Acute Abdominal Pain MS-General surgery lecture.ppt

Acute Abdominal Pain MS-General surgery lecture

1. Acute Abdomen
Hani Albrahim,MD
Head of the EMS Unit
Department of Emergency Medicine

2. Which one has the highest
mortality rate ?
Ruptured AAA
Perforated peptic ulcer
Mesenteric ischemia
Bowel obstruction

3. Which one has the highest
mortality rate ?
Ruptured AAA
Perforated peptic ulcer
Mesenteric ischemia
Bowel obstruction

4. Pain is out of proportion
is a characteristic feature of:
Mesenteric ischemia
Ruptured AAA
Perforated peptic ulcer
Intestinal obstruction

5. Pain is out of proportion
is a characteristic feature of:
Mesenteric ischemia
Ruptured AAA
Perforated peptic ulcer
Intestinal obstruction

7. Is the most commonpresenting surgical
emergency. It has been estimated that at
least 50% of general surgical admissions
are emergencies and 50% of them present
with acute abdominal pain.

8. ‘Acute abdomen’ is a term used to
encompass a spectrum of surgical, medical
and gynecological conditions, ranging from
the trivial to the life-threatening, which
require hospital admission, investigation and
treatment.

9. The acute abdomen may be defined
generally as an intra-abdominal process
causing severe pain requiring admission to
hospital, and which has not been previously
investigated or treated and may need
surgical intervention.

10. The mortality rate varies with age, being the
highest at the extremes of age.
The highest mortality rates are associated with
laparotomy for unresectablecancer, ruptured
abdominal aortic aneurysm and perforated peptic
ulcer.
Most common causes in any population will vary
according to age, sex and race, as well as genetic
and environmental factors.

11. Causes-
A.Gastrointestinal-
1-Gut
Acute appendicitis
Intestinal obstruction
Perforated peptic ulcer
Diverticulitis
Inflammatory bowel disease
2-Liver and biliary tract
cholecystitis
cholangitis
Hepatitis
3-Pancreas
Acute pancreatitis
4-Spleen
Splenic infarct and
spontaneous rupture

12. Causes-
B. Urinary tract
Cystitis
Acute pyelonephritis
Ureteric colic
Acute retention
C. Vascular
Ruptured aortic aneurysm
Mesenteric embolus
Mesenteric venous thrombosis
Ischemic colitis
D. Abdominal wall conditions
Rectus sheath haematoma
E. Peritoneum
Primary peritonitis
Secondary peritonitis

13. Causes-
F. Retroperitoneal
Hemorrhage e.ganticoagulants
G. Gynecological
Torsion of ovarian cyst
Ruptured ovarian cyst
Fibroid denegeration
Ovarian infarction
Pelvic endometriosis
Endometriosis

14. Causes-
H. Extra-abdominal causes
Lobar pneumonia
MI
Sickle cell crisis
Uremia
DKA
Addison’s disease

15. Management
History
Physical examination
Management

16. Characteristics of abdominal pain
•Site
•Time and mode of onset
•Severity
•Nature/Character
•Progression
•Radiation
•Duration
•Cessation
•Exacerbating/relieving factors
•Associated symptoms

18. Symptoms--Pain
Onset
Sudden: perforation of bowel.
Slow insidious onset: inflammation of visceral peritoneum
Severity
Patient asked to rate pain from 1-10
Ureteric colic is one of worst pains
Character
Aching-dull pain poorly localized
Burning-peptic ulcer symptoms
Stabbing-ureteric colic
Gripping-smooth muscle spasm e.g. intestinal obstruction worse
by movement .

19. Symptoms--Pain
Progression
-Constant e.g. peptic ulcer
-Colicky e.g. seconds(bowel), minutes(ureteric colic) or
tens of minutes (gallbladder)
Radiation of the pain
Back: duodenal ulcer, pancreatitis, aortic aneurysm
Scapula: gall bladder
Sacroiliac region: ovary
Loin to groin: ureteric colic
Groin: testicular torsion

20. Cessation-
Abrupt ending-colicky pains
Resolving slowly-inflammatory pain, biliary pain
Exacerbating/relieving factors-
Movement/Rest-inflammatory conditions
Food-peptic ulcers

21. History

22. History
Past history
previous surgery
trauma
any medical diseases
Drug history
corticosteroid: mask pain
anti-coagulant: intra-mural hematoma
NSAIDS: gastritis, peptic ulcer
Family history
colon cancer
IBD

23. Physical Examination
General appearance
-Patient is lying motionless
acute appendicitis, peritonitis
-Rolling in bed
ureteric colic, intestinal colic
-Bending forward
chronic pancreatitis

24. Physical Examination
Vital signs
Temp.
low grade: appendicitis, acute cholycystitis
high grade: abscess
General examination-
Conjuctivalpallor
cyanosis
jaundice
Signs of dehydation
lymphadenopathy

25. Physical Examination
Cardio-pulmonary examination
-MI
-basal pneumonia
-pleural effusion

26. Physical Examination
Abdomen
*Inspection
*Palpation
*Percussion
*Auscultation

27. Physical Examination
Inspection
-movement with respiration
-distension, peristalsis, mass, scars and any obvious
cough impulse at hernia site
Palpation
*Superficial palpation
-tenderness, rebound tenderness, guarding, rigidity,
masses, hernialorifices
*Deep palpation
-organomegaly

28. Physical Examination
Percussion
-Tympanic note: intestinal obstruction
-Dullness over bladder: acute retention
Auscultation
-Silent abdomen: peritonitis
-Increase bowel sound: intestinal obstruction

29. Investigation
•CBC
•Urea, electrolyte, creatinine, glucose
•LFT
•Lipase
•Urinalysis
•CXR
•AXR
•CT SCAN
•U/S
•Angiography
•Pregnancy test

30. Treatment
1. Relieve the pain
2. IV fluids and nasogastric suction
3. Antibiotics
4. Surgery if indicated

31. Case #1
24 yo healthy M with one day hx of abdominal pain.
Pain was generalized at first, now worse in right lower
abd & radiates to his right groin. He has vomited twice
today. Denies any diarrhea, fevers, dysuria or other
complaints. No appetite today.
PMHx: negative
PSurgHx: negative
Meds: none

32. Physical exam:
T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat: 100%
room air
Uncomfortable appearing, slightly pale
Abdomen: soft, non-distended, tender to palpation
in RLQ with mild guarding; hypoactive bowel
sounds
Genital exam: normal
What is your differential diagnosis and what
do you do next?

33. Appendicitis
Classic presentation
•Periumbilical pain
•Anorexia, nausea, vomiting
•Pain localizes to RLQ
•Occurs only in ½ to 2/3 of patients
26% of appendices are retrocecal and cause pain in the
flank; 4% are in the RUQ
A pelvic appendix can cause suprapubic pain, dysuria
Males may have pain in the testicles

34. Urinalysis abnormal in 19-40%
CBC is not sensitive or specific
CT scan
Pericecalinflammation, abscess,
periappendicealphlegmon, fluid collection,
localized fat stranding

35. Appendicitis: CT findings
Abscess, fat
stranding
Cecum

36. Appendicitis
Diagnosis
•WBC
•Clinical appendicitis
•Maybe appendicitis -CT scan
•Not likely appendicitis –
observe for 6-12 hours or re-
examination in 12 hrs
Treatment
•NPO
•IVFs
•Preoperative antibiotics
–decrease the incidence
of postoperative wound
infections
•Analgesia

37. Case #2
68 yo F with 2 days of LLQ abd pain,
diarrhea, fevers/chills, nausea; vomited
once at home.
PMHx: HTN, diverticulosis
PSurgHx: negative
Meds: HCTZ

38. Case #2 Exam
T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99%
room air
Gen: uncomfortable appearing, slightly pale
CV/Pulmonary: normal heart and lung exam, no LE
edema, normal pulses
Abd: soft, moderately TTP LLQ
Rectal: normal tone, guiacnegbrown stool
What is your differential diagnosis & what next?

39. Diverticulitis
Risk factors
•Diverticula
•Increasing age
Clinical features
•Steady, deep discomfort
in LLQ
•Change in bowel habits
•Urinary symptoms
•Tenesmus
•Paralytic ileus
•SBO
Physical Exam
•Low-grade fever
•Localized
tenderness
•Rebound and
guarding
•Left-sided pain on
rectal exam
•Occult blood
•Peritoneal signs

40. Diverticulitis
Diagnosis
•CT scan (IV and oral contrast)
•Pericolic fat stranding
•Diverticula
•Thickened bowel wall
•Peridiverticular abscess
•Leukocytosis present in only 36% of patients

41. Treatment
•Fluids
•Correct electrolyte abnormalities
•NPO
•Abx: gentamicin AND metronidazole OR
clindamycin OR levaquin/flagyl
•For outpatients (non-toxic)
•liquid diet x 48 hours
•cipro and flagyl

42. Case #3
46 yoM with hxof alcohol abuse with 3
days of severe upper abdpain, vomiting,
subjective fevers.
Med Hx: negative
SurgHx: negative
Meds: none; Allergies: NKDA

43. Case #3 Exam
Vital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat: 95%
room air
General: ill-appearing, appears in pain
CV: tachycardic, normal heart sounds, pulses normal
Lungs: clear
Abdomen: mildly distended, moderately TTP epigastric,
+voluntary guarding
Rectal: heme neg stool
What is your differential diagnosis & what next?

44. Pancreatitis
Risk Factors
•Alcohol
•Gallstones
•Drugs
•Amiodarone, antivirals, diuretics, NSAIDs
•Severe hyperlipidemia
•Idiopathic
Clinical Features
•Epigastric pain
•Radiates to back
•Severe
•N/V

45. Physical Findings
•Low-grade fevers
•Tachycardia, hypotension
•Respiratory symptoms
•Atelectasis
•Pleural effusion
•Peritonitis –a late finding
•Ileus
•Cullen sign*
•Bluish discoloration around the umbilicus
•Grey Turner sign*
•Bluish discoloration of the flanks

46. Pancreatitis
Diagnosis
Lipase
•Elevated more than 2 times normal
•Sensitivity and specificity >90%
Amylase
•Nonspecific
CT scan
•Insensitive in early or mild disease
•NOTnecessary to diagnose pancreatitis
•Useful to evaluate for complications

47. Treatment
•NPO
•IV fluid resuscitation
•NGT if severe, persistent nausea
•No antibiotics unless severe disease
•E coli, Klebsiella, enterococci,
staphylococci, pseudomonas
•Imipenem or ciprowith metronidazole
•Mild disease, tolerating oral fluids
•Discharge on liquid diet
•Follow up in 24-48 hours
•All others, admit

48. Case #4
72 yoM with hxof CAD on aspirin and Plavix
with several days of dull upper abdpain and
now with worsening pain “in entire abdomen”
today. Some relief with food until today, now
worse after eating lunch.
Med Hx: CAD, HTN, CHF
SurgHx: appendectomy
Meds: Aspirin, Plavix, Metoprolol, Lasix
Social hx: smokes 1ppd, denies alcohol or drug
use, lives alone

49. Case #4 Exam
T: 99.1, HR: 70, BP: 90/45, R: 22, O2sat: 96%
room air
General: elderly, thin male, ill-appearing
CV: normal
Lungs: clear
Abd: mildly distended and diffusely tender to
palpation, +rebound and guarding
Rectal: blood-streaked heme+ brown stool
What is your differential diagnosis & what
next?

50. Peptic Ulcer Disease
Risk Factors
•H. pylori
•NSAIDs
•Smoking
•Hereditary
Clinical Features
•Burning epigastric pain
•Sharp, dull, achy, or
“empty” or “hungry” feeling
•Relieved by milk, food, or
antacids
•Awakens the patient at night
•Nausea, retrosternal pain
and belching are NOT
related to PUD
Physical Findings
•Epigastric tenderness
•Severe, generalized pain
may indicate perforation
with peritonitis
•Occult or gross blood per
rectum or NGT if bleeding

51. Peptic Ulcer Disease
Diagnosis
•Rectal exam for occult
blood
•CBC
•LFTs
•Definitive diagnosis is
by EGD or upper GI
barium study
Treatment
•Empiric treatment
•Avoid tobacco, NSAIDs,
aspirin
•PPI or H2 blocker
•Immediate referral to GI if:
•>45 years
•Weight loss
•Long h/o symptoms
•Anemia
•Persistent anorexia or
vomiting
•GIB

52. Here is your patient’s x-ray….

53. Perforated Peptic Ulcer
Abrupt onset of severe epigastric pain followed
by peritonitis
IV, oxygen, monitor
CBC, T&C, Lipase
Acute abdominal x-ray series
Lack of free air does NOT rule out perforation
Broad-spectrum antibiotics
Surgical consultation

54. Case #5
35 yohealthy F to ED c/o nausea and vomiting
since yesterday along with generalized
abdominal pain. No fevers/chills, +anorexia.
Last stool 2 days ago.
Med Hx: negative
SurgHx: s/p hysterectomy (for fibroids)
Social Hx: denies alcohol, tobacco or drug use

55. Case #5 Exam
T: 36.9, HR: 100, BP: 130/85, R: 22, O2 sat: 97%
room air
General: mildly obese female, vomiting
CV: normal
Lungs: clear
Abd: moderately distended, mild TTP diffusely,
hypoactive bowel sounds, no rebound or guarding
What is your differential and what next?

56. Upright abd x-ray

57. Bowel Obstruction
Mechanical or nonmechanical
causes
1 -Adhesions from previous surgery
2 -Groin hernia incarceration
Clinical Features
•Crampy, intermittent pain
•Periumbilical or diffuse
•Inability to have BM or flatus
•N/V
•Abdominal bloating
•Sensation of fullness, anorexia
Physical Findings
•Distention
•Tympany
•Absent, high pitched or
tinkling bowel sound or
“rushes”
•Abdominal tenderness:
diffuse, localized, or
minimal

58. Bowel Obstruction
Diagnosis
•CBC and electrolytes
•Electrolyte abnormalities
•WBC >20,000 suggests bowel
necrosis, abscess or peritonitis
•Abdominal x-ray series
•Flat, upright, and chest x-ray
•Air-fluid levels, dilated loops of
bowel
•Lack of gas in distal bowel and
rectum
•CT scan
•Identify cause of obstruction
•Delineate partial from complete
obstruction
Treatment
•Fluid
•NGT
•Analgesia
•Surgical consult
•OR for complete obstruction
•Peri-operative antibiotics

59. Case #6
48 yo obese F with one day hx of upper abd
pain after eating, does not radiate, is
intermittent cramping pain, +N/V, no diarrhea,
subjective fevers. No prior similar symptoms.
Med hx: denies
Surg hx: denies
No meds or allergies
Social hx: no alcohol, tobacco or drug use

60. Case #6 Exam
T: 100.4, HR: 96, BP: 135/76, R: 18, O2 sat:
100% room air
General: moderately obese, no acute distress
CV: normal
Lungs: clear
Abd: moderately TTP RUQ, +Murphy’s sign,
non-distended, normal bowel sounds
What is your differential and what next?

61. Cholecystitis
Clinical Features
•RUQ or epigastric pain
•Radiation to the back or
shoulders
•Dull and achy →sharp
and localized
•N/V/anorexia
•Fever, chills
Physical Findings
•Epigastric or RUQ
pain
•Murphy’s sign
•Patient appears ill
•Peritoneal signs
suggest perforation

62. Cholecystitis
Diagnosis
•CBC, LFTs, Lipase
•Elevated alkaline phosphatase
•Elevated lipase suggests gallstone
pancreatitis
•RUQ US
•Thicken gallbladder wall
•Pericholecysticfluid
•Gallstones or sludge
•Sonographic murphy sign
•HIDA scan
•more sensitive & specific than US

63. Treatment
•Surgical consult
•IV fluids
•Correct electrolyte abnormalities
•Analgesia
•Antibiotics
•NGT if intractable vomiting

64. Case #7
34 yohealthy M with 4 hour hxof sudden onset
left flank pain, +nausea/vomiting; no prior hxof
similar symptoms; no fevers/chills. +difficulty
urinating, no hematuria. Feels like has to urinate
but cannot.
PMHx: neg
SurgHx: neg
Meds: none, Allergies: NKDA

65. Case #7 Exam
T: 98.9, HR: 110, BP: 150/90, R: 20, O2 sat:
99% room air
General: writhing around on stretcher in pain,
+diaphoretic
CV: tachycardic, heart sounds normal
Lungs: clear
Abd: soft; non-tender
Back: mild left CVA tenderness
Genital exam: normal
Neuro exam: normal

66. Renal Colic
Clinical Features
•Acute onset of severe,
dull, achy visceral pain
•Flank pain
•Radiates to abdomen or
groin including testicles
•N/V and sometimes
diaphoresis
•Fever is unusual
Physical Findings
•non tender or mild
tenderness to
palpation
•Anxious, unable to
sit still

67. Renal Colic
Diagnosis
Urinalysis
•RBCs
•WBCs suggest infection
CBC
•If infection suspected
BUN/Creatinine
•In older patients
•If patient has single kidney
•If severe obstruction is suspected
CT scan

68. Treatment
IV fluid boluses
Analgesia
•Narcotics
•NSAIDS
Follow up with urology in 1-2 weeks
If stone > 5mm, consider admission and
urology consult
If toxic appearing or infection found
•IV antibiotics
•Urologic consult

69. Thank You