THE ACUTE ABDOMEN

1. THE ACUTE ABDOMEN Hugh M. Foy, MD Harborview Medical Center University of Washington School of Medicine

2. “BEGIN WITH THE END IN MIND” Stephen Covey The 7 Habits of Highly Effective People

3. Acute Abdominal Pain • Considerations: • VS: stable or unstable? • PQRST • Precipitating or alleviating factors • Quality-bright, sharp, dull, achy • Radiation- scapula, inguinal, supraclav • Severity- 1 to 10 scale • Timing- sudden, insidious • Crampy or continuous

4. HPI part 2 • Past Surgical History • Previous abdominal or pelvic operation • Prior work-up for abdominal pain • Past Medical History • IDDM • ASCVD

5. Common Abdominal Conditions • Ileus from narcotics • Constipation/Obstipation • Appendicitis • Cholecystitis/Biliary Colic • Small Bowel Obstruction • Perforated Peptic Ulcer • Pancreatitis

6. Past Medical History • Medications • Valproic acid • Allergies • Bugs, bites or stings

7. LOOK • Description of abdominal habitus • scaphoid, • Flat • Rotund Scars, wounds, erythema Anatomic Confines

8. Anatomic Landmarks • Divided in quadrants • RUQ, LUQ, RLQ, LLQ • Anatomic: • Epigastrium • Umbilical • Suprapubic (hypogastrium)

9. Listen • Listen with stethoscope • Not necessary in all quadrants • Quantitative • Absent • Decreased • Hyperactive • Qualitative • Normal • Borbyrigmy • Obstructive • Bruits

10. Bowel Tones • Pathologic • Obstructive • Hollow • Air-fluid interface • Like a pebble dropped in to a partially filled barrel • “Tinkles and Rushes”

11. Percussion • Abdomen • Tympanitic gas • Dull fluid (ascites or blood) • Liver Span • mid clavicular line by convention • Bladder, Uterus • Rising out of the pelvis Percussion is also a very sensitive sign of peritonitis

12. PALPATION Prepare the patient • warn them • make them comfortable • take tension off the abdominal wall • Pillow or bend the knees • Expose the entire abdomen • Xiphoid to pubis

13. PALPATION • Note the patient’s attitude • (physically and emotionally) • Watch their eyes as you touch them • After percussion: • Softly at first • Deeper • LUQ-RUQ note liver edge • Then LLQ-RUQ

14. The Painful Abdomen • Pain vs Tenderness • Distinction is critical to making the diagnosis • Be precise: • Conceptually, • Verbally • Written Documentation Pain- is a subjective symptom Tenderness is an objective sign

15. Pain vs Tenderness • Based on abdominal innervation: • Visceral Pain • Sense stretching and ischemia only • mediated via Visceral Afferent fibers • Follow the blood supply • Difuse, not mapped 1:1 on sensory cortex

16. Pain and Tenderness(continued) • Tenderness • Somatic Afferent Innervation • Parietal peritoneum • Abdominal Wall • Precisely mapped on sensory cortex

17. Examination of the Acute Abdomen • Observe the pt. • Reassure • Auscultate • Percuss and Palpate • Begin in quadrant opposite the suspected pathology • Percussion is very sensitive peritoneal sign

18. Examination of the Acute Abdomen II • Guarding • Voluntary • Involuntary • Peritoneal Signs: • Rebound • Percussion tenderness

19. Peritoneal TendernessAssociated findings • Eyes dilate, • Exquisitely tender • “bright tenderness” • akin to fracture tenderness • “electric shock-like”

20. Examination of the Painful Abdomen • Advanced palpation tricks • Sneak up on them • Distract with conversation • Watch their eyes • Palpate with the stethoscope • Bump the stretcher

21. Advanced and Adjuvant Exams • Shifting Dullness • CVA Tenderness • Digital Rectal Exam • Bimanual Pelvic Exam • Listening to lower lung fields

22. Exam for Ascites • Fluid Wave • Shifting Dullness • Associated findings: • Caput Medusa • Spider Angioma

23. “6 Dermatomal” Pain Syndrome • Due to poorly localizing visceral innervation, diseases can present in vague, confusing manner • Pneumonia • Acute MI • GERD • Biliary Colic • PUD • Pancreatitis • Hepatitis

24. Diagnostic Approach • Essential Questions: • Stable or Unstable? • Do I need the surgeon now? • Is it obvious that they need an operation?

25. Diagnostic Approach • What is your clinical Diagnosis? • Options: • Upright CXray and Abdomen, KUB • CT + IV or PO contrast • Ultrasound • Nothing

26. Diagnostic Modalities • CT: 15-20% false negative for acute perforation • Poor study for gallstones • Contrast obscures kidney stones

27. When to call the surgeon? • Unstable VS- call immediately • Obvious peritonitis • Work up complete in stable, less obvious • CBC, coags • Blood gas • Lytes • Amylase • Bilirubin(s) • LFTs • Imaging

28. Chores in the interim • ABCs • Does this pt need intubated, O2? • IVs- large bore, 2 if unstable • Resuscitation- NS vs LR • Bolus therapy- 20cc/kg, repeat if necessary • Foley Catheter • ?Central line • Type and Cross • Antibiotics- Gram Neg and Anaerobic • Cipro/Flagyl • Pip-Tazo • Cefotetan • Pain Medication?

29. Common Pitfalls • Acute Mesenteric Ischemia • Intestinal Volvulus • Gallstone “Illeus” • AAA and backpain • “It’s just gastroenteritis”

30. Evaluation of Abdominal PainSummary: • Patient Condition guides the urgency • Clinical Diagnosis is the first step • Imaging studies depend on Clinical Dx. • Patient Preparation is crucial to outcome