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The acute abdomen

2. Case Female, 43 yrs old, 85 kg, 1.75cms Severe pain, sudden onset
Right upper quadrant
Urge to move, unable to sit or lie still
The acute abdomen

3. Case Female, 43 yrs old, 75 kg, 1.75cms Severe pain, sudden onset
Right upper quadrant
Urge to move, unable to sit or lie still
Diagnosis possible?
More information needed?
The acute abdomen

4. Case Female, 43 yrs old, 75 kg, 1.75cms Severe pain, sudden onset
Right upper quadrant
Urge to move, unable to sit or lie still
Plan for treatment possible?
More information needed?
The acute abdomen

5. Acute abdomen You need to act swiftly: diagnosis plan for treatment
The acute abdomen

6. Acute abdomen - definition
An acute abdominal is a situation in which urgent and specific medical attention is needed to save the patient’s life

7. Acute abdomen - definition

8. The acute abdomen
versus
Acute abdominal pain
The acute abdomen

9. Acute abdomen Definition Causes Diagnosis: symptoms and signs
Additional exams Examples
Specific issues: role of specific doctors, timing intervention
The acute abdomen

10. Acute abomen Causes Peritonitis Obstruction Ischemia Bleeding
Penninckx, “Aandoeningen van het
spijsverteringsstelsel”, 2011
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

11. Causes Peritonitis Inflammation of an organ
Free fluid in abdominal cavity
perforation hollow organ
blood
spontaneous bacterial peritonitis
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

12. Aids in diagnosis
Wide variety of causes / pathology Tools for diagnosis:
general characteristics
logical reasoning
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

13. Diagnosis Characteristics Symptoms Pain Fever
Nausea, vomitus Absence of defecation
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

14. Diagnosis Characteristics Symptoms Pain Local Diffuse Radiation
Referred
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

15. Pain in acute abdomen Characteristics
Symptoms Pain
Local
Diffuse
Radiation
Referred
Example of referred pain: acute cholecystitis
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

16. Pain in acute abdomen Referred pain
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

17. Pain in acute abdomen Evolution of pain in time
Visceral versus parietal pain
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

18. Pain in acute abdomen Evolution of pain in time
Visceral peritoneum / -pain Autonomic nervous system
pain due to local inflammation organ and distension
vague pain, aspecific location (midline)
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

19. Pain in acute abdomen Evolution of pain in time
Parietal peritoneum / - pain Somatic nervous system
Localized sharp pain
Guarding
Diffuse pain (diffuse peritonitis)
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

20. Pain in acute abdomen Evolution of pain in time Case 13 yr old boy
<24 hrs anorexia
T 37.4°C
Epigastric pain
 Differential diagnosis?
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

21. Pain in acute abdomen Evolution of pain in time Case 13 yr old boy
<24 hrs anorexia
T 37.4°C
Epigastric pain
 Changing to a sharp pain RLQ
 Diagnosis?
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

22. Example of evolution in time: acute appendicitis
Pain in acute abdomen
Evolution of pain in time
Case
13 yr old boy
<24 hrs anorexia
T 37.4°C
Epigastric pain
Example of evolution in time: acute appendicitis
 Changing to a sharp pain RLQ
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

23. Diagnosis Pain in acute abdomen Pain at moving, coughing
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

24. Diagnosis Characteristics Signs Abdominal
Observation Auscultation Palpation
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

25. Diagnosis Characteristics Least painful exam first! Signs Abdominal
Observation Auscultation Palpation
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

26. Diagnosis Characteristics Signs Abdominal Observation: respiration
absence of abdominal respiration
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

27. Diagnosis Characteristics Signs Abdominal Auscultation: peristalsis
Peritonitis: absence
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

28. Diagnosis Characteristics Signs Abdominal Auscultation: peristalsis
Obstruction: loud, gutter sounds, hyperactive, tinkling
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

29. Diagnosis Characteristics Signs Abdominal
Palpation: guarding, tenderness, mass
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

30. Diagnosis Characteristics Be gentle! Signs Abdominal
Palpation: tenderness
Locally
General
Rebound
Be gentle!
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

31. Diagnosis Characteristics Signs
General (i.e. = not per se any or all) Hypotension
Tachycardia
Dehydration
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

32. Diagnosis Characteristics bowel distension reduced intake
Signs
General (i.e. = not per se any or all) Hypotension
bowel distension
reduced intake
inflammatory mediators
Tachycardia Dehydration
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

33. Diagnosis Aids in diagnosis Logical reasoning
based on symptoms and signs based onn additional information
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

34. Aids in diagnosis Other information Age?
Appendicitis: 5-35, 35-50, >50yrs?
Diverticulitis: 5-35, 35-50, >50yrs?
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

35. Aids in diagnosis Other information Age?
Appendicitis: most prevalent 5-35
Diverticulitis: most prevalent >50yrs?
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

36. Aids in diagnosis Other information Age Gender?
Female: cholecystitis, adnexitis, EUG
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

37. Aids in diagnosis Other information Age Gender? Female: cholecystitis
FFFF: fat, female, forty, fertile (/fair)
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

38. Aids in diagnosis Other information Age Gender Previous history?
Ilnesses, operations
Correspondence!
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

39. Aids in diagnosis Other information Age Gender Previous history?
Ilnesses: e.g. diverticulosis
 +older age, +pain (left) lower abdomen:
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

40. Aids in diagnosis Other information Diverticulitis? Age Gender
Previous history?
Ilnesses: e.g. diverticulosis
 +older age, +pain (left) lower abdomen:
Diverticulitis?
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

41. Aids in diagnosis Diverticulosis
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

42. Aids in diagnosis Other information Age Gender Previous history?
Abdominal surgery
 +diffuse pain, +swelling abdomen, +vomitus
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

43. Aids in diagnosis Other information
Age Gender
Previous history?
Abdominal surgery
 +diffuse pain, +swelling abdomen, +vomitus
small bowel obstruction (ileus) due to adhesions?
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

44. Diagnosis Caveats, beware! Small children Old patients
Patients in poor condition
symptoms and signs less pronounced
 delay in diagnosis
 increase in morbidity and mortality
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

45. Additional exams Laboratory Leucocytosis CRP
Specific, if already differential diagnosis
e.g. livertests if suspicion gallstone disease
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

46. Additional exams Radiology? Plain abdominal X ray Ultrasound CT scan …
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

47. Additional exams Radiology Plain abdominal X ray bowel distension
air-fluid levels
psoas muscle visible or not
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

48. Additional exams
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

49. Additional exams Small bowel obstruction = ileus
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

50. Additional exams
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

51. Additional exams Radiology Plain X ray Thorax Free air below diafragm
Pneumonia
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

52. Additional exams Additional exams?
The diagnosis acute cholecystitis is only definite after an ultrasound has confirmed the diagnosis
 True of false?
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

53. Additional exams The acute abdomen is a clinical diagnosis!
But additional exams can be helpful in localizing the cause
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

54. Additional exams Radiology Ultrasound
Gallbladder: stones, cholecystitis
Appendicitis
Free fluid
and more
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

55. Additional exams Radiology CT scan All of the previous findings But:
more expensive
more radiation toxicity
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

56. Additional exams
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

57. Additional exams Bowel ischemia with intramural pneumatosis
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

58. The acute abdomen Examples of acute abdomen Peritonitis
Inflammation of an organ
Free fluid in abdominal cavity
Obstruction Ischemia Bleeding
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

59. Examples Peritonitis Pancreatitis Appendicitis Diverticulitis
1. Inflammation of an organ, e.g.: Cholecystitis
Pancreatitis Appendicitis Diverticulitis
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

60. Peritonitis Inflammation of an organ
Some (but not all) characteristics
Cholecystitis:
pain ROQ, previous colics, radiation of pain to
right flank, referring of pain to right shoulder
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

61. Peritonitis Inflammation of an organ
Some (but not all) characteristics
Pancreatitis: alcohol, sudden onset, radiation to back
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

62. Peritonitis Inflammation of an organ
Some (but not all) characteristics
Diverticulitis: older age, pain LLQ or lower mid abdomen, diverticulosis or difficult defecation
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

63. Peritonitis Free fluid in abdominal cavity perforation hollow organ
Gastric/duodenal ulcer
Diverticulitis
Tumor
Bowel distension
Corpus alienum ….
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

64. Peritonitis Free fluid in abdominal cavity Blood Traumatic
Rare: spontaneous bleeding
e.g. from tumour liver of spleen
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

65. Peritonitis Free fluid in abdominal cavity Bacterial peritonitis
“Spontaneous” = without perforation
Liver insufficiency
Compromised immune system
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

66. Peritonitis Free fluid in abdominal cavity What really hurts!
Gastric/duodenal content
Bowel content
What hurts less
Blood
Only pus
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

67. The acute abdomen Examples Peritonitis Obstruction Ischemia Bleeding
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

68. Examples Obstruction of bowel Small bowel (ileus)
Large bowel (large bowel obstruction [LBO], large bowel ileus)
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

69. Examples Ileus (small bowel) Paralytic Mechanic
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

70. Examples Ileus (small bowel) Paralytic Absence of peristalsis Causes:
Diffuse peritonitis (ileus = early phenomenon)
Bowel dilatation (ileus = late phenomenon)
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

71. Examples Ileus Mechanic Small bowel and large bowel Causes:
Adhesions (esp. small bowel)
Tumor (esp. large bowel)
Herniation / strangulation
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

72. Examples Ischemic but still vital small bowel: “just in time”
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

73. Examples Ileus Mechanic Small bowel and large bowel Causes:
Adhesions (esp. small bowel)
Tumor (esp. large bowel)
Herniation / strangulation
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

74. Examples sigmoid tumor, no obstruction yet
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

75. Examples Ileus Mechanic Small bowel and large bowel Causes:
Adhesions (esp. small bowel)
Tumor (esp. large bowel)
Herniation / strangulation
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

76. Examples
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

77. Examples
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

78. Examples Incarcerated femoral hernia with small bowel obstruction
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

79. Examples Obstruction of other origin
Bile duct (cystic duct, hepatic duct)
stones Ureter
stones
Symptoms: acute, severe, colicy pain
Ovarian duct
torsion
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

80. The acute abdomen Examples Peritonitis Obstruction Ischemia Bleeding
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

81. Examples
Ischemia
Less frequent cause than peritonitis or obstruction Difficult diagnosis!
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

82. Examples Ischemia Cause Venous or arterial occlusion
Venous: thrombosis
Arterial: thrombosis (on pre-existent stenosis) or embolism (from heart or aorta/main branches)
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

83. Examples Ischemia If: Rule out ischemia! Diagnosis Elderly patient
No overt other cause Patient: extreme pain
Doctor: mild findings at physical exam
Rule out ischemia!
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

84. The acute abdomen Examples Peritonitis Obstruction Ischemia Bleeding
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

85. Examples Bleeding Intra abdominal: see before Intra luminal:
Can be acute abdominal situation (=acute abdomen)
But rarely fulminant acute abdominal pain
 only brief discussion
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

86. Examples Bleeding Intraluminal bleeding Proximal or distal GI tract
Symptoms:
Hematemesis and melena (proximal GI tract)
Clear blood per anum (distal GI tract)
Signs of anemia and hypovolemia
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

87. The acute abdomen Specific issues
The different roles of different doctors
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

88. Specific issues Different roles for different doctors
GP (General practitioner)
Suspects patient of acute abdomen
 What to do?
 Additional exams?
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

89. Specific issues Different roles for different doctors
GP (General practitioner) Short evaluation
Recognition of urgent situation
Swift referral to hospital
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

90. Specific issues Different roles for different doctors Doctor at ER
Differential diagnosis based on clinical grounds Start treatment asap
Additional exams only if additional information and
influence on treatment
Swift referral to appropriate specialist
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

91. Specific issues Different roles for different doctors Surgeon
Confirmation of diagnosis Decision: operate of not?
incl. timing of operation
The acute abdomen
The acute abdomen
Definition – Causes – Diagnosis – Additional exams – Examples – Specific issues

92. Conclusion Acute abdomen
Acute evaluation Swift decision making Swift treatment
The appropriate doctor
 Tools: knowledge and logical reasoning
The acute abdomen

93. The acute abdomen Laurents Stassen
gastro intestinal surgeon