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