The Acute Surgical Abdomen
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The Acute Surgical Abdomen

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Physical exam of an acute surgical abdomen. Using detailed descriptions of pain along with onset and physical exam tests including peritoneal signs and more advanced physical exam maneuvers in order ...

Physical exam of an acute surgical abdomen. Using detailed descriptions of pain along with onset and physical exam tests including peritoneal signs and more advanced physical exam maneuvers in order to formulate a diagnosis and severity of illness.

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  • Unbearable Pain:-urolithiasis-biliary colic – actually constant painSmall Bowel Obstruction (SBO)-bearable deep seated dull colicky pain
  • Rectorrhagia – bleeding not associated with BMs
  • Make sure to say “may indicate”

The Acute Surgical Abdomen The Acute Surgical Abdomen Presentation Transcript

  • The Acute Abdomen Samuel Hamner Gay UMMC School of Medicine Surgical Clerkship
  • The Acute Abdomen • Sudden nontraumatic disorder of the abdomen for which urgent operation may be necessary • Goal of acute abdomen H/P: – Diagnose or at least and most importantly determine if the acute abdomen is a life-threatening surgical emergency or indolent medical condition
  • The most common causes of the Acute Abdomen For adults: • Appendicitis • Bowel obstruction • Acute vascular condition • Cancer • Cholecystitis For children: • Appendicitis (1/3) • Nonspecific abdominal pain (2/3)
  • Other causes of the Acute Abdomen • Can be caused by disorders within organs outside the abdominal cavity: – lower lobe pneumonia, inferior MI, bursitis and hip joint disorders, thoracic radiculopathy, and a variety of pelvic disorders
  • Abdominal Pain Visceral pain • Afferent C fibers innervating walls of hollow organs or capsules of solid organs • Stimulated by distention, inflammation, ischemia • Generally dull, poorly localized, mild to moderate pain • Most often felt in midline • Pt constantly moving • Not aggravated by coughing • Its usually the first type of pain felt in an AA • May be more indicative of a medical condition Parietal pain • Afferent C and A delta fibers innervating the parietal peritoneum • Stimulated by pus, bile, urine, GI secretions • A delta fibers are responsible for the more acute, sharper, localized severe pain • Pt doesn’t want to move • Aggravated by coughing/breathing • Rectus muscle rigidity (aka Guarding) • May be more indicative of a surgical acute abdomen
  • Visceral Pain
  • Colic Pain • Type of visceral pain • Defined as pain with pain-free intervals reflecting intermittent peristalsis • Sharp or dull intermittent pain – Sharp colicky pain: ureters or uterine tube obstruction – Dull colicky pain: bowel obstruction • Caused by the obstruction of a visceral conduit like the intestine, ureters, uterine tubes • “Biliary colic” is not colicky pain – The gallbladder and bile duct, in contrast to the intestine and ureters, do not have peristaltic movements
  • Referred Pain • Type of parietal pain • Due to the confluence of afferent fibers w/in the posterior horn that innervate separate cutaneous areas • Example: Shoulder pain – Subdiaphragmatic irritation by air and/or blood in peritoneal fluid is referred to the shoulder via C4 mediated phrenic nerve
  • Shifting Pain • Pain that changes location overtime, paralleling the coarse of the underlining condition • Example: Acute Appendicitis – Begins with visceral pain within the peri-umbilical area followed by parietal pain within the RLQ
  • Referred and Shifting Pain
  • Location, onset, and character of pain
  • Abdominal Pain Sharp, superficial, constant pain is most likely caused by which of the following? a) b) c) d) Small bowel obstruction Large bowel obstruction Perforated ulcer Kidney stone
  • Abdominal Pain Intermittent, vague, deep-seated, dull crescendo pain is most likely due to which of the following? a) b) c) d) Kidney stone Small bowel obstruction Ruptured appendix Ruptured ovarian cyst
  • Abdominal Pain Unbearably intense, sharp, intermittent pain is most likely due to which of the following? a) b) c) d) Cholecystitis Large bowel obstruction Ruptured ectopic pregnancy Non-ruptured ectopic pregnancy
  • Abdominal Pain No pain w/ a vague feeling of abdominal fullness that feels like it could be relieved by a bowel movement is most likely caused by which of the following? a) b) c) d) Cholecystitis Pancreatitis SBO Retrocecal appendicitis
  • Gas Stoppage Sign • Abdominal fullness that feels as though it could be relieved by a bowel movement • Sign of reflex ileus caused by inflammatory process – Most commonly retrocecal or retroileal appendicitis
  • Vomiting • Did the vomiting occur before or after the onset of pain? – Pain before vomiting: surgical condition – Vomiting before pain: medical condition • Did the vomiting come before or after nausea? – Prolonged nausea before vomiting may be an indication for LBO
  • Vomiting • Appearance helps indicate the location of an obstruction • What does it look like? – Green – SBO – No green – Pyloric Stenosis – Feculent material – LBO
  • Constipation Constipation • Constipation is the absence of passage of stool • Post-surgical constipation is most likely reflex ileus induced by visceral afferent fibers stimulating efferent splanchnic nerves • Not an indicator of intestinal obstruction Obstipation • Absence of passage of both stool and gas • Strongly suggest bowel obstruction, especially if there is painful abdominal distention or repeated vomiting
  • Diarrhea • Usually an indicator of a medical cause of an acute abdomen: – Non-blood-stained diarrhea: • Gastroenteritis – Blood-stained diarrhea: • dysentery, ulcerative colitis, Crohn’s disease • SURGICAL CAUSE OF BLOOD STAINED DIARRHEA = ISCHEMIC COLITIS
  • Bloody Diarrhea and RUQ pain w/ a Hx of Travel
  • Other Specific Symptoms • • • • • • • Jaundice Hematemesis Melena Hematochezia Rectorrhagia Hematuria Passage of blood clots
  • Other relevant aspects of the History • Gynecological Hx – Menstrual Hx • Drug Hx – Anticoagulants – retroperitoneal and intramural duodenal and jejunal hematomas – Oral contraceptives – mesenteric venous infarction and benign hepatic adenomas – Corticosteroids – mask signs of advanced peritonitis – Crack smoking – pyloric perforation • Family Hx • Travel Hx • Surgical Hx
  • Physical Exam • General observation • Systemic signs – Tachycardia and diaphoresis – Fever • Low-grade – Inflammatory conditions (polyarthritis nodosa, UC, Crohn’s) • High grade – Severe infections • Abdominal exam
  • Abdominal exam • • • • • • Inspection Auscultation Cough Tenderness Percussion Guarding or rigidity Palpation – – – – Light palpation Deep palpation Rebound tenderness Punch tenderness • Costal area • Costovertebral area • Special tests/signs • Rectal and pelvic examination
  • Inspection • • • • Distention – SBO, LBO, or Ileus Scaphoid – Perforated Ulcer Cullen Sign – Intraperitoneal Hemorrhage Grey Turner Sign - Intraperitoneal Hemorrhage
  • Auscultation • Mostly useless due to the many variant noises of any given abdominal disorder • Strong peristaltic rushes synchronous w/ colic = Early SBO • Silent abdomen = LATE SBO • High-pitched hyperperistaltic sounds = enteritis
  • Cough Tenderness • Tests for presence and severity of parietal pain • Important preliminary test if pt is in severe abdominal pain
  • Percussion • Assess size of liver • Test for shifting dullness • Test for midline tympany
  • Palpation • Begin away from area of pain • Test for Guarding – Voluntary spasm – Involuntary spasm • only caused by peritoneal inflammation and, for unknown reasons, renal colic • Parietal pain is aggravated by touch, therefore this most be performed gently and slowly
  • Special Tests/Signs • • • • Carnett’s Sign Murphy’s Sign Psoas Sign Obturator Sign
  • Pelvic Examination • Crucial in women with – discharge, dysmenorrhea, menorrhagia, or LLQ pain • Young women w/ an acute abdomen have the highest risk for an incorrect diagnosis
  • Investigative Studies • H/P provides the diagnosis in 2/3 of acute abdomen cases
  • Which of the following is the best method of confirming a perforated peptic ulcer? a) b) c) d) e) Barium swallow Leukocytosis Upper endoscopy Upright abdominal radiograph Colonoscopy
  • Which of the following is the best test to diagnose cholecystitis? a) b) c) d) e) Abdominal radiograph Ultrasound of abdomen Dimethyl iminodiacetic acid (HIDA) scan MRI of abdomen Upper endoscopy
  • Pancreatitis • Severe abdominal pain that radiates to back, accompanied by vomiting • The addition of peritoneal signs and Cullen sign – Necrotizing pancreatitis • Cloudy (lactescent) serum in a pt w/ abdominal pain – Pancreatitis even if serum amylase is normal
  • Specific findings in chest and abdominal X-rays • Small and large bowel dilation w/ diffuse gas pattern w/ air outlining the rectal ampulla is suggestive of Paralytic Ileus • Dilated small bowel loops w/ air-fluid levels along w/ absence or minimal colonic gas is suggestive of SBO • Distended Cecum w/ small bowel dilation and absence of air within the rectum is suggestive of LBO • Free gas under the hemidiaphragm is suggestive of Perforated Peptic Ulcer
  • Summary • The variety of acute abdominal presentations and the frequency at which they present atypically can make a diagnosis challenging • The H/P is the most valuable tool that a physician can use when managing an acute abdomen workup, yet interpretive studies can help establish a diagnosis, especially in atypical presentations • The ability to recognize a life-threatening acute abdomen is a vital skill that can be done using one’s knowledge of abdominal pain and other acute abdominal symptoms