Acute Abdomen

Acute Abdomen Anatomy review Non-hemorrhagic abdominal pain Gastrointestinal hemorrhage Assessment Management

Abdominal Anatomy Review

Abdominal Cavity Superior border = diaphragm Inferior border = pelvis Posterior border = lumbar spine Anterior border = muscular abdominal wall

Peritoneum Abdominal cavity lining Double-walled structure Visceral peritoneum Parietal peritoneum Separates abdominal cavity into two parts Peritoneal cavity Retroperitoneal space

Primary GI Structures Mouth/oral cavity Pharynx Lips, cheeks, gums, teeth, tongue Pharynx Portion of airway between nasal cavity and larynx

Primary GI Structures Esophagus Stomach Portion of digestive tract between pharynx and stomach Stomach Hollow digestive organ Receives food from esophagus

Primary GI Structures Small intestine Large intestine Between stomach and cecum Composed of duodenum, jejunum and ileum Site of nutrient absorption into body Large intestine From ileocecal valve to anus Composed of cecum, colon, rectum Recovers water from GI tract secretions

Accessory GI Structures Salivary glands Produce, secrete saliva Connect to mouth by ducts

Accessory GI Structures Liver Large solid organ in right upper quadrant Produces, secretes bile Produces essential proteins Produces clotting factors Detoxifies many substances Stores glycogen Gallbladder Sac located beneath liver Stores and concentrates bile

Accessory GI Structures Pancreas Endocrine pancreas secretes insulin into bloodstream Exocrine pancreas secretes digestive enzymes, bicarbonate into gut Vermiform appendix Hollow appendage Attached to large intestine No physiologic function

Major Blood Vessels Aorta Inferior vena cava

Solid Organs Liver Spleen Pancreas Kidneys Ovaries (female)

Hollow Organs Stomach Intestines Gallbladder and bile ducts Ureters Urinary bladder Uterus and Fallopian tubes (female)

Right Upper Quadrant Liver Gallbladder Duodenum Transverse colon (part) Ascending colon (part)

Left Upper Quadrant: Stomach Liver (part) Pancreas Spleen Transverse colon (part) Descending colon (part)

Right Lower Quadrant Ascending colon Vermiform appendix Ovary (female) Fallopian tube (female)

Left Lower Quadrant Descending colon Sigmoid colon Ovary (female) Fallopian tube (female)

Acute Abdomen

Abdominal Pain Visceral Somatic Referred

Abdominal Pain Visceral pain Stretching of peritoneum or organ capsules by distension or edema Diffuse Poorly localized May be perceived at remote locations related to organ’s sensory innervation

Abdominal Pain Somatic pain Inflammation of parietal peritoneum or diaphragm Sharp Well-localized

Abdominal Pain Referred pain Perceived at distance from diseased organ Pneumonia Acute MI Male GU problems

Non-hemorrhagic Abdominal Pain

Esophagitis Inflammation of distal esophagus Usually from gastric reflux, hiatal hernia

Esophagitis Signs and Symptoms Substernal burning pain, usually epigastric Worsened by supine position Usually without bleeding Often temporarily relieved by nitroglycerin

Acute Gastroenteritis Inflammation of stomach, intestine May lead to bleeding, ulcers Causes  acid secretion Chronic EtOH abuse Biliary reflux Medications (ASA, NSAIDS) Infection

Acute Gastroenteritis Signs and Symptoms Epigastric pain, usually burning Tenderness Nausea, vomiting Diarrhea Possible bleeding

Chronic Infectious Gastroenteritis Long-term mucosal changes or permanent damage Due primarily to microbial infections (bacterial, viral, protozoal) Fecal-oral transmission More common in underdeveloped countries Nausea, vomiting, fever, diarrhea, abdominal pain, cramping, anorexia, lethargy Handwashing, BSI

Peptic Ulcer Disease Craters in mucosa of stomach, duodenum Males 4x > Females Duodenal ulcers 2 to 3x > Gastric ulcers Causes: Infectious disease: Helicobacter pylori (80%) NSAIDS Pancreatic duct blockage Zollinger-Ellison Syndrome

Peptic Ulcer Disease Duodenal Ulcers Gastric Ulcers 20 to 50 years old High stress occupations Genetic predisposition Pain when stomach is empty Pain at night Gastric Ulcers > 50 years old Work at jobs requiring physical activity Pain after eating or when stomach is full Usually no pain at night

Peptic Ulcer Disease Complications Hemorrhage Perforation, progressing to peritonitis Scar tissue accumulation, progressing to obstruction

Peptic Ulcer Disease Signs and Symptoms Steady, well-localized pain “Burning”, “gnawing”, “hot rock” Relieved by bland, alkaline food/antacids Worsened by smoking, coffee, stress, spicy foods Stool changes, pallor associated with bleeding

Pancreatitis Inflammation of pancreas in which enzymes auto-digest gland Causes include: EtOH (80% of cases) Gallstones obstructing ducts Elevated serum triglycerides Trauma Viral, bacterial infections

Pancreatitis May lead to: Peritonitis Pseudocyst formation Hemorrhage Necrosis Secondary diabetes

Pancreatitis Signs and Symptoms Mid-epigastric pain radiating to back Often worsened by food, EtOH Bluish flank discoloration (Grey-Turner Sign) Bluish periumbilical discoloration (Cullen’s Sign) Nausea, vomiting Fever

Cholecystitis Gall bladder inflammation, usually 2o to gallstones (90% of cases) Risk factors Five Fs: Fat, Fertile, Febrile, Fortyish, Females Heredity, diet, BCP use

Cholecystitis Acalculus cholecystitis Burns Sepsis Diabetes Multiple organ systems failure Chronic cholecystitis (bacterial infection)

Cholecystitis Signs and Symptoms Sudden pain, often severe, cramping RUQ, radiating to right shoulder Point tenderness under right costal margin (Murphy’s sign) Nausea, vomiting Often associated with fatty food intake History of similar episodes in past May be relieved by nitroglycerin

Appendicitis Inflammation of vermiform appendix Usually secondary to obstruction by fecalith May occur in older persons secondary to atherosclerosis of appendiceal artery and ischemic necrosis

Appendicitis Signs and Symptoms Classic: Periumbilical pain  RLQ pain/cramping Nausea, vomiting, anorexia Low-grade fever Pain intensifies, localizes resulting in guarding Patient on right side with right knee, hip flexed

Appendicitis Signs and Symptoms McBurney’s Sign: Pain on palpation of RLQ Aaron’s Sign: Epigastric pain on palpation of RLQ Rovsing’s Sign: Pain in LLQ on palpation of RLQ Psoas Sign: Pain when patient: Extends right leg while lying on left side Flexes legs while supine

Appendicitis Signs and Symptoms Unusual appendix position may lead to atypical presentations Back pain LLQ pain “Cystitis” Rupture: Temporary pain relief followed by peritonitis

Bowel Obstruction Blockage of intestine Common Causes Adhesions (usually 2o to surgery) Hernias Neoplasms Volvulus Intussuception Impaction

Bowel Obstruction Pathophysiology Fluid, gas, air collect near obstruction site Bowel distends, impeding blood flow/ halting absorption Water, electrolytes collect in bowel lumen leading to hypovolemia Bacteria form gas above obstruction further worsening distension Distension extends proximally Necrosis, perforation may occur

Bowel Obstruction Signs and Symptoms Severe, intermittent, “crampy” pain High-pitched, “tinkling” bowel sounds Abdominal distension History of decreased frequency of bowel movements, semi-liquid stool, pencil-thin stools Nausea, vomiting ? Feces in vomitus

Hernia Protrusion of abdominal contents into groin (inguinal) or through diaphragm (hiatal) Often secondary to  intra-abdominal pressure (cough, lift, strain) May progress to ischemic bowel (strangulated hernia)

Hernia Signs and Symptoms Pain  by abdominal pressure Past history Inguinal hernia may be palpable as mass in groin or scrotum

Crohn’s Disease Idiopathic inflammatory bowel disease Occurs anywhere from mouth to rectum 35-45%: small intestine; 40%: colon Runs in families High risk groups White females Jews Persons under frequent stress

Crohn’s Disease Pathophysiology Mucosa of GI tract becomes inflamed Granulomas form, invade submucosa Muscular layer of bowel become fibrotic, hypertrophied Increased risk develops for Obstruction Perforation Hemorrhage

Ulcerative Colitis Idiopathic inflammatory bowel disease Chronic ulcers develop in mucosal layer of colon Spread to submucosal layer uncommon 75% of cases involve rectum (proctitis) or rectosigmoid portion of large intestine Inflammation can spread through entire large intestine (pancolitis)

Ulcerative Colitis Severity of signs, symptoms depends on extent Classic presentation Crampy abdominal pain Nausea, vomiting Blood diarrhea or stool containing mucus Ischemic damage with perforation may occur

Diverticulitis Diverticula Pouches in colon wall Typically in older persons Usually asymptomatic Related to diets with inadequate fiber

Diverticulitis Diverticula trap feces, become inflamed Occasionally result in bright red rectal bleeding Rupture may cause peritonitis, sepsis

Diverticulitis Signs and Symptoms Usually left-sided pain May localize to LLQ (“left-sided appendicitis”) Alternating constipation, diarrhea Bright red blood in stool

Hemorrhoids Small masses of veins in anus, rectum Most frequently develop when patients are in 30s or 40s; common past 50 Most are idiopathic, can be associated with pregnancy, portal hypertension Cause bright red bleeding, pain on defecation May become infected, inflamed

Peritonitis Inflammation of abdominal cavity lining Signs and Symptoms Generalized pain, tenderness Abdominal rigidity Nausea, vomiting Absent bowel sounds Patient resistant to movement

Hemorrhagic Abdominal Problems Gastrointestinal Hemorrhage Intraabdominal Hemorrhage

Esophageal Varices Dilated veins in esophageal wall Occur 2o to hepatic cirrhosis, common in EtOH abusers Obstruction of hepatic portal blood flow results in dilation, thinning of esophageal veins

Esophageal Varices Portal hypertension Hepatic scarring slows blood flow Blood backs up in portal circulation Pressure rises Vessels in portal circulation become distended

Esophageal Varices Signs and Symptoms Hematemesis (usually bright red) Nausea, vomiting Evidence of hypovolemia Melena (uncommon)

Mallory-Weiss Syndrome Longitudinal tears at gastroesophageal junction Occur as result of prolonged, forceful vomiting, retching Common in alcoholics May be complicated by presence of esophageal varices

Peptic Ulcer Disease Ulcer erodes through blood vessel Massive hematemesis Melena may be present

Aortic Aneurysm Localized dilation due to weakening of aortic wall Usually older patient with history of hypertension, atherosclerosis May occur in younger patients secondary to Trauma Marfan’s syndrome

Aortic Aneurysm Usually just above aortic bifurcation May extend to one or both iliac arteries

Aortic Aneurysm Signs and Symptoms Unilateral lower quadrant pain; low back or leg pain May be described as tearing or ripping Pulsatile palpable mass usually above umbilicus Diminished pulses in lower extremities Unexplained syncope, often after BM Evidence of hypovolemic shock

Ectopic Pregnancy Any pregnancy that takes place outside of uterine cavity Most common location is in Fallopian tube Pregnancy outgrows tube, tube wall ruptures Hemorrhage into pelvic cavity occurs

Ectopic pregnancy does NOT necessarily cause missed period Suspect in females of child-bearing age with: Abdominal pain, or Unexplained shock When was last normal menstrual period? Ectopic pregnancy does NOT necessarily cause missed period

Assessment of Acute Abdomen

History Where do you hurt? What does pain feel like? Onset of pain? Try to point with one finger What does pain feel like? Steady pain = Inflammatory process Cramping pain = Obstructive process Onset of pain? Sudden = Perforation or vascular occlusion Gradual = Peritoneal irritation, distension of hollow organ

History Does pain travel anywhere? Gallbladder = Angle of right scapula Pancreas = Straight through to back Kidney/ureter = Around flank to groin Heart = epigastrium, neck/jaw, shoulders, upper arms Spleen = Left scapula, shoulder Abdominal Aortic Aneurysm = low back radiating to one or both legs

History How long have you been hurting? Nausea, vomiting >6 hours = increased probability of surgical significance Nausea, vomiting How much, How long? Consider possible hypovolemia Blood, coffee grounds? Any blood in GI tract = emergency until proven otherwise

History Urine Change in urinary habits? Frequency Urgency Color? Odor?

History Bowel movements Change in bowel habits? Color? Odor? Bright red blood Melena = black, tarry, foul-smelling stool Dark stool Suspect bleeding Other causes possible (iron or bismuth containing materials)

History Last normal menstrual period? Abnormal bleeding? In females, lower abdominal pain = GYN problem until proven otherwise In females of child-bearing age, lower abdominal pain = ectopic pregnancy until proven otherwise

Physical Exam Position and General Appearance Still, refusing to move = Inflammation, peritonitis Extremely restless = Obstruction Gross appearance of abdomen Distended Discolored Consider possible third spacing of fluids

Physical Exam Vital signs Tachycardia = more important sign of volume loss than falling BP Rapid, shallow breathing = possible peritonitis Consider performing “tilt” test

Physical Exam Bowel sounds Auscultate BEFORE palpating One minute in each abdominal quadrant Absent sounds = possible peritonitis, shock High-pitched, tinkling sounds = possible bowel obstruction

Physical Exam Palpation Palpate each quadrant Palpate area of pain LAST Do NOT check rebound tenderness in prehospital setting ALL abdominal tenderness significant until proven otherwise

Management Oxygen by non-rebreather mask IV LR or NS PASG (demonstrated benefit in intrabdominal hemorrhage) Keep patient from losing body heat Monitor vital signs

Management Monitor EKG Consider possible MI with pain referred to abdomen in patients >30 years old Keep patient npo Analgesia controversial Demerol is preferred narcotic analgesic