Acute Abdomen Andreas M Kluftinger MD FRCSC Kelowna General Hospital
Disclosure Hernia Advisory Panel Ethicon, Johnson & Johnson Funding nil, zilch, zippo, nada, zero
Objectives Understand the Pathophysiology and Etiology of the acute abdomen Approch to acute abdomen in rural practice Case presentations
Stedman's Medical Dictionary 27th Edition any serious acute intra-abdominal condition attended by pain, tenderness, and muscular rigidity, and for which emergency surgery must be considered. "
Acute Abdominal Pain 5-10 % of ER visits Complex black box Delays in diagnosis i can increase morbidity Excessive consultations (+/- transport) and imaging can be costly and tax resources. Primary assessment and triage are key
History & Physical Onset, nature, duration, location, radiation Aggravating and relieving factors Associated GI or GU symptoms Past history (Surg and Med) Review of Systems Full physical exam
Stereotypes of Pain Onset and Associated Pathology Sudden S onset Rapid R onset Gradual G d l onset (full pain in seconds) (initial sensation to (hours) full pain over minutes or hours) Perforated ulcer Mesenteric infarction Ruptured abdominal aortic aneurysm Ruptured ectopic pregnancy Ovarian torsion or ruptured cyst Pulmonary embolism Acute myocardial infarction Strangulated hernia Volvulus Intussusception Acute pancreatitis Biliary colic Diverticulitis Ureteral and renal colic Appendicitis Strangulated hernia Chronic pancreatitis Peptic ulcer disease Inflammatory bowel disease Mesenteric lymphadenitis Cystitis and urinary retention Salpingitis and prostatitis
Abdominal Innervation
Simplified in Thirds Embryologic Structures Nerves Arteries Pain Location Foregut Esophagus, stomach,3/4 duod,liver, gb panc Thoracic splanchnics, vagus Coeliac Epigastrium Midgut ¼ duod to Thoracic SMA Periumbilical splenic flexure splanchnics, vagus Hindgut Left colon, Pelvic IMA Hypogastrium rectum, GU tract splanchnics, lesser thoracic splanchnics
Possible Causes of Pain by Location Location of Pain Right upper quadrant (liver, kidney, gallbladder) Right lower quadrant (ascending colon, appendix, ovary, fallopian tube) Left upper quadrant (pancreas, spleen, kidney) Left lower quadrant (sigmoid and descending colon, ovary, fallopian tube) Midline or periumbilical Flank Front to back Suprapubic or lower abdominal Associated Diseases Acute cholecystitis, biliary colic, acute hepatitis, duodenal ulcer, right lower lobe pneumonia Appendicitis, cecal diverticulitis, ectopic pregnancy, tubo-ovarian ovarian abcess, ruptured ovarian cyst, ovarian torsion Gastritis, acute pancreatitis, splenic pathology, left lower lobe pneumonia Diverticulitis, ectopic pregnancy, tubo-ovarian abcess, ruptured ovarian cyst, ovarian torsion Appendicitis (early), gastroenteritis, mesenteric lymphadenitis, myocardial ischemia or infarction, pacreatitis Abdominal aortic aneurysm, renal colic, pyelonephritis Acute pancreatitis, ruptured abdominal aortic aneurysm, retrocecal appendicitis, posterior duodenal ulcer Ectopic pregnancy, mittelschmerz, ruptured ovarian cyst, pelvic inflammatory disease, endometriosis, urinary tract infection
Sign Finding Association Cullen's sign Grey Turner s sign Bluish periumbilical discoloration Bluish flank discoloration Retroperitoneal hemorrhage pancreatitis, abdominal aortic aneurysm rupture) Kehr's sign Severe left shoulder pain Splenic rupture Ectopic pregnancy McBurney's sign Tenderness located 2/3 distance from Appendicitis ASIS to umbilicus on right side Murphy's sign Iliopsoas sign Obturator's sign Abrupt interruption of inspiration on palpation of right upper quadrant Hyperextension of right hip causing abdominal pain Internal rotation of flexed right hip causing abdominal pain Acute cholecystitis Appendicitis Appendicitis Chandelier sign Manipulation of cervix causes patient Pelvic inflammatory to lift buttocks off table disease Rovsing's sign Right lower quadrant pain with palpation of the left lower quadrant Appendicitis
Referred Pain Structure Irritated Diaphragmatic Ureteral Cardiac pain Appendix Location of Referred Pain Supraclavicular area (Kehr's sign) Hypogastrium, groin, inner thigh Epigastrum, jaw, shoulder Periumbilical via T10 nerve Duodenum Umbilical l region via greater thoracic splanchnic nerve Hiatal hernia Pancreas or gallbladder Gallbladder and bile duct Epigastrum via T7 and T8 nerves Epigastrum Epigastric pain that wraps around to the scapula
Imaging for Appendicitis
Imaging g Accuracy in Appendicitis iti Modality Sensitivity Specificity Pos PredValue Neg Pred Value Plain Film 10% 90% Ultrasound 85-90% 92-96% 95% 80-90% CT 95-97% 95% 97% 95-100% MRI 93% 91% 92% 100%
Laboratory in Appendicitis Test Sensitivity Neg Pred Value 1. WBC >10.5 85% 2. Neutrophils >75% 78% 94% 3. C reactive protein 93-96% 96% 1+2 96% 1+3 92.3% 1+2+3 99.2% (81% in children)
Urinalysis in Appendicitis 30% of appendicitis patients have some urinary syptoms 14% have >10 WBC/hpf 18% have > 3 RBC/hpf
Imaging in Pregnancy Ultrasound Safest Useful for fetal assessment (dates, viability, placenta, amniotic fluid) NPV for appendicitis 80-90% PPV for appendicitis 95%
Imaging in Pregnancy Procedure Chest radiograph (2 views) Abdominal film (single view) Intravenous pyelography Hip film (single view) Mammography Barium enema or small bowel series CT (computed tomography) scan head or chest CT scan abdomen and lumbar spine CT pelvimetry Fetal Exposure 0.02-0.07 mrad 100 mrad >1 rad* 200 mrad 7-20 mrad 2-4 rad <1 rad 3.5 rad 250 mrad No evidence of teratogenesis or fetal loss if cumulative dose < 5 rads
Early pregnancy Acute Abdomen Caused by Pregnancy Ruptured ectopic pregnancy Septic abortion with peritonitis Acute urinary retention due to retroverted gravid uterus Torsion of the pregnant uterus Later pregnancy Red degeneration of myoma Torsion of pedunculated myoma Placental abruption, Placenta percreta HELLP (hemolysis, elevated liver function, and low platelets) syndrome Spontaneous rupture of the liver Uterine rupture Chorioamnionitis
Conditions Associated with Acute pyelonephritis Acute cystitis Pregnancy Acute cholecystitis Acute fatty liver of pregnancy Rupture of rectus abdominis muscle
Case #1 68 male, 48 hrs RLQ pain Quick onset, in RLQ No nausea or anorexia No urinary syptoms PHx: GERD, dyslipidemia Tender RLQ and flank with peritonism WBC 9.2 Urine clear
CT abdomen
Case #2 BW 41 yo electrician collapsed at home with chest, abd pain CPR by family, EHS to KGH PHx: appe Meds: ASA Exam: BP 60 sys, HR 100 RR 16 Chest clear Abdomen tender, acute
Investigations Hb 108 WBC 8.9 Plts 256 Hep panel normal Lipase 43 ECG normal Trop < 0.1
CT with Aorta Protocol
Laparotomy 3 litres blood intact liver, spleen, viscera blood from lesser sac rupured splenic artery aneurysm at hilum splenectomy, distal pancreatectomy 4 units FP, 6 units RBC Recovery uneventful