surgery 2008

좌하복부 통증의 치료 Sabiston: Textbook of Surgery 2008

Summary 급성복증의 진단은 여전히 어려운 문제이다. 철저한 병력청취, 신체검사는 환자의 평가에 매우 중요하다. 영상학적 검사로는 CT scan의 유용성이 매우 크다. 적절한 수술적 치료가 지연된 경우 이환율과 사망률이 증가한다. 간혹 진단이 애매한 경우 진단적 복강경 또는 개복술 등이 필요할 수도 있다.

감사합니다