Postoperative abdominal pain Flashcards
What are the three categories of causes of postoperative abdominal pain?
Disruption of normal healing, infection, or other benign physiologic processes.
What is the first step in evaluating a patient with postoperative abdominal pain?
Perform ABCDE assessment to determine if the patient is stable or unstable.
What are examples of conditions causing instability in postoperative abdominal pain?
Acute abdomen (free air or diffuse fluid spillage), vascular rupture (e.g., ruptured abdominal aortic aneurysm), necrotizing fasciitis.
What are some clinical signs of acute abdomen requiring immediate intervention?
Severely distended and rigid abdomen, diffuse tenderness, rebound pain and guarding, tachycardia, tachypnea.
What are some signs of a ruptured abdominal aortic aneurysm?
A high index of suspicion is critical in postoperative patients presenting with hypotension and abdominal pain, especially if there is a history of vascular disease or prior AAA repair.
Following a stressful surgery like abdominal aortic repair, what cardiovascular condition could result in epigastric pain?
myocardial infarction
Twenty-four hours after undergoing surgical repair of an abdominal aortic aneurysm, a 77-year-old man has the onset of mild confusion. His urine output has been 10 ml/h over the past 3 hours. He is diaphoretic. He is oriented to person but not to place or time. His temperature is 38.2°C (100.8°F), pulse is 110/min, respirations are 20/min, and blood pressure is 80/60 mm Hg. The upper and lower extremities are cold and clammy. Pulmonary artery catheterization shows a pulmonary capillary wedge pressure of 23 mm Hg (N=5-16). What is the most likely explanation for these findings?
Postoperative myocardial infarction is a complication that can occur following physiologically stressful surgical procedures, especially those with high blood loss in patients already predisposed to myocardial infarction (e.g., older, male smokers with history of atherosclerotic cardiovascular disease). Myocardial infarction can present nonspecifically but classically occurs with shortness of breath, chest pain, lightheadedness, nausea, vomiting, or altered mental status, and may be complicated by cardiogenic shock, seen as tachycardia, hypotension, and impaired end-organ perfusion (cool extremities, low urine output). In postoperative cases, especially with intubated patients, it may be difficult to assess the presence of myocardial infarction. Evaluation using ECG, serial troponin assays, and echocardiogram should be considered in such cases. Right-heart catheterization can be used to determine cardiac output and index, along with pulmonary capillary wedge pressure, which can distinguish right heart failure from left heart failure. An increased pulmonary capillary wedge pressure indicates that filling pressures in the left heart are abnormal, which is consistent with myocardial infarction and cardiogenic shock.
What are the clinical features of necrotizing fasciitis?
Severe pain, crepitus under the skin, and critical illness requiring surgical intervention.
What is the next step if a patient with postoperative pain is unstable?
Stabilize the airway, provide supplemental oxygen, establish IV access, start IV fluids, and monitor vitals.
What signs on physical exam suggest an acute abdomen?
Severely distended and rigid abdomen with diffuse tenderness, rebound pain, guarding, tachycardia, and tachypnea.
What is the role of exploratory laparotomy in an acute abdomen?
It is both therapeutic and diagnostic and should not be delayed. If there is a possibility to obtain imaging, get a CXR and/or a bedside ultrasound.
What imaging can help diagnose acute abdomen if time allows?
Bedside ultrasound (to check for free fluid) or upright chest x-ray (to check for free air).
Which two broad categories differentiate the types of postoperative abdominal pain?
Superficial vs Deep
What are key features of superficial postoperative abdominal pain?
Localized soreness, often pointing to one exact spot, and commonly caused by fascial dehiscence, seromas, hematomas, or surgical site infections.
What are the risk factors for fascial dehiscence?
Obesity, diabetes, immunocompromised status (e.g., steroid use).
What imaging findings suggest a mechanical obstruction or paralytic ileus?
X-ray or CT shows distended loops of bowel with air-fluid levels and no air in the colon.
When an imaging finding shows a dilated bowel with collapsed distal colon, what is the likely cause?
mechanical obstruction or paralytic ileus
What unique findings are associated with postoperative paralytic ileus?
- Normal labs
- XR shows dilated bowels with no transition point
- Air in the colon
A patient presents with pain to deep palpation near the side of surgery along with nausea, vomiting, oral intolerance, changes in bowel habit, fever and chills, what is the likely underlying issue?
Abdominal abscess.
How can you differentiate CO2 peritonitis from a surgical emergency?
CO2 peritonitis resolves over time with serial x-rays showing decreasing air; surgical emergencies worsen clinically.
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On a physical exam, you might find a soft, non-distended abdomen, and mild diffuse tenderness with clean, dry, and intact incisions. On chest x-ray, this appears as air under the diaphragm. So if you see this, it’s important to know if the patient just had laparoscopic surgery because it could be normal postoperatively. The patient will look well instead of sick, and serial chest x-rays will show the air decreasing. On the other hand, if the serial chest x-rays reveal increasing air under the diaphragm, or exam reveals a peritoneal or acute abdomen, they need to go to surgery. Keep in mind that CO2 peritonitis is a diagnosis of exclusion, so make sure you rule out all other causes first!
