腹部急症-2

急診部 陳思州主任/施長志醫師104年12月15日

第二版

核心課程編號：E10

學習目標

PGY知識

1. 能夠對腹部急症之病患進行重點病史詢問及理學檢查，並進行初步須手術治療之急性腹痛鑑別診斷。

2. 能夠對腹部急症之病患安排適當的檢查並早期診斷危及性命之急性腹痛，如腸穿孔或缺血性腸壞死等給予適當的初步處置及疼痛處理。

3. 能夠對腹部急症之病患安排進一步的治療、照會及動向安排，瞭解腹部急症之手術適應症。

4. 能夠對腹部急症之病患及其家屬進行適當的病情解釋及醫病溝通。

安排適當的檢查並給予適當的初步處置及疼痛處理、安排進一步的治療

Analgesics

Do not withhold analgesia from patients with acute undifferentiated abdominal pain.

The early administration of opioid analgesia does not obscure physical findings, delay diagnosis, or lead to increased morbidity/mortality.

The information on the safety of opioids cannot be extrapolated to NSAIDs such as parenteral ketorolac, because NSAIDs are not pure analgesics and can mask early peritoneal inflammation.

Antiemetics The liberal use of antiemetics may make the insertion of

a nasogastric tube unnecessary. Therapeutic value of nasogastric tube placement in

abdominal pain has never been convincingly demonstrated

Headache is a reported side effect. Patients with akathisias or dystonic reactions from

metoclopramide cannot tolerate any other agents of the same class and should be given ondansetron.

Such reactions are extremely rare from ondansetron.

Antibiotics

腹部急症之手術適應症

Acute abdomen Indications for urgent operation

■ Physical findingsInvoluntary guarding or rigidity, especially if spreadingIncreasing or severe localized tendernessTense or progressive distentionTender abdiminal or rectal mass with high fever or hypotensionRectal bleeding with shock or acidosisEquivocal abdominal findings along with Septicemia (high fever, leukocytosis, mental changes, increasing glucose)Bleeding (unexplained shock or acidosis, falling hematocrit)Suspected ischemia (acidosis, fever, tachycardia)Deterioration on conservative treatment

■ Radiologic findingsPneumoperitoneumGross or progressive bowel distensionFree extravasation of contrast materialSpace-occupying lesion on CT scanMesenteric occlusion on angiography

■ Endoscopic findingsPerforated or uncontrollably bleeding lesion

■ Paracentesis findingsBlood, bile, pus, bowel contents, or urine

照會及動向安排

ConsultationGS Hollow organ perforation, acute

appendicitis, peritonitis

CVS、RAD ischemic bowel disease、Abdominal Aortic aneurysm

CRS Colon Ca with intestinal obstruction

Disposition and follow-up Patients who are elderly, immune compromised, unable

to communicate, or cognitively impaired are especially high risk.

Patients who appear ill, have intractable pain or vomiting, are unable to comply with discharge or follow-up instructions, or who lack appropriate social support should also be considered for admission.

Patients with an unclear diagnosis at discharge (or for whom response to treatment is a concern) should be asked to return to the ED or their primary care physician for reevaluation within 12 hours.

Discharge instructions should address diet clear liquids only push fluids no fatty foods no acidic foodsmedications

The patient and the patient's family should understand that the diagnosis is uncertain, and they should know which symptoms warrant a return to the ED (e.g., increased/different pain, fever, vomiting, syncope, bleeding).

Diagnosis you should not miss

Ruptured/leaking aortic aneurysm

Perforated viscus

Acute pancreatitis

Intestinal obstruction

Mesenteric ischemia

Ruptured/leaking AAA

Risk factors: age, man, smoking, HTN, DM, CAD

Acute epigastric and back pain often associated with or followed by syncope or signs of shock. Pain may radiate to back, groin, or testes.

Vital signs may be normal; palpation of a pulsatile mass is usually possible in aneurysms 5 cm or greater. Bruits or inequality of femoral pulses may be evident.

If suspected, echo/CT indicated

AAA rupture

Hollow organ perforation

Risk factors: age, peptic ulcer or diverticulum Hx

Acute onset of epigastric pain is common. Vomiting in 50%. Fever may be present later. Pain may localize with omental walling off of peritonitis.

Fever and tachycardia. Abdominal examination reveals diffuse guarding and rebound. Bowel sounds are decreased.

Upright view of radiographs reveals free air in 70 - 80% of cases with perforated ulcers. Leukocytosis and elevated amylase level.

Left lateral decubitus view

Double wall Sign

Acute pancreatitis

Risk factors: male, alcohol, biliary disease

Acute onset of epigastric pain radiating to the back. Nausea and vomiting common. Pain disproportionate to PE findings.

Low grade fever common. Some epigastric tenderness usually present. Guarding or rebound not present unless severe.

Lipase is test of choice. Amylase 3 × normal more specific for diagnosis. CT indicated if severe pancreatitis, i.e. with multi - organ involvement .

Acute Pancreatitis

Intestinal obstruction

Risk factors: age, previous abdominal surgery.

Crampy diffuse abdominal pain associated with vomiting.

Abdominal distention, hyper active bowel sounds, and diffuse tenderness. Local peritoneal signs indicate strangulation.

Abdominal films are useful for identifying level of obstruction. Leukocytosis may indicate strangulation.

Volvulus of the Sigmoid

Ischemic bowel

Risk factors: age, CHF, arrhythmias, DM, sepsis, dehydration.

Severe pain, colicky, starts in periumbilical region and then becomes diffuse. Often associated with vomiting and diarrhea.

Early physical examination results can be remarkably benign.

Leukocytosis . Elevations of amylase and CK. Metabolic acidosis due to lactic acidemia . Plain films of limited benefit. CT, MRI, and angiography may be indicated.

Pneumatosis intestinalis & Portal vein Air

對腹部急症之病患及其家屬進行適當的病情解釋及醫病溝通

腹部急症急診就醫後之注意事項

1.多休息,勿做勞累活動或劇烈運動。 2.依醫囑指示服藥。 3.如可進食請攝取清淡易消化飲食。 4.兩天內無特殊狀況請至腸胃科門診追蹤。 5.如有下列徵象請速返急診室：

(1)嘔吐症狀加劇

(2)由無腹脹痛變成腹脹或僵硬 (3)腹痛無緩解現象且加劇 (4)右下腹疼痛 (5)吐血或解血便 (6)併發頭暈或暈倒 (7)呼吸短促 (8)體溫超過 39℃