The ACUTE ABDOMEN

Simon LauMike BozinThe ACUTE ABDOMENThe Acute Abdomen: an acute change in the condition of the intra abdominal organsUsually related to inflammation or infectionDemands IMMEDIATE and accurate diagnosis (but this does not always correlate with the need for an operation)Abdominal PainOne of the most frequent presentations to EDsMost are self limitingSome are not!

Case 127yo female presents with 1d of abdominal painAssociated with:AnorexiaNausea, no vomitingSome diarrhoeaVisceral vs ParietalVisceral Pain:Related to stretching of the walls of hollow viscera, or the capsules of solid onesDullPoorly localised but usually central

Visceral vs Parietal PainParietal PainOrigin anywhere in the abdominal wall from the skin to the parietal peritoneumIntenseWell localised

Transition from Visceral to ParietalInitial visceral pain irritates parietal peritoneum, causing parietal pain wherever they are in contactCont Case 1Abdominal Pain:Initially midline/umbilicalOver 24/24 transitioned to the RIFSevere, constantApplied AnatomyWhat anatomical structures reside in the Right Iliac Fossa? (in a girl)

The Right Iliac FossaCaecumAppendixIleocaecal junction/valveRight Ovary/Fallopian tubeRight Ureter

ExaminationHR110 BP95/70 O2: 98% 4LNP RR20 T37.8CAbdo Ex:RIF tendernessPercussion tendernessRovsing SignPR: nil blood, nil melena InvestigationsFBE: 120/15.2/214 neut 11.2UEC: 140/4.3 Cr 64 eGFR >90INR: 1.0-HCG: negUrinalysis: NAD

Imaging???DDx?Acute AppendicitisInflammation of the appendix, usually secondary to obstruction of the appendiceal lumenAlvarado ScoreComplications of untreated appendicitis?Perforation and peritonitisAppendiceal abscessFeatureScoreMigration of pain - 1Nausea/vomiting - 1Anorexia - 1RIF tenderness - 2Rebound pain - 1Temperature >37.3 - 1WCC > 10x109/L - 2PMN > 75% - 14 or less: Dx unlikely5-6: observe7 or more: operation required

13Other DDxsGIT: DiverticulitisBowel obstructionVolvulus/strangulationCx of herniasGynaecological:Ectopic pregnancyAdnexal torsionUrological:PyelonephritisRenal stonesTesticular torsionVascular:Ischaemic colitis

Case 246yo male presents with 12hrs of worsening abdominal painModerate in severityInitially colicky but now constantLocated in the RUQ with radiation to the tip of the right shoulderAssociated with nausea and vomiting and feversApplied AnatomyWhat structures are found in the RUQ?

The Right Upper QuadrantLiverGall BladderBiliary TreePancreasStomachDuodenumRight kidney

ExaminationHR: 115 BP: 120/70 RR: 19 O2: 99% 2L NP T: 38.1CAbdo Ex: Tender RUQ with some (voluntary) guardingMurphys sign positive

InvestigationsFBE: 123/13.9/285 neut 10.2UEC: normalLFTs: bilirubin, GGT and ALP elevated

Imaging??DDx?CholecystitisInflammation of the gallbladder, most commonly from obstruction of the cystic ductCf with choleduocholithiasis and cholangitis and biliary colic

Biliary colic constant severe pain for >6hrs21Cont CholecystitisImaging: US Abdo or CT A/PTreatmentIV resusAnalgesiaAbxLaproscopic cholecystectomy

Other DDxs?Hepatobiliary:CholeduocholithiasisCholangitisPancreatitisGIT: Perforated peptic/duodenal ulcerGastritis/GORDUrological:PyelonephritisRenal stonesCase 387yo male presents to the ED with sudden onset abdominal painSevere and constantInitially developed in the LIF but quickly became widespreadAssociated with one large passage of bloody diarrhoeaCont Case 3PMHx:IHD AMI 2yrs ago with PCIT2DM OHG onlyAF warfarinised recentlyPVD Fem-Pop Bypass Graft 4yrs agoNil history of abdominal surgeryMeds:Warfarin, -blocker, ACE-I, metformin, aspirin, statinActive smoker 4-5 cigarettes per day, 40+ PYHExaminationHR: 130, BP: 90/60, O2: 99% 2LNP, RR: 17, T: 37.9CLooks flat/sick. Unwilling to move much. DrowsyAbdo Ex: Abdominal guarding and rigidityInvestigationsFBE: 75/15.2/246 neut 11.2UEC: 150/3.2 Cr 265 eGFR 30 (baseline Cr 125)LFTs: normalCoags: INR 1.6ABG: pH 7.29 pCO2 29 HCO3 19 lactate 5.2

AXR: dilated oedematous bowel loopsDDx? Use Applied Anatomy!

Descending and Sigmoid ColonUreterLeft Ovary/Fallopian Tube

Treatment:IV resuscitationBlood Cultures and AbxNGT, IDCVit K (IV) to reverse INRConsent for urgent laparotomy + washout +/- proceed (eg Hartmans). Consider need for intraoperative Angiogram

Hartmans Procedure

Lets go back to Case 127yo female presents with 1d of abdominal painAbdominal Pain:Initially midline/umbilicalOver 24/24 transitioned to the RIFSevere, constantFurther Hx:LMP 8 weeks agoNo PV bledingSmokerHx of chlamydiaPrevious laparoscopic surgery for endometriosis

Onset, character and location of the pain Associated symptoms: bleeding, discharge, anorexia, vomiting,diarrhoea, fever Gynaecological history including menstrual history, last period,sexual history, contraception, Pap smears, dyspareunia Obstetric, surgical and medical history32O/EPain 2/10 after 10mg morphine IVObs: HR110 BP95/70 O2: 98% 4LNP RR20 T37.8CAbdominal examination as aboveWhat else do you need to do?ALL FEMALE PATIENTS OF REPRODUCTIVE AGE ARE PREGNANT UNTIL PROVEN OTHERWISE - b-HCG!Speculum examination and bimanual examination

O&G DifferentialsObstetricNon-ObstetricGynaecologicalEarly PregnancyEctopic pregnancyMiscarriageLate PregnancyPlacental abruptionUterine ruptureLabour / PPROMBraxton-HicksHELLPAcute fatty liverChoramnionitisSymphysis pubis dysfunctionRound ligament painFibroid degenerationAppendicitisPyelonephritisUTIGORDConstipationPancreatitisRenal colicCholecystitisBowel obstructionDiverticulitisIBDTrauma / AssaultMedical causes (pneumonia, DKA)

Ovarian torsionPIDRuptured ovarian cystEndometriosisAdenomyosisMittelschmertz

ACUTE ABDOMEN + POSITIVE PREGNANCY = ECTOPIC

until proven otherwise..Risk factors for Ectopic pregnancySmokingClomipheneIUDPIDPrevious ectopic pregnancyAdhesionsPelvic and tubal surgeryEndometriosisPelvic massesChromosomal abnormalitiesInvestigationCultures: urine B-HCGBloods: FBE, UEC, LFT, G+H, COAG, Serum B-HCG, Serum progesteroneSerum B-HCG >1500 I/U should see gestational sacSerum B-HCG > 10,000 should see heart beatSerum B-HCG should double every 48 hoursImaging: Transvaginal ultrasoundScopic: Diagnostic laparoscopy FIRST RESUSCITATITE, then..

IF PATIENT IS UNSTABLE DESPITE RESUSITATION URGENT LAPAROTOMY IS INDICATED

ManagementMedical:ONLY if fulfill criteria MethotrexateAnti-D if mum Rh-veFollow upContraception for 3 months as methotrexate teratogenic!Surgical:Anti-D if mum Rh-veDiagnostic Laparoscopy if patient is haemodynamically stableLaparotomy if patient unstableSalpingectomy or SalpingotomyManagement

Ovarian TorsionTorsion of ovary on its vascular, tubal and ligamentous pedicle (adnexal torsion)Results in ischaemia and eventual infarction if not relievedGYNAECOLOGICAL EMERGENCYRisk factors:Ovarian massCystMore common in reproductive ageSudden onset lower quadrant visceral painRadiate to flank or inner thighN+VCan sometimes develop slowlyTender lower quadrant Adnexal tenderness on bimanual examination +/- palpable mass

Investigation and ManagementB-HCG to rule out ectopic pregnancy!WCC tubo-ovarian abscessUrinalysis Doppler Ultrasound>50% sensitivity for torsion, but arterial flow does not rule outAbsence of arterial flow high predictive valueLaparoscopy / laparotomy +/- salpingo-oophorectomyOvarian Torsion

Other Differentials NOT TO MISSAATesticular torsionAMILower lobe pneumoniaQuestions???