Assessment and Management of the Acute Abdomen Yingda Li Neurosurgery HMO 23 September 2010

Objectives Develop a rational approach to assessing and managing the acute abdomen in adults Identify red-flags on history and examination Consolidate information previously learnt about specific pathologies Have a set of rules to fall back on Familiarise with the style of questions commonly asked in exams

Overview Definition History Examination Investigations Management Multi-choice questions

Definition Abdominal pain Acute onset Usually severe Requiring urgent attention Not always surgical Not always intra-abdominal source

Golden Rule 1 Upper abdominal pain may be from supra- diaphragmatic pathology Acute myocardial infarct and lower lobe pneumonia should always be in your differential diagnosis

History Demographics Tempo Site and radiation Quality Associated symptoms Antecedent events Pre-morbidities Prior episodes Menstrual Preoperative history

Golden Rule 2 A woman of childbearing age is pregnant till proved otherwise A woman of childbearing age who has acute abdominal pain is pregnant and has a ruptured ectopic till proved otherwise

Golden Rule 3 Never dismiss or underestimate acute abdominal pain in an elderly patient They probably have mesenteric ischaemia, ruptured AAA, perforated diverticular abscess or a strangulated hernia

Golden rule 4 Vomiting is the key associated symptom Pain before vomiting is usually surgical Combination of vomiting and diarrhoea is usually gastroenteritis, but gastroenteritis must remain a diagnosis of exclusion

Examination General appearance and vital signs Inspection and palpation Bedside tests Rectal, testicular and pelvic Auscultation

Golden Rule 5 Vital signs are vital You can tell a lot just by looking at a patient

Investigations Diagnostic Pancreatic enzymes, cardiac enzymes US, CT, MRCP Angiography Laparoscopy MSU Supportive X-ray LFTs Lactate, PO4 WCC, neutrophils pH, ketones Associated UEC, CMP Preoperative Grp and Hold Severity and Prognosis CRP, platelets Clotting, albumin CT Criteria

Management Resuscitative cascade Airway, breathing, circulation General measures Analgesia, antiemesis NBM, IV fluids NGT, IDC Serial examinations Specific measures Antibiotics, image-guided drainage Open surgery, laparoscopic-assisted ERCP Angiographic intervention Sigmoidoscopic decompression

What is the difference between an incarcerated vs. obstructed vs. strangulated hernia?

1.Hepatitis serology 2.Upper abdominal ultrasound 3.Full blood examination 4.ERCP 5.Liver biopsy What would be your clinical concern if he was febrile? What eponymous triad would that constitute?

How would you explain the low serum bicarbonate?

A.Erect abdominal X-ray B.Full blood examination C.Liver function tests D.Serum lipase E.Upper G.I. endoscopy

A.CT kidney, ureter and bladder B.Ultrasound renal tract C.24-hour urinary calcium excretion D.Plain X-ray kidney, ureter and bladder E.Mid-stream urine for phase microscopy What is phase microscopy designed to look for?

What do you think is the most likely diagnosis?

Golden rules 1. Upper abdominal pain may be from supra- diaphragmatic pathology 2. Woman of childbearing age is pregnant till proved otherwise 3. Acute abdominal pain in elderly patients must not be dismissed or underestimated 4. Vomiting is the key associated symptom 5. Vital signs are vital