recent updates in acute abdomen management dr. dr. toar jm lalisang, spb(k)bd digestive surgery...
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Recent Updates in Recent Updates in Acute Abdomen Acute Abdomen
ManagementManagement
DR. Dr. Toar JM Lalisang, SpB(K)BDDR. Dr. Toar JM Lalisang, SpB(K)BDDigestive Surgery Division – Department of Surgery Digestive Surgery Division – Department of Surgery
Faculty of Medicine, University of IndonesiaFaculty of Medicine, University of Indonesia
Cipto Mangunkusumo HospitalCipto Mangunkusumo Hospital
The Acute Abdomen
The Abdomen - Anatomy
Acute Abdomen
Hippocrates Celsus
illiac passion ileus volvulus
Digestive Surgery Division – Department of Surgery Faculty of Medicine, University of Indonesia - Cipto Mangunkusumo Hospital
Acute Abdomen
• Be defined generally as an intra abdominal process causing severe pain and often requiring surgical intervention.
Acute AbdomenAcute conditions of the abdomen are produced by : congenital inflammatory obstructive trauma vascular mechanisms or high intra abdominal pressure
manifested by sudden onset of abdominal pain, gastrointestinal symptoms and varying degrees of local and systemic reaction.
Causes and Pathophysiology of Acute Abdomen
Inflamation
Causes and Pathophysiology of Acute Abdomen
Perforated Viscous
Causes and Pathophysiology of Acute Abdomen
Mechanical
HISTORY IN PATIENT WITH ACUTE ABDOMEN
Where is the pain ?
Question No.1 :
It is important to know :The originThe locationRadiation and Character of abdominal pain
in order to understand its significance.
Characteristics of the Acute Abdomen
• Since pain is the most prominent presenting complaint in a patient with an acute abdomen,
• The perception of abdominal pain is first visceral and then becomes somatic.
Pathophysiology • Visceral pain :– Distention, inflammation or
ischaemia in hollow viscous & solid organs
– Localisation depends on the embryologic origin of the organ:
• Forgut to epigastrium• Midgut to umbilicus• Hindgut to the
hypogastric region• Parietal pain :
– is localised to the dermatome above the site of the stimulus.
• Referred pain :– produces symptoms, not
signs e.g. tenderness
Acute Abdominal Pain
Visceral Pain Somatic Pain
Visceral sensation Parietal sensation
Ischemic/Extention Mechanic/Chemical
Vague Localized
Dull Sharp
Autonomy symptomps (+) Autonomy symptomps (-)
Does the pain travel to any other part of the body ?
Question No. 2 :What is the pain like ?
• Acute waves of sharp constricting pain that “take the breath away” renal or biliary colic
• Waves of dull pain with vomiting intestinal obstruction• Colicky pain that becomes steady appendicitis, strangulating
intestinal obstruction, mesenteric ischemia• Sharp, constant pain, worsened by movement peritonitis• Tearing pain dissecting aneurysm• Dull ache initial epigastric pain in appendicitis, diverticulitis,
pyelonephritis• Aching pelvic inflammatory disease • Pleuritic intensified by breathing • Lancinating acute pancreatitis
Classic Appendicitis
• Patient presents initially with vague peri-umbilical pain with associated nausea and vomitting due to distention of the appendix (visceral peritoneum).
• Followed by localized RLQ pain due to progression of inflammation to parietal peritoneum.
Infected Appendix and Fecolith
Perforated Appendicitis
Meckel’s Diverticulum
Intestinal Perforation
If the answer is “Yes” suggests recurrent problems such as ulcer disease, gallstone colic or diverticulitis.
Question No. 3 :Have you had it before ?
Question No. 4 :Was the onset sudden ?• Yes, Sudden : “like a light switching on”
(perforated ulcer, renal stone, ruptured ectopic pregnancy, torsion of ovary or testis, some ruptured aneurysms).
• No, Less sudden : most other causes (gradual pain mesenteric thrombosis)
Question No. 5 :How severe is the pain (intensity of the pain) ?
• Severe pain (perforated viscus, kidney stone, peritonitis, pancreatitis)
• Moderate appendicitis • Pain out of proportion to physical findings (mesenteric
ischemia)
Gaster Perforation
Kidney Stone
Ureter Stone
Question No.6 :What is the temporal features of the pain ?
• Continuous - acute pancreatitis • Pulsatile - abdominal aneurysm • Colicky - lumen obstruction, intermittent
severe pain with pain-free intervals
Frequency & duration transient pain of short duration which does not recur is usually insignificant.
The longer the duration the more likely a surgical condition.
Question No. 7 :What other symptoms occur with the pain?
• Vomiting precedes pain and is followed by diarrhea (gastroenteritis).
• Delayed, repeated vomiting, absent bowel movement and flatus, large amounts, often bile stained and may become fecal (acute intestinal obstruction; the delay increases with a lower site of obstruction).
Erect Supine
LLD
Mechanical Obstruction
Strangulated Right Scrotal Hernia
Protracted vomiting
• Early : in high GI obstruction
• Late : in low GI obstruction
• Character of vomitus : blood - bleeding ulcer bile stained - obstruction below ampulla of
Vater fecal - intestinal obstruction, mechanical or with
paralytic ileus; copious amount
Question No. 8 :What are the factors which may intensify or relieve pain ?
• Relation to meals - peptic ulcer pain relieved by food. Cholecystitis pain aggravated by fatty meal.
• Posture jack-knifing leg drawn up, to decrease peritoneal irritation in suppurative appendicitis.
• Motion - any movement causes intense pain in generalized peritonitis and the patient lies motionless.
• Diarrhea most common with acute gastroenteritis or food poisoning, but it may occur with appendicitis or other focal inflammatory lesions of the gut
• Constipation or obstipation – Complete small bowel obstruction -
unrelenting constipation (obstipation) after fecal material below obstruction has been passed.
– Progressive constipation with carcinoma of the large bowel.
• Gas stoppage with decreased or absent bowel sounds - paralytic ileus
Pain Vomiting Abdominal distension Constipation Diarrhea Hematemesis & Melena Haematoschezia
Acute ABDOMEN - Symptoms & Sign
Patient's Symptoms
• All of the patient's symptoms must be carefully considered and analyzed, especially with regard to organs most likely to give rise to acute conditions.
• Extra-abdominal conditions which simulate the acute abdomen arise most often in the heart, lungs, urinary tract and female reproductive organs.
System Disease System Disease
Cardiac Myocardial infarction
Acute pericarditis
Endocrine Diab ketoacidosis
Addisonian crisis
Pulmonary Pneumonia
Pulmonary infarction
PE
Metabolic Acute porphyria
Mediterranean fever
Hyperlipidemia
GI Acute pancreatitis
Gastroenteritis
Acute hepatitis
Musculo- skeletal
Rectus muscle hematoma
GU Pyelonephritis CNS
PNS
Tabes dorsalis (syph)
Nerve root compression
Vascular Aortic dissection Heme Sickle cell crisis
Extra – abdominal Conditions Associated with Acute Abdominal Pain
Volvulus
Invagination
The age and sex…..
• Females - gallbladder - female, fair, fat, forty (4F), Ectopic pregnancy, PID.
• Older age - mesenteric thrombosis or embolus often after myocardial infarction, large bowel neoplasms, diverticulitis.
• Past history of disease or abdominal operation :– abdominal scars – adhesions – intestinal obstruction, peptic ulcer - possible perforation – chronic cholecystitis or biliary colic - acute cholecystitis
PHYSICAL EXAMINATION
Important Signs in Patients with Abdominal Pain
Sign Finding Association
Cullen's sign Bluish periumbilicaldiscoloration
Retroperitoneal haemorrhage
Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy rupture
McBurney's sign Tenderness located 2/3 distance fromanterior iliac spine to umbilicus on right side
Appendicitis
Murphy's sign Abrupt interruption of inspiration on palpationof right upper quadrant
Acute cholecystitis
Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis
Obturator's sign Internal rotation of flexed right hip causingabdominal pain
Appendicitis
Grey-Turner's sign
Discoloration of the flank Retroperitoneal haemorrhage
Chandelier sign Manipulation of cervix causes patient to liftbuttocks off table
Pelvic inflammatory disease
Rovsing's sign Right lower quadrant pain with palpation of the left lower quadrant
Appendicitis
Digital Rectal Examination
• Important physical examination in acute abdomen :
Abdominal Compartment Syndrome
Physical Examination in Acute Abdomen
General Condition Circulation Tenderness Fever Shock
Laboratory Examination
Routine Blood Test Specific Test (amilase) Urine test
Certain lab tests when associated with characteristic clinical features :
• Markedly elevated serum amylase levels acute pancreatitis
• Free air under diaphragm in an upright x-ray film perforation of a hollow viscus usually a duodenal ulcer
• Distended loops of small bowel above the level of obstruction in small bowel obstruction with absence of gas below by x-ray; generalized distention of large and small bowel paralytic
Imaging
Plain abd X - rays USG CT Scan DPL Endoscopic Laparoscopic
Free Air
Free Air
Double Wall and Football Sign
Double Wall and Football Sign
MANAGEMENT IN ACUTE ABDOMEN
I V line Resuscitation Decompression Catheterization Antibiotic
Acute Abdomen Management
Pain is the most aggravated symptoms must be overcome first !!!
Action on Acute Abdomen
• Require immediate surgery• Require watchful expectancy, • Require medical rather than surgical management
• Often the patient's condition is such that extensive laboratory investigation requiring many hours would compromise the patient's life.
• The outcome often depends on a precise and detailed history and physical examination.
Surgical Interventions
• Surgical intervention is mandatory in : Severe abdominal pain in patients who have
been fairly well, and which persists as long as six hours.
Persistent localized tenderness with muscle spasm, indicative of localized peritoneal inflammation The tenderness may be best determined by rectal or pelvic exam.
Characteristic, severe, intermittent cramping, colicky pain, with obstruction of a hollow viscus.
Surgical Case• Markedly hyperactive bowel sounds with
small intestinal obstruction, or decreased to absent bowel sounds with paralytic ileus.
• Paralytic ileus not secondary to other abdominal pathology is treated nonsurgically.
• Paralytic ileus as an end-result of mechanical small bowel obstruction or perforated duodenal ulcer requires surgical intervention to relieve the underlying pathology.
• Repeated vomiting of copious amounts of bile-stained or fecal material - in small bowel obstruction.
• Palpation of a mass : In RLQ or RUQ intussusception. Adnexal mass by pelvic exam ectopic pregnancy. Tender and thickened adnexae by pelvic PID. An irreducible incarcerated inguinal hernia. A tender RLQ mass by abdominal palpation or rectal
exam appendiceal abscess.
Surgical Case
Surgical Intervention in Acute Abdomen Severe contaminated peritonitis Strangulated GI Obstruction GI obstruction + Respiratory distress Perforation Abdominal shot gun wound. Penetrated Abdominal wound Massive GI bleeding ABOMINAL COMPARTMENT SYNDROME (ACS)
ABDOMINAL TRAUMA :BLUNT TRAUMA
PENETRATING TRAUMA
Blunt Abdominal TraumaMechanisms• Direct impact• Acceleration-deceleration
forces• Shearing forces
• No correlation between size of contact area and resultant injuries.
• Abdomen = potential site of major blood loss.
Is there a surgical intraabdominal injury?
PE: guarding, peritoneal signs, tenderness, nausea. DRE.Lower rib fxs: 10-20% a/w spleen/liver injury Seatbelt sign a/w intestinal injury and mesenteric tears.
Direct blunt trauma: rupture/tear of solid organs.Flank pain or contusion often late signs of retroperitoneal bleed
Rapid resuscitationCXR, Pelvic X-rayFAST v DPL v CTLabs: Hct, WBC, amylase, UA, ABG, T+C
Blunt Abdominal Trauma
Shock with expanding abdomen,pnemoperitoneum,retroperitoneal air
Peritoneal signs, HD unstable, sepsis
Stable w/ peritoneal signs
Imaging:CXRFAST/DPL/CT
Observe,+/- re-image
INDICATIONS FOR LAPAROTOMYIN BLUNT ABDOMINAL TRAUMA
Role of Diagnostic Laparoscopy
• Hemodynamically stable patients• Inadequate/equivocal FAST or borderline
DPL (80K-120K RBC/HPF)• Intermittent mild hypotension or persistent
tachycardia• Persistent abdominal signs/symptoms• Potential to decrease numbers of
nontherapeutic laparotomies (negative laparotomy)
Blunt Abdominal Trauma
Bruises in the Abdomen and Flank Region
Perforated Ileum due to Blunt Abdominal Trauma
Perforated Ileum
Penetrating Abdominal Trauma
Penetrating Abdominal Trauma
Evaluation of Stab Wounds• Local exploration• DPL
– 5cc gross blood on aspiration– >20K RBC/mm3– >500 WBC/mm3– >175U amylase/100mL– Bacteria– Bile, Food particles
• CT– Limited ability to dx hollow organ
injury– Useful for posterior SW
• FAST
– Limited, high false negative rate
– Useful for pericardial injuries
• Diagnostic laparoscopy
– Useful for assessing peritoneal penetration, diaphragm injury
– Shorter LOS than negative laparotomy
Penetrating Abdominal Trauma
Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Anterior Abdominal
Flank
Peristernal Potential
Mediastinal
Back
Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Anterior Abdominal Explore locally, manage expectantly with serial PE
Flank
Peristernal Potential
Mediastinal
Back
Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Anterior Abdominal Explore locally, manage expectantly with serial PE
Flankexplore
locally
triple contrast CT
Peristernal Potential
Mediastinal
Back
Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest
Anterior Abdominal Explore locally, manage expectantly with serial PE
Flankexplore
locally
triple contrast CT
Peristernal Potential
Mediastinal
Backadmit for obs
Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest?Thoracoscopy,
Laparoscopy
Anterior Abdominal Explore locally, manage expectantly with serial PE
Flankexplore
locally
triple contrast CT
Peristernal Potential
Mediastinal
Backadmit for obs
Penetrating Abdominal TraumaPenetrating Abdominal Trauma
Stab Wounds: Stratification by loci
Lower Chest?Thoracoscopy,
Laparoscopy
Anterior Abdominal Explore locally, manage expectantly with serial PE
Flankexplore
locally
triple contrast CT
Peristernal Potential
Mediastinal
Backadmit for obs
CVP monitor, U/S
Observe >6h, repeat CXR
Stab Wound and Liver Laceration
Diagnostic Laparoscopy
•Usually require urgent exploration.
•Evaluation for peritoneal penetration vs tangential GSW. • CT, diagnostic laparoscopy• Use of DPL controversial due to high false negative
rate
Gun Shot Wound
• Ballistics: • Civilian=lower velocity handgun missiles; military = higher
velocity rifle missiles.
• Permanent and temporary cavities: Yaw, Bullet size and type.
• Shotgun: • Short range: high-velocity and more concentrated• Distant range: multiple low-velocity projectiles, more
diffuse, less severe
Balistic Gel
Terrorism and Bomb
Blast Injury
Blast Abdominal Trauma• Primary Damage
Shear injury in solid organ
•Secondary DamagePenetrating injury due to projectile
•Tertiary Damage Impact of victim being thrown By the blast
Management BAT
• A B C • Demand Laparotomy • Stop bleeding & Contamination • Temporary reconstruction • Ongoing process • Plan Laparotomy/Second look
Blast Injury• Correlate to others Injury• Tympanic injury• Lung Injury
References :
• DebasDePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast Injuries. N Engl J Med 2005; 352:1335-42.
• Hoff SW. Practice Management Guidelines for the Evaluation of Blunt Abdominal Trauma. Eastern Association for The Surgery of Trauma, 2001.
• Diagnostic Laparoscopy. Practice/Clinical Guidelines 2007. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).
• Ahmed, N., Whelan, J., Brownlee, J., Chari, V., and Chung, R. The Contribution of Laparoscopy in Evaluation of Penetrating Abdominal Wounds. Journal of the American College of Surgeons 2005;201(2):213-6.