Download ACUTE ABDOMEN

ACUTE ABDOMEN
DR. D.VINDHYA
Dept of Emergency & Critical Care Medicine,
Vinayaka Mission Medical College & Hospital,
Salem
• Visceral pain
– Distension, inflammation or ischemia in hollow viscous &
solid organs
– Localisation depends on the embryologic origin of the
organ:
• Foregut to epigastrium
• Midgut to umbilicus
• Hindgut to the hypogastric region
• Parietal painis localised to the dermatome
above the site of the
stimulus.
• Referred pain
– produces symptoms, not
signs e.g. tenderness
Abdominal topography
HISTORY
•
Site
• Nature & character
• Duration
• Intensity
• Precipitating & relieving factors
• Associated symptoms
• Previous episodes of AP
• Investigations
• Chronic disease
• Immunosuppression
• Medications (NSAIDs)
• surgeries
Generalised abdominal pain
•
•
•
•
•
Perforation
AAA
Acute pancreatitis
DM
Bilateral pleurisy
Central abdominal pain
• Early appendicitis
• SBO
• Acute gastritis
• Acute pancreatitis
• Ruptured AAA
• Mesenteric thrombosis
Epigastric pain
• DU / GU
• Oesophagitis
• Acute pancreatitis
• AAA
RUQ pain
• Gallbladder disease
• DU
• Acute pancreatitis
• Pneumonia
• Sub phrenic abscess
Differential diagnosis of RUQ pain
CONDITION
CLUES
Biliary colic, acute cholecystitis
Recurrent attacks, tender over gall
bladder area
Acute hepatitis
Alcohol h/o, medications, icterus
Acute pyelonephritis
Dysuria, fever, costovertebral angle
tenderness
CCF
Edema, dyspnoea, elevated JVP
Retrocaecal appendicitis
Shift of pain, tenderness
Right lower lobe pneumonia
Fever, tachypnoea, bronchial
LUQ pain
• GU
• Pneumonia
• Acute pancreatitis
• Spontaneous splenic
rupture
• Acute perinephritis
• Sub phrenic abscess
Differential diagnosis of LUQ &
epigastric pain
CONDITION
CLUES
Splenic rupture
h/o trauma or splenic disease
Fractured ribs
h/o trauma, gross deformity, extreme
tenderness on palpation
pancreatitis
h/o alcohol consumption, past h/o,
labs
Gastritis, peptic ulcer disease
Recurrent relationship to posture or
meals
Supra pubic pain
• Acute urinary retention
• UTIs
• Cystitis
• PID
• Ectopic pregnancy
• Diverticulitis
RIF pain
• Acute appendicitis
• Mesenteric adenitis
• DU perf, Diverticulitis
• PID, Salpingitis
• Ureteric colic
• Meckel’s diverticulum
• Ectopic pregnancy
• Crohn’s disease
• Biliary colic (low-lying gall bladder)
Differential diagnosis of RLQ pain
CONDITIONS
CLUES
Mesentric adenitis
Fever, inconstant signs
Rt renal colic
Colic pain ,haematuria
Rt.testis torsion
Tender swollen testis
Crohns disease
Recurrent h/o diarrhoea, colicky
pain, wt loss
Gynecological causes of RLQ pain
CONDITION
CLUES
Ruptured follicle
Fever, cervical discharge
Torsion ovary
Midcycle, sudden onset
Ruptured ectopic pregnancy
Severe pain, shock, missed periods
PID
sever pain, foul smelling
discharge, dyspareunia
LIF pain
•
Diverticulitis
•
Constipation
•
IBS
•
PID
•
Rectal Ca
•
UC
• Ectopic pregnancy
Differential diagnosis of LLQ pain
CONDITIONS
CLUES
Diverticular disease
Elderly patient recurrent
Acute urinary retention
Palpable bladder, difficulty in
passing urine
Urinary tract infection
Dysuria, frequency
Inflammatory bowel disease
Recurrent attacks, diarrhoea
Large bowel obstruction
Colicky pain, constipation
Ischemic bowel disease
Rectal bleeding, pain out of
proportion to examination
Systemic examination
• Inspection- Flat, reduced movements in peptic ulcer perforation
- Distended in ascites or intestinal obstruction
- Visible peristalsis in a thin or malnourished patient (with
obstruction)
GREY TURNER’S
SIGN
RETROPERITONEAL
HEMORRAGE
• Discoloration of the
flank
CULLEN’S SIGN
RETROPERITONEAL
HEMORRAGE
• Bluish periumbilical
discoloration
Palpation
• Check for Hernia sites
• Tenderness
• Rebound tenderness
• Guarding- involuntary spasm of muscles
during palpation
• Rigidity- when abdominal muscles are tense & board-like.
Indicates peritonitis. Do not miss tetanus!
MC BURNEY’S SIGN
ACUTE APPENDICITIS
• Tenderness located 2/3
distance from
anterior iliac spine to
umbilicus on right side
ILIO PSOAS SIGN
ACUTE APPENDICITIS
• Hyperextension of right
hip causing abdominal
pain ( retrocecal)
OBTURATOR SIGN
ACUTE APPENDICITIS
• Internal rotation of
flexed right hip causing
abdominal pain (pelvic)
MURPHY’S SIGN
Acute cholecystitis
• Abrupt interruption of
inspiration on palpation
of right upper quadrant
ROVSING’S SIGN
Acute appendicitis
• Right lower quadrant
pain with palpation of
the left lower quadrant
KEHR’S SIGN
• Severe left shoulder
pain
• Splenic rupture
Ectopic pregnancy
rupture
CHANDELIER’S SIGN
PELVIC INFLAMMATORY
DISEASE
• Manipulation of cervix
causes patient to lift
buttocks off table
• Auscultation
• BS
– > 2min to confirm absent
– High pitched, hyperactive or tinkling
– Bruit in epigastrium
PR Examination:
- tenderness
- induration
- mass
- frank blood
Investigations
• CBC
• Amylase & lipase
• Erect & supine abdominal XRay
• stool & Urine analysis,
• pregnancy test, USG, CT scan
• If severe, unrelenting pain urgent surgical referral
Initial management
• Stabilise ABC
• Resuscitate the patient
• Shift for investigation only after stabilising
the pt
• Remember to reassess patient on a regular basis.
Airway management
• Pt’s SPO2 – is low or when RR IS > 35/min
• When the depth of breathing is shallow &
inadequate
• When the pt’s GCS is not adequate to
maintain a patent airway
• When the pattern of breathing is inappropriate
circulation
• Care to adequately hydrate the pt.
• If pt’s cardiac status is compromised then
CVP guided fluids should be administered.
• A careful monitoring of I/O should be maintained
Analgesia
• Adequate analgesia should be provided in
the ER
• Shift the pt only when the pt is stabilised
Supine ray
• Dilated bowel loop
pattern, obstruction,
closed loop, bowel
wall edema
Chest xray
• Gas under diaphragm
IVP
To detect renal calculi,
ureteric obstruction
USG
ascitis
cholecystitis
Acute pancreatitis
• CT detects acute
pancreatitis, small
bowel obstruction,
diverticulitis, abscess,
bowel infarction
CT images
Ureteric calculi
• Detecting ureteric calculi ,
appendicitis
CASE DISCUSSIONS
Case 1
• A male pt aged 17yrs developed mild periumblical
discomfort not influenced by activity. Several hrs
later pain intensifies but is now localised to
RLQ.Movement becomes painful
• INVESTIGATION OF CHOICE ?
• Abdomino pelvic CT
Treatment
• Initial stabilisation
• Early appendicectomy within 4-12 hrs of initial
presentation
CASE 2
• A 47 yr old obese lady developed severe mid-epigastric
pain. Pain not influenced with any position or movement.
• O/E pt’s temp -100 degree, Tachycardia +, murphy’s sign
positive
• INVESTIGATIONS?
• Xray
• USG – study of choice to detect stone < 2mm
• HIDA scans – investigation of choice
Treatment
• Initial stabilisation
• cholecystectomy
•
open
laparoscopy
CASE 3
• A 62yr old man C/O severe abdominal pain – generalised in
nature. H/O consumption of NSAIDS. He also c/o lt
shoulder pain. He feels more comfortable sitting than lying.
• O/E pt conscious ,afebrile, sweating profusely
• HR-120/min, BP-120/90 mm hg
• Abd- rigid, tenderness ,rebound tenderness & guarding
present in all quadrants .percussion –absence of liver
dullness
• What is the likely diagnosis?
• Investigations ?
Chest xray
• IMP- PERITONITIS
FOLLOWING DU
PERFORATION
• ? tetanus
Treatment
• Initial stabilisation
• Laparotomy & DU perforation closure
Case 4
• A 34y old female pt rushed to ER in shock. O/E
• HR-120/min, BP- 90/60mmhg,
• RR-26/min, SPO2-94% on RA
• CVS, RS – NAD
• ABD – LLQ tenderness +
•
Next ?
• Pt’s LMP – 1&1/2 mth back – H/O
• Investigation?
• Urine HCG
• Pelvic USG
• IMP- ECTOPIC
PREGNANCY
Treatment
• Initial stabilisation
• Anti D in RH negative mother
•
laparoscopic salpingostomy
Case 5
• A 23 yr old student brought to ER writhing with pain
radiating from lt lumbar to groin associated with vomiting
• Next ?
• Xray KUB ,IVP
• USG
• IMP- URETERIC COLIC
Treatment
• Initial stabilisation
• Expectant treatment
• Ureteroscopic removal
• ureterolithotomy
Case 6
• A 65 yr old male, known diabetic admitted at 9pm with h/o
abdominal pain associated with profuse sweating &
vomiting since evening 7pm O/E HR- 68/min, BP – 90/70
mmhg. What next?
•
ECG done – ANTERIOR
WALL MI
Management
• Initial stabilisation
• Nasal O2,Aspirin, clopilet, NTG
• Consider thrombolysis
Case 7
• A 42yr old male pt, known alcoholic presented to our ER
with H/O persistent epigastric pain improving on bending
forward & worsens with lying down .
• O/E vitals are stable except for tachycardia
• Systemic examination – NAD except for tenderness in the
epigastric region
• What is the likely diagnosis?
• What are the investigations to
be done?
• S.amylase elevated
• Xray – colon cutoff
sign
IMP- ACUTE PANCREATITIS
Management
• Initial stabilisation
• Prophylactic antibiotics
• Nutrition
• Treat the cause
Case 8
• 23 yr old female pt delivered 2 days back with c/o vomiting,
abdominal pain & constipation since the time of delivery
• Usg abdomen
shows -
• Target sign.
• Diagnosis?
• Treatment ?
Carry home message
• Our priority- ABC
• All abdominal aches need not arise from the abdomen
• Adequate hydration, adequate analgesia, appropriate
antibiotic coverage at ER
THANQ