Acute Abdomen

History: focus on GI, GU and CVS

  • Onset (sudden in vascular accident, perforation, renal colic; rapid in pancreatitis, mesenteric thrombosis, strangulation; gradual in appendicitis, cholecystitis, diverticulitis)
  • Length of attack
  • Severity/Quality
  • Location/Radiation
  • Alleviating factors – movement/no movement
  • Aggravating factors
  • Associated symptoms
    • Nausea and vomitting, anorexia, change in bowel habits (constipation, diarrhea), urinary (dysuria, rentention, frequency, hematuria), gynaecologic (vaginal D/C or bleeding, LNMP, missed period, dyspareunia)

Past Medical History

  • Abdominal
  • CVS – Risk factors for coronary artery disease
  • Gynecological
  • Surgeries
  • Medications

Physical exam

  • Vitals and general appearance (pale, writhing, lying still, perspiring)
  • Inspection: Expose entire abdomen, look for scars, distension, visible peristalsis, hernias
  • Auscultation: Bowel sounds, bruits, breath sounds
  • Palpation: Watch the patients face!!!  (Rebound, guarding, hernia sites, femoral pulses
  • Percussion: good for rebound, shifting dullness, loss of liver dullness suggests free air
  • Rectal
  • Pelvic (Vaginal discharge, masses, cervical motion tenderness)

 
Differential diagnosis by location

  • Generalized:
    • Perforated viscus
    • Pancreatitis
    • Bowel obstruction
    • Mesenteric ischemia  
  • RUQ
    • Gall bladder, liver, kidney, high appendix, DU, CHF, RLL pneumonia
  • Epigastric and LUQ
    • Pancreas, DU, Stomach, high SBO, MI, kidney
  • Periumbilical
    • Stomach, constipation, IBS, early appendicities, SBO, ischemic gut
  • RLQ
    • Appendix, mesenteric adenitis, renal colic, testicular torsion, Crohn’s, Gyne
  • Suprapubic and LLQ
    • Diverticuli, GU (rentention, UTI, renal colic), IBD, testicular torsion, Gyne
  • Other: CVS (MI, pericarditis), pneumonia, hepatitis, DKA, herpes zoster, RBC abnormalities

Labs and investigations

  • CBCD, lytes, BUN, Cr, lipase (pancreatitis, perf DU, SBO, ectopic, parotitis), lactate (ischemic conditions)
  • Beta HCG
  • U/A
  • AXR 3 views
  • ABG (pancreatitis – ARDS)
  • U/S, CT, MRI

Specific Conditions:

Appendicitis

  • Periumbilical pain –>RLQ pain
  • Nausea and vomitting, anorexia
  • Rebound pain in RLQ, fever, WBC
  • U/A (diapedesis through ureter)
  • CT, Ultrasound, 3 views of abdomen
  • Complications: rupture, abscess, portal phlebitis
  • Microbiology of colon: B. fragilis (E.coli, Klebsiella, Proteus, C. welchii)

Acute Diverticulitis

  • LLQ pain +/- guarding
  • Fever, Leukocytosis
  • Oral antibiotics
  • Ba enema in 4-6 weeks
  • If moderate: CT scan shows thick walled sigmoid colon, mesenteric stranding; IV antibiotics
  • If severe: may have perforation or abscess
  • Surgery if:
    • Perforation, Non-resolving abscess, Obstruction
    • Chronic causes – obstruction, 2nd attack over 40 y.o., 1st attack under 40 y.o., cannot rule out cancer

Small bowel obstruction (SBO)

  • Crampy upper or mid abdominal pain
  • Nausea and vomitting, abdominal distension, tympanism, high pitched bowel sounds, obstipation
  • Adhesions, Hernias, Crohn’s, intussisception, internal hernia
  • Surgery if:
    • Irreducible hernia
    • Signs of compromised bowel (fever, increased WBC, pain, rebound toxic)

Large bowel obstruction (LBO)

  • Always do a rectal
  • 3 views of abdomen
  • Gastrograffin enema
  • May require a Hartmann’s – the lower end of the rectum is closed with sutures or staples and left in situ. The upper end of the bowel is bought out as a descending colostomy

Acute cholecystitis

  • RUQ pain, radiating to shoulder or back; Murphy’s sign
  • Nausea and vomitting, may have a fever
  • Acalculous in burn patients, ICU patients
  • Investigations: CBCD, electrolytes, BUN, Creatinine, LFTs (Total bilirubin, Alk phos, ALT), Lipase, U/S (Murphy’s, pericholecystic fluid, thick wall) or HIDA (for a bile leak, will not show on U/S) or MRCP/ERCP
  • Treatment: NPO, rehydrate, IV abics (ancef, flagyl), percutaneous cholecystostomy (rule out cholangitis)

Acute pancreatitis

  • Epigastric pain radiating through back
  • Vomiting
  • Causes: Gallstones, alcohol abuse, ERCP, Viral (EBV, CMV, coxsackie), scorpion venom, medications (hormones, Imuran, quinine), trauma, ischemia, hyperlipidemia, hypercalcemia, divisum (embryologic)
  • Pathology: suponification of fat – autodigestion b/c of exocrine release
  • Ranson’s criteria

    Early

    Delayed (48 hr)

    WBC > 16

    Ca ionized < 2

    LDH > 350

    HCT drop > 10

    Glucose > 11

    pO2 < 60

    Age > 55

    Fluid sequestration > 6 L

    AST >250

    BUN increased by 1.8

     

    Base deficit – 4 (excess)

  • Pt looks unwell, tender epigastrium, ileus, may lean forward
  • Investigations: CBCD, lytes, BUN, Cr, Lipase, LFTS, triglyceride, Calcium, U/S and contract CT abdomen (look for necrosis)
  • Treatment: NPO, IV fluids, start on Imipenem (1-2 wks) if devascularized pancreas on CT (decrease septic complications)

Perforated Duodenal Ulcer

  • Mid epigastric pain with radiation all over abdomen
  • NSAIDs
  • Motionless, rigid quiet abdomen
  • CBCD, lipase, AXR 3 views
  • Treatment – resuscitate, OR, post op treat H. pylori

Mesenteric vascular accident – pain out of proportion to exam

  • WBC, lactate, metabolic acidosis

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