Professional Documents
Culture Documents
Acute Abdomen: The "Black Hole" of Medicine
Acute Abdomen: The "Black Hole" of Medicine
• A Full history
• Thorough physical examination
Diagnosis can be made most of the time by
a good history and a proper physical
examination.
1. Visceral
2. Parietal
3. Referred
1. Visceral Pain
• Duration?
• Nausea, vomiting? Bloody? (Coffee grounds emesis?)
• Change in urinary habits? Urine appearance?
• Change in bowel habits? Melena (Dark, tarry stools?)
• Regular food/water intake?
History (S)
• Females
–Last menstrual period?
–Abnormal bleeding?
• UA / Urine culture
• Lactic acid
• LFT / Amylase / Lipase
• CE / Troponin
• HCG (quant / qual)
• Stool Culture
Radiographic Test
• Plain abdominal radiographs or abdominal
series has several limitations and is subject to
reader interpretation.
• In patients under fifty years of age the top three reasons for
acute abdominal pain are: NSAP (40%,) Appendicitis (32%,)
and Other (13%.)
Appendicitis
• Usually due to
obstruction with
fecalith
• Appendix becomes
swollen, inflamed
gangrene, possible
perforation
Appendicitis
• Pain begins periumbilical; moves to RLQ
• Nausea, vomiting, anorexia, fever
• Patient lies on side; right hip, knee flexed
• Pain may not localize to RLQ if appendix in odd
location
• Sudden relief of pain = possible perforation
Acute Appendicitis
• Steady, well-localized
epigastric or LUQ pain
• Described as a “burning”,
“gnawing”, “aching”
• Increased by coffee,
stress, spicy food,
smoking
• Decreased by alkaline
food, antacids
Peptic Ulcer Disease
• Erosion of the lining of the stomach,
duodenum, or esophagus
• May cause massive GI bleed
• Patient lies very still with complaint of intense,
steady pain, rigid abdomen with exam,
suspect perforation
Gastroesophageal Reflux
• Inflammation of gall
bladder
• Commonly associated
with gall stones
• More common in 30 to 50
year old females
• Nausea, vomiting; RUQ
pain, tenderness; fever
• Attacks triggered by
ingestion of fatty foods
Biliary Tract Disease
• Most common diagnosis in ED of pts > 50.
– Composed of:
• Acute Cholecystitis (acalculus / calculus)
• Biliary Colic
• Common Duct Obstruction (Ascending Cholangitis –
painful jundice / fever / MSΔ).
• Pt is obese
• Technical limitations
ABDOMINAL XR
Bowel Obstruction
• Small Bowel Large Bowel
– Central Peripheral
– Valvulae conniventes Haustrae
– Dia > 5cm > 10cm
SBO LBO
Small Bowel Obstruction
• CT scan is better than plain film in detecting
high grade SBO.
• Inflammation of pancreas
• Triggered by ingestion of
EtOH; large amounts of
fatty foods
• Nausea, vomiting;
abdominal tenderness;
pain radiating from upper
abdomen straight through
to back
• Signs, symptoms of
hypovolemic shock
Acute Pancreatitis
• 80% of cases are due to ETOH abuse or gallstones.
• Definition :
– Inflammation of the pancreas
– Associated with edema, pancreatic autodigestion, necrosis and possible
hemorrhage
Acute Pancreatitis
Biliary pancreatitis
-Due to CBD obstruction.
-Can lead to Ascending Cholangitis
Radiological std:
MRCP - Test of choice to get clear images of the pancrease and CBD.
Double contrast CT - can also be use, may have limited view of the CBD – 2nd most
common test to be ordered in ED
Ultrasound – 1st most common test to be order in ED to evaluate for CBD obstruction.
More sensitive than CT scan to evaluate the CBD. Its use is safer in pregnancy.
Acute Pancreatitis
Peripancreatic complications:
• Necrosis (Necrotizing Pancreatitis)
• Hemorrhage (Hemorrhagic Pancreatitis)
• Drainable fluid collections (Ruptured Pancreatic Pseudocyst)
– Lab findings: No definite lab test will help in the diagnosis. May
see decrease Hg or ↑Lactic Acid level.
• Pouches become
blocked and infected
with fecal matter
causing inflammation.
• Pain, perforation,
severe peritonitis.
Acute Diverticulitis
• Less than ¼ of pts present with LLQ pain.
• US:
– Relies on identification of an inflamed
diverticulum to make the diagnosis which is often
obscured in pts with complicated diverticulitis.
Esophageal Varices
• Dilated veins in
lower part of
esophagus
• Common in EtOH
abusers, patients
with liver disease
• Produce massive
upper GI bleeds
Renal Colic
• Pts may present with abrupt, colicky, unilateral flank pain that
radiates to the groin, testicle, or labia.
• Fertilized egg is
implanted outside the
uterus.
• Growth causes
rupture and can lead
to massive bleeding.
• Patient c/o of severe
RLQ or LLQ pain with
radiation.
Ectopic Pregnancy
• Symptoms include abdominal pain (most
common) and vaginal bleeding (maybe the
only complaint).
• Inflammation of the
fallopian tubes and
tissues of the pelvis
• Typically lower
abdominal or pelvic
pain, nausea, vomiting
Abdominal Aortic Aneurysm
• Localized weakness of
blood vessel wall with
dilation (like bubble on
tire)
• Pulsating mass in
abdomen
• Can cause lower
back pain
• Rupture shock,
exsanguination
Abdominal Aortic Aneurysm
• Dissections produce chest or upper back pain
that can migrates to abdomen as the dissection
extend distally.
• AAA rather than dissect, it enlarge, leak, and
rupture.
• <50% of pts with AAA present with hypotension,
abdominal/back pain, and/or pulsatile abd mass.
Can present similar to renal colic.
• Neither the presence or the absence of femoral
pulse or an abdominal bruit are helpful clinically.
Abdominal Aortic Aneurysm
• Palpation is an important part of physical exam. Maybe
able to detect an enlarged aorta.
• Can use bedside ultrasound FAST scan, but this will not
provide information about leakage or rupture.
1. Arterial insufficiency
• Occlusive – Embolic (A. Fib) / Thrombotic
– Embolic MI has the most abrupt onset.
• Protrusion of the
intestine through a
tear in the inguinal
canal.
• Usually identified by
abnormal mass in
lower quadrant, with
or without pain.
• Strangulation can lead
to necrosis.
Toxic causes for
Acute Abdominal Pain
• Pt may present with symptoms of N/V/D and/or +/- fever to
suggest a gastroenteritis or enterocolitis.
• Hypotension:
– In younger pts probably due to volume depletion
from vomiting, diarrhea, decreased oral intake or
third spacing.
• Treatment would be isotonic crystalloid.
– Younger patients may also have abdominal sepsis
(septic shock).
• Treatment would include isotonic crystalloid,
antibiotics, and vasopressors (levophed or dopamine).
Treatment of Acute Abdominal Pain
• Hypotension:
– In older patients CV disease should be added to
the differential.
• If AMI is the diagnosis, a aortic balloon pump may be
needed until angioplasty or bypass is done. If CHF is
diagnosed than dobutamine with isotonic crystalloid
may be used
– Must also consider hemorrhage as a cause:
• Initiate treatment with isotonic crystalloid then
consider blood transfusion
Treatment of Acute Abdominal Pain
• Analgesics:
– Though in past ER physicians did not treat acute
abdominal pain with analgesics for fear of altering
or obscuring the diagnosis, current literature
favors the use of opoids judiciously in such
patients.
Treatment of Acute Abdominal Pain
• Antibiotics:
– Must be consider when treating suspected
abdominal sepsis or diffuse peritonitis.
– Coverage should be aimed at anaerobes and aerobic
gram negatives.
– If SBP suspected, must cover for gram positive
aerobes.
– Examples of mononotherapy are cefoxitin, cefotetan,
ampicillin-sulbactam, or ticarcillin-clavulanate.
Disposition of Acute Abdominal Pain
• Indications for admissions:
– Pts who appear ill.
– Very young / Elderly
– Immunocompromised
– Unclear diagnosis
– Intractable pain, nausea, or vomiting
– Altered mental status
– Those using drugs, alcohol, or that lack social
support.
– Pts with poor follow-up and/or noncompliant.
Disposition of Acute Abdominal Pain
A. Perforated appendicitis
B. Acute unperforated appendicitis
C. Perforated gallbladder
D. Ruptured diverticulum
E. Acute cholecystitis
??? QUESTION #2 ???
• A 45 year-old male with peptic ulcer disease (PUD) presents to the ED
with an abrupt onset of severe epigastric pain 1 hour prior to arrival. Abd
exam leads you to suspect an early acute surgical abdomen. Describe the
findings and treatment with this complication of PUD. Physical
examination findings suggestive of perforation include all of the following
except?