Transcript Addominal Anatomy - Hatzalah of Miami-Dade

Acute Abdomen
Acute Abdomen
 Anatomy
review
 Non-hemorrhagic abdominal pain
 Gastrointestinal hemorrhage
 Assessment
 Management
Abdominal Anatomy
Review
Abdominal Cavity
 Superior
border = diaphragm
 Inferior border = pelvis
 Posterior border = lumbar spine
 Anterior border = muscular
abdominal wall
Peritoneum
Abdominal cavity lining
 Double-walled structure

» Visceral peritoneum
» Parietal peritoneum

Separates abdominal cavity into two parts
» Peritoneal cavity
» Retroperitoneal space
Primary GI Structures

Mouth/oral cavity
» Lips, cheeks, gums, teeth, tongue

Pharynx
» Portion of airway between nasal cavity and
larynx
Primary GI Structures

Esophagus
» Portion of digestive
tract between
pharynx and stomach

Stomach
» Hollow digestive
organ
» Receives food from
esophagus
Primary GI Structures

Small intestine
» Between stomach and cecum
» Composed of duodenum,
jejunum and ileum
» Site of nutrient absorption
into body

Large intestine
» From ileocecal valve to anus
» Composed of cecum, colon,
rectum
» Recovers water from GI tract
secretions
Accessory GI Structures
 Salivary
glands
»Produce, secrete saliva
»Connect to mouth by ducts
Accessory GI Structures

Liver
» Large solid organ in right upper quadrant
» Produces, secretes bile
» Produces essential proteins
» Produces clotting factors
» Detoxifies many substances
» Stores glycogen

Gallbladder
» Sac located beneath liver
» Stores and concentrates bile
Accessory GI Structures

Pancreas
» Endocrine pancreas secretes insulin into
bloodstream
» Exocrine pancreas secretes digestive
enzymes, bicarbonate into gut

Vermiform appendix
» Hollow appendage
» Attached to large intestine
» No physiologic function
Major Blood Vessels
 Aorta
 Inferior
vena cava
Solid Organs
 Liver
 Spleen
 Pancreas
 Kidneys
 Ovaries
(female)
Hollow Organs
 Stomach
 Intestines
 Gallbladder
and bile ducts
 Ureters
 Urinary
bladder
 Uterus and Fallopian tubes (female)
Right Upper Quadrant
 Liver
 Gallbladder
 Duodenum
 Transverse
colon (part)
 Ascending colon (part)
Left Upper Quadrant:
 Stomach
 Liver
(part)
 Pancreas
 Spleen
 Transverse colon (part)
 Descending colon (part)
Right Lower Quadrant
 Ascending
colon
 Vermiform appendix
 Ovary (female)
 Fallopian tube (female)
Left Lower Quadrant
 Descending
colon
 Sigmoid colon
 Ovary (female)
 Fallopian tube (female)
Acute Abdomen
Abdominal Pain
 Visceral
 Somatic
 Referred
Abdominal Pain
 Visceral
pain
»Stretching of peritoneum or organ
capsules by distension or edema
»Diffuse
»Poorly localized
»May be perceived at remote locations
related to organ’s sensory innervation
Abdominal Pain
 Somatic
pain
»Inflammation of parietal peritoneum or
diaphragm
»Sharp
»Well-localized
Abdominal Pain
 Referred
pain
»Perceived at distance from diseased organ
»Pneumonia
»Acute MI
»Male GU problems
Non-hemorrhagic
Abdominal Pain
Esophagitis
 Inflammation
of distal esophagus
 Usually from gastric reflux, hiatal
hernia
Esophagitis
 Signs
and Symptoms
»Substernal burning pain, usually epigastric
»Worsened by supine position
»Usually without bleeding
»Often temporarily relieved by nitroglycerin
Acute Gastroenteritis
 Inflammation
of stomach, intestine
 May lead to bleeding, ulcers
 Causes
» acid secretion
»Chronic EtOH abuse
»Biliary reflux
»Medications (ASA, NSAIDS)
»Infection
Acute Gastroenteritis
 Signs
and Symptoms
»Epigastric pain, usually burning
»Tenderness
»Nausea, vomiting
»Diarrhea
»Possible bleeding
Chronic Infectious
Gastroenteritis






Long-term mucosal changes or permanent
damage
Due primarily to microbial infections
(bacterial, viral, protozoal)
Fecal-oral transmission
More common in underdeveloped countries
Nausea, vomiting, fever, diarrhea, abdominal
pain, cramping, anorexia, lethargy
Handwashing, BSI
Peptic Ulcer Disease




Craters in mucosa of
stomach, duodenum
Males 4x > Females
Duodenal ulcers 2 to 3x
> Gastric ulcers
Causes:
» Infectious disease:
Helicobacter pylori (80%)
» NSAIDS
» Pancreatic duct blockage
» Zollinger-Ellison Syndrome
Peptic Ulcer Disease

Duodenal Ulcers
» 20 to 50 years old
» High stress
occupations
» Genetic
predisposition
» Pain when
stomach is empty
» Pain at night

Gastric Ulcers
» > 50 years old
» Work at jobs
requiring physical
activity
» Pain after eating
or when stomach
is full
» Usually no pain at
night
Peptic Ulcer Disease
 Complications
»Hemorrhage
»Perforation, progressing to peritonitis
»Scar tissue accumulation, progressing to
obstruction
Peptic Ulcer Disease
 Signs
and Symptoms
»Steady, well-localized pain
»“Burning”, “gnawing”, “hot rock”
»Relieved by bland, alkaline
food/antacids
»Worsened by smoking, coffee,
stress, spicy foods
»Stool changes, pallor associated
with bleeding
Pancreatitis
Inflammation of pancreas in which
enzymes auto-digest gland
 Causes include:

» EtOH (80% of cases)
» Gallstones obstructing ducts
» Elevated serum triglycerides
» Trauma
» Viral, bacterial infections
Pancreatitis
 May
lead to:
»Peritonitis
»Pseudocyst formation
»Hemorrhage
»Necrosis
»Secondary diabetes
Pancreatitis
 Signs
and Symptoms
»Mid-epigastric pain radiating to back
»Often worsened by food, EtOH
»Bluish flank discoloration (Grey-Turner
Sign)
»Bluish periumbilical discoloration
(Cullen’s Sign)
»Nausea, vomiting
»Fever
Cholecystitis


Gall bladder
inflammation, usually
2o to gallstones (90%
of cases)
Risk factors
» Five Fs: Fat, Fertile,
Febrile, Fortyish,
Females
» Heredity, diet, BCP
use
Cholecystitis

Acalculus cholecystitis
» Burns
» Sepsis
» Diabetes
» Multiple organ systems failure

Chronic cholecystitis (bacterial
infection)
Cholecystitis
 Signs
and Symptoms
»Sudden pain, often severe, cramping
»RUQ, radiating to right shoulder
»Point tenderness under right costal
margin (Murphy’s sign)
»Nausea, vomiting
»Often associated with fatty food intake
»History of similar episodes in past
»May be relieved by nitroglycerin
Appendicitis



Inflammation of
vermiform appendix
Usually secondary to
obstruction by fecalith
May occur in older
persons secondary to
atherosclerosis of
appendiceal artery and
ischemic necrosis
Appendicitis

Signs and Symptoms
» Classic: Periumbilical pain  RLQ pain/cramping
» Nausea, vomiting, anorexia
» Low-grade fever
» Pain intensifies, localizes resulting in guarding
» Patient on right side with right knee, hip flexed
Appendicitis

Signs and Symptoms
» McBurney’s Sign: Pain on palpation of RLQ
» Aaron’s Sign: Epigastric pain on palpation
of RLQ
» Rovsing’s Sign: Pain in LLQ on palpation
of RLQ
» Psoas Sign: Pain when patient:
– Extends right leg while lying on left side
– Flexes legs while supine
Appendicitis

Signs and Symptoms
» Unusual appendix position may lead to atypical
presentations
– Back pain
– LLQ pain
– “Cystitis”
» Rupture: Temporary pain relief followed by
peritonitis
Bowel Obstruction
Blockage of intestine
 Common Causes

» Adhesions (usually 2o to surgery)
» Hernias
» Neoplasms
» Volvulus
» Intussuception
» Impaction
Bowel Obstruction

Pathophysiology
» Fluid, gas, air collect near obstruction site
» Bowel distends, impeding blood flow/ halting
absorption
» Water, electrolytes collect in bowel lumen
leading to hypovolemia
» Bacteria form gas above obstruction further
worsening distension
» Distension extends proximally
» Necrosis, perforation may occur
Bowel Obstruction
 Signs
and Symptoms
» Severe, intermittent, “crampy” pain
» High-pitched, “tinkling” bowel sounds
» Abdominal distension
» History of decreased frequency of bowel
movements, semi-liquid stool, pencil-thin
stools
» Nausea, vomiting
» ? Feces in vomitus
Hernia
Protrusion of abdominal contents into
groin (inguinal) or through diaphragm
(hiatal)
 Often secondary to  intra-abdominal
pressure (cough, lift, strain)
 May progress to ischemic bowel
(strangulated hernia)

Hernia
 Signs
and Symptoms
»Pain  by abdominal pressure
»Past history
»Inguinal hernia may be palpable as
mass in groin or scrotum
Crohn’s Disease
Idiopathic inflammatory bowel disease
 Occurs anywhere from mouth to rectum
 35-45%: small intestine; 40%: colon
 Runs in families
 High risk groups

» White females
» Jews
» Persons under frequent stress
Crohn’s Disease

Pathophysiology
» Mucosa of GI tract becomes inflamed
» Granulomas form, invade submucosa
» Muscular layer of bowel become fibrotic,
hypertrophied
» Increased risk develops for
– Obstruction
– Perforation
– Hemorrhage
Ulcerative Colitis
Idiopathic inflammatory bowel disease
 Chronic ulcers develop in mucosal
layer of colon
 Spread to submucosal layer
uncommon
 75% of cases involve rectum (proctitis)
or rectosigmoid portion of large
intestine
 Inflammation can spread through
entire large intestine (pancolitis)

Ulcerative Colitis
Severity of signs, symptoms depends
on extent
 Classic presentation

» Crampy abdominal pain
» Nausea, vomiting
» Blood diarrhea or stool containing mucus

Ischemic damage with perforation may
occur
Diverticulitis

Diverticula
» Pouches in colon
wall
» Typically in older
persons
» Usually
asymptomatic
» Related to diets with
inadequate fiber
Diverticulitis
Diverticula trap feces, become inflamed
 Occasionally result in bright red rectal
bleeding
 Rupture may cause peritonitis, sepsis

Diverticulitis
 Signs
and Symptoms
»Usually left-sided pain
»May localize to LLQ (“left-sided
appendicitis”)
»Alternating constipation, diarrhea
»Bright red blood in stool
Hemorrhoids
Small masses of veins in anus, rectum
 Most frequently develop when patients
are in 30s or 40s; common past 50
 Most are idiopathic, can be associated
with pregnancy, portal hypertension
 Cause bright red bleeding, pain on
defecation
 May become infected, inflamed

Peritonitis
 Inflammation
of abdominal cavity lining
 Signs and Symptoms
»Generalized pain, tenderness
»Abdominal rigidity
»Nausea, vomiting
»Absent bowel sounds
»Patient resistant to movement
Hemorrhagic Abdominal
Problems
Gastrointestinal Hemorrhage
Intraabdominal Hemorrhage
Esophageal Varices



Dilated veins in
esophageal wall
Occur 2o to hepatic
cirrhosis, common
in EtOH abusers
Obstruction of
hepatic portal blood
flow results in
dilation, thinning of
esophageal veins
Esophageal Varices

Portal hypertension
» Hepatic scarring
slows blood flow
» Blood backs up in
portal circulation
» Pressure rises
» Vessels in portal
circulation become
distended
Esophageal Varices
 Signs
and Symptoms
»Hematemesis (usually bright red)
»Nausea, vomiting
»Evidence of hypovolemia
»Melena (uncommon)
Mallory-Weiss Syndrome




Longitudinal tears at
gastroesophageal
junction
Occur as result of
prolonged, forceful
vomiting, retching
Common in alcoholics
May be complicated by
presence of esophageal
varices
Peptic Ulcer Disease
 Ulcer
erodes through blood vessel
 Massive hematemesis
 Melena may be present
Aortic Aneurysm
Localized dilation due to weakening of aortic
wall
 Usually older patient with history of
hypertension, atherosclerosis
 May occur in younger patients secondary to
»Trauma
»Marfan’s syndrome

Aortic Aneurysm
Usually just
above aortic
bifurcation
 May extend to
one or both iliac
arteries

Aortic Aneurysm
 Signs
and Symptoms
»Unilateral lower quadrant pain; low back
or leg pain
»May be described as tearing or ripping
»Pulsatile palpable mass usually above
umbilicus
»Diminished pulses in lower extremities
»Unexplained syncope, often after BM
»Evidence of hypovolemic shock
Ectopic Pregnancy




Any pregnancy that
takes place outside of
uterine cavity
Most common location
is in Fallopian tube
Pregnancy outgrows
tube, tube wall ruptures
Hemorrhage into pelvic
cavity occurs
Ectopic Pregnancy

Suspect in females of child-bearing age with:
» Abdominal pain, or
» Unexplained shock

When was last normal menstrual period?
Ectopic pregnancy does
NOT necessarily cause
missed period
Assessment of Acute
Abdomen
History

Where do you hurt?
» Try to point with one finger

What does pain feel like?
» Steady pain = Inflammatory process
» Cramping pain = Obstructive process

Onset of pain?
» Sudden = Perforation or vascular occlusion
» Gradual = Peritoneal irritation, distension of
hollow organ
History

Does pain travel anywhere?
» Gallbladder = Angle of right scapula
» Pancreas = Straight through to back
» Kidney/ureter = Around flank to groin
» Heart = epigastrium, neck/jaw, shoulders,
upper arms
» Spleen = Left scapula, shoulder
» Abdominal Aortic Aneurysm = low back
radiating to one or both legs
History

How long have you been hurting?
» >6 hours = increased probability of surgical
significance

Nausea, vomiting
» How much, How long?
– Consider possible hypovolemia
» Blood, coffee grounds?
– Any blood in GI tract = emergency until
proven otherwise
History
 Urine
»Change in urinary habits?
–Frequency
–Urgency
»Color?
»Odor?
History
 Bowel
movements
»Change in bowel habits? Color? Odor?
–Bright red blood
–Melena = black, tarry, foul-smelling stool
–Dark stool
Suspect bleeding
 Other causes possible (iron or bismuth
containing materials)

History
 Last
normal menstrual period?
 Abnormal bleeding?
 In females, lower abdominal pain =
GYN problem until proven otherwise
 In females of child-bearing age, lower
abdominal pain = ectopic pregnancy
until proven otherwise
Physical Exam
 Position
and General Appearance
»Still, refusing to move = Inflammation,
peritonitis
»Extremely restless = Obstruction
 Gross
appearance of abdomen
»Distended
»Discolored
»Consider possible third spacing of fluids
Physical Exam
 Vital
signs
»Tachycardia = more important sign of
volume loss than falling BP
»Rapid, shallow breathing = possible
peritonitis
»Consider performing “tilt” test
Physical Exam
 Bowel
sounds
»Auscultate BEFORE palpating
»One minute in each abdominal quadrant
»Absent sounds = possible peritonitis,
shock
»High-pitched, tinkling sounds = possible
bowel obstruction
Physical Exam
 Palpation
»Palpate each quadrant
»Palpate area of pain LAST
»Do NOT check rebound tenderness in
prehospital setting
»ALL abdominal tenderness significant
until proven otherwise
Management
 Oxygen
by non-rebreather mask
 IV LR or NS
 PASG (demonstrated benefit in
intrabdominal hemorrhage)
 Keep patient from losing body heat
 Monitor vital signs
Management

Monitor EKG
Consider possible MI with
pain referred to abdomen in
patients >30 years old
Keep patient npo
 Analgesia controversial
 Demerol is preferred narcotic analgesic
