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acute abdomen.ppt

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acute abdomen.ppt

  1. 1. Acute Abdomen in the ICU Patient Simon Kimm and Edward Melkun December 11, 2006
  2. 2. Definition <ul><li>Acute abdominal pathology that if left untreated will increase patient M&M </li></ul>
  3. 3. Physiology <ul><li>Visceral and parietal peritoneum </li></ul><ul><li>Peritoneal fluid normally <50ml </li></ul><ul><li>Absorbed via lymphatics in omentum and diaphragmatic peritoneum (30%) </li></ul><ul><li>Omentum acts as physiologic “patch” for perforation or infection </li></ul>
  4. 4. Physiology <ul><li>Pain – somatic and visceral </li></ul><ul><li>Somatic from direct irritation of parietal peritoneum, visceral follows embryologic origin or major splanchnic vessels </li></ul><ul><li>Refered pain – ex. Shoulder and phrenic nerve </li></ul>
  5. 5. Pathophysiology <ul><li>Similar incidence of common diseases as general population plus more unique processes </li></ul><ul><li>Post-surgical state </li></ul><ul><li>Hypotension and low flow states </li></ul><ul><li>Antibiotic therapy (Overgrowth ex. C. diff) </li></ul><ul><li>Narcotics </li></ul><ul><li>Poor nutrition </li></ul><ul><li>Co-morbidities </li></ul><ul><li>Trauma </li></ul>
  6. 6. Presentation <ul><li>Always start with ABCs, eyeball test, and adjuncts to ABCs </li></ul><ul><li>H&P </li></ul><ul><li>If possible review symptoms in awake patient </li></ul><ul><li>OLDCARTS </li></ul>
  7. 7. History <ul><li>Location gives clues to pathology </li></ul><ul><li>Character – crampy usually from hollow viscus </li></ul><ul><li>Progression often more important in post op patients </li></ul>
  8. 8. Physical <ul><li>Again difficult in non-awake patients </li></ul><ul><li>Vitals </li></ul><ul><li>Remember lines and wounds </li></ul><ul><li>Inspect, auscultate, percuss, palpate </li></ul><ul><li>Genital and rectal exam </li></ul>
  9. 9. Labs <ul><li>CBC – wbc trend, left shift, anemia </li></ul><ul><li>UA – wbcs, LE, Nitrite </li></ul><ul><li>LFTs – tbili can be elevated in biliary dz, sepsis, hemolysis, and cholestasis from TPN </li></ul><ul><li>Amylase/Lipase – amylase elevated in pancreatitis, perfed ulcer, mesenteric ischemia, parotid injury or inflam, and ruptured ectopic </li></ul><ul><li>ABG – acidosis, hypoxia </li></ul>
  10. 10. Imaging <ul><li>Bedside films vs. in department </li></ul><ul><li>CXR – free air,PNA, effusions </li></ul><ul><li>Abd films – colonic volvulus, obstruction, stones, pneumobilia </li></ul><ul><li>US – biliary system </li></ul><ul><li>CT – little use in 1 st post-op week for abscess </li></ul><ul><li>Angio – mesenteric ischemia, GI bleeds </li></ul><ul><li>Nuclear scans – tagged rbc </li></ul>
  11. 11. Imaging <ul><li>Endoscopy – UGI bleed, colonic ischemia, ? Role in C. diff (1/3 negative toxin assays) </li></ul>
  12. 12. Postoperative Considerations <ul><li>Bleeding </li></ul><ul><li>Anastamotic leak </li></ul><ul><li>Fascial Dehiscence </li></ul><ul><li>Bowel obstruction </li></ul><ul><li>Abscess </li></ul><ul><li>Abdominal Compartment Syndrome </li></ul>
  13. 13. Bowel obstruction <ul><li>Diagnosis often confounded by normal post-op adynamic illeus </li></ul><ul><li>Patients on narcotic pain meds </li></ul><ul><li>Management per standard protocol </li></ul><ul><li>Complete obstruction or nonresolving/ worsening PSBO requires reoperation </li></ul>
  14. 14. Leak <ul><li>In cases where leak controlled by drainage with little or no peritoneal contamination, may not need early operative intervention </li></ul><ul><li>Percutaneous drainage </li></ul><ul><li>NPO, TPN, ? octreotide </li></ul><ul><li>If peritoneal spillage or signs of intraabdomial sepsis, need emergent reoperation </li></ul>
  15. 15. Abscess <ul><li>Need approximately 7 post op days to organize an abscess </li></ul><ul><li>Small may only require abx </li></ul><ul><li>Larger or those with continued enteric contamination (leak) require drainage </li></ul><ul><li>Percutaneous, operative if not accessible </li></ul>
  16. 16. Cholecystitis <ul><li>Acalculous – may see sludge in GB in US or nonvisualization on HIDA (hepato-iminodiacetic acid) scan </li></ul><ul><li>Can see these findings in nl patients maintained on TPN </li></ul><ul><li>Percutaneous cholecystostomy tube for critically ill patients </li></ul>
  17. 17. Ischemic Bowel <ul><li>Low flow </li></ul><ul><li>Embolic </li></ul><ul><li>Abd films – pneumatosis, pneumobilia, free air, double wall sign </li></ul><ul><li>CTA </li></ul><ul><li>Lactate levels </li></ul>

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