Transcript A Cute Abdomen Goal  not exact diagnosis  but that a surgical condition exists.

A Cute Abdomen
Goal
 not exact diagnosis
 but that a surgical condition exists
“The general rule can
be laid down that the
majority of severe
abdominal pains that
ensue in patients
who have been
previously fairly well,
and that last as long
as six hours, are
caused by
conditions of
surgical import.”
Silen W: Cope’s Early Diagnosis of the Acute Abdomen. 1996,p.6.
Diagnose Early
• Better outcome
• Pain relief (narcotics)
• Antibiotics
History
• Age
• Onset -
how long ago
sudden or gradual
• Distribution - area of maximal pain
localization
radiation
• Character - sharp or dull, burning,
steady or cramping
History
• Nausea, vomiting, anorexia
• Diarrhea, constipation, flatus, blood, tenesmus
• Menstruation - where in the cycle
sexual activity
• Previous episodes relationship to meals:
2 - 2 1/2 hrs = duodenal
worse with food = gastric
fatty foods = gallstones
weight loss?
Vomiting
• Relationship to pain
appendicitis - pain precedes vomiting
gastroenteritis - vomiting precedes pain
• Character feculent vomiting pathognomonic of
obstruction of distal small intestine, rare in
colonic obstruction
Physical Examination
• General appearance restlessness = colic
immobility with knees flexed = peritonitis
• Blood pressure
• Pulse - “too optimistic a friend to be relied upon…”
• Respiratory rate - may suggest a thoracic origin
• Temperature - could be normal, high or low
> 104oF (40oC) suggests thorax or kidney
Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996,p.32.
PE: Chest
•
•
•
•
Inspection
Palpation
Percussion
Auscultation
PE: Abdomen
• Inspection - distention, hernias
DON”T FORGET THE FEMORAL CANAL
• Auscultation
• Palpation rigidity
area of greatest pain last
• Percussion - “rebound”, cough tenderness
Rosving’s sign
Levien: Intro to Surg 1987, p.41.
PE: Abdomen
“of all the modalities of physical diagnosis
of the abdomen, auscultation is one of
the least valuable and most misleading.”
Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996,p.43.
PE: Pelvis
• Pelvic examination bimanual
• Rectal examination mass, tenderness, blood
“Overreliance on laboratory tests and
radiological evaluations will very often
mislead the clinician, especially if the
history and physical examination are
less than diligent and complete.”
Silen W: Cope’s Early Diagnosis of the Acute Abdomen, 1996,p.57.
Laboratory Tests
•
•
•
•
•
CBC - leukocytosis, anemia
Urinalysis - infection, blood, pregnancy
Electrolytes - renal function, dehydration
Amylase, lipase
LFTs
Radiographic Studies
• Flat & upright abdomen air-fluid levels, distended loops, edema in
bowel wall, volvulus, fecolith
• CXR - free air, lower lobe pneumonia
• Contrast studies H2O soluble if perforation
disadvantage - aspiration, quality
Appendicitis
• Fecolith
• Young
1. Dull pain in midepigastrium
2. Nausea/vomiting follows
pain
3. Localizes to RLQ
* Anorexia
+ Fever
• Leukocytosis
Reginald H. Fitz
1843 - 1913
McBurney’s Incision
McBurney C: NY State Med J 1889;50,676-684.
McBurney C: Ann Surg 1894;20,38-43.
Perforated Ulcer
• Sudden onset
• Previous episodes of
pain ~ 2 hrs after
eating
• CXR - free air
Graham RR: Surg Gynecol Obstet 1937;64,235-238.
Pancreatitis
•
•
•
•
•
•
•
Alcohol
Gallstones
Trauma
Hyperlipidemia
Hyperparathyroidism
Drugs - thiazide diuretics
Unknown (10%)
Pancreatitis
•
•
•
•
•
Excruciating pain
Fever - almost always
Ranson’s criteria
Grey Turner sign
Cullen’s sign
Cullen TS: Am J Obstet 1918;78(Sept),457.
Turner GG: Brit J Surg 1920;7(Jan),394-395.
Ranson’s Criteria
Admission
1.
2.
3.
4.
5.
During Initial 48 Hours
Age > 55
1.
WBC > 16,000/mm3
2.
Glucose > 200 mg/100 ml
3.
LDH > 350 I.U./L
4.
SGOT > 250 Frankel units % 5.
6.
Hematocrit fall > 10%
BUN rise > 5%/mg/100 ml
Ca++ < 8 mg/100 ml
Arterial pO2 < 60 mmHg
Base Deficit > 4 meq/L
Fluid sequestration > 6 L
Ranson et al: Surg Gynecol Obstet 1974;139,69.
Amylase
• Pancreatitis
• Cholecystitis
• High intestinal
obstruction
• Acute renal insufficiency
• Perforated ulcer
• & others
Cholecystitis
• Radiopaque gallstones (10-15%)
• Pain - RUQ, “colic”, radiates to the
ipsalateral
scapula
• Pain brought on with fatty foods
• US - stones, thickening, fluid, air in wall
Intestinal
Obstruction
•
•
•
•
pain - colic
Vomiting, distention
Obstipation
Auscultation - quiet to high-pitched, tinkling
rushes to borborygmi
• X-ray - air-fluid levels, fixed loops
Small Bowel Obstruction
1. Adhesions (74%)
1/ 2o to gynecologic or colonic operations
2
2. Neoplasm (8.6%)
3. Hernias (8.1%)
most common cause in children
• Inflammatory bowel disease (5.2%)
• Gallstone ileus, radiation enteritis, intussusception
• Unknown
Bizer et al: Surgery 1981;89,407-413.
Adynamic Ileus
• 2o to general peritonitis, severe chest injuries, after
myocardial infarction, pneumonia, operations on the
spine or abdomen, or narcotics
• Auscultation - quiet, no borborygmi
• Involves both small & large bowel
• Gaseous distention of both small & large bowel
Large Bowel
Obstruction
1. Cancer (70%)
2. Volvulus (10%)
3. Diverticulitis (5%)
• Intussusception, uremia
Volvulus
•
•
•
•
Sigmoid (most common)
Ileocecal
Transverse (rare)
Barium enema is diagnostic
& often therapeutic
• Sigmoidoscopy - alternative
diagnostic & therapeutic
modality
“bent inner tube sign”
Diverticulitis
•
•
•
•
•
LLQ pain
Fever, leukocytosis
CT scan - pericolic abscess
Antibiotics, NPO, NG decompression
Operation for persistent symptoms (7 days)
or recurrent episodes
Hernias
• Indirect inguinal most common in both males
& females
• Femoral is more common in females
• Direct inguinal, umbilical, ventral, incisional,
Spigelian, Richter’s, lumbar, obturator, etc.
Renal Colic
•
•
•
•
Radiopaque ureteral calculus (85-90%)
Pain radiating to the testicle or vulva
Vomiting
Microscopic hematuria
Female Disorders
• Ectopic pregnancy, PID, mittelschmerz,
appendicitis
• Chandelier sign
• Urinalysis
• Ultrasound
• Laparoscopy
Mesenteric Vascular
Occlusion
• Pain out of proportion to physical examination
• Risk factors - atrial fibrillation, digitalis, diuretics,
cardiopulmonary bypass
• Barium enema may show “thumbprinting”
• Angiography, MRI
• Mortality = 50%
Summary
 not exact diagnosis
 but that a surgical condition exists