Clinical Applications: Acute Abdomen Flashcards
Characteristics of Acute abdomen
- Rapid onset
- Severe pain
- Requires urgent decision/diagnosis
- Treatment often surgical
Statistics of acute abdomen
Why are older patients difficult diagnosis?
- Difficult to examine
- Patient doesn’t respond
- Low rate of fever
NOTE: This can also apply to the very young
What is the pathophysiology of abdominal pain?
-
Referred pain
- Pain occuring a considerable distance from the source
-
Somatic pain
- Segmental spinal nerves
-
Visceral pain
- Sympathetic, parasympathetic, or somatic pathways
What should be covered in a history when examining a patient with acute abdomen?
- Description of pain
- Associated symptoms
- Gynecologic/ genitourinary (GU) history
- Past medical history
- Family, social history
What are some symptoms associated with acute abdomen?
- Nausea, vomiting
- Fever, chills
- Anorexia, weight loss
- Food intolerance
- Pulmonary symptoms
- Cange in bowel habits
- Genitourinary complaints
What should be considered regarding gynecologic or genitourinary history when screening for acute abdomen?
- Last menses
- Contraception
- Sexual history
- Obstetric history
- Vaginal discharge, bleeding
- Previous STDs
What components of past medical history are important when screening for acute abdomen?
- Cardiac or pulmoanry disorders
- GI, vascular diseases
- Diabetes, HIV
- Medications
- Specifically, all over the counter meds
- Recent invasive procedures
- Trauma
- Recent URI or strep throat
Which components of family and social history should be gather when questioning for acute abdomen?
- Inflammatory bowel disease
- Connective tissue disorders
- Bleeding conditions/problems
- Cancer
- Recent travel
- Environmental hazards
- Drugs, alcohol
What are the components of a physical examination for acute abdomen?
- General appearance
- Chest
- Abdomen
- Rectal
- pelvic
- GU
What are the components of a general examination for acute abdomen?
- Distress
- Acutely or chronically ill
- Body position
- Color
- Vital signs
What the components of a chest exam for acute abdomen?
- Cardiac arrhythmias
- Murmurs
- Mechanical heart valves
- Signs of pneumonia
NOTE: Mechanical valves can get clots and throw emboli into systemic circulation, which can cause problems in the GI tract
What are the three components to an abdominal exam?
- Look
- Distention
- Breathing pattern
- Discolaroration
- Scars and hernia
- Listen
- Auscultation
- Percussion
- Fluid
- Air
- Feel
- Areas of maximal tenderness
- Costoverterbal angle or flank tenderness
- Masses
- Hernia
- Peritoneal signs
NOTE: The components should take place in this order
What abdomen conditions can result in shortness of breath?
Inflammation of gall bladder. Patients will have shortness of breath to prevent the gall bladder from hitting up against the periteneum.
What are the physical characteristics of a person with hemorrhagic pancreatitis?
Light skin
When listening to a patient during an abdominal exam, where should you begin?
With quadrant opposite to location of pain
NOTE: You should listen to all 4 quadrants
If a person has inflammation of kidney you can thumb or percuss in the ___________.
Costovertebral angle
Rovsing’s sign
- If palpation of the left lower quadrant of a person’s abdomen increases the pain felt in the right lower quadrant
Appendix is main culprit
Psoas sign
Indicates that the inflamed appendix is retrocaecal in orientation (as the iliopsoas muscle is retroperitoneal).
RARE
Obturator sign
- performed when acute appendicitis is suspected.
- indicates the presence of an inflamed pelvic appendix.
RARE
Murphy’s sign
- positive in cholecystitis, but negative in choledocholithiasis, pyelonephritis, and ascending cholangitis.
*
Mechanism for testing for Murphy’s sign
- Ask patient to take a deep breath
- Palpate right upper quadrant
- Ask patient to release breath
- You will see a cessation of breathing in a positive Murphy sign, becuase diaphragm pushes down and gallbladder hits peritoneum
What should be accessed in a pelvic/rectal/ genitofemoral exam?
- Tenderness
- Masses
- Hernias
- Discharge, bleeding
- Blood-occult or gross
NOTE: A complete acute abdomen assessement includes a pelvic/rectal exam
What is a basic work-up of acute abdomen?
- Urinalysis
- CBC
- Includes a WBC and a hemoglobin/hemocrit
- Amylase, lipase
- Pregnancy test
- Liver test
- EKG
- Chest x-ray
- Abdominal x-ray
What’s included in a complex work-up of acute abdomen?
- Computed tomography
- ultrasound
- Angiography
- Barium Enema
- Contrast in rectum to see colon
- Endoscopy
- Laparoscopy, especially in women
- Done when we are not sure what is going on but we know it’s something serious
Appendicitis
- History: Periumbilical pain migrating to RLQ; anorexia
- Exam: tenderness in RLQ and on rectal or pelvic
- Rovsing’s sign, Psoas sign, obturator sign
- Ultrasound useful in women
- CT in equivocal cases
- Laparoscopy
- Appendix comes off where the 3 tenia colace
Small Bowel Obstruction
- History of previous abdominal operation
- Triad of diagnostic symptoms
- Cramping abdominal pain
- Vomiting
- Obstipation
-
Usually abdomen is symmetrically distended
- If colon, is obstructed, it will be lopsided because it is located on the side
- Quartet of physical findings
- Distention
- Early: no tenderness
- Late: Tenderness and guarding
- Borborygmi (growling bowel sounds)
What are the radiographic findings of a small bowel obstruction?
- Air-fluid levels in dilated loops of small bowel
- Paucity/absence of air in colon/ rectum
What are the most common causes of a small bowel obstruction?
Post-surgical adhesions
- Most common in a person who has had a hysterectomy
Large Bowel Obstruction
- Better tolerated than small bowel obstuction
- Less fluid and electrolyte disturbance
- Abdomen asymmetrically distended
- Sudden onset of abdominal distention
Causes of large bowel obstruction
- Extrinsic: Volvulus (#2), hernia
- Intrinsic: Cancer (#1)
- Inflammatory: Ulcreative colitis, diverticulitis, radiation, ischemic structure
- Congenital: Imperforate anus
- Intraluminal: Meconium ileus, intussusception, impaction
- Adynamic: Ogilvie’s-electrolyte abnormal, post-op, opoids, intra-abdominal infection, anticholinergics Hirchsprung’s
NOTE: Adhesions almost never cause obstruction of the colon, because the colon is too powerful to give time for adhesions to obstruct
Volvulus
- Twisting of a loop of bowel
NOTE: A sigmoid volvulus is the most common because the sigmoid is redundant and floppy and has a long mesentery
Perforated Peptic Ulcer
- History: Peptic ulcer disease, NSAIDS, steroids, critically ill
- @ stomach and 1st part of duodenum
- Exam: Generalized peritonitis
- Free air seen on plain radiographs or CT
How is a perforated duodenal ulcer treated?
- Antibiotics
- Tie greater omentum over perforation, suture like a patch
- Do not close hole
NOTE: Patient will be extremely sick ICU afterwards
Acute diverticulitis
- History: LLQ pain, fever, constipation, diarrhea
- Exam: LLQ tenderness, mass
- Labortatory tests
- Pyuria, WBC elevated
- CT- up to 93% sensitivity
What is the gold standard used to diagnose acute diverticulitis?
CT scan of the abdomen and pelvis
- If a diverticulitis is associated with an abscess you will see puss in the pelvis
Tx for acute diverticulitis
- Antibiotics
- Surgery is not a great situation. Nothing looks normal due to inflammation
Pancreatitis
- History: alcohol, gallstones, epigastric pain radiating to the back
- Exam: Generalized upper abdominal tenderness, most marked in epigastrium
- Increased amylase and lipase levels
How is acute pancreatitis diagnosed?
- With murphy’s sign at RUQ
- Use ultrasound for confirming acute pancreatitis
- In CT, pancreas will appear light
Cholecystitis
- History: Crampt epigastric and RUQ pain, fatty food intolerance
- Exam: RUQ tenderness, +Murphy’s sign, jaundice
- US- thickened GB wall, pericholecystic fluid
NOTE: If jaundice is present, there is a stone in the common bile duct
What is the diagnostic procedure of choice for acute cholecystitis?
Ultrasound
- Fluid around gallbladder
- Acoustic shadow from gall stones
Cholecystectomy
- Laparoscopic
- Does NOT require emergency operation
- Urgent operation is what is done- 24-48 hrs
- Make sure they are hydrated
Common Causes of Acute Abdomen
Appendicitis
Diverticulitis
Cholecystitis
Pancreatitis
Bowel obstruction
- Small Bowel Obstruction
- Large Bowel Obstruction
- Colorectal cancer
- Colonic Volvulus
Perforated viscus
IBD
Ectopic pregnancy
PID/TOA
Gastroenteritis
Mesenteric ischemia
Nephrolithiasis
Additional Causes of Acute Abdomen
Cholangitis
Pneumonia
Acute MI
Ovarian torsion/cyst
Hepatitis
Sickle cell disease
Ureterolithiasis
IBD: Crohn Disease
Gastroenteritis
Diabetic ketoacidosis
Uremia
Porphyria
Intussusception
Lupus
HIV intestinal disease
Mesenteric ischemia/ Infarction
