From Inflammation to Ischemia May apply to all luminal structures Obstruction Small or large bowel Appendix Gall bladder Ureter Hydrostatic Pressure:

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1 The Acute Abdomen Surgical Issues for the Family Practitioner Rochelle A. Dicker, MD Assistant Professor of Surgery and Anesthesia UC San Francisco Visceral Pain Vague Deep Associated with nausea/vomiting Dull and poorly pinpointed Somatic Pain Sharp Pinpoint Peritoneal/pleural lining rich in these nerve fibers Examples of Painful Processes Visceral: Early intestinal processes like appendicitis Other early luminal processes like cholecystitis Somatic Perforation Frank ischemia 1

2 From Inflammation to Ischemia May apply to all luminal structures Obstruction Small or large bowel Appendix Gall bladder Ureter Hydrostatic Pressure: Luminal versus vessel-lymphatics/veins/arterioles lymphatics/veins/arterioles Peptic Ulcer Disease 2

3 Peptic Ulcer Disease A surgical disease if: Perforation Bleeding (potentially) With endoscopic therapy and more than 6 unit loss Obstruction Gastroparesis/post-operative operative ileus Paralytic Ileus Try to make the distinction between ileus and obstruction It is physiologically an obstruction NGT decompression-why? Contraction alkalosis Is TPN an instrument of the devil? Ileus Small Bowel Obstruction Etiology Should we never let the sun set on a bowel obstruction? IV replacement Pain management Walking Signs of improvement Signs of demise 3

4 The SIRS Response SYSTEMIC INFLAMMATORY RESPONSE 1. Elevated WBC (or below 3) 2. Tachycardia 3. Fever SIGNIFICANCE The History Pain with straining Tender to touch Nausea and vomiting-the the implication Who needs an operation Who needs an emergent operation 4

5 Hernias Hernia Hernia-The Exam 68 year-old man with acute onset abdominal pain History: Atrial fibrillation Hypertension Mild COPD Sudden writhing pain Examination Minimal tenderness Irregularly irregular No abdominal wall erythema 5

6 Laboratory tests: CBC WBC 12, HCT 49, Plts 480 Electrolytes Na 142, K 4.3, Chloride 94, Bicarb 30, BUN 20, Creat 2 Troponin.8 Arterial blood gas 7.5/20/120 Lactic acid 3.0 Additional Studies TIME IS EVERYTHING! Small Bowel Ischemia Ischemic Colitis 6

7 Diverticulitis Diverticulosis Diverticulitis: Outpatient or In? ANY peritoneal signs-in Two SIRS criteria-in Can hold down fluids and vitals okay-out Failing outpatient therapy-in Outpatient abx: Ciprofloxacin/Flagyl Young people with diverticulitis Appendicitis Pain often periumbilical first Point tenderness at McBirney s usually Rule out urinary tract infection Rule out PID, ovarian torsion Not everyone needs a CT scan 7

8 Appendicitis Appendicitis Post-Operative Complications Wound Infection-MOST common Prophylaxis-ONE dose of immediate preoperative gram positive coverage Treat Promptly! Delay could lead to deep infection, fascial involvement, hernia?atalechtasis Abscess Dehiscence 8

9 Necrotizing Fasciitis Necrotizing Soft Tissue Infection Pain out of proportion Often very elevated WBC Mixed bacteria but often Group A beta hemolytic strep MUST get timely surgical consultation and debridement May not be able to wait for adjuvant studies What Are Hemorrhoids? Alternative Names Rectal Lump Piles Lump in the Rectum Definition: Dilated or enlarged veins in the lower portion of the rectum or anus. Cont. Two Types: Internal- Under the skin External- Around the anus Grades: I- Hemorrhoids only bleed II- Prolapse and reduce spontaneously III- Require replacement!v- Permanently Prolapsed 9

10 Symptoms Rectal Bleeding Bright red blood in stool Pain during bowel movements Anal Itching Rectal Prolapse Thrombus Gastroenterologists Referral Seek emergency care if : large amounts of rectal bleeding Lightheadedness Weakness Rapid HR < 100 BPM Treatment Non-surgical Mild cases are controlled by: Preventing constipation Drinking Fluids High-fiber diet Use of Fiber supplements Stool softeners 10

11 Cont. Apply and OTC cream or suppository containing hydrocortisone Keep anal area clean Soak in a warm bath Apply ice packs or compresses x 10min Biliary Disease: HISTORY and PHYSICAL EXAM History: Duration of Illness Acute or Chronic Process-Major Symptoms Risk Factors for Specific Etiologies Physical Exam Findings: Hepatomegaly-Hepatic Hepatic and Posthepatic etiologies Palpable Mass-Malignancy Malignancy or Stone Disease PHYSICAL EXAM Courvoisier's Sign. Pancreatic Cancer Murphy s Sign Cholecystitis Sceleral Icterus Bilirubin >2.0 Abdominal Tenderness PHYSICAL EXAM Lymphadenopathy Charcot s Triad-RUQ pain, jaundice, fever Acute cholangitis Reynold s Pentad Addition of mental status changes and hypotension 11

12 DIAGNOSTIC IMAGING Ultrasound Cholelithiasis 98% specific and >95% sensitive DIAGNOSTIC IMAGING Cholecystitis ERCP DIAGNOSTIC IMAGING MANAGEMENT BILIARY INFLAMMATORY PROCESSES Cholecystitis IVF, IV Antibiotics, +/- ERCP, Cholecystectomy during SAME hospitalization Role of cholecystostomy tube Cholangitis- abscess of the bile duct Treatment is biliary decompression ERCP/Sphincterotomy, surgery 12

13 MANAGEMENT Biliary Colic Elective cholecystectomy Other Options?? Choledocholithiasis-CBD CBD stone Etiology Treatment with ERCP and Surgery GALLSTONES Asymptomatic Gallstones 60-80% remain silent Role of cholecystectomy: ALMOST NONE During obesity surgery During hepatic resection Pancreatitis Repeat episodes often happen with alcohol as etiology Strategy for biliary etiology Who needs admission? The retroperitoneal burn 13

14 Incidence in Etiology Breast Masses Carotid Artery Disease How does carotid artery disease lead to stroke? 14

15 65 year old man presents to the ER with acute onset of left sided weakness How do you approach this patient? He is found to have 80-99% stenosis of the right internal carotid artery. How might this be responsible for his symptoms? Who should be evaluated for carotid artery disease? So you find 60% stenosis in a carotid artery. What does that mean for the patient? 15

16 12% ACST versus ACAS 5-year Stroke Risks Asymptomatic Carotid Stenosis Trial CSM and 5-year Non-perioperative Strokes 10% 8% 6% 4% 2% ACST ACAS 2.8% 2.3% p< % 6.4% p= % 5.1% 10% 8% 6% 4% 60-79%, p< %, p< % 9.6% 0% CSM ACST ACAS CEA No CEA 2% 0% 2.7% 2.9% 3.2% 2.1% CSM CEA No CEA 60-79% 80-99% Randomized Endarterectomy Trials Symptomatic Patients 30% 25% 20% 15% NEJM 1991 Mean 18 mos P< % Lancet 1991 Mean 3 yrs P< % Abdominal Aortic Aneurysms Aneurysm: Definition = diameter > 50% above the normal diameter, for aorta, generally defined as diameter > 3 cm 10% 5% 0% 9% NASCET Surgical Medical 12% ECST 16

17 Classification Layers of the aortic wall Intima Media Adventitia True v false Physical Exam Xray Duplex CT Angio Diagnosis of AAA Natural History Growth not predictable Factors associated with growth Smoking, presence of emphysema, renal insufficiency, larger initial diameter, CV disease Protective Female gender, African American, diabetes Clinical Presentation and Indications for Intervention Asymptomatic Rupture risk associated with size 4-5 cm 0.5 5% per year 5-6 cm 3-15% per year 6-7 cm 10-20% per year 7-8 cm 20-40% per year Pain back or abdominal Rupture Syncope, severe pain, hypotension 17

18 Treatment Lower Extremity Occlusive Disease Critical Stenosis Degree of stenosis that causes a reduction in pressure and flow Arterial stenosis of 50% diameter is equal to a cross-sectional sectional area decrease of 75% Critical Single Arterial Stenosis Fall in pressure distal to the lesion because increased resistance results in a pressure drop along the length of the stenotic segment Collateralization and autoregulation act to maintain resting blood flow Clinical Presentations Non limb-threatening Asymptomatic decrease in pulses Claudication Limb-threatening Nonhealing ulcers Rest pain Gangrene 18

19 Diagnostic Aids Ankle pressure, toe pressure Exercise Testing Duplex Waveform evaluation Direct pressure measurement Angiography Velocity Waveform Triphasic Normal Reverse flow component present (early diastole) Biphasic Loss of reverse flow component b/c of vasodilation Monophasic ABIs and correlation with symptoms Natural History of Claudication Claudication has relatively benign course Major amputation 2-7% over 5 years 12% over 10 years ¼ of patients deteriorate Deterioration most common in 1st year (10%) then 2-3% per year 19

20 Limb-Threatening Ischemia Risk of limb loss 25-35% in next year Only 40% of patients are alive in 5 years 1-year mortality of 20% in several series 20