The Acute Abdomen Flashcards
What is the acute abdomen?
Sudden onset of severe abdominal pain of less than 24 hours duration
What are some examples of presentations that require urgent surgery?
-
Bleeding
e. g. AAA rupture, ruptured ectopic pregnancy, bleeding ulcer & trauma - Perforated viscus
- Ischaemic bowel
What is the most serious cause of intra-abd bleeding?
Ruptured abdominal aortic aneurysm
How does intra-abdominal bleeding present clinically?
Hypovolemic shock:
- Tachycardia and hypotension
- “Thready” pulse
- Pale and clammy on inspection
- Cool to touch
What is peritonitis & what most commonly causes it?
Inflammation of the peritoneum
General peritonitis is most commonly caused by perforation of an abdominal viscus.
Give some causes of vicsus perforation.
- Peptic ulceration
- Small / large bowel obstruction
- Diverticular disease
- Inflammatory bowel disease.
What features do patients with peritonitis present with?
- Patients often lay completely still, trying not to move their abdomen
- Important in comparison to renal colic patients who constantly move & can’t get comfortable.
- Tachycardia and potential hypotension
- Completely rigid abdomen w/ percussion tenderness
- Involuntary guarding
- Reduced / absent bowel sounds
- Suggests paralytic ileus
What is guarding?
Patient involuntarily tenses their abdominal muscles when you palpate the abdomen
A patient presents with severe pain out of proportion to any of their clinical signs, what is the most likely diagnosis?
Ischaemic bowel until proven otherwise.
Give the:
- Clinical symptoms/signs
- Investigations
- Management
of ischaemic bowel
- Diffuse & constant pain w/ typically unremarkable examination
- CT scan with IV contrast
- Early surgical involvement
What are some less acute presentations seen in the surgical unit?
- Colic
- Peritonism
What is colic? & when is it seen?
Abdominal pain that crescendos, becoming very severe and then goes away completely
Most typically seen in ureteric obstruction / bowel obstruction.
Why is biliary colic not a true colic
Pain does not go away completely, instead periodically improves and worsens (colloquially termed ‘waxes and wanes’).
What is peritonism? & how does it typically present?
Localised inflammation of the peritoneum due to inflammation of a viscus that irritates the visceral and subsequently, parietal peritoneum.
Pain starts in one place due before localising to another area / becoming generalised. Due to irritation of the visceral peritoneum initially, followed by irritation of the parietal peritoneum (e.g. migratory pain in acute appendicitis)
What are your differentials when approaching an acute adomen?
Give vascular causes of abdo pain
Vascular
- AAA rupture
- Mesenteric ischaemia
- MI
Give examples of infective causes of abd pain
Infective
- Gastroenteritis
- Appendicitis
- Diverticulitis
- Pyelonephritis
- Cholecystitis
- PID
- Pneumonia
Give examples of inflammatory causes of abdo pain
Inflammatory
- Pancreatitis
- Peptic ulcer disease
Give examples of traumatic causes of abd pain.
Trauma
- Ruptured spleen
- Perforated viscus (oesophagus, stomach, bowel)
Give metabolic causes of abd pain
Metabolic
- Renal/ureteric stone
- DKA
How do you take a history from a patient presenting with an acute abdomen?
- Presenting complaint
- SOCRATES/SQITAR
- Associated symptoms (e.g. fever, chills, N&V)
- Timing & nature of last bowel habit
- PMHx (Surgical & Medical)
- Ask specifically about HT, DM, Heart, Blood clot, Asthma
- Personal Hx
- Smoking & Alcohol Hx
- Sexual history
- Menstrual history
- History of trauma
- Medication Hx
- Allergies
- Family Hx
- Travel Hx
- Occupational Hx
- Social Hx
- Type & timing of oral intake
- Anything else?
How would you examine a patient presenting with abdo pain?
- Abdominal exam (inc. auscultation of chest)
- DRE
- Pelvic exam (For women w/ lower abdo pain)
- Testicular / Scrotal exam
What lab investigations are indicated w/ presentation of an acute abdo?
- Pregnancy test for all women of reproductive age.
-
Urine dipstick +/- MC&S
* To look for sign of infection or haematuria ± MC&S. -
ABG
* In bleeding / septic patients to assess pH, pO2, pCO2, and lactate for signs of tissue hypoperfusion, as well as a rapid haemoglobin. - Routine bloods
- FBC, U&Es, LFTs, CRP, Amylase
- Serum calcium
- In suspected pancreatitis.
- Group & save (G&S)
- If patient is likely to need surgery soon
-
Blood cultures
* If considering infection as a potential diagnosis
What imaging is indicated for patients presenting with abdo pain
-
ECG
* To exclude myocardial infarction. - USS:
-
Kidneys, ureters and bladder (KUB)
- For suspected renal tract pathology
-
Biliary tree / liver
- For suspected gallstone disease
-
Ovaries, fallopian tubes and uterus
- For suspected tubo-ovarian pathology
-
Erect chest X-ray (eCXR)
* Presence of free air under diaphragm is diagnostic of perforated viscus - CT imaging (discussed with a senior)
What sign is seen here?
Free air under the peritoneum (pneumoperitoneum), which is a sign of perforated viscus.
What is the management of the acute abdomen
- Admission
- IV access
- NBM
- Analgesia +/- antiemetics
- Imaging
- VTE prophylaxis
- Urine dip
- Bloods
- Consider a urinary catheter and/or nasogastric tube if necessary
- IV fluids & fluid balance monitoring
