Acute Abdomen

Question 1

acute abdomen (definition)

Answer 1

*a severe, often life threatening disease of abdominal organs, < 24 hours, usually the primary sx of which is pain
*traditionally connotes surgically treated diseases, but not all are surgically treated

Question 2

general approach to the acute abdomen

Answer 2

*is this patient severely acutely ill?
*is this perforation, obstruction, or bleeding? (if yes, prob needs surgery)

Question 3

acute abdominal pain - visceral source

Answer 3

*described as deep, dull, crampy
*sources include stretch, ischemia, contraction against obstruction

Question 4

acute abdominal pain - parietal source

Answer 4

*described as sharp, focal, intense, and constant
*sources include trauma to peritoneum, infection/inflammation, irritants

Question 5

acute abdomen - big 12 common disorders

Answer 5

*appendicitis
*biliary colic
*diverticulitis
*mesenteric ischemia
*pelvic inflammatory disease
*small bowel obstruction
*acute pancreatitis
*Meckel’s diverticulum
*lower GI bleed
*acute severe colitis
*colonic obstruction
*perforated ulcer disease

Question 6

appendicitis & the acute abdomen

Answer 6

*age: 20s-40s most common
*signs/sx: generalized (periumbilical) abdominal pain progressing to RLQ pain
*imaging: CT very sensitive; rule out gyn problems
*tx: fluids, antibiotics; lap appendectomy

Question 7

biliary colic & the acute abdomen

Answer 7

*age: fertile, fat, and forty
*signs/sx: colicky upper abd pain, stool/urine for bilirubin; palpable GB; +/- jaundice
*imaging: RUQ ultrasound; liver functions; CT if jaundice
*tx: lap chole; +/- ERCP

Question 8

diverticulitis & the acute abdomen

Answer 8

*age: common in middle age/elderly
*signs/sx: severe left lower or suprapubic pain; tender in LLQ
*imaging: CT scan
*tx: antibiotics if w/o peritonitis; laparotomy if peritonitis

Question 9

mesenteric ischemia & the acute abdomen

Answer 9

*age: 70s+
*signs/sx: abdominal pain out of proportion to exam; diffuse & colicky pain; central tenderness
*imaging: CT or CTA (high index of suspicion)
*tx: laparotomy; heparin, embolectomy, palliative care

Question 10

pelvic inflammatory disease & the acute abdomen

Answer 10

*age: 30s
*signs/sx: crampy lower abd pain, fever, vaginal discharge; cervical motion tenderness; pus per os
*imaging: ultrasound; diagnostic laparoscopy
*tx: antibiotics (ceftriaxone / doxy)

Question 11

small bowel obstruction & the acute abdomen

Answer 11

*age: any age; hx of prior surgery or hernia
*signs/sx: nausea & vomiting; distension, tenderness
*imaging: CT to look for level of obstruction & transition zone
*tx: conservative management early & laparotomy for failures

Question 12

acute pancreatitis & the acute abdomen

Answer 12

*age: most common in women; 50-70 yrs; alcohol and gallstones most common
*signs/sx: acute central abd pain, REFERRED TO BACK; generalized tenderness
*imaging: CT
*tx: mostly non-surgical; ~20% have virulent disease and need drainage

Question 13

Meckel’s Diverticulum & the acute abdomen

Answer 13

*age: most less than age 10
*signs/sx: painless bleeding, anemia, or pain
*imaging: Meckel’s scan
*tx: resection if symptomatic

Question 14

lower GI bleed & acute abdomen

Answer 14

*age: most 6th decade and older
*signs/sx: melena or crampy abd pain; bleeding, anemia, shock
*imaging: colonoscopy, tagged RBC study angiogram
*tx: most are self limited; resection if bleeding uncontrolled

Question 15

acute severe colitis & the acute abdomen

Answer 15

*age: teens & 20s
*signs/sx: malaise; bloody diarrhea; diffuse mild tenderness
*imaging: colonoscopy
*tx: medical management, colectomy

Question 16

colonic obstruction & the acute abdomen

Answer 16

*age: 60s+
*signs/sx: gradual distension; tenderness; nausea & vomiting; obstipation
*imaging: CT or water sol enema
*tx: laparotomy for resection or diversion

Question 17

perforated ulcer disease & the acute abdomen

Answer 17

*age: any age; risks = smoking, NSAIDs, ASA
*signs/sx: sudden onset of upper abd pain; diffuse abd tenderness
*imaging: free air on plain films; CT
*tx: lap vs open closure/pach

Question 18

causes of bowel obstruction

Answer 18

*adhesions from prior surgery or peritonitis
*hernia
*anatomic colonic obstruction

Question 19

hernia

Answer 19

*any defect in the abdominal wall that may allow peritoneal contents to protrude through the defect
*many are chronic and minimally symptomatic

Question 20

volvulus

Answer 20

*any twisting of the bowel on its own mesentery
*causes vascular compromise with pain and obstruction
*requires reduction (endoscopic or surgical)