1、1,THE ACUTE ABDOMEN,2,Contents,History Physical examination Investigative studies Differential diagnosis,3,History,Abdominal pain Location of pain Mode of onset and progression of pain Character of pain,4,What kind of pain is it?,Visceral Involves hollow or solid organs; midline pain due to bilatera
2、l innvervation Steady ache or vague discomfort to excruciating or colicky pain Poorly localized Epigastric region: stomach, duodenum, biliary tract Periumbilical: small bowel, appendix, cecum Suprapubic: colon, sigmoid, GU tract Parietal Involves parietal peritoneum Localized pain Causes tenderness
3、and guarding which progress to rigidity and rebound as peritonitis develops Referred Produces symptoms not signs Based on developmental embryology Ureteral obstruction testicular pain Subdiaphragmatic irritation ipsilateral shoulder or supraclavicular pain Gynecologic pathology back or proximal lowe
4、r extremity Biliary disease right infrascapular pain MI epigastric, neck, jaw or upper extremity pain,5,Surgical causes?,6,Acute Surgical Abdomen,RUQ/LUQ PPU Acute cholecystitis RLQ/LLQ Acute appendicitis Acute diverticulitis Meckels diverticulitis SBO SMA occlusion AAA rupture Ectopic pregnancy,7,N
5、on-surgical causes?,8,Acute Non-surgical Abdomen,Obs/Gyn PID, ovarian cyst rupture, mittelschmerz* Uro Renal stone, APN, cystitis Refer pain AMI, pneumonia Others AGE, pancreatitis, mesenteric adenitis, Crohns disease, DKA, porphyria,9,Other syptoms associated with abdominal painVomiting boerhaaves
6、syndrom Mallory-weiss syndrom Constipation DiarrheaSepcific gastrointestinal sysmptoms Jaundice Hematochezia or hematemesis Mallory-weiss syndrom Hematuria Ureteral colic or cystitis,10,Other relevant aspects of history Menstrual history Ectopic pregnancy mittelschmerz Drug history Anticoagulants Or
7、al contraceptives corticosteroids Family historyTravel history Amebic liver abscess/hydatid cyst Malarial spleen Tb Salmonella typhia infection,11,Physical examination,General observation System signs Fever Examination of the acute abdomen Inspection Auscultation (precede) Coughing to elicit pain Pe
8、rcussion Palpation Induina and femoral rings: male genitalia Rectal examination Pelvic examination,12,Abdominal Findings,Guarding Voluntary Contraction of abdominal musculature in anticipation of palpation Diminish by having patient flex knees Involuntary Reflex spasm of abdominal muscles aka: rigid
9、ity Suggests peritoneal irritation Rebound Present in 1 of 4 patients without peritonitis Pain referred to the point of maximum tenderness when palpating an adjacent quadrant is suggestive of peritonitis Rovsings sign in appendicitis Rectal exam Little evidence that tenderness adds any useful inform
10、ation beyond abdominal examination Gross blood or melena indicates a GIB,13,Appendicitis: Psoas Sign,14,Appendicitis: Psoas Sign,15,Appendicitis: Obturator Sign,Passively flex right hip and knee then internally rotate the hip,16,Investigative studies,Laboratory investigations Blood studies Urine tes
11、ts Stool tests Imaging studies Plain Chest X-ray Studies Plain abdominal X-ray Studies Angiography Contrast X-ray studies ultasonography and CT scan Radionuclide Scans Endoscopy Paracentesis Laparoscopy,17,Diagnostic Work-up,18,Diagnostic Work-up,History-PE,Echo,B-U-S,X-rays,CT scans,Exploratory lap
12、arotomay,19,Abdominal X-rays: what views?,Free intra-peritoneal airAir-fluid levels (ileus)Level of obstruction in ileus,20,Abdominal X-rays: what views?,Free intra-peritoneal air Upright CXR, standing abdomen, left lateral decubitus Air-fluid levels (ileus) Standing abdomen, lateral decubitus Level
13、 of obstruction in ileus Supine abdomen, KUB,21,Differential Diagnosis,Gastritis, ileitis, colitis, esophagitis Ulcers: gastric, peptic, esophageal Biliary disease: cholelithiasis, cholecystitis Hepatitis, pancreatitis, Cholangitis Splenic infarct, Splenic rupture Pancreatic psuedocyst Hollow viscou
14、s perforation Bowel obstruction, volvulus Diverticulitis Appendicitis Ovarian cyst Ovarian torsion Hernias: incarcerated, strangulated Kidney stones Pyelonephritis Hydronephrosis Inflammatory bowel disease: crohns, UC Gastroenteritis, enterocolitis pseudomembranous colitis, ischemia colitis Tumors:
15、carcinomas, lipomas Meckels diverticulum Testicular torsion Epididymitis, prostatitis, orchitis, cystitis Constipation Abdominal aortic aneurysm, ruptures aneurysm Aortic dissection Mesenteric ischemia Organomegaly,Hemilith infestation Porphyrias ACS Pneumonia Abdominal wall syndromes: muscle strain
16、, hematomas, trauma, Neuropathic causes: radicular pain Non-specific abdominal pain Group A beta-hemolytic streptococcal pharyngitis Rocky Mountain Spotted Fever Toxic Shock Syndrome Black widow envenomation Drugs: cocaine induced-ischemia, erythromycin, tetracyclines, NSAIDs Mercury salts Acute ino
17、rganic lead poisoning Electrical injury Opioid withdrawal Mushroom toxicity AGA: DKA, AKA Adrenal crisis Thyroid storm Hypo- and hypercalcemia Sickle cell crisis Vasculitis Irritable bowel syndrome Ectopic pregnancy PID Urinary retention Ileus, Ogilvie syndrome,22,Differential Diagnosis,Gastritis, i
18、leitis, colitis, esophagitis Ulcers: gastric, peptic, esophageal Biliary disease: cholelithiasis, cholecystitis Hepatitis, pancreatitis, Cholangitis Splenic infarct, Splenic rupture Pancreatic psuedocyst Hollow viscous perforation Bowel obstruction, volvulus Diverticulitis Appendicitis Ovarian cyst
19、Ovarian torsion Hernias: incarcerated, strangulated Kidney stones Pyelonephritis Hydronephrosis Inflammatory bowel disease: crohns, UC Gastroenteritis, enterocolitis pseudomembranous colitis, ischemia colitis Tumors: carcinomas, lipomas Meckels diverticulum Testicular torsion Epididymitis, prostatit
20、is, orchitis, cystitis Constipation Abdominal aortic aneurysm, ruptures aneurysm Aortic dissection Mesenteric ischemia Organomegaly,Hemilith infestation Porphyrias ACS Pneumonia Abdominal wall syndromes: muscle strain, hematomas, trauma, Neuropathic causes: radicular pain Non-specific abdominal pain
21、 Group A beta-hemolytic streptococcal pharyngitis Rocky Mountain Spotted Fever Toxic Shock Syndrome Black widow envenomation Drugs: cocaine induced-ischemia, erythromycin, tetracyclines, NSAIDs Mercury salts Acute inorganic lead poisoning Electrical injury Opioid withdrawal Mushroom toxicity AGA: DK
22、A, AKA Adrenal crisis Thyroid storm Hypo- and hypercalcemia Sickle cell crisis Vasculitis Irritable bowel syndrome Ectopic pregnancy PID Urinary retention Ileus, Ogilvie syndrome,23,Appendicitis: CT findings,Abscess, fat stranding,Cecum,24,Pancreatitis,Risk Factors Alcohol Gallstones Drugs Amiodaron
23、e, antivirals, diuretics, NSAIDs, antibiotics, more Severe hyperlipidemia Idiopathic Clinical Features Epigastric pain Constant, boring pain Radiates to back Severe N/V bloating,Physical Findings Low-grade fevers Tachycardia, hypotension Respiratory symptoms Atelectasis Pleural effusion Peritonitis
24、a late finding Ileus Cullen sign* Bluish discoloration around the umbilicus Grey Turner sign* Bluish discoloration of the flanks,*Signs of hemorrhagic pancreatitis,25,Hollow viscous perforation,26,27,Bowel obstruction,28,Cholecystitis,Clinical Features RUQ or epigastric pain Radiation to the back or
25、 shoulders Dull and achy sharp and localized Pain lasting longer than 6 hours N/V/anorexia Fever, chills,Physical Findings Epigastric or RUQ pain Murphys sign Patient appears ill Peritoneal signs suggest perforation,29,GI Bleeding,Upper Proximal to Ligament of Treitz Peptic ulcer disease most common
26、 Erosive gastritis Esophagitis Esophageal and gastric varices Mallory-Weiss tear Lower Hemorrhoids most common Diverticulosis Angiodysplasia,30,Testicular Torsion,Sudden onset of severe testicular painIf torsion is repaired within 6 hours of the initial insult, salvage rates of 80-100% are typical.
27、These rates decline to nearly 0% at 24 hours. Approximately 5-10% of torsed testes spontaneously detorse, but the risk of retorsion at a later date remains high. Most occur in males less than 20yrs old but 10% of affected patients are older than 30 years.,Detorsion Emergent urology consult Ultrasoun
28、d with doppler,31,Ovarian Torsion,Acute onset severe pelvic pain May wax and wane Possible hx of ovarian cysts Menstrual cycle: midcycle also possibly in pregnancy Can have variable exam: acute, rigid abdomen, peritonitis Fever Tachycardia Decreased bowel sounds May look just like Appendicitis,Obtai
29、n ultrasound Labs CBC, beta-hCG, electrolytes, T&S IV fluids NPO Pain medications GYN consult,32,Thank You!,33,Management,Early GI consult for severe bleeds Therapeutic Endoscopy: band ligation or injection sclerotherapy Also.electrocoagulation, heater probes, and lasers Drug Therapy: somatostatin,
30、octreotide, vasopressin, PPIs Balloon tamponade: adjunct ortemporizing measure Surgery: if all else fails,34,Differential diagnosis (10 points),Surgical indication Any patients last for over 6 hours Well localized pain and tenderness With associate systemitec toxicity Most common surgical disease in
31、 older: Acute cholecystitis Appendicitis Bowel obstruction Cancer Acute vascular conditions In child: Appendisitis 1/3 Special appendicitis and difficult events: Pelvic pregfnancyMedical cause of the acute abdominal pain should be excluded Myocardial infarction Acute pulmonary conditions Acute hepat
32、itis Rhaumatic fever Polyarteritis nodosa Diffuse vasculitis Acute intermittent porphyria Acute pleurodynia Osteoarthritis ( Sharp flank pain/rectus spasm, cutaneous ) Bursitis,35,Differential diagnosis (10 points) -cont,Acute cholecystitis/acute appendicitis/perorated peptic ulcer Salpingitis/mesenteric adenitis/gastroenteritis/pyelonephritis/acute viral hepatitis Nonspecific,
