Acute Abdomen

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Acute Abdomen. Melissa Cunha Transplant Fellow Manchester Royal Infirmary 28 th February 2011. Objectives. Definition Approach Commonest causes History Clinical Examination Investigations Management Cases. Definition.
Acute AbdomenMelissa Cunha Transplant Fellow Manchester Royal Infirmary28th February 2011Objectives
  • Definition
  • Approach
  • Commonest causes
  • History
  • Clinical Examination
  • Investigations
  • Management
  • Cases
  • Definition
  • Someone who becomes acutely ill and signs are chiefly related to the abdomen has an acute abdomen
  • A systematic approach
  • History, Examination, Investigations, Treatment Plan
  • May require simultaneous resuscitation and treatment.
  • Final diagnosis in UK
  • Non-specific abdominal pain 30-40%
  • Appendicitis 20-25%
  • Cholecystitis / Biliary Colic 7-8%
  • Peptic ulcer disease 4%
  • Urinary retention 4%
  • Acute pancreatitis 3%
  • Small bowel Obstruction 3%
  • Renal Colic 3%
  • Trauma 3%
  • Malignant disease 2-4%
  • Medical diagnosis 2-4%
  • Acute diverticulitis 2%
  • Large bowel obstruction 2%
  • Vascular Disease 2%
  • Gynaecological disease 1%
  • History
  • Pain
  • SOCRATES
  • Site
  • Onset
  • Character
  • Radiation
  • Associated symptoms
  • Time course
  • Exacerbating/relieving factors
  • Severity
  • Specific questioning
  • GI symptoms
  • Similar episodes
  • Swellings in groin or abdomen
  • Gynaecological and Obstetric history
  • Vaginal discharge
  • History
  • Past medical history
  • Past surgical history
  • Drug history and allergies
  • Social history
  • Alcohol
  • Tobacco
  • Family history
  • Systemic inquiry
  • Clinical Examination
  • General state & demeanour of patient
  • Dehydration
  • Jaundice
  • Anaemia
  • Cyanosis
  • Oedema
  • Clinical Examination
  • ALWAYS:
  • BP, HR, RR, Temperature, SpO2
  • Cardiovascular Examination
  • Respiratory Examination
  • Clinical examination
  • Abdominal examination:
  • Inspection
  • Palpation
  • Percussion
  • Auscultation
  • Clinical Examination
  • Always include:
  • Back
  • Groins
  • Hernias
  • Perineum and genitalia
  • Consider patient’s dignity
  • Clinical Examination
  • Abdominal examination findings:
  • Murphy’s sign
  • Rovsing’s sign
  • Iliopsoas’ sign
  • Obturator’s sign
  • Guarding
  • Rebound
  • Murphy’s sign
  • Elicitation: Palpate the right subcostal area while the patient inspires deeply
  • Positive response: The patient feels pain upon this manoeuvre and may have an associated inspiratory cessation
  • Rovsing’s sign
  • Elicitation: Palpate the left lower quadrant of the abdomen
  • Positive response: The patient feels pain in the right lower quadrant
  • Iliopsoas’ sign
  • Elicitation: patient on left lateral decubitus and examiner extends patients right leg at the hip
  • Positive response: The patient feels pain in the right lower quadrant
  • Obturator’s sign
  • Elicitation: flexion and external rotation of the hip
  • Positive response: The patient feels pain in the right lower quadrant
  • Bedside investigations
  • Vomit
  • Stools
  • Urine
  • Basic Blood Tests
  • Full Blood Count
  • Urea and Electrolytes
  • Liver Function Tests
  • Bone Profile
  • Amylase
  • Coagulation Screen
  • Pregnancy test
  • Other investigations
  • Urine test
  • Stools culture
  • Radiology
  • Chest X-Ray:
  • Pneumonia, Perforation, Subphrenic abcess
  • Abdominal X-Ray:
  • Ileus, Obstruction, Stones, Air above liver.
  • Contrast studies:
  • Gastrograffin, barium enema
  • USS
  • CT
  • MRI
  • Ultrasound
  • Gallstones, Liver abscess, Biliary tree, Pancreas
  • Urinary Tract: Hydronephrosis, Stones
  • Pelvis: Abscess, appendicitis, Gynaecological conditions, ectopic pregnancy
  • Ascites
  • Abdominal Aortic Aneurysm
  • CT Scan
  • Useful for retroperitoneal structures
  • Pancreatitis
  • Abdominal Aortic aneurysm
  • Management
  • Resuscitate
  • Conservative treatment
  • Medical management
  • Surgical treatment
  • Case 1
  • Male, 35 years old
  • Central abdominal pain, colic in nature that then shifts to RIF and becomes constant
  • Anorexia
  • Constipation
  • Otherwise fit and well
  • Case 1
  • What are the possible findings from Physical examination?
  • Physical examination
  • Tachycardia
  • Low grade fever
  • Lying still
  • Foetor
  • Tenderness and guarding RIF
  • Rebound tenderness
  • PR: painful on right
  • Case 1
  • What are the differential diagnosis?
  • Differential Diagnosis
  • Appendictis
  • Mesenteric adenitis
  • Salpingitis/PID
  • UTI
  • Cholecystitis
  • Diverticulitis
  • Chrohn’s disease
  • Food poisoning/gastroenteritis
  • Case 1
  • What tests would you request?
  • Investigations
  • U&E, FBC, CRP
  • Urine sample
  • Pregnancy test
  • CXR and AXR
  • USS
  • CT abdomen
  • Do not rely on tests for appendicitis
  • Case 1
  • How would you manage this case?
  • Appendicitis
  • RIF pain, low grade fever
  • Guarding and tenderness RIF
  • Raised WCC and CRP
  • Management:
  • IV fluids
  • IV antibiotics
  • Surgery:
  • Laparoscopic
  • Open
  • Other causes RIF pain
  • Gynaecological and Obstetric causes:
  • Salpingitis
  • Pelvic inflammatory disease
  • Ectopic pregnancy
  • Medical causes
  • Crohn’s disease
  • Case 2 Female, 40 years old, obese Sudden onset of right upper quadrant pain associated with nausea and vomiting after eating pork pie. Feels hot and unwell. No changes in bowel habit.No urinary symptoms. PMH: nil Case 2 What are the possible findings from Physical examination?Physical examination Tachycardia Fever Local peritonism Murphy’s sign Gallbladder mass Case 2 What are the differential diagnosis?Differential DiagnosisAcute cholecystitisChronic cholecystitis Biliary colic Cholangitis Hepatitis Pneumonia Case 2What tests would you request?Investigations Renal profile and Liver function testsFull blood count USS HIDA scan ERCPMRCP Management How would you manage this case?Acute Cholecystitis
  • Management:
  • NBM
  • Analgesia
  • IV fluids
  • IV antibiotics
  • Cholecystectomy
  • Chronic Cholecystitis Chronic inflammationAbdominal discomfortDistension Nausea and/or vomiting Intolerance of fatsChronic cholecystitis
  • Investigations:
  • USS: stones
  • Bloods: normal
  • Management:
  • Cholecystectomy
  • Biliary colicRUQ painNausea and/or vomiting Intolerance of fatsJaundice may be present Biliary colic
  • Management:
  • Analgesia
  • USS – check CBD
  • HIDA scan
  • Cholecystectomy
  • ERCP – if retained stones
  • Cholangitis
  • Inflammation of bile duct with obstruction of the biliary tree:
  • RUQ pain
  • Jaundice
  • Rigors
  • Investigations:
  • U&E, LFTs and clotting
  • USS
  • ERCP
  • Cholangitis
  • Management
  • IV fluids
  • IV antibiotics
  • Vitamin K
  • ERCP
  • Medical causesHepatitisHepatomegaly Peptic ulcer Pneumonia Case 3 Female, 43 years oldSudden onset of severe epigastric pain radiated to the back, severe intensity Nausea and vomiting +++No jaundiceNo changes in bowel habit No urinary symptoms PMH: Recently diagnosed gallstones Case 3 What are the possible findings from Physical examination?Physical ExaminationTachycardiaFever Jaundice Rigid abdomen Localised tenderness Case 3What are the differential diagnosis?Differential DiagnosisAcute Pancreatitis Perforated peptic ulcerCholecystitisCholangitis Acute MI Case 3What tests would you request?Investigations U&E, FBC, LFT and amylaseErect CXRAXRABGUSS abdomen CT abdomen ERCP if jaundice Management How would you manage this case?Acute Pancreatitis
  • Clinical Diagnosis
  • Epigastric pain radiating to the back
  • Nausea and Vomiting
  • Severe upper abdominal tenderness
  • Guarding and rigidity
  • Diagnosis (2 of the following)
  • Abdominal pain characteristic of acute pancreatitis
  • Serum amylase or lipase ≥ 3 times upper limit
  • Characteristic findings on CT scan
  • Acute Pancreatitis
  • Causes
  • “ GET SMASHED”
  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune
  • Scorpion venom
  • Hyperlipidaemia
  • ERCP
  • Drugs
  • Acute Pancreatitis
  • Management
  • NBM at least 24 hours
  • IV fluids
  • Urinary catheter – monitor urine output
  • Analgesia
  • Vital signs to be checked regularly
  • If deterioration – Transfer to HDU
  • Treat the cause
  • Acute Pancreatitis
  • Complications:
  • Shock
  • ARDS
  • Renal failure
  • DIC
  • Pancreatic necrosis
  • Pancreatic collections
  • Pseudocysts
  • Bleeding
  • Portal vein thrombosis
  • Perforated Ulcer Epigastric or retrosternal discomfortRelated to hunger or eating specific foods or at the time of the dayHeaviness, bloating or fullnessSudden or gradual onsetTenderness over epigastrium Guarding or rigidity Ileus Investigations U&E, FBC, LFT Erect CXR Management
  • IV fluids, Analgesia, Urinary catheter
  • Theatre
  • Oversewn of perforated ulcer – laparoscopic or open
  • Epigastric pain
  • Medical causes:
  • Ulcers
  • Gastroenteritis
  • MI
  • Case 4 Female, 27 years oldSudden onset of left side pain Radiated to the left groin Frequency and dysuria Otherwise fit and well Case 4 What are the possible findings from Physical examination?Physical examination Febrile Flank tendernessSuprapubic tendernessPain on back percussion Case 4What are the differential diagnosis?Differential DiagnosisPyelonephritis Renal stones Ruptured spleen Perforated colon Pneumonia Case 4What tests would you request?Investigations U&E, FBC, Calcium, CRP Urine for MSUUrine composition Blood culture KUB X-Ray, USS or CT Case 4 How would you manage this case?Acute Pyelonephritis
  • Flank pain (right or left)
  • Can radiate to the groin
  • Urinary symptoms:
  • Frequency
  • Dysuria
  • Fever
  • Urine sample: nitrates negative and lecucocyte count raise
  • Acute Pyelonephritis IV fluids IV antibiotics Renal stones
  • Loin pain that can radiate to groin
  • Dysuria, frequency and/or haematuria
  • Diagnosis:
  • U&E, calcium, Phosphate, bicarbonate and urates
  • CT KUB or USS KUB
  • Renal stones
  • Management
  • IV fluids
  • Analgesia
  • Stones:
  • <5mm – pass spontaneously
  • >5mm – fragmented or removed cystoscopically
  • Urgent urological referral if:
  • If signs of obstruction – fever, urinary infection
  • Ruptured spleen
  • Symptoms and signs
  • Trauma
  • Left upper quadrant pain
  • Tachycardia
  • Haematoma LUQ
  • Shock
  • Investigations: CT
  • Management:
  • Conservative
  • Surgical
  • Left upper quadrant pain
  • Other surgical causes
  • Perforated colon
  • Abdominal pain, changes in bowel habit, vomiting
  • Tenderness , guarding and rigidity
  • AXR: air under diaphragm
  • Management: IV fluids, analgesian and surgery
  • Medical causes:
  • Pneumonia
  • Gastric ulcer
  • Case 5Male, 56 years old Gradual onset of left iliac fossa painColickyNausea and vomiting Constipation PMH: Known diverticular disease Case 5 What are the possible findings from Physical examination?Physical examination TachycardiaFebrile Tenderness over LIFGuarding Absent bowel soundsPR: no masses Case 5What are the differential diagnosis?Differential diagnosisDiverticular disease/ Diverticulitis Perforated colon Crohn’s diseaseUlcerative colitis Ureteric colic Salpingitis/PIDEctopic pegnancy Case 5What tests would you request?Investigations U&E, FBC, CRP, G+SUrine test CXRAXRCT abdomenCase 5 How would you manage this case?Diverticulitis IV fluids, NBM IV antibiotics If any abdominal collection – percutaneous drainage If perforation or peritonitis – surgery Case 6Male, 65 years old Continuous central abdominal painVomiting +++Anorexia Constipation for 3 days Known: IHD, hypercholestrolaemia, HTN and gallstones Case 6 What are the possible findings from Physical examination?Physical Examination Tachycardia Dehydrated Hypotensive Abdominal distension Generalised tendernessPR: empty rectum Case 6What are the differential diagnosis?Differential diagnosisObstruction of the bowelMesenteric artery occlusion AAAPancreatitis Diverticulitis Case 6What tests would you request?InvestigationsU&E, FBC, CRP, G+SUrine test CXRAXRCT abdomenCase 6How would you manage this case?Bowel obstruction
  • NBM
  • IV fluids
  • NG tube
  • Surgery:
  • No response to conservative management
  • Volvulus
  • Signs of strangulation
  • Mesenteric IschaemiaIV fluidsIV antibiotics Angiogram Surgery AAATreat shock with IV fluids and bloodDo not waste time Take home messages
  • Careful history
  • Remember differential diagnosis in broad categories
  • Narrow differential diagnosis based on history, examination and investigations
  • Do not forget medical and gynaecological causes
  • Take home messages
  • For acute abdomen think of these commonly:
  • Appendicitis
  • Cholecystitis
  • Perforated duodenal ulcer
  • Diverticuitis ±perforation
  • Acute pancreatitis
  • Bowel obstruction
  • Ruptured aneurysm
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