Surgical Education Series

Transcription

1 Surgical Education Series The Acute Abdomen Ahmad kachooei, MD MPH Assistant Professor Division of General Surgery Department of Surgery University of Qom Outline Definitions What causes an acute abdomen Differential Diagnosis History and physical Labs Diagnostic imaging Special emphasis Appendicitis Bowel infarction Perforated viscous ١

2 Acute Abdomen Symptoms and signs of acute intra- abdominal disease processes, usually treated best by surgical operation Common Causes of Abdominal Pain of Surgery, ١۶th ed. ٢

3 Acute Abdomen-Symptoms Symptoms linked to visceral distention or ischemia Inflammation of the peritoneum Parietal component provides localization End result of a process involving viscera Early diagnosis means understanding the patterns that lead up to peritoneal irritation Timing Symptom Quality Matched to clinical condition Emerges over time and then concentrates (acute app) Sudden onset (perforated viscous) Referred pain Linked to anatomic distribution ٣

4 History of Present Illness O nset P recipitating/ relieving Q uality R adiation S everity T iming Physical Examination Overall appearance Walking and recumbent Vital signs Temperature High/low/low-grade Tachycardia Hypotension Inspection: scars, hernias, masses Auscultation Palpation ۴

5 Physical Examination Percussion: Tympanitic Dull Palpation _ Tenderness No sudden moves Take your time Rigidity and guarding Board-like abdomen Lab Tests WBC + differential Basic chemistry panel K Bicarbonate Amylase Liver function tests Urinalysis Pregnancy test ۵

6 Diagnostic Imaging Plain Films Upright CXR Free air KUB (kidney/ureter/bladder) Calcifications Air/ Fluid levels Reactive bowel patterns Foreign bodies ۶

7 Lateral Decubitus Film Ultrasound Rapid, safe, low cost Operator dependent Fluid, inflammation, air in walls, masses Liver, GB, CBD, Spleen, Pancreas, Appendix, Kidney, Ovaries, Uterus ٧

8 Ultrasound Textbook of Sabiston, ١۶th ed. CT Scans Better than plain films and US for evaluation of solid and hollow organs Intravenous contrast Oral contrast Per rectal contrast High use in appendicitis, diverticulitis, abscess, pancreatitis ٨

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10 When to Operate? Peritonitis Excluding primary peritonitis Abdominal pain/tenderness + sepsis Acute intestinal ischemia Pneumoperitoneum Make sure pancreatitis is excluded ١٠

11 What if it s not clear? Challenging patients Neurologically compromised Intoxicated Steroids Inmmunosupressed If signs and symptoms are equivocal Serial exams (same person) Imaging Serial labs (check for WBC increases) Keep off antibiotics Tincture of time When NOT to Operate? Cholangitis Appendiceal abscess Acute diverticulitis + abscess Acute pancreatitis or hepatitis Ruptured ovarian cysts Long standing perforated ulcers? ١١

12 Non Surgical Causes MI, Acute pericarditis pulmonary infarction GE reflux, hepatitis DKA, Acute Adrenal Insufficiency Acute Porphyria Rectus muscle hematoma Pyelonephritis, Acute salpingitis Sickle cell crisis Appendicitis ١٢

13 Appendicitis ٧-١٢% lifetime risk of appendectomy ~۵٠٠,٠٠٠ performed yearly ١۵% misdiagnosed ۴٧,٠٠٠ /year ١ in ۴ women will have a negative appendectomy $٧۴٠ million dollars spent/yr on misdiagnosis Pathophysiology Obstruction of the appendiceal lumen Lymphoid hyperplasia Fecalith Inspissated stool Not always present Foreign body ١٣

14 Pathophysiology of Appendicitis obstruction bacterial overgrowth mucous secret distention Increased intraluminal pressure lymphatic obstruction venous obstruction inflammation edema ischemia necrosis perforation abscess or localized peritonitis diffuse peritonitis History and Physical Exam Table ۶ --Clinical Features of Appendicitis Symptoms Duration of symptoms (hrs, median) ٢٢ ٠ hrs Abdominal pain (% of cases) ١٠٠ ٠ Nausea or vomiting (% of cases) ۶٧ ۵ Anorexia (% of cases) ۶١ ٠ Fever by history (% of cases) ١٧ ٩ Dysuria or frequency (% of cases) ١٠ ۶ Physical Findings Right lower quadrant tenderness (% of cases) ٩۵ ٩ Rebound tenderness (% of cases) ۶٩ ۵ Rectal tenderness (% of cases) ۴١ ۵ Source: Berry J Jr, Malt RA. Appendicitis near its centenary. Ann Surg ١٩٨۴;٢٠٠:۵۶٧. ١۴

15 Distinguishing Appendiceal Perforation Duration of symptoms (hrs, median) Fever as presenting complaint (% of cases) Nausea or vomiting (% of cases) Appendicitis With Perforation N=٧٠ Appendicitis w/o Perforation N=١٧۶ ۴٨ ۵ hrs ١٨ ٠ hrs ٣۴ ٣ ١١ ۴ ۶٠ ٠ ٧٠ ۵ Anorexia (% of cases) ۵٢ ٩ ۶۴ ٢ Urinary symptoms (% of cases) Rebound tenderness (% of cases) Rectal tenderness (% of cases) Impression of a mass (% of cases) ١٠ ٠ ١٠ ٨ ۶۴ ٣ ٧١ ۶ ۴١ ۴ ۴١ ۵ ٢١ ۴ ۶ ٢ Source: Berry J Jr, Malt RA. Appendicitis near its centenary. Ann Surg ١٩٨۴;٢٠٠:۵۶٧. Signs and Symptoms Umbilical then migrates towards the RLQ Tenderness, then rebound Rovsing Psoas Extension of leg-pt on left Obturator Rotation of flexed thigh-pt supine Rectal Perforation related symptoms ١۵

16 Differential Diagnosis Preschool-age Intussusception, acute gastroenteritis, Meckel s diverticulum School-age Acute GE, constipation, Sickle cell Young males Crohn s, UC, epididymitis Young females Crohn s, PID, ovarian cysts, UTI, pregnancy Older adults Malignancies of GI and GU Diverticulitis Perforated ulcers Cholecystitis Labs WBC: ١٢,٠٠٠-١٨,٠٠٠ left shift important HCG negative U/A mild pyuria possible ١۶

17 Radiographics Plain films fecolith, ileus CT scan Distention of appendix, thickened > ۵-٧ mm walls, target sign US Non-compressible, >۶mm, fluid, mass Nuclear : Tc ٩٩ WBC Ig G Appendicitis U/S ١٧

18 Appendicitis CT Scan Treatment Urgent appendectomy Antibiotics Only preoperative abx needed for uncomplicated cases For complicated appendicitis ٧-١٠ days ١٨

19 Appendectomy Textbook of Sabiston, ١۶th ed. Laparoscopic Appendectomy ١٩

20 Postoperative Complications Infection: < ۵ % to ۶٠ % Wound Closure Primary Delayed primary Secondary Bowel obstruction Infertility-no longer suspected Normal appearing appendix? Remove appendix anyway? Especially if the pt has a RLQ incision Negative predictive value of macroscopic judgments of the appendix are low Check for ovarian pathology Check for mesenteric adenitis ٢٠

21 Name That Disease Meckel s Diverticulitis Rule of s % incidence types of mucosa feet from ileocecal valve - % (now % with Meckel s develop symptoms < yr olds bleeding ( % ٢١

22 Infarcted/Ischemic Bowel Mesenteric Infarction/Ischemia Always consider in patient with atypical presentation of abdominal pain- Older patients Hx of arrhythmias or previous emboli Pain out of proportion to exam Evidence of visceral complaints without peritonitis Systemic complications Acidosis ٢٢

23 Infarction by Endoscopy Anatomy of the SMA ٢٣

24 Occlusion of the SMA Source Embolic (>۵٠%) Venous, Atherosclerotic (thrombotic), NOMI Chronic Mesenteric/intestinal angina ٣٠-۶٠ minutes post eating Voluntary anorexia/wt loss Acute (>۶٠% mortality) Abdominal apoplexy Variable symptoms at first with progression System collapse Arteriogram of Normal SMA ٢۴

25 Occluded SMA Treatment of Acute SMA Occlusion High index of suspicion Arteriogram Medical therapy Papavarin Heparin Surgical intervention ٢۵

26 Perforated Viscous Perforated Viscous Sudden onset of pain Set your watch to it Epigastric/shoulder/RLQ-often DU Lower quadrant-often diverticulum Often pre-existing history of ulcer or diverticular disease ٢۶

27 Diagnosis Plain x-rays often demonstrate Upright CXR ٧۵% of perforated DU will have free air Sensitive to ۵ cc CT scan Sensitive to <٢ cc air Management Acute perforation of a viscous requires emergent exploration Delayed presentations are more complex Can avoid operation if the perforation is contained May require delayed interventions ٢٧

28 Acute Abdomen-Summary History and physical more important than tests Making the decision to operate is much more important than making the diagnosis Treatment is often (BUT NOT ALWAYS) surgical Very old, very young, very odd be very careful! de Domball ٢٨