Download Acute Abdomen

Acute Abdomen
Bondoc - Carrabeo
History of Present Illness
• 45 year old
• male
• CC: Severe abdominal Pain
History of Present Illness
3 days PTC
2 Hours PTC
ADMISSION
– On and off mild epigastric pain
– Radiating to the back
– relieved by food intake and intake of
omeprazole.
– severe epigastric pain
– became generalized
Past Medical History
• Past 6 months
– Recurrent epigastric pain
– Relieved by intake of Omeprazole (taken
irregularly)
Personal and Social History
• Smoker
• Occasional alcoholic beverage drinker
PHYSICAL EXAMINATION
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BP: 120/90
PR: 98/min
Temp: 37.9’C
RR:23/min.
The heart and lungs are unremarkable.
Abdominal findings
– absence of liver dullness
– direct and rebound tenderness
– generalized muscle guarding
• Rectal exam
– empty rectal vault.
Salient Features
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45-year old
male
with severe abdominal pain (2 hours duration)
radiating to the back
relieved by food intake and intake of omeprazole (irregular intake)
recurrent epigastric pain for the past 6 months
Smoker
occasionally drinks alcoholic beverages.
BP is 120/90; PR of 98/min; Temp of 37.9’C; RR of 23/min.
absence of liver dullness
with direct and rebound tenderness
generalized muscle guarding
empty rectal vault.
What is the diagnosis?
Perforation Secondary to Peptic
Ulcer Disease
Clinical Manifestations
• History: 90% complain of abdominal pain
– Nonradiating, ill-defined, aching sensation/hunger
pain, burning or gnawing in quality
• Physical examination: most common findings is
epigastric tenderness
• Pain that is relieved by antacids (Omeprazole) and food
occurs in Duodenal Ulcers
• Associated with nausea, bloating, weight loss and
(+) stool for occult blood and anemia
• Complications in decreasing order of
frequency include: bleeding >> perforation
and obstruction
– Sudden onset of severe generalized abdominal
pain with severely tender board-like abdomen
• Radiates to the back
– Ratinale: Duodenal ulcers tend to penetrate posteriorly into
the pancreas
What are the differential diagnoses?
How do you rule out the other
differential diagnoses?
Differential Diagnosis
• Patient
– 45-year old
– Male
– Severe epigastric pain
which became
generalized
• Acute Appendicitis
– Persons of any age may
be affected (20’s-40’s)
– Occurs more frequently
in males
– Epigastric or periumbilical pain localizing
to the RLQ
Differential Diagnosis
• Patient
– Started 3 days ago,
• on and off mild epigastric
pain, radiating to the back
– Recurrent epigastric pain
for the past 6 months
relieved by intake of
omeprazole
• Acute Appendicitis
– Pain is initially in the
epigastric or umbilical
area, moderately
severe, and steady,
sometimes with
intermittent cramping.
– After a period varying
from 1–12 h, the pain
localizes to the RLQ.
– Anorexia
– Vomiting
Differential Diagnosis
• Patient
– Vital signs:
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BP is 120/90
PR of 98/min
Temp of 37.9°C
RR of 23/min
– Direct and rebound
tenderness and
generalized muscle
guarding
• Acute Appendicitis
– Vital signs
• Minimally changed
• Temperature elevation is
rarely more than 1◦C
• the pulse rate is normal
or slightly elevated.
– Direct rebound
tenderness
• Maximal at the McBurney
point
Differential Diagnosis
• Patient
• Acute Pancreatitis
– 45-year old
– > 40
– Male
– M>F
– Severe epigastric pain
which became
generalized
– Severe epigastric pain
radiating to the back
Differential Diagnosis
• Patient
– Started 3 days ago,
• on and off mild epigastric
pain, radiating to the back
– Recurrent epigastric pain
for the past 6 months
relieved by intake of
omeprazole
• Acute Pancreatitis
– Pain is sudden in onset
– Gradual increase until it
reaches a steady, dull,
boring pain
Differential Diagnosis
• Patient
– Vital signs:
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BP is 120/90
PR of 98/min
Temp of 37.9°C
RR of 23/min
– Direct and rebound
tenderness and
generalized muscle
guarding
• Acute Pancreatitis
– Fever
– Tachycardia
– Abdominal tenderness,
muscle guarding (upper)
– Cullen’s/Grey Turner sign
Differential Diagnosis
• Patient
• Acute Cholecystitis
– 45-year old
– Male
– F>M
– Severe epigastric pain
which became
generalized
– Colicky RUQ pain,
radiating to the scapula
Differential Diagnosis
• Patient
– Started 3 days ago,
• on and off mild epigastric
pain, radiating to the back
– Recurrent epigastric pain
for the past 6 months
relieved by intake of
omeprazole
• Acute Cholecystitis
– History of biliary pain
– Epigastric pain which
then localizes to the
RUQ
– Colicky becoming
constant
Differential Diagnosis
• Patient
– Vital signs:
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• Acute Cholecystitis
– ...
BP is 120/90
PR of 98/min
Temp of 37.9°C
RR of 23/min
– Direct and rebound
tenderness and
generalized muscle
guarding
– Biliary colic, RUQ
tenderness, guarding
– Murphy’s/Courvoisier
sign
What are the laboratory tests to
be requested?
Laboratory Exams
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CBC- repeat WBC
Urinalysis
BUN, Serum creatinine
Serum electrolytes
Serum amylase
Serum alkaline
phosphatase, bilirubin,
serum transaminase
• Pregnancy test
• Upright chest film, flat
plate, SFA
• Ultrasound
• CT scan
What imaging studies to
request?
Upper GI Endoscopy
• a diagnostic endoscopic procedure that visualizes
the upper part of the gastrointestinal tract up to
the duodenum
• a minimally invasive procedure since it does not
require an incision and does not require any
significant recovery after the procedure
• Biopsy may be taken from stomach wall to test
for H. Pylori
• by direct visual identification, the location and
severity of an ulcer can be described.
– if no ulcer is present, EGD can often provide an
alternative diagnosis.
Upper GI Series
• A series of X-ray images of the esophagus,
stomach, and duodenum
• Preparation:
– Fasting the day prior to imaging
– Two medications
• Highly Carbonated
• Contrast agent (Barium swallow)
Upper GI Xray with Barium
1. Peptic ulcer
2. Body of the stomach
3. First part of duodenum
4. Peptic orifice
5. Pyloric antrum
Upright Chest X-ray
• free air in about 80% of patients
Pneumoperitoneum. Upright chest radiograph shows a
large pneumoperitoneum outlining the spleen and the
superior surface of the liver.
MANAGEMENT
A. Preoperative Preparation
Before Laparotomy
• Fluid resuscitation (with CVP or Swan Ganz
monitoring)
– CVP – catheterization in thoracic vena cava
– Swan Ganz – catheterization into the pulmonary artery
• Analgesia
• Antibiotics
• Nasogastric intubation
What IVF to use?
What antibiotics should be used?
Antimicrobial Agent Therapy
• Primary and Tertiary peritonitis
– Antimicrobial agents directed against pathogens
identified by cultures
• Secondary peritonitis
– Empiric therapy against gram negative aerobes
and anaerobes
Antimicrobial Agent Therapy
• Standard dual-agent therapy
• Non-standard dual-agent therapy
• Broad-spectrum single-agent therapy
Standard dual-agent therapy
• Aminoglycoside + either Clindamycin or
Metronidazole
– Effectively treats most gram negative aerobic and
anaerobic pathogens
– Previously healthy with normal renal function not
requiring a prolonged therapy
Nonstandard dual-agent therapy
• Aminoglycoside component is replaced
• Second or third generation cephalosporins
without anaerobic coverage
– Cefotaxime, Cefepime
• Monobactam
– Aztreonam
• Quinolone
– Ciprofloxacin, Levofloxacin
• + Clindamycin or Metronidazole
Broad-spectrum single-agent therapy
• Possess aerobic and anaerobic activity
– Ampicillin-sulbactam
– Cefoxitin
– Cefotetan
– Ceftriaxone
• For mild to moderate disease
– Gangrenous appendicitis
– Peridiverticular absces
Broad-spectrum single-agent therapy
• Severe initial disease, secondary peritonitis
after abdominal surgery, immunosuppressed
– Imipenem-cilastatin
– Meropenem
– Piperacillin-tazobactam
– Ticarcillin-clavulanate
Duration of antimicrobial therapy
• Uncomplicated disease
–Gangrenous appendicitis
–3 -5 days
• Complicated disease
–With diffuse fibrinopurulent peritonitis
–5 -10 days
• Immunosuppressed
–10 -14 days
Peptic Ulcer Perforation
Bismuth triple therapy
PPI triple therapy
Quadruple therapy
Bismuth, 2 tablets QID
+
Metronidazole 250 mg TID
+
Teracycline 500 mg QID
Proton-pump inhibitor BID
+
Amoxicillin 1000 mg BID
+
Clarithromycin 500 mg BID
or
Metronidazole 500 mg BID
Proton-pump inhibitor BID
+
Bismuth 2 tabs QID
+
Metronidazole 250 mg TID
+
Tetracycline 500 mg QID
Criteria for cessation of antibiotic therapy
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Good general condition
Afebrile for at least 24 hours
Normal abdominal findings
Return of bowel function
WBC < 12000/mm3
Monitoring of fluid resuscitation
Monitoring of fluid resuscitation
• Reversal of the signs of volume deficit
– Restoration of vital signs
– Maintenance of adequate urine output
• (0.5 to 1 mL/kg per hour)
– Correction of base deficit
• Patients who fail to correct their volume deficit,
those with impaired renal function, and the
elderly
– ICU setting
– Central venous pressure
B. Intraoperative Care
Intraoperative Care
• Simple closure reinforced with Graham’s
omental patch, with or without vagotomy and
pyloroplasty, or with a highly selective
vagotomy
• Oversew of ulcer first performed by Dean in
1894
• Usually performed through
an upper midline incision
Graham’s Omental Patch
• Oversew perforation with omental
patch
• Take 1 cm bites either side of ulcer
• Multiple seromuscular 2-0 silk
sutures are placed adjacent to the
edges of the perforated ulcer.
• A segment of omentum is placed
over the perforation, and the sutures
are tied down.
• Thorough wash out and irrigation of
peritoneal cavity with 0.9% saline
Intraoperative Care
• Multiple perforations can occur
• If unable to find perforation open the less sac
• If closure secure and adequate toilet then a
drain is not required
• Definitive ulcer surgery may not be required
C. Postoperative Care
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Monitor vital signs
Analgesics are given as needed
Antimicrobial treatment 3-5 days
Intravenous therapy
Assess surgical site infections
Antibiotics for H.pylori
Thank You!