1. Christian Sonnier M.D. LSU Family Medicine Alexandria PGY-2 6/16/15 This is supplemental information and is not intended to replace the information presented on the AFMB review lecture. In the event of any discrepancy between the information here and the AFMB review, you should err on the side of the AFMB review.

2. goals/learning points Definition of acute abdomen Differential Diagonosis Clinical manifestation and diagnosis Treatment Atypical abdominal pain

3. DEFINITION The term acute abdomen refers to a sudden, severe abdominal pain that is less than 24 hours in duration. abdominal pain Abdominal pain can be Visceral Somatic Referred/neurological

4. CLINICAL ASSESSMENT: Characterizing the pain is the key Visceral pain Stretching of peritoneum or organ capsules by distension or edema Diffuse Poorly localized May be perceived at remote locations related to organ’s sensory innervation Somatic pain Inflammation of parietal peritoneum or diaphragm Sharp Well-localized Referred pain Perceived at distance from diseased organ Pneumonia Acute MI Male GU problems Right shoulder pain can be gall bladder or pancrease

5. CLINICAL ASSESSMENT Location Upper abdomen → PUD, cholecystitis, pancreatitis Lower abdomen → Diverticulitis, ovary cyst, TOA Mid abdomen → early appendicitis, SBO Migratory pattern Epigastric → Peri-umbil → RLQ = Acute appendicitis Localized pain → Diffuse = Diffuse peritonitis “Referred pain” Biliary disease → R shoulder or back Sub-left diaphragm abscess → L shoulder Above diaphragm(lungs) → Neck/shoulder Acute onset & unrelenting pain = bad/consider sugical emergency Other red flags: rebound, rigidity, hemodynamic instability Pain which resolves usually. not surgical

6. Clinical Assessment : Other History GI symptoms Nausea, emesis ( bilious or bloody) Constipation, obstipation (last BM or flatus) Diarrhea (? bloody) Both Nausea/Diarrhea present usu. medical Change in sx w eating? NSAID use (perf DU) Jaundice, acholic stools, dark urine Drinking history (pancreas) Prior surgeries (adhesions → SBO, ?still have gallbladder & appendix) History of hernias Urine output (dehydrated) Constituational Sx Fevers/chills Sexual history

7. Clinical Diagnosis Location of pain by organ* RUQ Gallbladder Epigastrum Stomach Pancreas Mid abdomen Small intestine Lower abdomen Colon, GYN pathology

8. Clinical Diagnosis

9. Think Broad categories for DDx Inflammation Obstruction Ischemia Trauma infection Perforation (any of above can end here) Offended organ becomes distended Lymphatic/venous obstrux due to ↑ pressure Arterial pressure exceeded → ischemia Prolonged ischemia → perforation

10. Inflammation versus Obstruction OrganLesion Stomach Gastric Ulcer Duodenal Ulcer Biliary Tract Acute chol’y +/- choledocholithiasis Pancreas Acute, recurrent, or chronic pancreatitis Small Intestine Crohn’s disease Meckel’s diverticulum Large Intestine Appendicitis Diverticulitis LocationLesion Small Bowel Obstruction Adhesions Bulges Cancer Crohn’s disease Gallstone ileus Intussusception Volvulus Large Bowel Obstruction Malignancy Volvulus: cecal or sigmoid Diverticulitis

11. Ischemia / Perforation Acute mesenteric ischemia Usually acute occlusion of the SMA from thrombus or embolism “cramping/tight/pressure feeling of abdomen” Think the acs of the bowels Chronic mesenteric ischemia Typically smoker, vasculopath with severe atherosclerotic vessel disease Ischemic colitis Any inflammation, obstructive, or ischemic process can progress to perforation Ruptured abdominal aortic aneurysm Profound hemodynamic instability

12. GYN Etiologies OrganLesion Ovary Ruptured graafian follicle Torsion of ovary Tubo-ovarian abscess (TOA) Fallopian tube Ectopic pregnancy Acute salpingitis Pyosalpinx Uterus Uterine rupture Endometritis

13. Labs & Imaging TestReason CBC w diff Left shift can be very telling CMP N/V, lytes, acidosis, dehydration Amylase Pancreatitis, perf DU, bowel ischemia LFT Jaundice,hepati tis UA GU- UTI, stone, hematuria Beta-hCG Ectopic TestReason KUB Flat & Upright SBO/LBO, free air, stones Ultrasound Cholecystitis, jaundice, GYN pathology CT scan -Diagnostic accuracy Anatomic dx, Case not straightforward

14. CT scan What is the diagnosis?Acute appendicitis

15. Non-Surgical Causes by Systems SystemDiseaseSystemDisease Cardiac Myocardial infarction Acute pericarditis Endocrine Diab ketoacidosis Addisonian crisis Pulmonary Pneumonia Pulmonary infarction PE Metabolic Acute porphyria Mediterranean fever Hyperlipidemia GI Acute pancreatitis Gastroenteritis Acute hepatitis Musculo- skeletal Rectus muscle hematoma GU Pyelonephritis CNS PNS Tabes dorsalis (syph) Nerve root compression Vascular Aortic dissection Heme Sickle cell crisis

16. Special Circumstances [Atypical presentations] Situations making diagnosis difficult Stroke or spinal cord injury Influence of drugs or alcohol Severity of disease can be masked by: Steroids Immunosuppression (i.e. AIDS) Threshold to operate must be even lower

17. MANAGEMENT O2 by nc  mask  cpap/bipap  mechanical ventilation IV LR or NS Emperic antibiotic treatment as appropriate Management of sepsis as needed Determine if need for surgical consult as well as need for ICU care

18. MANAGEMENT [contd.] Monitor EKG CONSIDER POSSIBLE MI WITH PAIN REFERRED TO ABDOMEN IN PTs >30 YEARS OLD Keep pt NPO Analgesia – controversial, Demerol has some limited evidence of being superior however goal is to relieve pain so may require opiods PASG* J Trauma. 1993 May;34(5) This stands for Pneumatic Abdominal Anti-Shock Garment. An inflated abdominal wrapping designed to place pressure on the abdomen in the setting of intra-abdominal hemorrhage. Fallen out of use but you may still see it

19. Decision to operate Peritonitis Tenderness w/ rebound, involuntary guarding Severe / unrelenting pain “Unstable” (hemodynamically, or septic) Tachycardic, hypotensive, white count Intestinal ischemia, including strangulation Pneumoperitoneum Complete or “high grade” obstruction

20. Take Home Points Careful history (pain, other GI symptoms) Remember DDx in broad categories Narrow DDx based on hx, exam, labs, imaging Always perform ABC, Resuscitate before Dx If patient’s sick or “toxic”, get to OR (surgical emergency) Ideally, resuscitate patients before going to the OR Don’t forget GYN/medical causes, special situations For acute abdomen, think of these commonly (below) Perf DUAppendicitis +/- perforation Diverticulitis +/- perforation Bowel obstruction CholecystitisIschemic or perf bowel Ruptured aneurysm Acute pancreatitis

21. Pt is a 55 year old male with history of 30 pack year smoking, prior MI with stents, and long term heavy alcohol abuse. Presents to the ED following MVC one hour ago. The patient has stable vital signs and is complaining of intense abdominal pain diffusely. Labs show wbc of 25 with left shift. CMP is wnl with a metabolic acidosis. EKG, CT abdomen/pelvis and cxr as well as other labs are pending. What should be included on differential dx? A) acute MI B) Gastroenteritis C) Pancreatitis D) Bowel perforation E) Aortic Aneurysm F) Ischemic coltis

22. Answer: All of the above. Rational: -Acute MI: patient has prior MI and has significant CAD history -Gastroenteritis: should always been on the differential of abdominal pain as it is one of the most common reasons for abdominal pain -Pancreatitis: patient has significant alcohol abuse history -Bowel perforation: any acute abdominal process can lead to perforation if inflammation or trauma is bad enough. Trauma from mvc -Aortic Aneurysm: patient has significant cad history -ischemic Colitis: significant CAD history Take home point: acute severe abdominal pain under the right circumstances has a very broad ddx

23. Suppose the same patient has the following: Sudden acute hemodynamic instability and on exam patient has intense abdominal pain with light palpation and shaking of bed or legs as well as percussion of the abdomen. During exam and interview the patient suddenly develops hypotension and respiratory distress and a decrease in GCS from 15 to 6 as he becomes somulent. The patient has not made it to the CT scanner yet. What is the best next course of action? A)Stabilize patient with intubation as needed and cvc with rapid fluid infusion B)Obtain stat surgical consult C)Apply PASG D)Perform diagnostic peritoneal lavage and FAST Scan E)Admit to SICU F)Wait for ct scan of abdomen and pelvis before further action

24. Answer: All of the above with exception of waiting for ct scan are valid option. The patient is becoming rapidly unstable and needs stabilization and stat surgical consult. The differential diagnosis is still very broad as he may have aortic dissection, perforation or intra-abdominal hemorrhage. Fast Scan if available can remove need for diagnostic perotoneal lavage and per ATLS is replacing this as the prefered diagnostic modality however it is still an option if ultrasound is not available however it would be best to run this by the surgical consult first. PASG: Pneumatic Abdominal Anti-Shock Garment is a pressurized air wrapping which is used to apply pressure to intra-abdominal space to stabilize hemmorrage

25. 27 yo female G2P2 with history of PUD, c-section x2, and smoking history presents to ED with sudden onset abdominal pain described as sharp and 10/10 with n/v for the past 1 day. The patient reports her entire abdomen is sore with pain worse in the RLQ. She is sexually active with a new partner. She reports vague history of attending outdoor picnic and eating room temperature potato salad yesterday, she also reports the pain was worse in the middle of her abdomen and the most intense pain is now over the RLQ. Vitals are wnl as is cbc and cmp. The patient has further imaging studies pending and you are called by the ED to evaluate the patient. What should be included on the DDx A)Appendicitis B)Food poisoning C)PID D)Ectopic pregnancy E)Perforated gastric ulcer Follow up question: what else would you like to order?

26. Answer: all of the above and more As stated previously the ddx for acute abdominal pain is very broad an this patient has several things in her history which cloud the picture Appendicitis: the history of sudden onset with pain over umbilicus then moving to the RLQ is suspicious however in females of reproductive age ectopic pregnancy should always be considered. Also remember even in early appendicitis cbc can be normal PID: new sexual partner increases risk of this Food poisoning: while this should be lower on the list the hx of recent picnic and exposed food should be kept in mind Gastric ulcer: patient has history of PUD in the past, no mention of what treatment she received therefore it is conceivable she could have another

27. Other things to consider ordering: 1)Pregnancy test 2)Ultrasound of abdomen such as fast scan 3)Ua to look for uti 4)Perform pelvic exam with culture 5)Blood cultures or urine cultures 6)Egd (history of PUD) 7)Fobt 8)Stool studies

28. Questions?

29. Sources Uptodate AAFP notebook Harrisons textbook of medicine Cecils textbook of medicine NIH archives