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Intraperitoneal & retroperitoneal haemorrhage Complex ethiology any vascular lesion if big enough Lesions of solid organs – Liver, spleen, kidney, pancreas Lesions of hollow organs and mesentery Lesions of parietal vessels (cirrhosis) Genital lesions: extra uterine pregnancy Fractures of vertebral column Lesions of big retroperitoneal vessels (aorta, IVC, etc) Postoperative Many others Symptoms Hemorrhagic syndrome – Symptoms develop in hours – Cataclismic hemorrhage Clinical presentations – – – – Pale Agitation, pseudo-psychotic manifestations Hypotension Oliguria/anuria Abdominal evaluation Inspection: may be enlarged, especially in massive haemorrhage Sensibility: spontaneous and o palpation Ausculation: intestinal sound may be diminished due to peritoneal irritation Percution: – free liquid in the abdomen (movable dullness) – Increased liver or splenic dullness Careful anamnesis: STRANGE SITUATION Ectopic pregnancy – major cause of hemoperitoneum Progression of a hematoma in sequences Pelvic griddle and vertebral fractures can bleed in the free peritoneum Iatrogenic lesions Progression with a FREE INTERVAL Trauma Silent period – almost no symptoms – SUBCAPSULAR HEMATOMA will form in this time – Hematoma ruptures in the peritoneal cavity hemoperitoneum Lab work Plain abdominal X-Ray Abdominal US – Can demonstrate free liquid in the peritoneal cavity + specific character of blood – Can show lesions and abnormalities in the structure of solid organs – Can demonstrate pregnancy or signs associated with ectopic preganancy Paracentesis + lavaj Particular aspects of retroperitoneal hemorrhage Frequently in the context of polytrauma “No room” closed space –possible spontaneus hemostasis Clinical forms – Small unnoticed hematoma – Large volume: “tumor like” appearance – Echimosis may appear due to blood migration Special evaluation aiming for a retroperitoneal hematoma US scan – special attention for kidney and large vessels Intravenous urography Rx for vertebral column and pelvic griddle CT scan Paracentesis + lavaj Upper GI bleeding Syndrome: GROUP of diseases which may be unrelated Upper GI bleeding - definition Internal hemorrhage becoming exteriorized Hematemesis – above the angle of Treitz Melena – above the ileo-cecal valve Hematochesis (fresh blood per anum) – bellow splenic flexure Hypovolemic shock – the only manifestation Main causes Duodenal ulcer Erosive gastritis Gastric ulcer Esofageal varices Esofagitis Sdr. M-W Erosive duodenitis Tumors 24% 23% 21% 10% 8% 7% 6% 3% Large geographical variations DIAGNOSTIC VS TREATAMENT EMERGENCY Urgent treatment should precede complete diagnostic Sequence – Positive diagnostic - GI bleeding – Resuscitation – Empiric treatment – Ethologic diagnostic – Specific treatment Homodynamic evaluation pulse + blood pressure Shock – systemic blood pressure in decubitus <90mmHG – 50% din VC No shock – BP and pulse checked in ortostatism – BP<90 lost = 25-50% – BP-10 or pulse >120/min = 20-25% MONITOR PATIENTS -REBLEEDING MODELS CONTINUOUS BLEEDING • No response to treatment • No major rebleeding • Clinical observation = ESSENTIAL MAJOR REBLEEDING EPISODE • Sudden onset • Most frequently in ICU • Cases only with hypovolemic shock Rebleeding – major prognostic factor Definition: bleeding after a succesfull attempt to maintain hemodynamic stability High mortality: 3x 3 major risk factors for morbidity and mortality Major rebleeding in the hospital Old age Total amount of transfused blood WHAT IS THE CAUSE? Clinical evaluation X-Ray and US scan endoscopy “GOLD DIAGNOSTIC” ANAMNESIS patient + relatives Describe bleeding – Quantities can not be approximated Other signs during or before onset PMH – suggestive for a medical problem that may cause bleeding Hereditary problems Alcohol intake False bleeding, false upper GI bleeding Medication Coughing before hematemesis Mouth bleeding CLINIICAL EVALUTATION Hemodynamic evaluation Confirm upper GI bleeding • HEMATEMESIS, MELENA or RECTAL • ENT evaluation. Clinical signs suggestive for liver cirrhosis (liver and spleen size, ascites,colateral circulation, spider hemangioma,Dupuytren,etc) Tumors Other diseases that can produce GI bleeding IMAGISTICS Can be of major interest Rx thorax • Pleuresia • Tuberculosis • Primary or secundary tumors US abdominal • Liver cirrhosis • Abdominal tumors Barium meal • Bad alternative when endoscopy is irrelevant ENDOSCOPY Establishes: SOURCE OR SOURCES OF BLEEDING Evaluation of RISK OF REBLEEDING THERAPEUTIC ACCES to lesion FIRST LESION: “MIRAGE” Esophageal causes Varices Mallory-Weiss Hiatal hernia and reflux Esophageal tumors Varices Endoscopic diagnosis can be difficult • • • • Massive bleeding Clots Gastric varices Portal encephalopathy 60% of cirrhotic pateints bleed form varices M-W SYNDROM Diagnostic possible ONLY WITH EMERGENCY ENDOSCOPY • Lesions are short lived – Hypovolemic shoch is unlikely but not impossible – Short hospital stay – Very small risk of rebleeding Hiatus hernia and reflux Stigmata of recent bleeding HH is very frequent TUMORS Overt GI bleeding is rare, frequently occult bleeding Gastric sources of bleeding Hemorrhagic gastritis Gastric ulcer Benign tumors Malignant tumors Hemorrhagic gastritis DG: morphologic criteria Endoscopic aspect is not diagnostic Barium meal: useless and loss of money Gastric ulcer Diagnostic can be difficult EDS: stigmata of recent bleeding Risk of rebleeding evaluation Benign tumors Very unlikely, round circumscribed tumors with central ulcerations Malignant tumors Ex. endoscopic Locally advanced tumor Endoscopic hemostasis US scan MTS + lymphnodes Upper GI bleeding with duodenal origin Very frequent Empiric treatment of upper GI bleeding It is much to easy to say that a bleeding originates from a duodenal ulcer without endoscopy Erosive gastritis Term misused for many unknown situations responsible for bleeding Superficial ulcerations usually described as superficial ulcer – easier to comprehend HP infection Bleeding peptic duodenal ulcer Relatively frequent although potent medication is on the market 53% previous diagnostic of ulcer 17% iterative: More serious, high risk of rebleeding 25% no previous cause!!! Known diagnostic-treat that Rebleeding risk INTESTINAL OBSTRUCTION SYNDROME, MANY DISEASES Small bowell obstruction Essentials of diagnostic Complete high obstruction Low obstruction – Colicky pain – Vomiting – Vomiting – Abdominal discomfort – Abdominal distension – Rx changes – No intestinal transit – Hyperperistaltic movements – A/F levels 2 major forms of obstruction Simple – Mechanical – Paralitical Strangulation – Vascular component Causes Postoperative adhesions – most frequent All hernias Tumors (intraluminal, parietal sor extraintestinal) Invagination Volvulus Foreign bodies Billiary ileus Inflammatory bowel disease Stenosis Hematoma Etc Symptoms Colicky abdominal pain (no in very high small bowell obstruction) – Crescendo-descrescendo – Seconds - minutes – No pain between Vomiting – Dominant symptom – Intervals depending on localization of obstruction – More distal - fecaloid Symptoms No transit for feaces or gas per anum – Feaces can be present in large bowel. Initial normal defecation General signs may be absent or minimal – Dehydration – No fever Abdomen: – – – – – – Abdominal distension (not in high obstruction) Hyperperistaltic waves can be seen on the abdomen Abdomen may be tender NO signs of peritoneal iritation Abnormal sounds CHECK FOR HERNIA Paraclinical Lab: non-specific – Hemoconcentration (increased WBC, hyperglicemia) – Electrolytic imbalance – High level serum amilase Plain abdominal X-Ray – A/F levels and their position and form – Hydrosoluble contrast media Particularities of strangulation Shock develops very early Pain is less colicky and becomes permanent Fever Vomiting + blood strikes Abdominal guarding Particularities of strangulation High WBC Rx: – Loss of normal mucosal lining – Air in portal veins or in intestinal wall – F/A levels outside intestinal lumen: abscess or pneumoperitoneum LARGE BOWEL OBSTRUCTION Essentials of diagnostic Constipation or no feaces or flatus per anum Meteorism +/- guarding Abdominal pain Nausea and vomiting – late Important Rx findings Frequent causes Colonic malignant tumor Volvulus Diverticulosis infected IBD Benign tumors Fecal impactation Lesions outside digestive tract Symptoms Dependent on the cometepence of ileocecal valve – Valvular lesion – similar with ileal obstruction – Competent valve – no vomiting – Incompetent valve - vomiting Closed loop syndrome – Risk of cecal perforation Symptoms Progressive onset (mechanical obstruction) Dull pain mainly in hypogastrium – Fixed colonic lesion may produce localized pain – Continuous pain - ischemia Borborism associated with colicky pain No feaces no flatus Vomiting: changing character Clinica examination Meteorism and timpanism Peristaltic waves on abdominal wall Specific sounds - obstruction Peritoneal irritation symptoms Rectal – Bloos – Tumor – Invagination pseudotumor Radiology Colonic distention with gas F/A levels (colonic) Mixed A/F level signs if the ileo-cecal valve is incompetent Barium enema (or water-soluble solution) – Level of obstruction – Ethiology – Devolvulation Differential diagnostic Low/high obstruction Ileus (paralitic) Pseudo-obstruction Signs in acute pancreatitis Abdominal drama Essentials of diagnostic ABDOMINAL PAIN – Sudden onset – Dull pain irradiating transverse and to the back Vomiting, Sweating, Fever Distended abdomen High WBC, amilazemia, amilazuria, lipazemia PMH: alcohol, billiary calculus General data Severe inflammatory disease Abnormal activation of pancreatic enzymes Causes: – Alcohol, billiary calculus – Hypercalcemia, hyperlipidemie, trauma, reaction to medicines, vasculitis, infections Inflamation: edema – hemorrhagic, necrotic severe form Symptoms PAIN Epigastric, severe, continuous, relieved in genu-pectoral position ; IRRADIATION: TRANSVERSE Nauseam vomiting: CHARACTERISTIC – impossibility to eat or drink PMH: alcohol or billiary colicky Abdominal examination Very few elements Diffuse sensibility in upper half of the abdomen Ussually no guarding and no signs of peritoneal irritation Paralitic Ileus – Abdominal distension – No bowel sounds – No flatus per anum Abdominal pseudotumor in epigastrium and left upper quadran General status High fever>38 Septic state (tachycardia, hypotension, septic shock, palor, could periphery) Jaundice (either compression, obstruction or secondary liver failure) Renal failure Lab WBC 10.000-30.000 Hyperglicemia High billirubin High alkaline fosfataze Hypocalcemia (loss of albumin through extraasation) ~ severity Amilaze si lipaze serum + pleural and peritoneal effusion Imagistic Plain abdominal X-Ray = MUST – Differential dg. acute abdomen – Sentinel looop – left upper quadrant – Left pleural effusion + atelectasis – Incomplete F/A levels – Billiary stones – Fluid in the abdominal cavity Imagistic US – Standard procedure in screening – PROBLEM: air content – Pancreas: dimensions, edema, liquid collection pseudocysts – Free fluid in the abdomen and pleura – Guided aspiration for diagnostic Imagistic CT scan + contrast – Best for diagnostic and follow up – Information on pancreatic structure and fluid collections – Pancreatic tissue viability – Evaluation of peripancreatic collections – Free air in collections!!!! Imagistic MRI – No major advantages – Superior for the description of billiary duct – Not specifically indicated in acute pancreatitis Differential diagnostic Anything in acute abdomen Myocardial infarction After ERCP Urlian virus infection Intestinal obstruction Aortic dissection Mesenteric obstruction Differential diagnostic SIGNIFICANCE NO LAPAROTOMY NO LAPAROSCOPY IF DIAGNOSTIC – Sure – No billiary obstruction (except compression) – No suspicion of infection