Transcript FORMĂ RARĂ DE ABCES DE GLANDĂ SUPRARENALĂ

Intraperitoneal &
retroperitoneal
haemorrhage
Complex ethiology
any vascular lesion if big enough
 Lesions of solid organs
– Liver, spleen, kidney, pancreas
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Lesions of hollow organs and mesentery
Lesions of parietal vessels (cirrhosis)
Genital lesions: extra uterine pregnancy
Fractures of vertebral column
Lesions of big retroperitoneal vessels (aorta,
IVC, etc)
 Postoperative
Many others
Symptoms
 Hemorrhagic syndrome
– Symptoms develop in hours
– Cataclismic hemorrhage
 Clinical presentations
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Pale
Agitation, pseudo-psychotic manifestations
Hypotension
Oliguria/anuria
Abdominal evaluation
 Inspection: may be enlarged, especially in
massive haemorrhage
 Sensibility: spontaneous and o palpation
 Ausculation: intestinal sound may be
diminished due to peritoneal irritation
 Percution:
– free liquid in the abdomen (movable dullness)
– Increased liver or splenic dullness
Careful anamnesis: STRANGE
SITUATION
 Ectopic pregnancy – major cause of
hemoperitoneum
 Progression of a hematoma in sequences
 Pelvic griddle and vertebral fractures can
bleed in the free peritoneum
 Iatrogenic lesions
Progression with a FREE
INTERVAL
 Trauma
 Silent period – almost no symptoms
– SUBCAPSULAR HEMATOMA will form in
this time
– Hematoma ruptures in the peritoneal cavity hemoperitoneum
Lab work
 Plain abdominal X-Ray
 Abdominal US
– Can demonstrate free liquid in the peritoneal
cavity + specific character of blood
– Can show lesions and abnormalities in the
structure of solid organs
– Can demonstrate pregnancy or signs
associated with ectopic preganancy
 Paracentesis + lavaj
Particular aspects of retroperitoneal
hemorrhage
 Frequently in the context of polytrauma
 “No room” closed space –possible
spontaneus hemostasis
 Clinical forms
– Small unnoticed hematoma
– Large volume: “tumor like” appearance
– Echimosis may appear due to blood migration
Special evaluation aiming for a
retroperitoneal hematoma
 US scan – special attention for kidney and
large vessels
 Intravenous urography
 Rx for vertebral column and pelvic griddle
 CT scan
 Paracentesis + lavaj
Upper GI bleeding
Syndrome: GROUP
of diseases which
may be unrelated
Upper GI bleeding - definition
 Internal hemorrhage becoming
exteriorized
 Hematemesis – above the angle of Treitz
 Melena – above the ileo-cecal valve
 Hematochesis (fresh blood per anum) –
bellow splenic flexure
 Hypovolemic shock – the only
manifestation
Main causes
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Duodenal ulcer
Erosive gastritis
Gastric ulcer
Esofageal varices
Esofagitis
Sdr. M-W
Erosive duodenitis
Tumors
24%
23%
21%
10%
8%
7%
6%
3%
Large
geographical
variations
DIAGNOSTIC VS
TREATAMENT
 EMERGENCY
 Urgent treatment should precede
complete diagnostic
 Sequence
– Positive diagnostic - GI bleeding
– Resuscitation
– Empiric treatment
– Ethologic diagnostic
– Specific treatment
Homodynamic evaluation
pulse + blood pressure
 Shock – systemic blood pressure in
decubitus <90mmHG – 50% din VC
 No shock – BP and pulse checked in
ortostatism
– BP<90 lost = 25-50%
– BP-10 or pulse >120/min = 20-25%
MONITOR PATIENTS
-REBLEEDING MODELS
 CONTINUOUS BLEEDING
• No response to treatment
• No major rebleeding
• Clinical observation = ESSENTIAL
 MAJOR REBLEEDING EPISODE
• Sudden onset
• Most frequently in ICU
• Cases only with hypovolemic shock
Rebleeding – major prognostic
factor
 Definition: bleeding after a succesfull
attempt to maintain hemodynamic stability
 High mortality: 3x
 3 major risk factors for morbidity and
mortality
Major rebleeding in the hospital
Old age
Total amount of transfused blood
WHAT IS THE CAUSE?
 Clinical evaluation
 X-Ray and US scan
endoscopy
“GOLD DIAGNOSTIC”
ANAMNESIS
patient + relatives
 Describe bleeding
– Quantities can not be approximated
 Other signs during or before onset
 PMH – suggestive for a medical problem that
may cause bleeding
 Hereditary problems
 Alcohol intake
 False bleeding, false upper GI bleeding
 Medication
 Coughing before hematemesis
 Mouth bleeding
CLINIICAL EVALUTATION
 Hemodynamic evaluation
 Confirm upper GI bleeding
• HEMATEMESIS, MELENA or RECTAL
• ENT evaluation.
 Clinical signs suggestive for liver cirrhosis (liver
and spleen size, ascites,colateral circulation,
spider hemangioma,Dupuytren,etc)
 Tumors
 Other diseases that can produce GI bleeding
IMAGISTICS
 Can be of major interest
 Rx thorax
• Pleuresia
• Tuberculosis
• Primary or secundary tumors
 US abdominal
• Liver cirrhosis
• Abdominal tumors
 Barium meal
• Bad alternative when endoscopy is irrelevant
ENDOSCOPY
 Establishes: SOURCE OR SOURCES OF
BLEEDING
 Evaluation of RISK OF REBLEEDING
 THERAPEUTIC ACCES to lesion
FIRST LESION: “MIRAGE”
Esophageal causes
 Varices
 Mallory-Weiss
 Hiatal hernia and reflux
 Esophageal tumors
Varices
 Endoscopic diagnosis can be difficult
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Massive bleeding
Clots
Gastric varices
Portal encephalopathy
 60% of cirrhotic pateints
bleed form varices
M-W SYNDROM
 Diagnostic possible ONLY WITH
EMERGENCY ENDOSCOPY
• Lesions are short lived
– Hypovolemic shoch is unlikely but not
impossible
– Short hospital stay
– Very small risk of rebleeding
Hiatus hernia and reflux
 Stigmata of recent
bleeding
 HH is very frequent
TUMORS
 Overt GI bleeding is
rare, frequently occult
bleeding
Gastric sources of bleeding
 Hemorrhagic gastritis
 Gastric ulcer
 Benign tumors
 Malignant tumors
Hemorrhagic gastritis
 DG: morphologic criteria
 Endoscopic aspect is not
diagnostic
 Barium meal: useless and
loss of money
Gastric ulcer
 Diagnostic can be
difficult
 EDS: stigmata of
recent bleeding
 Risk of rebleeding
evaluation
Benign tumors
 Very unlikely, round
circumscribed tumors
with central ulcerations
Malignant tumors
 Ex. endoscopic
Locally advanced
tumor
Endoscopic
hemostasis
 US scan
 MTS + lymphnodes
Upper GI bleeding with
duodenal origin
 Very frequent
 Empiric treatment of upper
GI bleeding
 It is much to easy to say
that a bleeding originates
from a duodenal ulcer
without endoscopy
Erosive gastritis
 Term misused for many unknown
situations responsible for bleeding
Superficial ulcerations usually described
as superficial ulcer – easier to comprehend
HP infection
Bleeding peptic duodenal ulcer
 Relatively frequent although potent
medication is on the market
 53% previous diagnostic of ulcer
 17% iterative:
More serious, high risk of rebleeding
25% no previous cause!!!
Known diagnostic-treat that
Rebleeding risk
INTESTINAL
OBSTRUCTION
SYNDROME, MANY
DISEASES
Small bowell
obstruction
Essentials of diagnostic
 Complete high
obstruction
 Low obstruction
– Colicky pain
– Vomiting
– Vomiting
– Abdominal discomfort
– Abdominal distension
– Rx changes
– No intestinal transit
– Hyperperistaltic
movements
– A/F levels
2 major forms of obstruction
 Simple
– Mechanical
– Paralitical
 Strangulation
– Vascular component
Causes
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Postoperative adhesions – most frequent
All hernias
Tumors (intraluminal, parietal sor extraintestinal)
Invagination
Volvulus
Foreign bodies
Billiary ileus
Inflammatory bowel disease
Stenosis
Hematoma
Etc
Symptoms
 Colicky abdominal pain (no in very high small
bowell obstruction)
– Crescendo-descrescendo
– Seconds - minutes
– No pain between
 Vomiting
– Dominant symptom
– Intervals depending on localization of obstruction
– More distal - fecaloid
Symptoms
 No transit for feaces or gas per anum
– Feaces can be present in large bowel. Initial normal defecation
 General signs may be absent or minimal
– Dehydration
– No fever
 Abdomen:
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Abdominal distension (not in high obstruction)
Hyperperistaltic waves can be seen on the abdomen
Abdomen may be tender
NO signs of peritoneal iritation
Abnormal sounds
CHECK FOR HERNIA
Paraclinical
 Lab: non-specific
– Hemoconcentration (increased WBC,
hyperglicemia)
– Electrolytic imbalance
– High level serum amilase
 Plain abdominal X-Ray
– A/F levels and their position and form
– Hydrosoluble contrast media
Particularities of strangulation
 Shock develops very early
 Pain is less colicky and becomes
permanent
 Fever
 Vomiting + blood strikes
 Abdominal guarding
Particularities of strangulation
 High WBC
 Rx:
– Loss of normal mucosal lining
– Air in portal veins or in intestinal wall
– F/A levels outside intestinal lumen: abscess or
pneumoperitoneum
LARGE BOWEL
OBSTRUCTION
Essentials of diagnostic
 Constipation or no feaces or flatus per
anum
 Meteorism +/- guarding
 Abdominal pain
 Nausea and vomiting – late
 Important Rx findings
Frequent causes
 Colonic malignant
tumor
 Volvulus
 Diverticulosis infected
 IBD
 Benign tumors
 Fecal impactation
 Lesions outside
digestive tract
Symptoms
 Dependent on the cometepence of ileocecal valve
– Valvular lesion – similar with ileal obstruction
– Competent valve – no vomiting
– Incompetent valve - vomiting
 Closed loop syndrome
– Risk of cecal perforation
Symptoms
 Progressive onset (mechanical obstruction)
 Dull pain mainly in hypogastrium
– Fixed colonic lesion may produce localized
pain
– Continuous pain - ischemia
 Borborism associated with colicky pain
 No feaces no flatus
 Vomiting: changing character
Clinica examination
 Meteorism and timpanism
 Peristaltic waves on abdominal wall
 Specific sounds - obstruction
 Peritoneal irritation symptoms
 Rectal
– Bloos
– Tumor
– Invagination pseudotumor
Radiology
 Colonic distention with gas
 F/A levels (colonic)
 Mixed A/F level signs if the ileo-cecal
valve is incompetent
 Barium enema (or water-soluble solution)
– Level of obstruction
– Ethiology
– Devolvulation
Differential diagnostic
 Low/high obstruction
 Ileus (paralitic)
 Pseudo-obstruction
Signs in acute
pancreatitis
Abdominal drama
Essentials of diagnostic
 ABDOMINAL PAIN
– Sudden onset
– Dull pain irradiating transverse and to the back
 Vomiting, Sweating, Fever
 Distended abdomen
 High WBC, amilazemia, amilazuria,
lipazemia
 PMH: alcohol, billiary calculus
General data
 Severe inflammatory disease
 Abnormal activation of pancreatic enzymes
 Causes:
– Alcohol, billiary calculus
– Hypercalcemia, hyperlipidemie, trauma,
reaction to medicines, vasculitis, infections
 Inflamation: edema – hemorrhagic,
necrotic severe form
Symptoms
PAIN
 Epigastric, severe, continuous, relieved in
genu-pectoral position ;
 IRRADIATION: TRANSVERSE
 Nauseam vomiting: CHARACTERISTIC –
impossibility to eat or drink
 PMH: alcohol or billiary colicky
Abdominal examination
 Very few elements
 Diffuse sensibility in upper half of the abdomen
 Ussually no guarding and no signs of peritoneal
irritation
 Paralitic Ileus
– Abdominal distension
– No bowel sounds
– No flatus per anum
 Abdominal pseudotumor in epigastrium and left
upper quadran
General status
 High fever>38
 Septic state (tachycardia, hypotension,
septic shock, palor, could periphery)
 Jaundice (either compression, obstruction
or secondary liver failure)
 Renal failure
Lab
 WBC 10.000-30.000
 Hyperglicemia
 High billirubin
 High alkaline fosfataze
 Hypocalcemia (loss of albumin through
extraasation) ~ severity
 Amilaze si lipaze serum + pleural and
peritoneal effusion
Imagistic
 Plain abdominal X-Ray = MUST
– Differential dg. acute abdomen
– Sentinel looop – left upper quadrant
– Left pleural effusion + atelectasis
– Incomplete F/A levels
– Billiary stones
– Fluid in the abdominal cavity
Imagistic
 US
– Standard procedure in screening
– PROBLEM: air content
– Pancreas: dimensions, edema, liquid collection
pseudocysts
– Free fluid in the abdomen and pleura
– Guided aspiration for diagnostic
Imagistic
 CT scan + contrast
– Best for diagnostic and follow up
– Information on pancreatic structure and fluid
collections
– Pancreatic tissue viability
– Evaluation of peripancreatic collections
– Free air in collections!!!!
Imagistic
 MRI
– No major advantages
– Superior for the description of billiary duct
– Not specifically indicated in acute pancreatitis
Differential diagnostic
 Anything in acute abdomen
 Myocardial infarction
 After ERCP
 Urlian virus infection
 Intestinal obstruction
 Aortic dissection
 Mesenteric obstruction
Differential diagnostic
SIGNIFICANCE
 NO LAPAROTOMY NO
LAPAROSCOPY IF DIAGNOSTIC
– Sure
– No billiary obstruction (except compression)
– No suspicion of infection