1. Stuart Danovitch, MD Washington VA Medical Center
Acute Abdomen
Stuart Danovitch, MD
Washington VA Medical Center
11/98
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2. Acute Abdomen - Conundrum
If I operate and the problem is not surgical, patient exposed to unnecessary risk, anesthetic, etc.
Risks greater with concomitant illness, older age
If I do not operate and problem is surgical, patient at risk because of wrong therapy.
Again the older patient is under greater burden.
11/98
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3. A Caricature - Surgery Acute pain Septic & toxic Board-like abdomen
Absent bowel sounds
WBC 25,000
Free air under diaphragm
11/98
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4. A Caricature - No Surgery
Trivial pain
Robust appearance
Soft abdomen with no guarding
Normal bowel sounds
Normal WBC
Normal pain and upright films of abdomen
11/98
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5. Acute Abdominal Pain Non-surgical Emergencies
Mesenteric Adenitis
Acute Enteric Infections
Acute Enteric Poisonings
Inflammatory Bowel Disease
Pancreatitis (usually)
11/98
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6. Acute Abdominal Pain Metabolic Causes
Diabetic Ketoacidosis
Heavy Metal Poisoning
Acute Porphyria
Tabes
Sickle Cell Crisis
11/98
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7. Acute Abdominal Pain Clinical Phenomena
2/3 of attacks typical, 1/3 atypical
Acute cholecystitis and perforated DU are rare, < 20 years
Acute diverticulitis rate, <30 years
80% of patients with bowel obstruction had previous surgery
75% of patients with cholecystitis had previous attacks
11/98
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8. Acute Abdominal Pain Confounding Clinical Features
Perforated duodenal ulcer
50% of patients had no previous pain
50% of patients had bowel sounds
Diverticulitis
40% of patients vomited
30% of patients have upper pain
Obstruction
40% of patients have no distension
11/98
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9. Acute Abdominal Pain Ancillary Diagnostic Studies
CBC
Urine
Amylase
Plain abdominal films
Paracentesis and lavage
Radionuclide Scans
11/98
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10. Acute Abdominal Pain The WBC in 570 patients
Diagnosis Sensitivity % Specificity %
Appendicitis ()
Cholecystitis ()
Obstruction ()
Gastroenteritis (N)
Other Non-surgical (N)
Predictive value of  WBC for surgical condition 29%
Predictive value of  WBC for non-surgical cond 93%
11/98
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11. Acute Abdominal Pain Sensitivity of Roentgen Findings - 249 Patients
% Abnormal
Appendicitis 48
Cholecystitis 64
Pancreatitis 60
Intestinal Obstruction 98
Perforated Ulcer 60
11/98
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12. Acute Abdominal Pain Specificity of Roentgen Findings - 249 Patients
Diagnostic %
Helpful %
Not Helpful %
Misleading %
11/98
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13. Diagnosis of Pancreatitis Amylase - What’s Right
Cheap
Quick
Non-invasive
A decent first approximation
11/98
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14. Diagnosis of Pancreatitis Amylase - Lack of Specificity
Organ non-specific
Disease non-specific
11/98
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15. Diagnosis of Pancreatitis Heterogeneity of Serum Amylase
40% pancreatic
60% salivary
If total activity doubles due to pancreatitis, p-isoenzyme must  3.5 x.
11/98
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16. Diagnosis of Pancreatitis Timing of Enzyme Measurement
% Activity
Days Trypsin Lipase P-amylase T-amylase
Eckenfeld, Arch Path Lab Med, 1986
11/98
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17. Acute Abdominal Pain The Serum Amylase in 37 Patients
Amylase  Amylase NL
Pancreatitis (23)
No pancreatitis (14)
Sensitivity Specificity +PV -PV
11/98
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18. Acute Abdominal Pain Frequency of Diagnoses in 1000 Patients
Unknown 41% Cholecystis %
Urinary Tract 9% Intestinal Obst %
Gastroenteritis 7% Constipation %
PID 7% Misc %
11/98
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19. Acute Abdominal Pain Diagnostic Errors - 1000 Patients
False+ Assessment Pre-op --20 Patients
Pre-op Post-op
Appendicitis Mesenteric Adenitis - 1 Ectopic Pregnancy - 5 PID - 5 “Acute” Abdomen - 5 Nothing - 13 Diverticulitis Pyelonephritis - 1 Tubp-ovarian Abscess - 3
11/98
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20. Acute Abdominal Pain Diagnostic Errors - 1000 Patients
False- Assessment Pre-op --11 Patients
Initial Dx Post-op
Endometriosis Appendicitis - 8 Gastroenteritis Obstruction - 3 UTI - 1 Uncertain - 5
11/98
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21. Acute Abdominal Pain Saga of 1190 Admissions
Etiology %
Nonspecific Appendicitis Intestinal Obstruction GU GB Diverticulitis PUD Pancreatitis Miscellaneous 13
11/98
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22. Acute Abdominal Pain Saga of 1190 Admissions
Effect of Age >60 (40%) <60 (60%)
Nonspecific Appendicitis Intestinal Obstruction GU IB Diverticulitis <1 PUD Pancreatitis Miscellaneous
11/98
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23. Computer-Aided Diagnosis of Acute Appendicitis
Favoring Dx Against Dx
 WBC Normal WBC RLQ location Other sites Pain < 12 hrs > 48 hrs Vomiting No Nausea Rebound, Guarding Female
11/98
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24. Computer-Aided Diagnosis of Acute Appendicitis
Reliability of Decision Rules %
Negative Lap Rate Sensitivity Specificity Predictive Value Predictive Value 95
11/98
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25. Decision Analysis in Management of Acute Abdominal Pain
% Error lap lap Computer
Surgery No surgery Uncertain Lap contraind
11/98
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26. Diagnosis Small Bowel Obstruction
Attribute Relative Risk
Hx Previous surgery
Colicky Pain
Distension on PE
Abnormal Bowel Sounds
11/98
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27. Acute Pancreatitis - Pathogenesis
Bernard’s Dictum
No enzymes, No Pancreatitis
11/98
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28. Acute Pancreatitis - Pathogenesis Mechanisms Limiting Intrapancreatic Enzyme Activation
Storage and secretion as proenzymes
Pancreatic trypsin inhibitors
 pH (8-9.5);  Ca (< 1mM) abet degradation
Mesotryptic digestion of enzymes
Plasma anti-trypsins
11/98
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29. Acute Pancreatitis - Pathogenesis Hypothesis for Intrapancreatic Enzyme Activation
Activation by thrombin, plasmin
Lysosomal cathepsin
Enterokinase
11/98
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30. Acute Pancreatitis - Pathogenesis In Vivo Enzyme Activation
Ascites and surgical findings
 phospholipase
 elastase
 lysosomal enzymes
 [;as,a amto-tryptic activity
Blood
 enzymes - active and inactive
11/98
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31. Etiology of Acute Pancreatitis
Cause %
Gallstones 40
EtOH
Hyperlipemia, Drugs, 10 Trauma, Tumor, Infection Idiopathic
11/98
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32. Drugs Associated with Acute Pancreatitis
Azathioprine L-Asparaginase
Diuretics -methyldopa
Pentamidine Captopril
Sulfonamides Procaninamide 6-MP Nitrofurantoin
11/98
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33. Diagnosis of Pancreatitis
Problems
Symptoms non-specific
Laboratory non-specific
No gold standard
11/98
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34. Diagnosis of Pancreatitis
Appropriate clinical circumstance
3-fold  amylase activity
Return to normal in one week
No gut perforation or infarction
 trypsiongen, lipase, pancreatic isoamylase
11/98
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35. DDx of Pancreatitis Perforated viscus Intestinal obstruction
Mesenteric vascular events
Acute cholecystitis
PID
11/98
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36. DDx of Pancreatitis
Clue that  amylase is not due to pancreatitis in sick patients
renal failure
early bacteremia
normal calcium
deterioration in pt with calcified gland
rising amylase after 48 hrs
11/98
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37. Diagnosis of Pancreatitis Pancreatic Imaging
Sensitivity
Ultrasound CT CT (Severe)
11/98
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38. Diagnosis of Pancreatitis % Concordance of Amylase and Imaging
Amylase <200u >200U
Normal CT Abn CT
Spechler, Dig Dis Sci, 1983
11/98
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39. Ranson Prognostic Criteria In Acute Pancreatitis
On admission
Over 55 years
WBC > 16,000 / mm3
BS > 200 mg / dl
LDH > 350 IU / L
AST IU / L
Within 48 hours
Hct decreased 10%
BUN increased 5 mg/dl
Ca++ < 8 mg/dl
PaO2 < 60 mmHg
Base dificit > 4 mEq/L
Fluid sequestration > 6L
11/98
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40. Local Complications of Acute Pancreatitis
Pseudocyst
Abscess
Ascites
Splenic v. occlusion
Phlegmon
Gut necrosis / Obstruction
11/98
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41. Systemic Complications of Acute Pancreatitis
Diabetes
Renal failure
Respiratory failure
Encephalopathy
Skin / skeletal
Sepsis / Shock
11/98
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42. Operative Findings # patients mortality %
Operative Appearance of the Pancrease Related to Mortality in 52 Patients Who Underwent Celiotomy on Days 0-5
Operative Findings # patients mortality %
Edema Hemorrhage Phlegmon
11/98
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