The acute abdomen © Maastricht University 2015-2016. All content may be used for educational purposes only. Printing & distributing to third parties is not allowed, unless specifically allowed by Maastricht University. The acute abdomen

Case Female, 43 yrs old, 85 kg, 1.75cms Severe pain, sudden onset Right upper quadrant Urge to move, unable to sit or lie still The acute abdomen

Case Female, 43 yrs old, 75 kg, 1.75cms Severe pain, sudden onset Right upper quadrant Urge to move, unable to sit or lie still Diagnosis possible? More information needed? The acute abdomen

Case Female, 43 yrs old, 75 kg, 1.75cms Severe pain, sudden onset Right upper quadrant Urge to move, unable to sit or lie still Plan for treatment possible? More information needed? The acute abdomen

Acute abdomen You need to act swiftly: diagnosis plan for treatment The acute abdomen

Acute abdomen - definition An acute abdominal is a situation in which urgent and specific medical attention is needed to save the patient’s life

Acute abdomen - definition

The acute abdomen versus Acute abdominal pain The acute abdomen

Acute abdomen Definition Causes Diagnosis: symptoms and signs Additional exams Examples Specific issues: role of specific doctors, timing intervention The acute abdomen

Acute abomen Causes Peritonitis Obstruction Ischemia Bleeding Penninckx, “Aandoeningen van het spijsverteringsstelsel”, 2011 Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Causes Peritonitis Inflammation of an organ Free fluid in abdominal cavity perforation hollow organ blood spontaneous bacterial peritonitis Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Aids in diagnosis Wide variety of causes / pathology Tools for diagnosis: general characteristics logical reasoning The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Characteristics Symptoms Pain Fever Nausea, vomitus Absence of defecation The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Characteristics Symptoms Pain Local Diffuse Radiation Referred The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Pain in acute abdomen Characteristics Symptoms Pain Local Diffuse Radiation Referred Example of referred pain: acute cholecystitis Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Pain in acute abdomen Referred pain Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Pain in acute abdomen Evolution of pain in time Visceral versus parietal pain The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Pain in acute abdomen Evolution of pain in time Visceral peritoneum / -pain Autonomic nervous system pain due to local inflammation organ and distension vague pain, aspecific location (midline) The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Pain in acute abdomen Evolution of pain in time Parietal peritoneum / - pain Somatic nervous system Localized sharp pain Guarding Diffuse pain (diffuse peritonitis) The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Pain in acute abdomen Evolution of pain in time Case 13 yr old boy <24 hrs anorexia T 37.4°C Epigastric pain  Differential diagnosis? The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Pain in acute abdomen Evolution of pain in time Case 13 yr old boy <24 hrs anorexia T 37.4°C Epigastric pain  Changing to a sharp pain RLQ  Diagnosis? The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Example of evolution in time: acute appendicitis Pain in acute abdomen Evolution of pain in time Case 13 yr old boy <24 hrs anorexia T 37.4°C Epigastric pain Example of evolution in time: acute appendicitis  Changing to a sharp pain RLQ The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Pain in acute abdomen Pain at moving, coughing The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Characteristics Signs Abdominal Observation Auscultation Palpation The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Characteristics Least painful exam first! Signs Abdominal Observation Auscultation Palpation The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Characteristics Signs Abdominal Observation: respiration absence of abdominal respiration The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Characteristics Signs Abdominal Auscultation: peristalsis Peritonitis: absence The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Characteristics Signs Abdominal Auscultation: peristalsis Obstruction: loud, gutter sounds, hyperactive, tinkling The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Characteristics Signs Abdominal Palpation: guarding, tenderness, mass The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Characteristics Be gentle! Signs Abdominal Palpation: tenderness Locally General Rebound Be gentle! The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Characteristics Signs General (i.e. = not per se any or all) Hypotension Tachycardia Dehydration The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Characteristics bowel distension reduced intake Signs General (i.e. = not per se any or all) Hypotension bowel distension reduced intake inflammatory mediators Tachycardia Dehydration Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Aids in diagnosis Logical reasoning based on symptoms and signs based onn additional information The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Aids in diagnosis Other information Age? Appendicitis: 5-35, 35-50, >50yrs? Diverticulitis: 5-35, 35-50, >50yrs? The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Aids in diagnosis Other information Age? Appendicitis: most prevalent 5-35 Diverticulitis: most prevalent >50yrs? The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Aids in diagnosis Other information Age Gender? Female: cholecystitis, adnexitis, EUG The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Aids in diagnosis Other information Age Gender? Female: cholecystitis FFFF: fat, female, forty, fertile (/fair) The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Aids in diagnosis Other information Age Gender Previous history? Ilnesses, operations Correspondence! The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Aids in diagnosis Other information Age Gender Previous history? Ilnesses: e.g. diverticulosis  +older age, +pain (left) lower abdomen: The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Aids in diagnosis Other information Diverticulitis? Age Gender Previous history? Ilnesses: e.g. diverticulosis  +older age, +pain (left) lower abdomen: Diverticulitis? The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Aids in diagnosis Diverticulosis Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Aids in diagnosis Other information Age Gender Previous history? Abdominal surgery  +diffuse pain, +swelling abdomen, +vomitus Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Aids in diagnosis Other information Age Gender Previous history? Abdominal surgery  +diffuse pain, +swelling abdomen, +vomitus small bowel obstruction (ileus) due to adhesions? Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Diagnosis Caveats, beware! Small children Old patients Patients in poor condition symptoms and signs less pronounced  delay in diagnosis  increase in morbidity and mortality Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Additional exams Laboratory Leucocytosis CRP Specific, if already differential diagnosis e.g. livertests if suspicion gallstone disease The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Additional exams Radiology? Plain abdominal X ray Ultrasound CT scan … The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Additional exams Radiology Plain abdominal X ray bowel distension air-fluid levels psoas muscle visible or not The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Additional exams Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Additional exams Small bowel obstruction = ileus Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Additional exams Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Additional exams Radiology Plain X ray Thorax Free air below diafragm Pneumonia The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Additional exams Additional exams? The diagnosis acute cholecystitis is only definite after an ultrasound has confirmed the diagnosis  True of false? The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Additional exams The acute abdomen is a clinical diagnosis! But additional exams can be helpful in localizing the cause The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Additional exams Radiology Ultrasound Gallbladder: stones, cholecystitis Appendicitis Free fluid and more Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Additional exams Radiology CT scan All of the previous findings But: more expensive more radiation toxicity The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Additional exams Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Additional exams Bowel ischemia with intramural pneumatosis Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

The acute abdomen Examples of acute abdomen Peritonitis Inflammation of an organ Free fluid in abdominal cavity Obstruction Ischemia Bleeding The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Peritonitis Pancreatitis Appendicitis Diverticulitis 1. Inflammation of an organ, e.g.: Cholecystitis Pancreatitis Appendicitis Diverticulitis The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Peritonitis Inflammation of an organ Some (but not all) characteristics Cholecystitis: pain ROQ, previous colics, radiation of pain to right flank, referring of pain to right shoulder The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Peritonitis Inflammation of an organ Some (but not all) characteristics Pancreatitis: alcohol, sudden onset, radiation to back The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Peritonitis Inflammation of an organ Some (but not all) characteristics Diverticulitis: older age, pain LLQ or lower mid abdomen, diverticulosis or difficult defecation The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Peritonitis Free fluid in abdominal cavity perforation hollow organ Gastric/duodenal ulcer Diverticulitis Tumor Bowel distension Corpus alienum …. The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Peritonitis Free fluid in abdominal cavity Blood Traumatic Rare: spontaneous bleeding e.g. from tumour liver of spleen The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Peritonitis Free fluid in abdominal cavity Bacterial peritonitis “Spontaneous” = without perforation Liver insufficiency Compromised immune system The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Peritonitis Free fluid in abdominal cavity What really hurts! Gastric/duodenal content Bowel content What hurts less Blood Only pus The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

The acute abdomen Examples Peritonitis Obstruction Ischemia Bleeding Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Obstruction of bowel Small bowel (ileus) Large bowel (large bowel obstruction [LBO], large bowel ileus) The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Ileus (small bowel) Paralytic Mechanic The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Ileus (small bowel) Paralytic Absence of peristalsis Causes: Diffuse peritonitis (ileus = early phenomenon) Bowel dilatation (ileus = late phenomenon) Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Ileus Mechanic Small bowel and large bowel Causes: Adhesions (esp. small bowel) Tumor (esp. large bowel) Herniation / strangulation The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Ischemic but still vital small bowel: “just in time” Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Ileus Mechanic Small bowel and large bowel Causes: Adhesions (esp. small bowel) Tumor (esp. large bowel) Herniation / strangulation The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples sigmoid tumor, no obstruction yet Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Ileus Mechanic Small bowel and large bowel Causes: Adhesions (esp. small bowel) Tumor (esp. large bowel) Herniation / strangulation The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Incarcerated femoral hernia with small bowel obstruction Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Obstruction of other origin Bile duct (cystic duct, hepatic duct) stones Ureter stones Symptoms: acute, severe, colicy pain Ovarian duct torsion The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

The acute abdomen Examples Peritonitis Obstruction Ischemia Bleeding Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Ischemia Less frequent cause than peritonitis or obstruction Difficult diagnosis! The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Ischemia Cause Venous or arterial occlusion Venous: thrombosis Arterial: thrombosis (on pre-existent stenosis) or embolism (from heart or aorta/main branches) The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Ischemia If: Rule out ischemia! Diagnosis Elderly patient No overt other cause Patient: extreme pain Doctor: mild findings at physical exam Rule out ischemia! Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

The acute abdomen Examples Peritonitis Obstruction Ischemia Bleeding Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Bleeding Intra abdominal: see before Intra luminal: Can be acute abdominal situation (=acute abdomen) But rarely fulminant acute abdominal pain  only brief discussion The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Examples Bleeding Intraluminal bleeding Proximal or distal GI tract Symptoms: Hematemesis and melena (proximal GI tract) Clear blood per anum (distal GI tract) Signs of anemia and hypovolemia Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

The acute abdomen Specific issues The different roles of different doctors The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Specific issues Different roles for different doctors GP (General practitioner) Suspects patient of acute abdomen  What to do?  Additional exams? The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Specific issues Different roles for different doctors GP (General practitioner) Short evaluation Recognition of urgent situation Swift referral to hospital The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Specific issues Different roles for different doctors Doctor at ER Differential diagnosis based on clinical grounds Start treatment asap Additional exams only if additional information and influence on treatment Swift referral to appropriate specialist Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Specific issues Different roles for different doctors Surgeon Confirmation of diagnosis Decision: operate of not? incl. timing of operation The acute abdomen The acute abdomen Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

Conclusion Acute abdomen Acute evaluation Swift decision making Swift treatment The appropriate doctor  Tools: knowledge and logical reasoning The acute abdomen

The acute abdomen Laurents Stassen gastro intestinal surgeon lps.stassen@mumc.nl