Tieman DSA- acute abdomen Flashcards
Sir Zachary Cope
Sir Vincent Zachary Cope MD MS FRCS (14 February 1881 – 28 December 1974) was an English physician and surgeon perhaps best known for authoring the book Cope’s Early Diagnosis of the Acute Abdomen from 1921 until 1971. New editions continue being published by editors long after his death, the most recent one being the 22nd edition, published in 2010.
MAKING THE DIAGNOSIS
Directed History
Physical Examination
Suspected Diagnosis / Severity
Labs / X-rays / Tests are Confirmatory,
You must think of the diagnosis
Initiate therapy / Elevate level of careAcute Abdomen—HISTORY
Pain (location, character, and change) Nausea, Anorexia Emesis (bilious, clear, feculent, coffee grounds) Flatus, Diarrhea, Melena Prior Surgery Trauma, Recent changes in Diet Weight loss Alcohol, Drugs, Medications Menstrual cycle, Family history
Acute Abdomen—PE
Sick or Well, Diaphoretic, pale, lethargic
Vital signs, Tachycardia, hypotension, fever
HEENT, Heart, Lungs
Abdomen- location of pain + tenderness
Guarding, Rigidity, Distention, Bowel sounds
Percussion and palpation tenderness
Referred pain, rebound, signs
Rectal Exam
? Pain out of proportion to physical exam?
Auscultation - quiet, rushes, pitch of bowel sounds
ORIGINS OF THE GI TRACT
Foregut:
Esophagus, Stomach, Duodenum, Liver, Gallbladder, Pancreas, Spleen
Midgut:
Jejunum, Ileum, Right Colon, Appendix, to mid-transverse Colon
Hindgut:
Mid-transverse Colon, Descending Colon, Sigmoid Colon, Rectum, Anus
Early Pain
Primarily visceral afferent pain fibers which respond to distension, increased pressure or ischemia. Not specific in location.
Foregut—Epigastrium
Midgut—Periumbilical
Hindgut—Suprapubic
Later pain
Peritoneal inflammation, conducted by somatic pain fibers. More specific in location
Localized vs. Generalized Peritonitis
How the GI tract gets sick
Bleeds, Obstructs, Perforates:
Infarct or Twist on blood supply Incarcerate in hernias, internal and external Become Infected Rupture / Perforate Grow tumors, benign and malignant Strictures, Obstructs
Foregut
Stomach Ulcers Duodenal Ulcers Gallstone Hepatitis, Liver Pancreatitis Spleen Infarcts
Perforated Ulcer Stomach or Duodenum
Sudden onset of epigastric pain,
Pain spread to entire abdomen
Patient lies very still, avoids motion
Sick, tachypnic, tachycardic
Tender “boardlike” abdomen, decr. BS
75% have free air on Upright CXR,virtually all can be seen on a good CT.
Inc. Amylase lipase possible, WBC Corticosteroids and immunosuppression Mask
Roux-en-Y Gastric Bypass
Most frequently performed bariatric procedure in the US
First done in 1967
Some technical modifications since (stomach is cut)
Laparoscopically since 1993
Stones
Cholelithiasis infected Cholecystitis
Choledocholithiasis-Suppurative cholangitis
Gallstone Ileus –perforation into surrounding organ
Necrotic perforated GB with abscess
Gallstone Pancreatitis
Acute Cholecystitis
Usually have Hx of Biliary Colic
Pain in RUQ, Epigastric, radiates to right scapula/shoulder
Dull, constant pain, Nausea, Emesis
BS decr. Tender RUQ, +/- mass, worse with deep inspiration (Murphy’s sign)
WBC, Bilirubin, LFT’s
US better than CT - thick wall, edema, stones, Rare but possible with no stones
Suppurative Cholangitis
Pus in CBD—usually from partially obstructing stone
Septic,Jaundice,Confused,Febile,Tachy
Charcot’s triad
Reynold’s pentad
Any or all could be missing
Powerful Antibiotcs
Urgent CBD drainage usually with ERCP
Acute Pancreatitis
Sudden onset, severe epigastric pain radiates direct to back, intolerable
Patient struggles to find comfortable position
Usually sitting up and leaning forward
Anorexia, Nausea, Vomiting
Epigastric tenderness, decreased BS
WBC inc, Amylase/ lipase incr..
CT shows inflammation of Pancreas
Acute Small Bowel Obstruction
Sharp colicky pain, periumbilical, episodic
Abdominal distention, usually non-tender
Nausea, Vomiting (bilious), > yellow brown >feculent
No flatus, BS high pitched, rushes
Kub/Upr/CXR Air fluid level, no gas in colon,now CT
Adhesions,Hernia,Mass,Volvulous
Acute Appendicitis
Pain in mid-abdomen, peri-umbilical migrates to RLQ in 6-8 hrs
Anorexia, nausea, vomiting
BS decr., guarding, percussion tenderness, Rovsing’s sign, Psoas sign, Obturator sign
labs may be normal or WBC incr, left shift
Gyn problems mimic appendicitis—always think gyn in female patients with RLQ pain
CT helpful (rectal contrast) (after pregnancy test)
Diagnostic laparoscopy / appendectomy
difficulty of the dx of appendix
Appendicitis is the most difficult diagnosis to make on a patient that is already an inpatient.
Appendicitis is difficult to diagnosis in the very old and the very young, and delayed diagnosis has severe complications.
The two diagnoses that you will miss are the one you don’t know about, and the one that you don’t think about.
Meckel’s Diverticulum
Rule of 2’s, Gastric and Pancreatic tissue
Persistence of vitelline duct on anti-mesenteric border of distal ileum
Bleeding, intestinal obstruction, diverticulitis
Similar to Appendicitis
Pelvic Inflammatory Disease and Ectopic Pregnancy
RLQ pain/ Pelvic pain, often just after menses complete for PID, late or atypical menses for Ectopic Pregnancy
Rarely have Anorexia, Nausea, Vomiting
Vaginal discharge, bleeding or cervical motion tenderness
Adnexal masses—TOA or ectopic
Remember to get serum pregnancy test
Acute Gynecologic Dz
Salpingitis
- usually gonococcal, periumbilical pain - RLQ, and LLQ, Vaginal discharge and CMT
Ovarian Cysts
- Sudden lower abdomen R or L, ruptured cysts may present similar to appendicitis
Ectopic Pregnancy
- Sudden lower abdominal pain, rupture of fallopian tube, +BHCG, vaginal bleeding
Renal Calculi
Severe sudden, colicky abdominal pain, flank, upper abdomen, subsides and recurs
Radiates to groin, testicle, perineum as stone descends
RBC, WBC in urine
X-RAY, IVP
Acute Diverticulitis
Initially lower abdominal pain, localizing to the LLQ
Fever, chills
Guarding LLQ, tender to palpation, mass
WBC
CT scan diagnostic plus to find complications of diverticulitis
Colonic Obstruction
Carcinoma, Volvulus, Diverticulitis
Abdominal distention, gradual onset
No flatus
X-ray dilated colon to point of obstruction
Volvulus has sudden onset of pain, characteristic X-rays
Gastrograffin enema, or endoscopy
Summary
History and Physical are essential to making the correct diagnosis
Pain location and character indicate the area of the GI tract involved—think anatomically
Use radiology and lab to confirm diagnosis, don’t rely on them to make the diagnosis
