1. The Acute Abdomen Yingda Li 6 th Oct, 2011 Royal Melbourne Hospital

2. Objectives 1.Develop a rational approach to assessing and managing the acute abdomen 2.Identify ‘red flags’ on history and examination 3.Have a set of ‘rules’ as safety nets 4.Familiarise with style of questions commonly asked in exams

3. Overview  Definitions  History  Examination  Investigations  Management  Multiple choice questions

4. Definitions  Pain  Acute  Severe  Requiring urgent attention  Not always surgical  Not always abdominal source Rule 1. Epigastric pain may be from supra-diaphragmatic source

5. History  Demographics  Tempo  Site, radiation  Quality  Associated symptoms  Risk factors  Previous surgery  Gynaecological history  AMPLE Rule 2. Women of childbearing age are pregnant till proved otherwise Rule 3. Never underestimate abdominal pain in the elderly Rule 4. Sudden onset pain equals perforation, vascular or torsion Rule 5. Vomiting is a key associated symptom

7. Red flags

8. Examination  Preparation (privacy, consent, exposure, positioning, chaperone)  End-of-the-bed appearance  Vital signs  Look, listen, feel  PR, PV, testicular  Eponymous signs  Bedside tests (FWT,  hCG, ECG, BSL)  Symptoms out of proportion to signs Rule 7. Is there peritonism, is there a hernia and is there a AAA? Rule 6. Vital signs are vital Do not hurt the patient!

9. Investigations  Laboratory  Radiology Diagnostic Pancreatic enzymes, cardiac enzymes MSU XR, USS, CT, MR Laparoscopy, ERCP Supportive Inflammatory markers UEC, LFTs Lactate Prognostic CRP, platelets, clotting profile CT Criteria Preoperative Group and screen Crossmatch

10. Management Resuscitation Airway Breathing Circulation General measures NBM, IV fluids, analgesia, antiemesis NGT, IDC Serial examination Specific measures Antibiotics Open surgery, laparoscopy ERCP, image-guided percutaneous drainage, sigmoidoscopic decompression, angioembolisation

11. MCQs

14. 1.Hepatitis serology 2.Upper abdominal ultrasound 3.Full blood examination 4.ERCP 5.Liver biopsy

15. 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