Acute AbdomenAcute Abdomen

Andreas M Andreas M KluftingerKluftinger MD FRCSCMD FRCSC

Kelowna General HospitalKelowna General Hospital

DisclosureDisclosure

• Hernia Advisory Panel

– Ethicon Johnson& Johnson

• Medical Director of Surgcial Weight Loss• Medical Director of Surgcial Weight Loss

– IQuest Healthcare and Fitness Centre

ObjectivesObjectives

• Understand the Pathophysiology and etiology of the acute abdomen

• Approch to acute abdomen in rural • Approch to acute abdomen in rural practice

• Case presentations

Stedman's Medical Dictionary Stedman's Medical Dictionary

27th Edition27th Edition

“any serious acute intra-abdominal condition attended by pain, tenderness, and muscular rigidity, and for which and muscular rigidity, and for which emergency surgery must be considered."

Acute Abdominal PainAcute Abdominal Pain

• 5-10 % of ER visits

• Complex “black box”

• Delays in diagnosis can increase morbidity

• Excessive consultations (+/- transport) and • Excessive consultations (+/- transport) and imaging can be costly and tax resources.

• Primary assessment and triage are key

History & PhysicalHistory & Physical

• Onset, nature, duration, location, radiation

• Aggravating and relieving factors

• Associated GI or GU symptoms

• Past history (Surg and Med)• Past history (Surg and Med)

• Review of Systems

• Full physical exam

Stereotypes of Pain Onset and Associated Pathology

•Sudden onset (full pain in seconds)

•Rapid onset(initial sensation to

full pain over

minutes or hours)

•Gradual onset

(hours)

•Perforated ulcer

•Mesenteric infarction

•Ruptured abdominal

aortic aneurysm

•Strangulated hernia

•Volvulus

•Intussusception

•Acute pancreatitis

•Appendicitis

•Strangulated hernia

•Chronic pancreatitis

•Peptic ulcer disease aortic aneurysm

•Ruptured ectopic

pregnancy

•Ovarian torsion or

ruptured cyst

•Pulmonary embolism

•Acute myocardial

infarction

•Acute pancreatitis

•Biliary colic

•Diverticulitis

•Ureteral and renal

colic

•Peptic ulcer disease

•Inflammatory bowel disease

•Mesenteric lymphadenitis

•Cystitis and urinary retention

•Salpingitis and prostatitis

Abdominal Abdominal InnervationInnervation

Simplified in ThirdsSimplified in Thirds

Embryologic Structures Nerves Arteries Pain Location

Foregut Esophagus,

stomach,3/4

duod,liver, gb

panc

Thoracic

splanchnics,

vagus

Coeliac Epigastrium

panc

Midgut ¼ duod to

splenic flexure

Thoracic

splanchnics,

vagus

SMA Periumbilical

Hindgut Left colon,

rectum, GU

tract

Pelvic

splanchnics,

lesser thoracic

splanchnics

IMA Hypogastrium

Possible Causes of Pain by Location

Location of Pain Associated Diseases

Right upper quadrant(liver, kidney, gallbladder)

Acute cholecystitis, biliary colic, acute hepatitis, duodenal ulcer, right lower lobe pneumonia

Right lower quadrant(ascending colon, appendix, ovary,

fallopian tube)

Appendicitis, cecal diverticulitis, ectopic pregnancy, tubo-ovarian abcess, ruptured ovarian cyst, ovarian torsion

Left upper quadrant(pancreas, spleen, kidney)

Gastritis, acute pancreatitis, splenic pathology, left lower lobe pneumonia

Left lower quadrant(sigmoid and descending colon,

ovary, fallopian tube)

Diverticulitis, ectopic pregnancy, tubo-ovarian abcess, ruptured ovarian cyst, ovarian torsion

Midline or periumbilical Appendicitis (early), gastroenteritis, mesenteric lymphadenitis, myocardial ischemia or infarction, pacreatitis

Flank Abdominal aortic aneurysm, renal colic, pyelonephritis

Front to back Acute pancreatitis, ruptured abdominal aortic aneurysm, retrocecalappendicitis, posterior duodenal ulcer

Suprapubic or lower abdominal Ectopic pregnancy, mittelschmerz, ruptured ovarian cyst, pelvic inflammatory disease, endometriosis, urinary tract infection

Sign Finding Association

Cullen's sign

Grey Turner’s sign

Bluish periumbilical

discoloration

Bluish flank discoloration

Retroperitoneal

hemorrhage

pancreatitis,

abdominal aortic

aneurysm rupture)

Kehr's sign Severe left shoulder pain Splenic rupture

Ectopic pregnancy

McBurney's sign Tenderness located 2/3 distance from

ASIS to umbilicus on right side

Appendicitis

Murphy's sign Abrupt interruption of inspiration on

palpation of right upper quadrant

Acute cholecystitis

Iliopsoas sign Hyperextension of right hip

causing abdominal pain

Appendicitis

Obturator's sign Internal rotation of flexed right hip

causing abdominal pain

Appendicitis

Chandelier sign Manipulation of cervix causes patient

to lift buttocks off table

Pelvic inflammatory

disease

Rovsing's sign Right lower quadrant pain with

palpation of the left lower quadrant

Appendicitis

Referred Pain

Structure Irritated Location of Referred Pain

Diaphragmatic Supraclavicular area (Kehr's sign)

Ureteral Hypogastrium, groin, inner thigh

Cardiac pain Epigastrum, jaw, shoulder

Appendix Periumbilical via T10 nerveAppendix Periumbilical via T10 nerve

Duodenum Umbilical region via greater thoracic

splanchnic nerve

Hiatal hernia Epigastrum via T7 and T8 nerves

Pancreas or gallbladder Epigastrum

Gallbladder and bile duct Epigastric pain that wraps around to the

scapula

Imaging for AppendicitisImaging for Appendicitis

Imaging AccuracyImaging Accuracy

in in

AppendicitisAppendicitis

Modality Sensitivity Specificity Pos PredValue Neg Pred ValueModality Sensitivity Specificity Pos PredValue Neg Pred Value

Plain Film 10% 90%

Ultrasound 85-90% 92-96% 95% 80-90%

CT 95-97% 95% 97% 95-100%

MRI 93% 91% 92% 100%

Laboratory in AppendicitisLaboratory in Appendicitis

Test Sensitivity Neg Pred Value

1. WBC >10.5 85%

2. Neutrophils >75% 78% 94%

3. C reactive protein 93-96%

1+2 96%

1+3 92.3%

1+2+3 99.2% (81% in children)

Urinalysis in AppendicitisUrinalysis in Appendicitis

• 30% of appendicitis patients have some urinary syptoms

• 14% have >10 WBC/hpf

• 18% have > 3 RBC/hpf• 18% have > 3 RBC/hpf

Imaging in PregnancyImaging in Pregnancy

• Ultrasound

– Safest

– Useful for fetal assessment (dates, viability,

placenta, amniotic fluid)placenta, amniotic fluid)

– NPV for appendicitis 80-90%

– PPV for appendicitis 95%

Imaging in PregnancyImaging in PregnancyProcedure Fetal Exposure

Chest radiograph (2 views) 0.02-0.07 mrad

Abdominal film (single view) 100 mrad

Intravenous pyelography >1 rad*

Hip film (single view) 200 mrad

Mammography 7-20 mrad

Barium enema or small bowel series 2-4 rad

CT (computed tomography) scan head

or chest

<1 rad

CT scan abdomen and lumbar spine 3.5 rad

CT pelvimetry 250 mrad

No evidence of teratogenesis or fetal loss if cumulative dose < 5 rads

Acute AbdomenAcute Abdomen

Caused by PregnancyCaused by Pregnancy

• Early pregnancy

– Ruptured ectopic pregnancy

– Septic abortion with peritonitis

– Acute urinary retention due to retroverted gravid uterus

– Torsion of the pregnant uterus

• Later pregnancy • Later pregnancy

– Red degeneration of myoma

– Torsion of pedunculated myoma

– Placental abruption, Placenta percreta

– HELLP (hemolysis, elevated liver function, and low platelets) syndrome

– Spontaneous rupture of the liver

– Uterine rupture

– Chorioamnionitis

Conditions Associated with Conditions Associated with PregnancyPregnancy

• Acute pyelonephritis

• Acute cystitis

• Acute cholecystitis

• Acute fatty liver of pregnancy • Acute fatty liver of pregnancy

• Rupture of rectus abdominis muscle

Case #1Case #1

• 68 male, 48 hrs RLQ pain

• Quick onset, in RLQ

• No nausea or anorexia

• No urinary syptoms• No urinary syptoms

• PHx: GERD, dyslipidemia

• Tender RLQ and flank with peritonism

• WBC 9.2 Urine clear

CT abdomenCT abdomen

Case #2Case #2

• BW 41 yo electrician

• collapsed at home with chest, abd pain

• CPR by family, EHS to KGH• CPR by family, EHS to KGH

• PHx: appe Meds: ASA

• Exam: BP 60 sys, HR 100 RR 16

Chest clear Abdomen tender, acute

InvestigationsInvestigations

• Hb 108 WBC 8.9 Plts 256

• Hep panel – normal

• Lipase 43

• ECG – normal• ECG – normal

• Trop < 0.1

CT with Aorta ProtocolCT with Aorta Protocol

LaparotomyLaparotomy

• 3 litres blood

• intact liver, spleen, viscera

• blood from lesser sac

• rupured splenic artery aneurysm at hilum• rupured splenic artery aneurysm at hilum

• splenectomy, distal pancreatectomy

• 4 units FP, 6 units RBC

• Recovery uneventful