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 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

    1. 1. The Acute Abdomen Samuel Hamner Gay UMMC School of Medicine Surgical Clerkship
    2. 2. 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
    3. 3. 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)
    4. 4. 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
    5. 5. 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
    6. 6. Visceral Pain
    7. 7. 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
    8. 8. 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
    9. 9. 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
    10. 10. Referred and Shifting Pain
    11. 11. Location, onset, and character of pain
    12. 12. 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
    13. 13. 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
    14. 14. 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
    15. 15. 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
    16. 16. 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
    17. 17. 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
    18. 18. Vomiting • Appearance helps indicate the location of an obstruction • What does it look like? – Green – SBO – No green – Pyloric Stenosis – Feculent material – LBO
    19. 19. 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
    20. 20. 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
    21. 21. Bloody Diarrhea and RUQ pain w/ a Hx of Travel
    22. 22. Other Specific Symptoms • • • • • • • Jaundice Hematemesis Melena Hematochezia Rectorrhagia Hematuria Passage of blood clots
    23. 23. 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
    24. 24. 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
    25. 25. 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
    26. 26. Inspection • • • • Distention – SBO, LBO, or Ileus Scaphoid – Perforated Ulcer Cullen Sign – Intraperitoneal Hemorrhage Grey Turner Sign - Intraperitoneal Hemorrhage
    27. 27. 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
    28. 28. Cough Tenderness • Tests for presence and severity of parietal pain • Important preliminary test if pt is in severe abdominal pain
    29. 29. Percussion • Assess size of liver • Test for shifting dullness • Test for midline tympany
    30. 30. 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
    31. 31. Special Tests/Signs • • • • Carnett’s Sign Murphy’s Sign Psoas Sign Obturator Sign
    32. 32. 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
    33. 33. Investigative Studies • H/P provides the diagnosis in 2/3 of acute abdomen cases
    34. 34. 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
    35. 35. 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
    36. 36. 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
    37. 37. 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
    38. 38. 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