Surgical Education Series The Acute Abdomen

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Surgical Education Series The Acute Abdomen
David Flum, MD MPH Assistant Professor Division
of General Surgery Department of
Surgery University of Washington
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Outline

• Definitions
• What causes an acute abdomen
• Differential Diagnosis
• History and physical
• Labs
• Diagnostic imaging
• Special emphasis
• Appendicitis
• Bowel infarction
• Perforated viscous

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Acute Abdomen

• Symptoms and signs of acute intra- abdominal
  disease processes, usually treated best by
  surgical operation

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Common Causes of Abdominal Pain
of Surgery, 16th ed.
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Acute Abdomen-Symptoms

• Symptoms linked to visceral distention or
  ischemia
• Inflammation of the peritoneum
• Parietal component provides localization
• End result of a process involving viscera
• Early diagnosis means understanding the patterns
  that lead up to peritoneal irritation

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Symptom Quality

• Timing
• Matched to clinical condition
• Emerges over time and then concentrates (acute
  appy)
• Sudden onset (perforated viscous)
• Referred pain
• Linked to anatomic distribution
• Required reading
• Copes Early diagnosis of the Acute abdomen

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History of Present Illness

• O nset
• P recipitating/ relieving
• Q uality
• R adiation
• S everity
• T iming

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Physical Examination

• Overall appearance
• Walking and recumbent
• Vital signs
• Temperature
• High/low/low-grade
• Tachycardia
• Hypotension
• Inspection scars, hernias, masses
• Auscultation
• Palpation

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Physical Examination

• Percussion
• Tenderness
• No sudden moves
• Take your time
• Rigidity and guarding
• Board-like abdomen
• Tympanitic
• Dull

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Lab Tests

• WBC differential
• Basic chemistry panel
• K
• Bicarbonate
• Amylase
• Liver function tests
• Urinalysis
• Pregnancy test

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Diagnostic Imaging
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Plain Films

• Upright CXR
• Free air
• KUB (kidney/ureter/bladder)
• Calcifications
• Air/ Fluid levels
• Reactive bowel patterns
• Foreign bodies

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Lateral Decubitus Film
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Ultrasound

• Rapid, safe, low cost
• Operator dependent
• Fluid, inflammation, air in walls, masses
• Liver, GB, CBD, Spleen, Pancreas, Appendix,
  Kidney, Ovaries, Uterus

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Ultrasound
Textbook of Sabiston, 16th ed.
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CT Scans

• Better than plain films and US for evaluation of
  solid and hollow organs
• Intravenous contrast
• Oral contrast
• Per rectal contrast
• High use in appendicitis, diverticulitis,
  abscess, pancreatitis

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When to Operate ?

• Peritonitis
• Excluding primary peritonitis
• Abdominal pain/tenderness sepsis
• Acute intestinal ischemia
• Pneumoperitoneum
• Make sure pancreatitis is excluded

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What if its not clear?

• Challenging patients
• Neurologically compromised
• Intoxicated
• Steroids
• Inmmunosupressed
• If signs and symptoms are equivocal
• Serial exams (same person)
• Imaging
• Serial labs (check for WBC increases)
• Keep off antibiotics
• Tincture of time

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When NOT to Operate ?

• Cholangitis
• Appendiceal abscess
• Acute diverticulitis abscess
• Acute pancreatitis or hepatitis
• Ruptured ovarian cysts
• Long standing perforated ulcers?

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Non Surgical Causes

• MI, Acute pericarditis
• PN, pulmonary infarction
• GE reflux, hepatitis
• DKA, Ac Adrenal Insufficiency
• Acute Porphyria
• Rectus muscle hematoma
• Pyelonephritis, Acute salpingitis
• Sickle cell crisis

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Appendicitis
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Appendicitis

• 7-12 lifetime risk of appendectomy
• 500,000 performed yearly
• 15 misdiagnosed
• 47,000 appys/year
• 1 in 4 women will have a negative appendectomy
• 740 million dollars spent/yr on misdiagnosis

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Pathophysiology

• Obstruction of the appendiceal lumen
• Lymphoid hyperplasia
• Fecalith
• Inspissated stool
• Not always present
• Foreign body

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Pathophysiology of Appendicitis

• obstruction
• bacterial overgrowth
• mucous secret
• distention
• Increased intraluminal pressure
• lymphatic obstruction
• venous obstruction

• inflammation
• edema
• ischemia
• necrosis
• perforation
• abscess or localized peritonitis
• diffuse peritonitis

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History and Physical Exam
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Distinguishing Appendiceal Perforation
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Signs and Symptoms

• Umbilical then migrates towards the RLQ
• Tenderness, then rebound
• Rovsing
• Psoas
• Extension of leg-pt on left
• Obturator
• Rotation of flexed thigh-pt supine
• Rectal
• Perforation related symptoms

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Differential Diagnosis

• Preschool-age
• Intussusception, acute gastroenteritis, Meckels
  diverticulum
• School-age
• Acute GE, constipation, Sickle cell
• Young males
• Crohns, UC, epididymitis
  
  
• Young females
• Crohns, PID, ovarian cysts, UTI, pregnancy
• Older adults
• Malignancies of GI and GU
• Diverticulitis
• Perforated ulcers
• Cholecystitis

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Labs

• WBC 12,000-18,000
• left shift important
• HCG negative
• UA
• mild pyuria possible

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Radiographics

• Plain films
• fecolith, ileus
• CT scan
• Distention of appendix, thickened gt 5-7 mm walls,
  target sign
• US
• Non-compressible, 7 mm, fluid, mass
• Nuclear MD Tc 99 WBC Ig G

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AppendicitisU/S
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AppendicitisCT Scan
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Treatment

• Urgent appendectomy
• Antibiotics
• Only preoperative abx needed for uncomplicated
  cases
• For complicated appendicitis 7-10 days

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Appendectomy
Textbook of Sabiston, 16th ed.
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Laparoscopic Appendectomy
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Postoperative Complications

• Infection lt 5 to 60
• Wound Closure
• Primary
• Delayed primary
• Secondary
• Bowel obstruction
• Infertility-no longer suspected

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Normal appearing appendix?

• Remove appendix anyway?
• Especially if the pt has a RLQ incision
• Negative predictive value of macroscopic
  judgments of the appendix are low
• Check for ovarian pathology
• Check for mesenteric adenitis

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Name That Disease
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Meckels Diverticulitis

• Rule of 2s
• 2 incidence
• 2 types of mucosa
• 2 feet from ileocecal valve
• 2-4 (now 6) with Meckels develop symptoms
• lt2 yr olds bleeding (50)

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Infarcted/Ischemic Bowel
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Mesenteric Infarction/Ischemia

• Always consider in patient with atypical
  presentation of abdominal pain-
• Older patients
• Hx of arrhythmias or previous emboli
• Pain out of proportion to exam
• Evidence of visceral complaints without
  peritonitis
• Systemic complications
• Acidosis

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Infarction by Endoscopy
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Anatomy of the SMA
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Occlusion of the SMA

• Source
• Embolic (gt50)
• Venous, Atherosclerotic (thrombotic), NOMI
• Chronic
• Mesenteric/intestinal angina
• 30-60 minutes post eating
• Voluntary anorexia/wt loss
• Acute (gt60 mortality)
• Abdominal apoplexy
• Variable symptoms at first with progression
• System collapse

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Arteriogram of Normal SMA
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Occluded SMA
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Treatment of Acute SMA Occlusion

• High index of suspicion
• Arteriogram
• Medical therapy
• Papavarin
• Heparin
• Surgical intervention

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Perforated Viscous
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Perforated Viscous

• Sudden onset of pain
• Set your watch to it
• Epigastric/shoulder/RLQ-often DU
• Lower quadrant-often diverticulum
• Often pre-existing history of ulcer or
  diverticular disease

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Diagnosis

• Plain x-rays often demonstrate
• Upright CXR
• 75 of perforated DU will have free air
• Sensitive to 5 cc
• CT scan
• Sensitive to lt2 cc air

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Management

• Acute perforation of a viscous requires emergent
  exploration
• Delayed presentations are more complex
• Can avoid operation if the perforation is
  contained
• May require delayed interventions

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Acute Abdomen-Summary

• History and physical more important than tests
• Making the decision to operate is much more
  important than making the diagnosis
• Treatment is often (BUT NOT ALWAYS) surgical
• Very old, very young, very oddbe very careful!
  de Domball