1. 급성 복통
김 경 종
조선대학교 의과대학
외과학교실

2. acute abdomen (급성복증)
: signs & Sx of abd. Pain and tenderness
: a clinical presentation that often requires
emergency surgical therapy
: common incidence
(7% in ER pts, 2% in primary pts)

3. 흔한 복통의 원인 의료보험 자료(1995년) 대학병원 환자(1989년) 위염 위궤양 장관 감염성 질환 비감염성 위장관염
소화궤양
십이지장 궤양
기타 기능성 장질환
기능성 위장질환
국한성 장염
특정 감염성 장염
급성 충수염
대학병원 환자(1989년)
위장관염
급성 충수염
요로 결석
간 담도 질환 위염
소화궤양
자궁 외 임신
골반 내 감염
췌장염
분변 매복
장폐쇄

4. Etiology

5. Non-abdominal causes

6. Surgical acute abdominal conditions
Infection
Perforation
Obstruction
Ischemia
Hemorrhage
appendicitis
ulcer perfo
adhesion
Buerger's disease
solid organ trauma
cholecystitis
cancer perfo
Volvulus
(sigmoid or cecum)
mesenteric thrombosis or embolism
leak or ruptured
a. aneurysm
Meckel’s diverticulitis
Boerhaave’s syndrome
Incarcerated
hernia
strangulated
hernias
ruptured ectopic pregnancy
hepatic abscess
diverticular perfo
IBD
ischemic colitis
bleeding GI
diverticulum
diverticulitis
GI cancer
testicular torsion
A-V malformation
Psoas abscess
Intussusception
ovarian torsion
intestinal ulcer
A-D fistula
hemorrhagic
pancreatitis
spontaneous rupture
of spleen

7. Abdominal region; 3 compartments
abdominal cavity
retroperitoneal cavity
pelvic cavity

8. 복막(peritoneum) 복통의 외과적 접근 Mesothelium (squamous epithelium)
Visceral peritoneum vs parietal peritoneum

9. 후복막(retroperitoneum)
복통의 외과적 접근
후복막(retroperitoneum)

10. 골반강(pelvic cavity)

11. 복막의 기능 복통의 외과적 접근 체액과 박테리아의 제거 (diaphragmatic stomata),
전신 순환계로 유입 (thoracic duct)
복막의 거식세포(macrophage)  cytokine 분비
백혈구의 복강 내 유입
복막의 비만세포(mast cell)  histamine  혈관확장
protein-rich fluid (Complement, Ig)
opsonization of bacteria by protein-rich fluid
abscess formation by sequestration of bacteria

12. Bacteria in peritoneal cavity ?
Diaphragmatic stomata  thoracic duct
early removal of bacteria from peritoneal cavity
sepsis in relative early period

13. : foregut, midgut, hindgut
Visceral pain
: foregut, midgut, hindgut
Parietal pain
: localization
Distension, stretching,
ischemia, vigorous contraction,

14. Referred pain Right shoulder Liver, GB, Rt. diaphragm Left shoulder
Heart, pancreas tail, spleen, lt diaphragm
Scrotum & testicles
Ureter

15. Approach to acute abd. pain

16. 병력청취 복통의 외과적 접근 The PQRST
P3: positional, palliating, & provoking factors
Q: quality
R3: region, radiation, referral
S: severity
T3: temporal factors (time & mode of onset,
progression, previous episodes)

17. History taking Location; visceral vs parietal, retroperitoneum
Character;
colicky pain by smooth muscle contraction
(d/t obstruction of GB, bowel, urinary tract)
Onset;
Intensity; acute onset, severe  serious or Cx
pattern of radiation and referral pain
duration and progression; persistent worsening
Provocative and palliating factors
Previous episodes

18. History taking Associated Symptoms Anorexia
Vomiting (pain -> vomiting in surgical)
Bowel symptoms (diarrhea, flatus, melena, blood)
other symptoms (genitourinary tract Sx.)
Medical and surgical History, current medication
Hx of abd. Surgery
medical condition (ex, AF or CHF  mesenteric ischemia)
NSAIDs medication (aspirin)
Social History (drug/alcohol)

19. 신체검사 복통의 외과적 접근 전신외양 및 복부관찰: (ex. peritonitis vs renal colic)
2. Vital sign
fever/hypotension/tachycardia
3. Inspection of abdomen
scar/distension
4. Auscultation
silent or high-pitched or metallic
5. Palpation
tenderness/rebound tenderness/rigidity

20. Physical examination Rectal examination
Other area (groin, ext. genitalia, back, chest)

21. Laboratory finding 복통의 외과적 접근
CBC with WBC diff (leukocytosis or bandemia)
LFT/Amylase/lipase
U/A
electrolyte, BUN/Cr
CRP/ESR
serum lactate level/ procalcitonin

22. Imaging studies plain X-ray
abd erect & KUB, chest P-A, lateral decubitus
free air, calcification
obstruction pattern
volvulus
Abdominal U/S
bedside exam. In unstable pt
other benefits

23. Abdominal (pelvic) CT scan
Imaging studies
Abdominal (pelvic) CT scan
revolutionized Dx tool of acute abdomen
almost all pts of acute abdomen
esp, appendicitis in young women
ischemic bowel in elderly patients

24. Diagnostic peritoneal lavage (DPL)
복통의 외과적 접근
Diagnostic peritoneal lavage (DPL)
WBC >250/mL
RBC >300,000/mL
Bilirubin: more than plasma
Particulate matter (stool)
Creatinine: higher than plasma level

25. 진단적 복강경 또는 개복술 (Diagnostic laparoscopy or laparotomy)
복통의 외과적 접근
진단적 복강경 또는 개복술 (Diagnostic laparoscopy or laparotomy)

26. ATYPICAL PATIENTS

27. Pregnancy Prone to delay in diagnosis 임신에 의한 증상으로 오인(복통, 오심, 구토, 식욕감퇴)
질병경과 또는 증상의 변화, 신체검사의 어려움(자궁확대)
검사결과의 변화
영상학적 검사의 부족 및 꺼림
더 보존적 치료의 경향

28. Appendicitis in pregnancy
m/c d’s requiring op.
False-positive Dx-> op: 15 ~ 35% ?
Perforation  high risk of fetal death (20%)

29. Other surgical ds in pregnancy
biliary tract disease, bowel obstruction
timing of op. : second trimester or postpartum period

30. Acut abdomen in the critically ill
cardiopulmonary bypass
-> ischemic bowel, ileus, pseudoobstruction, stress ulcer, acalculous chole, acute pancreatitis
vasoactive medication & ventilator support
Sx. (obscure)
abd. Pain (84%), abd. tenderness (95%), distension (73%)
all diagnsotic method
outcome: varied (MR; 31%-63%)

31. Immunocompromised pt with acute abdomen
elderly, malnourished, DM, transplant recipient,
cancer chemotherapy, HIV
atypical fashion (inflammation?) in acute abdomen
atypical infection:
TB peritonitis, fungal infection, CMV, EBV

32. Acute abdomen in the morbidly obese
challenge in acute Dx.
severe abd. Pain: not common
less specific finding: tachycardia, tachypnea, pleural effusion, or fever

33. Treatment algorithms for acute abdomen

34. Treatment of acute-onset severe generalized abd. pain
Sabiston: Textbook of Surgery 2008

35. Treatment of gradual-onset severe generalized abd. pain
Sabiston: Textbook of Surgery 2008

36. 우상복부 통증의 치료
Sabiston: Textbook of Surgery 2008

37. 우하복부 통증의 치료
Sabiston: Textbook of Surgery 2008

38. 좌상복부 통증의 치료
Sabiston: Textbook of Surgery 2008

39. 좌하복부 통증의 치료
Sabiston: Textbook of Surgery 2008

40. Summary 급성복증의 진단은 여전히 어려운 문제이다. 철저한 병력청취, 신체검사는 환자의 평가에 매우 중요하다.
영상학적 검사로는 CT scan의 유용성이 매우 크다.
적절한 수술적 치료가 지연된 경우 이환율과 사망률이 증가한다.
간혹 진단이 애매한 경우 진단적 복강경 또는 개복술 등이 필요할 수도 있다.

41. 감사합니다