1. Medical Student Small Group Discussion Topics
Acute Abdominal Crises

2. Suggested Reading Current Diagnosis and Treatment: Surgery
Chapter 21 “The Acute Abdomen”
Chapter 23: Stomach and Duodenum
Perforated Peptic Ulcer
Gastric Volvulus
Chapter 28: The Appendix
Acute appendicitis
Chapter 29: The Small Intestine
Obstruction of the Small Intestine
Acute Vascular Lesions of the Small Intestine & Mesentery
Chapter 30: Large Intestine
Diverticular Disease
Obstruction of the Large Intestine
Volvulus
Chapter 43: Pediatric Surgery
Intestinal obstruction in the newborn
Disorders of intestinal rotation
Intussusception
Necrotizing Enterocolitis
Current Diagnosis & Treatment: Surgery, Thirteenth Edition
Edited by Gerard M. Doherty
Copyright © 2010 by The McGraw-Hill Companies, Inc.

3. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
What are the borders of, the blood supply to, and the organs contained within:
The foregut?
The midgut?
The hindgut?

4. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Describe the relevance of somatic pain fibers in the evaluation of abdominal pain in terms of:
Location of somatic pain fibers (Parietal vs visceral peritoneum)?
Stimulants for somatic pain fiber activity?
Localization of pain when somatic fibers are stimulated?

5. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Describe the relevance of visceral pain fibers in the evaluation of abdominal pain in terms of:
Location of visceral pain fibers (Parietal vs visceral peritoneum)?
Stimulants for visceral pain fiber activity?
Localization of pain when visceral fibers are stimulated?

6. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
What are the important history of present illness questions to elicit from a patient complaining of abdominal pain?

7. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
What are the important physical examination components you would want to assess in a patient complaining of abdominal pain?

8. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #1
A 70 year old man presents with left lower quadrant abdominal pain

9. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #1
A 70 year old man presents with left lower quadrant abdominal pain
The patient’s pain began about 24 hours ago becoming progressively worse over the next few hours. He describes the pain as sharp since it began. It is now very severe and has been, and remains, well localized in his left lower quadrant. The pain is continuous and worsened with movement. He reports subjective fevers although he has not taken his temperature. No nausea or vomiting. Some loose stools over the past few days. No recent or past history of significant constipation. He is not particularly hungry. He has had no recent weight loss nor has he noted blood in his stool or any change in the caliber of his stools. Last bowel movement was earlier this morning and he has been having flatus.

10. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #1
A 70 year old man presents with left lower quadrant abdominal pain ?
How do you interpret the significance of the patient’s reported history? Consider the role of visceral and somatic pain fibers in the patient’s complaints and the possible pathophysiologic causes for the reported findings.

11. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #1
A 70 year old man presents with left lower quadrant abdominal pain
On examination, the patient is awake alert and oriented. He is lying still on the examining table. He has a temperature of 38.8°C (101.8°F). Heart is regular in rate and rhythm without murmur, rub, or gallop. On inspection, his abdomen is without distension, bruising, or previous incisions. Bowel sounds are hypoactive. Percussion of his abdomen reveals neither tympani nor dullness. However, the patient complains that percussion in the left lower quadrant is painful. His abdomen is tender to palpation in the left lower quadrant with significant rebound tenderness referred to the left lower quadrant. No abdominal masses are noted. There is some involuntary guarding in the left lower quadrant. He has no hernias on examination.

12. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #1
A 70 year old man presents with left lower quadrant abdominal pain ?
How do you interpret the significance of the patient’s physical examination findings? Consider the role of visceral and somatic pain fibers in the patient’s findings, and the possible pathophysiologic causes for the reported findings.

13. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #1
A 70 year old man presents with left lower quadrant abdominal pain ?
Based on your history and physical examination alone, what do you believe is the pathophysiology of the patients acute condition?

14. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #1
A 70 year old man presents with left lower quadrant abdominal pain ?
What is your differential diagnosis and which is most likely taking the patients history and physical examination findings into account?

15. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #2
A 55-year-old man with a complaint of severe, progressing abdominal pain.

16. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #2
A 55-year-old man with a complaint of severe, progressing abdominal pain.
History and Physical Findings
The patient, who is in general good health, arrives by ambulance with a complaint of severe, unrelenting abdominal pain which came on very suddenly three hours earlier. His blood pressure is 90/50, pulse 130, temperature 38° and respirations 16. His physical examination reveals abdominal distention, no bowel sounds, and involuntary guarding throughout, (a “board-like” abdomen).

17. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #2
An abdominal series is ordered with the following being one of those films.

18. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #2
A 55-year-old man with a complaint of severe, progressing abdominal pain.
What is your differential diagnosis?

19. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #2
A 55-year-old man with a complaint of severe, progressing abdominal pain.
What is your next diagnostic step in managing this patient?

20. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #2
A 55-year-old man with a complaint of severe, progressing abdominal pain.
Is there anything you would do prior to taking this patient to the operating room?

21. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #3
A 20-year-old woman comes to the emergency room with a complaint of right lower quadrant pain of 12 hours duration.

22. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #3
History and Physical Findings
The patient comes to your office with a complaint of right lower quadrant pain of 12 hours duration. She is sexually active and has had an episode of PID one year ago. The present pain is more severe and more on the right. Her last period was two weeks ago and was on time. She is anorectic and has had some burning on urination. She has a blood pressure of 110/60, pulse 100, temperature 38.5°C (101.3°F) and respirations 12. Physical examination of the abdomen is consistent with peritonitis in the right lower quadrant. Pelvic examination reveals minimal cervical tenderness with a tender fullness in the right adnexa.

23. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #3
A 20-year-old woman comes to the emergency room with a complaint of right lower quadrant pain of 12 hours duration.
What is your differential diagnosis?

24. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #3
A 20-year-old woman comes to the emergency room with a complaint of right lower quadrant pain of 12 hours duration.
How would you make the diagnosis?

25. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #3
What if the patient was male? Would this change your management?

26. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #4
A 44-year-old man is admitted to the hospital because of crampy abdominal pain and bilious vomiting that has lasted for three days.

27. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #4
A 44-year-old man is admitted to the hospital because of crampy abdominal pain and bilious vomiting that has lasted for three days.
History and Physical Findings
The patient has not had a bowel movement or flatus for two days. Ten years ago he had an appendectomy for a perforated appendicitis, with no postoperative complications. Physical examination reveals a pulse of 100, blood pressure 110/60, temperature 35.5°C. His abdomen is distended with hyperactive bowel sounds and tympany throughout. There is no abdominal tenderness to palpation.

28. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #4
A 44-year-old man is admitted to the hospital because of crampy abdominal pain and bilious vomiting that has lasted for three days.
Which diagnostic laboratory tests are indicated?

29. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #4
A 44-year-old man is admitted to the hospital because of crampy abdominal pain and bilious vomiting that has lasted for three days.
Which imagining study should be initially obtained to confirm your clinical diagnosis?

30. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #4
A 44-year-old man is admitted to the hospital because of crampy abdominal pain and bilious vomiting that has lasted for three days.
What is the most likely diagnosis and what is the likely etiology for this patient’s current condition?

31. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #4
A 44-year-old man is admitted to the hospital because of crampy abdominal pain and bilious vomiting that has lasted for three days.
What would be the most likely etiologies if the patient had never had any previous abdominal surgery?

32. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #4
A 44-year-old man is admitted to the hospital because of crampy abdominal pain and bilious vomiting that has lasted for three days.
What is your initial management plan for this patient?

33. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #4
A 44-year-old man is admitted to the hospital because of crampy abdominal pain and bilious vomiting that has lasted for three days.
Which findings, if present, would be ominous indications that the patient needed urgent operative treatment?

34. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #5
A 95-year-old man is sent to the emergency room from a nursing home with complaints of abdominal pain and distension.

35. Medical Student Small Group Discussion Topics
Acute Abdominal Crises
Case #5
History and Physical Findings
It is unclear, but staff at the nursing home think it has been about four days since he had a bowel movement. On examination, the patient has an expressive aphasia and a right hemiparesis from a previous stroke. His vital signs are pulse 90, blood pressure 120/80, and he is afebrile. There is no abdominal tenderness. Rectal exam reveals large quantities of soft, brown, guaiac negative stool. KUP and upright reveal markedly dilated colon consistent with obstruction.

36. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #5
A 95-year-old man is sent to the emergency room from a nursing home with complaints of abdominal pain and distension.
What is the differential diagnosis of a large bowel obstruction?

37. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #5
A 95-year-old man is sent to the emergency room from a nursing home with complaints of abdominal pain and distension.
What test(s) would you employ to determine a specific diagnosis?

38. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #5
A 95-year-old man is sent to the emergency room from a nursing home with complaints of abdominal pain and distension.
Outline your treatment plan for a patient with volvulus.

39. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #5
A 95-year-old man is sent to the emergency room from a nursing home with complaints of abdominal pain and distension.
Where can a volvulus develop and what are the typical patient characteristics?

40. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #5
How would this differ from your treatment of a patient with a colon cancer or impaction?

41. Medical Student Small Group Discussion Topics
Acute Abdominal Crises ?
Case #5
What are the potential complications of a patient with a large bowel obstruction if left untreated?