ACUTE ABDOMEN CLINICAL METHODS WITH DIAGNOSIS

Good and understandable slide for medical practice

1. ACUTE ABDOMEN Prof. S. A. Tabiri 1

2. The Condition Encompasses medical , surgical and gynaecological causes. Ranges from trivial to life threatening The challenge is to identify conditions that will benefit from IMMEDIATE management 2

3. Overview Definition Essential Embryology and Anatomy Pain history Types of pain Common causes History Examination Investigations Case histories Summary 3

4. Definition Sudden onset (abdominal pain) < 1week presenting as an emergency with no history of trauma ( WHICH MAY OR MAY NOT LEAD TO AN OPERATION) 4

5. Essential anatomy and embryology Embryology -midline origin - derivative of three special areas Anatomy - visceral and parietal peritoneum - innervation and blood supply - Referred v Radiant pain - Dermatomes 5

6. Diagnosis History Examination Investigation 6

7. Pain history S ite O nset C haracter R adiation A lleviating factors T iming E xacerbating factors S core 7

8. HISTORY PAIN Invariably 8

9. Types of pain-Visceral pain Dull, deep seated, midline Site due to embryological origin Foregut structures (oesophagus to 2 nd part of duodenum) -upper abdomen Midgut structures (2 nd part of duodenum to splenic flexure)- middle of abdomen Hindgut structures( splenic flexure to rectum)- lower abdomen 9

10. Types of pain-Somatic pain Sharp or knife like, well localised Worse on movement, coughing, inspiration Patient lies still taking shallow breaths Irritated parietal peritoneum - reflex contraction of muscle (guarding and rigidity) 10

11. Types of pain-Referred pain Back pain R subscapular Shoulder tip Groin MI, pneumonia, pulmonary embolism - pain felt at a distance from the source 11

12. Types of pain - Obstruction Intermittent, colicky pain Moves about to try get comfortable Smooth muscle peristaltic contraction to try overcome obstruction in hollow viscus (small intestine , ureter , biliary system, colon, uterus, fallopian tube, appendix) 12

13. Examination Observations-BP, pulse, RR, oxygen saturation, temperature Cardiorespiratory exam Adequate exposure-nipple to knees 13

14. Examination Inspection Unwell, pale Dehydration Lying still, shallow breaths/writhing about Jaundice Anaemia Previous scars Grey Turner’s sign/ Cullen’s sign Abdominal distension 14

15. Examination Palpation Watch for grimacing Think of underlying anatomical structure ?Peritonism - Guarding, rigidity, rebound tenderness. Localised/generalised Organomegaly/masses Pulsatile mass 15

16. Surgical abdomen Unstable vital signs Signs of peritonitis Concern life threatening condition 16

17. Investigations Urine-dipstick, pregnancy test - women of childbearing age, MSU FBC,U+E, LFTs, Amylase, Glucose, CRP, Clotting, G+S, Crossmatch, blood cultures, ABGs Stool culture ECG AXR CXR US CT Diagnostic laparoscopy /laparotomy 17

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19. CAUSES INFLAMATION PERFORATION INTESTINAL OBSTRUCTION HAEMORHAGE ACUTE PANCREATITIS COLICS GYNAECOLOGICAL CONDITIONS MEDICAL 19

20. CLINICAL FEATURES OF GROUPS Inflammatory group *insidious onset of pain *constant *worse on movement *signs of PERITONISM 20

21. Perforated V iscus sudden, severe, constant Constipation Note typhoid/ amoebic perforation can have diarrhea, fever, headache, prodromal symptom s 21

22. Intestinal obstruction Cardinal Symptoms *colicky abdominal pain *vomiting and / or distension *absolute constipation Note intussusception – bloody, mucoid , stools 22

23. Non- specific abdominal pain multi system—URTI, myalgia – viral diffuse upper& pulm –pleural/ pulm 23

24. Non – Specific abdominal Pain 24

25. Non-specific abdominal pain Multisystem URTI, Myalgia-------Viral Diffuse abdominal pain diffuse abdominal pain 25

26. Case histories AIMS Surgical abdominal pain only 4x Case histories RLQ; RUQ; LUQ; LLQ differential diagnoses 4x abdominal pain subjects in detail 26

27. Case Hx 1 A 22-year-old male presents to the emergency department with abdominal pain, anorexia, nausea and low-grade fever. Pain started in the mid-abdominal region centrally 6 hours ago and is now in the right lower quadrant of the abdomen. The pain was steady in nature and aggravated by coughing. O/E: 38°C, pain on palpation at right lower quadrant and pain in RLQ on palpation of LLQ 27

28. RLQ pain: differential diagnosis Appendicitis Ovarian cyst Ectopic pregnancy PID Meckel’s diverticulum Salpingitis Mesenteric adenitis Ureteric colic Strangulated hernia Psoas abscess Crohn’s disease R sided pneumonia 28

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30. Acute appendicitis: symptoms + signs Central abdominal pain: crampy /colicky RIF pain: sharp; worse on coughing Nausea; rarely vomiting Anorexia Usually constipation; occasional loose stool Pyrexia (low-grade) Tachycardia Furred tongue Foetor + flushing Tender + guarding in RIF over McBurney’s point Rovsing’s sign Tender PR anteriorly 30

31. Investigations Raised WCC CRP Pregnancy test Urine diptest Abdominal X-Ray Erect chest X-ray Abdominal Ultrasound Abdominal CT scan 31

32. The Alvarado score Feature Score Feature Score Migration of pain 1 Rebound pain 1 Nausea/ vomitting 1 Temp >37.3 1 Anorexia 1 WCC >10 2 RIF tenderness 2 Neuts count > 75% 1 TOTAL SCORE: if ≤ 4 diagnosis unlikely 5-6 = observe ≥ 7 = operation considered 32

33. Treatment 33

34. Complications of appendicitis Appendix mass Perforation Appendix abcess 34

35. CASE Hx 2 A 50-year-old obese woman presents to the emergency department with severe, constant right upper quadrant (RUQ) pain, nausea and vomiting after eating fried chicken for dinner the day before. She denies any chest pain or diarrhoea. Three months ago she developed intermittent, sharp RUQ pains. On physical examination she has a temperature of 38°C (100.4°F), moderate RUQ tenderness on palpation but no evidence of jaundice. 35

36. RUQ pain: differential diagnosis Acute cholecystitis Biliary colic Cholangitis Hepatitis Peptic ulceration Congestive hepatomegaly Pyelonephritis Right-sided pneumonia 36

37. Cholelithiasis (gallstones) 10 % of population over 50 Risk factors: female; multiparous; obesity; contraceptive pill; haemolytic disorders; ileal disease; smoking 3 types of stone: Cholesterol (5%)– yellowish green colour, most common accounting for, usually large Pigment stones (15%) – Smaller and darker, made up of bilirubin Mixed Stones (75%)– Mixture cholesterol, bile pigments, and calcium salt 37

38. Empyema Mucocele Gallstone ileus Pancreatitis Cholangitis Obstructive jaundice Perforation Carcinoma Chronic cholecystitis Acute cholecystitis GALLSTONES COMPLICATIONS 38

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40. Acute cholecystitis Follows stone or sludge impaction in the neck of the gallbladder. RUQ pain; vomitting; fever; local peritonism; GB mass Different from biliary colic as inflammation. If stone moves to CBD→obstructive jaundice +/- cholangitis. Murphy’s sign positive 40

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42. Case Hx 3 40 yr old male; alcohol dependence Sudden onset severe LUQ band-like pain radiating to back. Associated sweating + vomiting O/E: clammy; pale; agitated HR 115; BP stable epigastric guarding 42

43. LUQ pain: differential diagnosis Peptic ulceration Pancreatitis Splenic infarct/ rupture Perforated colon Pyelonephritis Cholecystitis Myocardial infarction 43

44. What is the likely diagnosis and what is this sign called? 44

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47. Causes of Acute pancreatitis Biliary tract disease (in UK: 80% due to alco + gallstones) Alcohol Hyperlipidaemia Hyperparathyroidism Viral infections (Mumps; Coxsackie virus) Hypothermia Trauma Drugs: steroids; oestrogen contraceptives; azathioprine; thiazide diuretics Familial; idiopathic Scorpion bites Autoimmune (polyarteritis nodosa) Post-ERCP Pancreatic carcinoma 47

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49. Glasgow Scale Other important investigations Age > 55 = 1 point Amylase >1000 AST/ ALT > 200 = 1 point ECG (?diminished T waves) Albumin < 32 = 1 point Hb pO2 (arterial) on r/a = 1 point AXR + CXR (small pleural effusions) WCC >15 = 1 point Calcium <2 = 1 point LDH > 600 = 1 point Glucose > 10 = 1 point Urea > 16 = 1 point 49

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52. Complications Acute renal failure Acute respiratory distress syndrome Gastric erosions ( haematemesis and melaena ) DIC Psychosis Diabetes LOCAL: pancreatic necrosis; abcess formation; pseudocyst formation; fistulae; thrombosis; bleeding 52

53. Case Hx 4 A 38 yr old gentleman arrives at A+E with acute LLQ pain radiating from the left loin. The pain is intermittent and he vomits on arrival. He complains of intermittent red coloured urine; denies trauma and cannot sit still while you try to examine him. 53

54. LLQ pain: differential diagnosis Sigmoid diverticular disease Ovarian cyst Ectopic pregnancy PID Ureteric colic Rectus sheath haematoma L sided lobar pneumonia 54

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56. Precipitating factors Diet Dehydration Stasis Infection Hyperparathyroidism Idiopathic hypercalciuria Milk-alkali syndrome Hypervitaminosis D Cystinuria Inborn errors of purine metabolism Gout Chemotherapy 56

57. Symptoms + signs Spasms of pain radiating from loin to groin Nausea + vomitting Unable to lie still (unlike peritonitis) Dysuria Urinary hesitancy Infection can co-exist: fever; rigors Haematuria Anuria 57

58. Investigations Urine dipstick and MSU U+Es; FBC; ESR; Calcium; Phosphate; uric acid; glucose 24hr urine for: Ca, oxalate, urate, citrate, Na, creatinine, stone biochemistry KUB US renal tract CT Urogram (superior to IVU) 58

59. History of Pain C) Radiation - Biliary Pain – RUQ between shoulder blades - Ureteric Colic d) Severity Severe, colicking +/- severity/ vomiting – colics Excruciating - AC pancreatictis , Ru ptured AAA 59

60. HISTORY OF PAIN Duration - Short : Inflammatory -Long : typhoid, obstruction… b) Location: Foregut -UPPER Mid-gut -CENTRAL Hindgut -HYPOGASTRIC 2) Visceral Pain – midline, Poorly localized Peritoneal Pain – Severe, Localized to dx organ 60

61. Assessment of the Acute Abdomen 61

62. Definition Sudden onset (abdominal pain) < 1week presenting as an emergency with no history of trauma Encompases medical , surgical and gynaecological causes. Ranges from trivial to life threatening The challenge is to identify conditions that will benefit from IMMEDIATE management. 62

63. History of Pain e) Aggravating factors -worse on movement, breathing, coughing Inflammation Fatty foods Gall bladder f) Relieving factors -Lying still ac. Inflammatory abd . Conditions -food and antacids gastritis, gastric ulcer 63

64. Common causes Appendicitis Cholecystitis Diverticulitis Pancreatitis Perforated peptic ulcer (Ischaemic gut) Renal colic UTI Intestinal obstruction GI bleeding Ruptured AAA NSAP 64

65. History Age Nausea/vomiting, haematemesis Diarrhoea, constipation, stool colour, PR blood/mucus Collapse Gynaecological-menstrual and sexual history Urinary symptoms-frequency, dysuria, haematuria Cardiorespiratory history PMH SH DH- NSAIDs, steroids Last meal and drink 65

66. Summary ABC approach History and examination important Always do a pregnancy test on women of childbearing age Amylase Don’t forget silent acute abdomen and AAA 66

67. Questions ? 67