Surgical Abdomen

Question 1

the surgical abdomen

Answer 1

• Patients with an acute/surgical abdomen are sick
• Surgical/Acute abdomen vs Medical abdomen
• “The Story” of each entity is key – drives your DDx
• Orders: IV NS 1L bolus, pain meds/antiemetic, belly labs, lactic acid, EKG if tachy/risk, CXR; specials
• Dynamic process - serial exams – documentation
• Keep anyone going to surgery NPO
• It is more important to know this abdomen needs a surgeon than to know the exact diagnosis

Question 2

ddx of acute abdomen

Answer 2

• Sudden/rapid onset and escalation
  
  • Vascular - hemorrhage, ischemia
  • Perforation - hollow viscous, ulcer/tumor erosion
  • Rupture - appy, ectopic pregnancy, ovarian etiology
  • Obstruction - bowel, gallbladder, ureter
  • Trauma
• Slower onset
  
  • Infection
  • Inflammation
  • Abscess

Question 3

approach/history of acute abdomen

Answer 3

• Observation: what do they look like, what are they doing?
• Been sick lately? Recent trauma?
• Last food/fluid intake? Are you hungry now?
• Hx surgery, hospitalization, recent procedure?
• PMH: GI, DM, atherosclerosis, cardiac, renal, CA, Sickle Cell, HIV
• Meds that matter
  
  • Steroids, coumadin, NSAID’s, Pepto Bismal, anticholenergics, CAM, current/recent antibiotics
• Family Hx: CAD, abdominal issues
• Habits that matter - ETOH, stimulants, IVDU
• Ever had this before??

Question 4

approach/physical exam

Answer 4

• Don’t focus only on the abdomen!
  
  • Skin, lungs, heart, CVAT, Gyn/GU, rectal
  • Watch them walk if possible
• The Abdomen: Goal = peritoneal or not?
  
  • One finger – point to where it hurts
  • Look at it. Then listen: Bowel sounds? Quality?
  • Percuss - organs, tympany, ascites, bladder
  • Palpation – Soft or hard? Flat or distended?
    
    • Do all the special moves on first pass
  • Guarding?
    
    • Involuntary = muscles rigid, hard = peritoneal
    • Voluntary = abd is soft, but pt resists touch

Question 5

Peritoneal signs

Answer 5

• Patients with peritoneal irritation lie still - movement is painful, involuntary guarding, abdomen is firm
• Heel tap
  
  • Tap soles of feet = abdominal pain
• “Sorry, I bumped the bed” sign
  
  • Unexpected movement = abdominal pain
• Jump up and down sign
  
  • Kids who do are not peritoneal

Question 6

specific signs

Answer 6

• Rebound - peritoneal
  
  • Pain increases as let go during deep palpation
• Psoas sign – peritoneal
  
  • Resisted hyperflexion or hyperextension @ hip
• Obturator – peritoneal
  
  • RLQ pain on flexion, internal rotation of R hip
• Rovsing’s sign - appy
  
  • Palpation of LLQ illicits tenderness in RLQ
• McBurney’s point - Midpoint of right iliac crest and symphysis pubis – appy house
• Murphy’s sign
  
  • Stops inhalation with GB palpation
• Grey-Turner’s signà
  
  • Flank ecchymoses - retroperitoneal bleeding
• Cullen’s signà
  
  • Umbilical ecchymoses - retroperitoneal bleeding
• Grey-Turner or Cullen’s – think hemorrhagic pancreatitis or ruptured AAA

Question 7

“oh my God” signs: big red flags

Answer 7

• Significant abdominal pain and:
  
  • Pulsatile abdominal mass
  • Pale, diaphoretic, hypotension
  • Febrile, rigors, hypotension
  • Pregnant with hypotension
  • Mottled skin, pettechiae, abd ecchymosis
  • Elderly - pain out of proportion to exam
    
    • Think mesenteric ischemia
  • Stimulants w/ abdominal pain
    
    • Think mesenteric ischemia

Question 8

Hemorrhage

Answer 8

• All look sick, are sick:
  
  • Abd pain, hypotension, tachy, pale, syncope
  • Stabilize: 2 IV’s, O2, monitor, EKG, labs, upreg
  • Bedside ULS, CT (when stable), consultant
• AAA – Abdominal Aortic Aneurysm
  
  • Leaking or dissecting – “tearing” pain, unstable
  • Risks: older, atherosclerosis, HTN, DM, connective tissue dz, Marfan’s, smoking, family hx
  • Flank, groin, hip, new atraumatic back pain
  • US, CT w/ IV contrast - <5cm dia lower risk rupture
• Ruptured ectopic pregnancy
• Delayed hemorrhage after trauma
• Massive GI bleeds, hemorrhagic pancreatitis, eroding tumors, massive bleeding in pregnancy

Question 9

Ischemia: testicular torsion, ovarian torsion, strangulated hernia, ischemia colitis

Answer 9

• Testicular torsion – Urologist
  
  • Testicle pain, abd/flank pain (referred)
  • Doppler ULS
• Ovarian torsion - OB/Gyn
  
  • In DDx for all female pelvic pain
  • Risk: ovarian cyst hx, polycystic dz
  • Formal ULS for flow, upreg
• Strangulated hernia - General Surgeon
  
  • Can’t reduce, hot, red, fever; WBC’s, lactate up
• Ischemic colitis - General Surgeon
  
  • Not common; Hx Crohn’s, ulcerative colitis
  • Fever, WBC’s/lactate up, +/- peritoneal; CT for dx

Question 10

mesenteric ischemia

Answer 10

• Not common but bad - 70% mortality. Elderly!
• Decreased flow in celiacs, SMA or IMA
• Arterial/venous thrombosis, embolism or spasm
• Pain out of proportion to exam – severe tenderness but soft abd, non-peritoneal
• N/V/D, bloody BM, hx pain after eating
• Risk factors
  
  • Afib, CAD, recent MI, HTN, DM, Cirrhosis
  • Cocaine/Meth in younger pt’s
• High index of suspicion required: tough Dx
  
  • Metabolic acidosis, high WBC’s, lactic acid, amylase; hypotension, tachycardia
  • CT angiography for dx
  • IV fluids, antibiotics, surgical consult
  • Time to surgery predictor of survival
• “Mesenteric angina” – pain after eating from atherosclerosis and decreased flow in small bowel vessels

Question 11

the elderly

Answer 11

• Frequently missed Dx’s in the elderly:
  
  • Mesenteric Ischemia
  • AAA
  • Appendicitis
  • Acute Cholecystitis
  • Perforated Peptic Ulcer
• The elderly are so tricky!
  
  • >60yo + Abd Pain = High Risk patient! Hx/PE/Chart/DDx – you considered
  • Elderly delay care, Hx difficult, atypical Hx/PE, no fever, subtle VS changes, comorbidities, etc, etc…
  • 20-40% of elderly w/ abdominal pain will require surgery!

Question 12

small bowel obstruction

Answer 12

• The Story - significant hx common
  
  • Intermittent, crampy, periumbilical
  • Rapid, not sudden onset - hours
  • Vomiting – bilious, “feculent” (late)
  • No BM - not passing gas - obstipation
  • Distention, diffusely tender, “tinkling” bowel sounds
  • Dehydration, low grade temp, tachy/tachy, +/- hypotension
• High WBC, a high lactate is worrisome
• High suspicion: plain abdominal series
• CT AP IV con, abx, NG, surgery consult

Question 13

bowel obstruction

Answer 13

• Biggest risks: Hx abd surgery, hx same
• Mechanical
  
  • Obstruction, compression, rotation
  • Usually needs surgical intervention
• Functional
  
  • Ileus - adynamic/paralytic; bowel stops functioning due to infection, irritation, inflammation à
  • Search for the cause and fix it
  • Distention both large/small bowel
    
    • “Sentinal Loop”à
  • Not a surgical emergency, but consult them
  • Tx conservative, NG, Surg admit, observe

Question 14

large bowel obstruction

Answer 14

• The Story
  
  • Older, significant Hx, slower onset, +/- severe
  • Low, mid-abdominal crampy pain
  • Vomiting less common than SBO
  • No BM, not passing gas (check for impaction)
  • Distended, tachy/tachy, guaiac +/-
  • Fever, toxic, WBC’s or high lactate = worrisome for necrosis
  • Plain film if suspect it, dilated loops lg bowel
  • CT abd/pelvis with IV contrast for dx
  • Abx, surgery consult, admit
• Common causes and Risk Factors
  
  • Neoplasm most common cause (~60%)
  • Diverticulitis (abscess, stricture)
  • Volvulus
  • Ulcerative colitis, ischemic colitis
  • Pseudo-obstruction (Ogilvie’s Syndrome)
    
    • Distended large bowel but not obstructed
    • Think tricyclics, anticholenergic agents
  • Fecal impaction - manual dis-impaction

Question 15

LBO - Volvulous

Answer 15

• The Story
  
  • Elderly, bedridden, psych, anticholinergics
  • Same presentation as LBO
  • Sigmoid (most common), cecal
  • Loop rotates, twists off, dilation
  • Abd distention, tympanic abdomen, pain
  • +/- fever, tachy, WBC’s, lactate up
  • Will get necrotic, then gangrenous: then septic
  • Plain film initially if suspect it – fast/easy
  • CT AP IV contrast for dx and for location
  • Antibiotics, surgical consult

Question 16

Perf - Pneumoperitoneum

Answer 16

• The Story:
  
  • Perforated viscous: air, bowel contents escape – air rises, see it under diaphragm
  • Rapid onset, constant, epigastric then generalized pain
  • Vomiting; fever 50%; tachy/tachy
  • Look ill first - then peritoneal - then shock
  • Risks: ulcer, gastritis, ETOH, colitis, ‘tics, recent procedure/surgery, abd cancer (erosion), steroids, NSAIDS
• Dx: CXR (first), then CT abd/pelvis
• Antibiotics, NG tube, surgical consult, admit
• Elderly – Hx PUD/gastritis, NSAIDS, steroids. CXR negative in 50%! Get CT

Question 17

Choecystitis

Answer 17

• The Story
  
  • The 4 “F’s, +/- Hx of stones
  • Sudden, RUQ/epigastric pain
  • N/V, fever; WBC’s, Murphy’s sign
  • LFT’s? Lipase? Location of obstruction, severity
  • Biliary colic = passing a stone
  • Cholecystitis: inflam/infection. Gangrene, emphysematous - bad
  • IV, pain control, antiemetics, NPO
  • RUQ ULS for Dx – thickened wall, pericholecystic fluid, US Murphy’s
  • CT is NOT best initial test
  • Antibiotics early, surgery consult

Question 18

types/location biliary tract dz

Answer 18

• Choledocolithiasis
  
  • CBD stone/obstruction: elevated LFT’s, Tbili, alk phos
    
    • Lipase usually normal until late
  • ERCP or MRCP to investigate/tx
• Gallstone pancreatitis
  
  • Stone at Ampulla of Vater, pancreatic duct
  • Cholecystitis Sx’s + elevated LFT’s and lipase
  • Cholecystectomy, ERCP
  • Gallstones are the most common cause of pancreatitis
• Acalculous cholecystitis
  
  • No stone seen, severe symptoms, ULS w/ inflammation, lactate up, LFT’s/lipase up
  • Elderly, DM, post trauma, vasculitis
• Surgery consult for all, admit

Question 19

cholangitis

Answer 19

• Rare, but bad. Suspect it if: abd pain, fever + jaundice
• Obstruction, dilation and infection of biliary tree
• Older, hx gallstones. Also biliary stricture, malignancy
• Life threatening - sick, sick, sick!
• Charcot’s Triad
  
  • RUQ pain, fever, jaundice
• Reynold’s Pentad
  
  • RUQ pain, fever, jaundice
  • Plus - shock, altered mental status
• WBC’s, LFT’s, lipase, lactic acid - all up. Sepsis common
• ULS first. Then CT. Antibiotics, surgical admit

Question 20

diverticulitis

Answer 20

• The Story
  
  • Diverticulosis - present, inflamed
  • Diverticulitis - infected
  • Middle age, older, often Hx same
  • Gradual onset, diarrhea, fever; WBC’s, lactate up
  • Lower abd pain; LLQ common
  • CT abd/pelvis IV/oral contrast; rectal contrast?
  • Antibiotics, surgical consult, admit.
  • If abscess: sick

Question 21

appendicitis

Answer 21

• Most common cause of the acute abd
• “Classic” Story (25-30% not “classic”)
  
  • Young adult, >6 but <48hrs of pain
  • Epigastric/periumbilical, “moves” to RLQ. Visceralàparietal pain
  • Vomiting after pain onset, nausea, anorexia, not hungry now
  • RLQ tender at McBurney’s point
  • RLQ +/- tender on rectal exam
  • Low grade temp, WBC 13-16k common
  • ULS, CT abd/pelvis w/ IV contrast
  • NPO, surgical consult early
• Visceral pain: Stretching of hollow viscus or capsule of an organ. Poorly localized, generalized pain. Preceeds Parietal pain. Due to local nerve fibers enter the spinal cord at multiple levels.
• Parietal (aka Somatic pain): Pain is now localized as nerve fibers innervating the parietal peritoneum are irritated. Touch = pain. Peritonitis, guarding
• In DDx for ALL patients w/ abdominal pain; especially RLQ or unilateral abdominal pain
• Tricky presentations: location of appy in relation to cecum
  
  • Retrocecal (flank/genital pain), pelvic (rectal/pelvic pain: less abd pain), left lower quad, umbilical
• No reliable risk factors; 15% diarrhea; hx same pain possible
• AGE (acute gastroenteritis) most common wrong Dx! Also PID, kidney stone, UTI, etc.
• Fever not common unless late/abscess/perf
• Positive psoas, obturator, rebound, Rovsings: ONLY if peritoneal irritation – late signs, usually perf’ed or abscess
• Pain meds good - re-eval frequently
• Serial exams, observation, repeat VS: best tools

Question 22

appendicitis - alvarado score

Answer 22

• Predicts likelihood of appy - Surgery tool
• “MANTRELS”
  
  • Temp >99.2
  • WBC >10k
  • Neut >75%
• <5 unlikely, 5-6 possible, 7-8 prob, >9 very prob
• May admit Alvarado 5-6 for observation

Question 23

special appendicitis

Answer 23

• Kids
  
  • Delay presentation, vague hx, tough if youngster (AGE?)
  • High perf rate: >65% if present 36hrs after sx onset
  • US/CT may be negative: not 100% reliable!
• Elderly (>60yrs)
  
  • Only 5-10% cases but >50% deaths (perf, sepsis, post-op comps)
  • No RLQ pain in 25%, no migration of pain in 50%!
  • UTI, kidney stone, AGE all common misdiagnoses
• Pregnant
  
  • 1st tri – RLQ pain; 3rd tri - RUQ, flank pain – uterus “moves” appy
  • Sx’s appy are common in preg: n/v, anorexia, WBC’s up (not >18k)
  • If perf – high risk for fetal demise
  • CT abdomen/pelvis ok but not preferred. MRI if possible

Question 24

abdominal/inguinal hernia

Answer 24

• Sites: ventral, umbilical, inguinal (indirect/direct), femoral, spigelian, incisional
• Check for hernia in everyone with abdominal pain
• Reducible: can push it back in = low risk
• Incarcerated: hurts, can’t reduce = high risk
• Strangulated: no blood supply, dead bowel
  
  • Tender, red, hot
  • Fever, tachy, maybe vomiting
  • Necrosis, gangrene, sepsis
• IV, belly labs, lactic acid, antibiotics, CT IV contrast
• Surgery if incarcerated or strangulated

Question 25

abdominal abscess

Answer 25

* Abdominal wall: DM, skin pop: MRSA * Intra-abdominal: liver, pancreas, diverticuli, colon, psoas, post-surg, etc... * Insidious onset, localized pain when present, wall cellulitis * Fever, vomiting, tachy; shock? Uh oh... * Labs may not point to cause of pain * CT abd/plevis – the “mystery patient” * If they look sick, are sick * Antibiotics, NPO, surgical consult for all intra-abdominal abscess and deep/large abdominal wall abscess

Question 26

abscess in women

Answer 26

* Mastitis * Cellulitis vs abscess * Breast feeding, blocked milk duct, cracked skin * Swelling, warm, pain, fever: US for abscess * Staph aureus, MRSA, strep, e.coli, etc * Abx, express milk, ok to feed, NSAIDs * Recurrent? Think breast cancer * Bartholin Cyst Abscess * Fluctuant mass just inside labia minora * Gland gets plugged, tx for GC/Chlamydia * Needs I&D – Word catheterà * No home antibiotics unless cellulitis * Recurrent gets marsupialization by GYN

Question 27

on the ddx for all women with lower abdominal pain

Answer 27

* Tubo-Ovarian Abscess (pyosalpinx) * Late progression/complication of PID * Low abd pain, n/v, fever, +CMT * Hypotensive? Sepsis if ruptures * CT better than US for Dx * IV, Abx, Gyn consult, admit * Ovarian torsion * Ovary twists, ischemic (16-24hr viability) * Sudden unilateral pain, n/v, usually afebrile * Hx same, ovarian cysts, pregnancy = risks * Endovaginal US w/ doppler for flow, cysts * Gyn consult, admit * Ruptured Ovarian Cyst (Dx of exclusion) * Sudden unilateral pain, +/- n/v * Otherwise well appearing, normal labs, VS * Transabd US for fluid, endovag US for DDx * Home if stable, improving

Question 28

1st trimester with abdominal pain, vaginal bleeding

Answer 28

* Threatened miscarriage * Internal cervical os: closed * Pt stable, mild/moderate pain * EVUS: \>5wks - gestational sac with fetal cardiac activity * Home w/ OB/Gyn f/u if stable * Complete miscarriage * Internal cervical os: closed. * May have passed POC’s. * +/- Abdominal pain. No clear gestational sac/fetal cardiac activity on EVUS, “empty uterus” * Inevitable miscarriage (miscarriage in progress) * Internal cervical os: open. Possible POC in os. * Abdominal pain. Declining b-hCG (if known) * EVUS w/ retained POC’s * Incomplete miscarriage * Os may open or closed. * May have passed partial POC’s or going to pass * Retained POC’s on EVUS but no fetal cardiac activity * Missed abortion (fetal death \<20wks) * Os closed * +/- abd pain, no passage of POC’s * No fetal cardiac activity on EVUS * Septic abortion * Os open or closed * Abd pain, fever, + CMT, foul smelling d/c, may be peritoneal * EVUS: thickened, irregular endometrium, no clear sac * OB/Gyn consult all (except Threatened). Tx = D&C (dilation and curettage) * Type/Screen – RhoGAM * EVUS: Endovaginal Ultrasound * POC: Products of Conception * CMT: Cervical Motion Tenderness

Question 29

foreign bodies

Answer 29

* Ingested * Body packers * Go-Lytely if stable, not obstructed * Bezoars * Psych patients * Plain KUB, CT if need surgery to remove * Rectal foreign bodies * Sexual misadventures * Remove w/ sedation, get KUB, CXR for perf

Question 30

Final points on abdominal pain

Answer 30

* Keep an open mind for atypical presentations in everyone – especially the elderly * Beware of diagnostic bias and anchoring! * AGE must have both vomiting and diarrhea; low-ish WBC’s * PID pain is usually bilateral, appy is unilateral * Blood in urine does not equal kidney stone * Female, sick, low abd pain? Think TOA and torsion * Think twice if Dx: Constipation, GERD, AGE!! * Careful discharge documentation, include red flags for pt, secure follow-up 6-24hrs, phone f/u is good * Exact diagnosis often surgical – ED determines if this abdomen needs a surgeon now