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Andrew Wright MD Department of Surgery
The Acute Abdomen Andrew Wright MD Department of Surgery
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What is an acute abdomen?
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What is an acute abdomen?
New onset abdominal pain Usually abdominal pain as main symptom Often seen by primary physician Signifies need for prompt diagnosis Does not necessarily imply need for surgical intervention
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How do you diagnose an acute abdomen?
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How do you diagnose an acute abdomen?
History and Physical
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History
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Exact time and onset Most slow Acute
Can guide prognosis – i.e. timing of appendicitis Acute Colic Bowel strangulation Rupture of viscera Torsion Fainting Abdominal apoplexy Perforated ulcer, ruptured aortic aneurysm, ruptured ectopic What was patient doing at time of onset? i.e. “minor” trauma
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Location Initial location Shifting of pain
Transition from visceral to parietal pain
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What is visceral pain? Intestines are: Location: Insensitive to touch
Sensitive to stretch, distension, or excessive contraction against resistance Location: Small intestine – umbilicus Large intestine – hypogastrium Biliary – RUQ, R subscapular Kidney – Loin, occ radiates to ipsilateral testicle
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What is visceral pain? Character Paroxysmal Often excruciating
Patients will writhe, twist, attempt to find a comfortable position In contrast to peritonitis – where patients will lie still to avoid further irritation
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Character Character Burning – i.e. ulcer Agony- i.e. pancreatitis
Sharp, constricting – i.e. biliary colic Tearing – i.e. dissecting aneurysm Gripping – i.e. obstruction Aching – i.e. appendicitis Dull, fixed – i.e. pyonephrosis
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Radiation Referred pain Diaphragm – shoulder
Biliary tract – tip of shoulder Pancreas – mid back Kidney – mid back Rectum- coccyx Uterus – coccyx
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Exacerbating factors Relationship to food Respiration Micturation
Pleuritic pain usually worse on deep inspiration Micturation UTI Bladder obstruction Nephrolithiasis Peri-bladder abscess Reclining Often retroperitoneal origon
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Vomiting Cause Frequency Relationship with pain Character
Obstruction Severe irritation of nerves of peritoneum i.e. pain, pancreatitis Frequency Relationship with pain Character Nausea and/or lack of appetite
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Bowel Movements Regularity Diarrhea Blood Mucus
True diarrhea vs. passage of several small loose stools Blood Mucus i.e. intussusception
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Menstruation Regularity Exact timing Pain
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History Prior similar episodes Prior illnesses that may relate
h/o peritonitis, appendicitis, pneumonia, etc. Previous attacks of jaundice, melena, hematemesis, hematuria Travel history PMH PSH
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Examination
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General appearance General gestalt – is he (or she) sick?
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Vitals Pulse Respiratory rate Temp Blood Pressure
Normal or mildly elevated typical High fever unusual – suspect kidney or thorax Hypothermic – suspect shock Blood Pressure
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Inspection Determine exact location of pain first Inspection Movement
Distension Bulge Hernia All potential orifices – including femoral Movement Rigidity with inspiration
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Palpation Keys to success Guarding Rebound Iliopsoas rigidity
Gentleness Thighs flexed Thorough exam Include back Guarding Rebound Iliopsoas rigidity
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Percussion Liver dullness Free-fluid
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Rectal exam
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Pelvic exam
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Should pain meds be given prior to diagnosis?
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Diagnostic Testing
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Diagnostic Testing CBC with dif
Electrolytes, BUN, creatinine, and glucose Aminotransferases, alkaline phosphatase, and bilirubin Lipase Urinalysis Pregnancy test in women of childbearing potential
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Imaging
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Imaging Imaging Additional Testing Plain XRays Ultrasound CT
Flat and Upright Left Lateral Decubitus if not able to stand) Chest Ultrasound CT Additional Testing Guide by Differential
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Causes of Abdominal Pain
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Extra-abdominal Herpes Zoster MI Pneumonia
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Biliary Disease Cholelithiasis Cholecystitis Cholangitis Pancreatitis
Biliary Dyskinesia
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GI GERD Gastritis Peptic Ulcer Disease Irritable Bowel Constipation
Diabetic Gastroparesis
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Infectious Appendicitis Diverticulitis Gastroenteritis Hepatitis
Viral Eosinophilic Yersinia Hepatitis Typhlitis Tropical infectious diseases (helminthic) Tuberculosis Typhlitis
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Appendicitis Acute Appendicitis Normal
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Appendicolith
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Appendiceal Phlegmon
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Peri-appendiceal Abscess
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Diverticulosis
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Diverticulitis
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Diverticular Abscess
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Bowel Obstruction Hernia Adhesion Malignancy Intussuception
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Epiploic appendagitis
Inflammatory Crohn’s Ulcerative Colitis Malignancy Epiploic appendagitis Epiploic appendagitis
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Gynecologic PID Adnexal Endometriosis Ectopic pregnancy Endometritis
Torsion Cyst Neoplasm Endometriosis Ectopic pregnancy Endometritis Leiomyomas
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Urologic UTI Nephrolithiasis Bladder distension
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Vascular Aneurysm Dissection Mesenteric Ischemia Sickle Cell Crisis
Acute Chronic Sickle Cell Crisis Colonic Ischemia
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Other Psychiatric Disease Spleen Musculoskeletal Abscess Infarct
Wandering Spleen Musculoskeletal Abdominal wall pain Painful rib syndrome (chostochondritis) Hernia
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Other Celiac artery compression Abdominal Migraine
Fitz-Hugh-Curtis syndrome Familial Mediterranean fever Hereditary angioedema Heavy Metal Poisoning Metabolic Diabetic Ketoacidosis Porphyria Lactose Intolerance
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Pediatric Henoch-Schönlein purpura Intussuception
Malrotation with midgut volvulus Recurrent Abdominal Pain – diagnosis of exclusion
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