the acute abdomen in the er edited

8/8/2019 The Acute Abdomen in the ER Edited

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Adapted from source


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D efinitionSIRS/Sepsis

Approach to Acute AbdomenCommon CausesCase studiesContacting Surgical Resident


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DEF INITION:refers to signs and symptoms of abdominal pain and tenderness, aclinical presentation that often requires emergency surgical therapy

This challenging clinical scenario requires a thorough andexpeditious workup to determine the need for operativeintervention and to initiate appropriate therapyMany diseases, some of which are not surgical or intra-abdominal, can produce acute abdominal pain andtendernessTherefore, every attempt is made to make a correctdiagnosis so that the chosen therapy, often a laparoscopyor laparotomy, is appropriate


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(All SIRS/Sepsis related)

Acute AppendicitisAcute PancreatitisAcute CholecystitisAcute D iverticulitis

OthersObstruction, Ulcer perforation, Trauma related, Intestinal ischaemia and infarction,Biliary colic, Renal colic, AAA, Ruptured ectopic, Meckel's diverticulitis, Boerhaave'ssyndrome, volvulus, Incarcerated/strangulated hernias, Inflammatory boweldisease, Gastrointestinal malignancy, Intussusception, Ovarian torsion, Testiculartorsion

Nonsurgical include uraemia, diabetic crisis, addisonian crisis, acute intermittentporphyria, acute hyperlipoproteinemia, hereditary Mediterranean fever, sickle cellcrisis, acute leukaemia, other blood dyscrasias, lead and other heavy metalpoisoning, narcotic withdrawal, black widow spider poisoning


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1. Systemic Inflammatory Response Syndrome(SIRS)

2. Sepsis

3. Severe Sepsis

4. Septic Shock


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Caused by mediators (cytokines, enzymes, andoxygen radicals) released from lymphocytes,macrophages, granulocytes, and vascular

endothelial cells

Presence of 2 or more of following:Temp > 38 C or < 36 CPuls e > 90bpmRe s piratory rate > 20 breath s per min

WCC > 12 or < 4 or > 10% band form s


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SIRS plus suspected or confirmed infectionIn most cases of sepsis the invading organisms arebacteria, but sepsis can also occur in patients withinfections caused by fungal, viral, and parasiticpathogens


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SIRS plus infection plus hypotensionwith evidence of organ dysfunction

Lacticacidaemia, oliguria, and a depressed level ofconsciousness

Hypotension responds to IV fluids


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SIRS plus infection plus organdysfunction plus hypotension persisting

despite fluid resuscitationPatients need an IV infusion of vasoactive drugsto restore perfusion pressureOrgan dysfunction in patients in septic shock mayprogress to organ failure


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Systolic blood pressure < 90mmHgF all of blood pressure of > 40mmHgMean arterial blood pressure < 65mmHg30% or greater drop in mean arterial pressure


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Systemic InflammatoryResponse Syndrome(SIRS)

Sepsis

Severe Sepsis

Septic Shock Mortality40 55%

Mortality15 25%

Mortality10 15%


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Resuscitation

Source Control

Antibiotics


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IV fluidsMonitoring

Invasive haemodynamic

CardiacUrine output

Inotropic supportOxygen +/- intubation and ventilationGlycaemic controlAcid/base statusAdrenal support


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Crystalloid fluid challenge of 30mls / Kg over 30minutes

Requires large bore central administration (ideally)CVLF emoral line

(Average 80 Kg person 2 .4L in 30 mins!)


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D rainage

D ebridement

Resection


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Biliary/Gastrointestinal Sepsis:IV Ampicillin 2g q6hIV Gentamicin dailyIV Metronidazole 500mg tds

(Also Intraabdominal sepsis,diverticulitis, perianalabscess)

Acute Cholecystitis:IV Ampicillin 1g q6h

IV Gentamicin dailyAscending Cholangitis:

IV Ampicillin 1g q6hIV Gentamicin daily+ IV F lagyl if History ofbiliary surgery or obstruction

Skin Source Sepsis:IV F lucloxacillin 2g q6h

(severe D iabetic F oot Ulcer infection IV Timentin 3 .1g q6h)

Urinary Sepsis:IV Ampicillin 2g q6hIV Gentamicin daily

Intravascular D evice Sepsis:IV F lucloxacillin 2g q6hIV Gentamicin daily


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Go

lden ho

ur!


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A detailed and organized history is essential toformulating an accurate differential diagnosis andsubsequent treatment regimenModern advances in imaging cannot and will neverreplace the need for a skilled clinician's bedsideexaminationPain

NILD OORCAR FAssociated symptoms

Nausea, vomiting, anorexia, constipation, diarrhoea, pruritus,melena, hematochezia, hematuria, dysuria, frequency, urgency,fevers, sweats, shakesPast medical/surgical history

History of medicationsGynaecologic history of female patientsSocial History

Alcohol, smoking, travel


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An organized and thoughtful physical examination is critical to the development of an accurate differential diagnosisand the subsequent treatmentA skilled clinician will be able to develop a narrow and accurate differential diagnosis in most patients at theconclusion of the history and physical examinationphysical examination always begins with a general inspection of the patient, followed by inspection of the abdomenitself

AbdomenInspection

contour of the abdomenscars presentherniasE cchymosis, erythema or oedema of skin

Auscultationquiethyperactive bowel soundshigh-pitched tinkling sounds

Percussiongaseous distension of the bowelfree intra-abdominal air

degree of ascitespresence of peritoneal inflammationPalpation

Palpation provides more information than any other single componentseverity and exact location of the abdominal painorganomegaly or an abnormal mass lesionInvoluntary/voluntary guarding

Testicles in menD igital rectal examinationPelvic examination is included in all women when evaluating pain located below the umbilicus


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SIGN DESCRIPTION DIAGNOSIS/CONDITION

A aron sign Pain or pressure in epigastrium or anterior chest with persistent firm pressure applied to McBurney's point A cute appendicitis

Bassler sign Sharp pain created by compressing appendix between abdominal wall and iliacus Chronic appendicitis

Blumberg'ssign

Transient abdominal wall rebound tenderness Peritoneal inflammation

Carnett's sign Loss of abdominal tenderness when abdominal wall muscles are contracted Intra-abdominal source of abdominal pain

Chandelier sign Extreme lower abdominal and pelvic pain with movement of cervix Pelvic inflammatory disease

Charcot's sign Intermittent right upper abdominal pain, jaundice, and fever Choledocholithiasis

Claybrook sign A ccentuation of breath and cardiac sounds through abdominal wall Ruptured abdominal viscus

Courvoisier'ssign

Palpable gallbladder in presence of painless jaundice Periampullary tumor

Cruveilhier sign Varicose veins at umbilicus (caput medusae) Portal hypertension

Cullen's sign Periumbilical bruising Hemoperitoneum

Danforth sign Shoulder pain on inspiration Hemoperitoneum

Fothergill's sign A bdominal wall mass that does not cross midline and remains palpable when rectus contracted Rectus muscle hematomas

Grey Turner'ssign

Local areas of discoloration around umbilicus and flanks A cute hemorrhagic pancreatitis

Iliopsoas sign Elevation and extension of leg against resistance creates pain A ppendicitis with retrocecal abscess

Kehr's sign Left shoulder pain when supine and pressure placed on left upper abdomen Hemoperitoneum (especially from splenicorigin)

Mannkopf'ssign

Increased pulse when painful abdomen palpated A bsent if malingering

Murphy's sign Pain caused by inspiration while applying pressure to right upper abdomen A cute cholecystitis

Obturator sign Flexion and external rotation of right thigh while supine creates hypogastric pain Pelvic abscess or inflammatory mass in pelvis

Ransohoff sign Yellow discoloration of umbilical region Ruptured common bile duct

Rovsing's sign Pain at McBurney's point when compressing the left lower abdomen A cute appendicitis

Ten Horn sign Pain caused by gentle traction of right testicle A cute appendicitis


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Laboratory and imaging studies can be used tofurther confirm the suspicions, reorder theproposed differential diagnosis, or less commonly,suggest unusual possibilities not yet considered

Haemoglobin, White blood cell count with differential,CRP, E lectrolytes, creatinine, lipase, Total and directbilirubin, L F Ts, A/VBG lactate/acid-base, Urinalysis,

Urine/serum human chorionic gonadotropin


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Plain filmsF ree gasVolvulusCalcifications

5% of appendicoliths, 10% of gallstones, and 90% of renal

stones, pancreatic calcifications, abdominal aorticaneurysms, visceral artery aneurysm, and atherosclerosisin visceral vessels

CTAppendicitis, diverticulitissmall bowel obstruction/ileusacute intestinal ischemia

USSGallstones, gallbladder wall thickness, fluid aroundthe gallbladder, diameter of the extrahepatic andintrahepatic bile ductsintraperitoneal fluidovaries, adnexa, and uterus


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RIF Pain D ifferential diagnosisAppendicitisMesenteric adenitisD iverticulitisBowel ischaemia/infarctionTumourOvarian pathologyPIDMittelschmerzE ndometriosisOvarian/testicular torsionE ctopicObstructionVolvulus

IntussusceptionIBD AAARenal pathologyBiliary pathologyMeckel's diverticulitisPsoas abscessRectus sheath haematoma

Hernia


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Obstruction of the lumenappendicolith, lymphoid hyperplasia, vegetable matteror seeds, parasites, neoplasm

perforation typically occurs after at least 48 hours abscess formationRarely, free perforation of the appendix into theperitoneal cavity - peritonitis and septic shock -complicated by multiple intraperitoneal abscessesBacteria

Escherichia coli, Streptococcus viridans, Bacteroides,Pseudomonas


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Historyperiumbilical painfollowed by anorexiaand nauseapain localizes to RI FF ever and leukocytosislethargy, irritability ininfantsOccasionally - urinarysymptoms ormicroscopic hematuriapossible cause of smallbowel obstruction(patients without priorabdominal surgery)

E xaminationlook ill and are lying stillLow-grade feverdiminished bowel soundsfocal tenderness (McBurneyspoint)In/voluntary guardingPercussion/rebound tendernessD

unphy's sign, Rovsing's sign,obturator sign, iliopsoas signIf the appendix perforates,abdominal pain becomes intenseand more diffuse, rigidity, HRrises, T > 39C


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LaboratoryWCC is elevated,75% neutrophilsWCC normal in 10%

urinalysis excludingpyelonephritis ornephrolithiasismicroscopichematuria iscommon inappendicitis

ImagingU ltrasonography sensitivity 85%,specificity 90% (operator dependent)

Paeds and pregnant

>7mm diameterTarget signAppendicolith

CT sensitivity 90%, specificity 90%>7 mm diametercircumferential wall thickeninghalo or targetfat stranding, oedema, peritonealfluid, phlegmon, abscessdetects appendicoliths in about 50%CT most valuable among olderpatients - diverticulitis andmalignancy


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Treatment:resuscitation

NBMIVF aggressive if perforation suspectedAntibioticsAnalgesia

antibiotics - aerobic and anaerobic colonic flora coverNon-perforated appendicitis - single preoperative dose of antibioticsreduces postoperative wound infections and intra-abdominal abscessformationperforated or gangrenous appendicitis, continue postoperativeintravenous antibiotics until the patient is afebrileSurgery

Laparoscopy and laparoscopic appendicectomyOpen appendicectomyLaparotomy


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PC:60yo male presented to ED at 0800, seen by PHOGeneralised abdominal pains eventually moving to right side sincenight before, retching

PMX:Calf cramps, D VT, Carpal tunnel release x 2

O/ E :Obs: HR 108, BP 166/79, RR 20, sat 97%, T 37 .1 SE P TIC (HR, RR,WCC later)HS x 2, lungs clearRIF tenderness and rebound acu te abdomen Suspected Appendicitis, food poisoning, wanting to excludeobstruction

BloodsAXRUSS


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Surg PHO contacted at 1330 (5.5 hours after arrival) withdiagnosis of appendicitis SE P TIC

WCC: 13.9Neutro: 11.55

CRP: 19USS appendicolith, appendicitis

On surgical arrival therapy thus far:Obs: HR 80, BP 124/78, RR 18, sat 95%, T 37 .8 now febrile as wellNBMNil F luidsNil Antibiotics

Laparoscopy F indings:Acute appendicitis with purulent ascites


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E pigastric pain differential diagnosispancreatitisMyocardial pathologyGastritisOesophagitisHiatus herniaAcute cholecystitisBiliary colicBiliary ObstructionCholangitisCholangiocarcinomaPancreatic carcinomaLiver AbscessHepatitisD

iaphragmatic abscessD iverticulitisAppendicitisD uodenitisBowel ischaemia/infarctionTumourBowel obstructionMeckel's diverticulitis

HCC


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Parenchymal and peripancreatic fat necrosis andan associated inflammatory reactionOedema, infiltration of inflammatory cells,

necrosis, thrombosis of intrapancreatic vessels,vascular disruption, intraparenchymalhaemorrhage, intrapancreatic or peripancreaticabscesses

Causes70% to 80% - Abuse of ethanol or Biliary tract stonesD rugs, E RCP, hypercalcaemia, hyperlipidaemia,idiopathic, infections, ischaemia, parasites, post-operative, trauma, scorpian sting


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HistoryAbdominal pain

Constant andincreasingE pigastricupper quadrantslower abdomenlower chestKnifelike, radiatingstraight through mid-central back

nausea, vomiting

E xaminationrolling or moving around in search of a morecomfortable positionill and anxious appearanceTemperatureHypovolemia

TachycardiaTachypnoeaHypotensioncollapsed neck veinsdry skindry mucous membranesdiminished subcutaneous elasticity

D iminished BS in lower lung fieldsAtelectasis, pleural effusionSome degree of jaundiceIleus silent, distended, tympaniticD irect, percussion, and rebound abdominaltendernessIn/voluntary guardingflank ecchymoses (Grey Turner's sign) or

periumbilical ecchymoses (Cullen's sign)


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Laboratoryincreased hematocrit,hemoglobin, creatininealbumin depressedhypochloremic metabolicalkalosis can develop(vomiting)WCC usually elevatedE levated CRPBSL may be elevatedHyperbilirubinemiaHypocalcemiadisseminated intravascularcoagulation

thrombocytopenia,prolonged aPTT, PT

E levated amylase/lipase

ImagingPlain

ChestAtelectasisE

ffusionpneumoniaAbdominal

Cut offileus

CTit is generally believed thatearly contrast-enhanced CTdoes not worsen pancreatitis

USSGBCholelithiasis


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PC:86 yo male presented to ED 1905, seen by RMORUQ pain, anorexia, vomiting, diaphoresis, SOB since 1400

PMHx:IHD and MI, infra renal AAA, HTN, hypercholesterolaemia, Gout,Type II I DD M, left adrenalo/nephrectomy for RCC, renal impairment,cholecystectomy (10yrs ago), malignant melanoma (face),hemicolectomy for colorectal Ca

O/ E :Obs: HR 92, BP 200/ 103, RR 24, sat 99%, no temperature until 203036.2 SE P TIC (HR, RR, WCC later)HS dual, lungs clear, Abdomen tense, distended, very tender RUQSuspected visceral perforation acu te abdomen

BloodsC/AXR

RMO (end of shift) handed over to Resident


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Contacted surg PHO 2200 (3 hours after arrival) with diagnosis of pancreatitisWCC: 14.7Neutro: 12.74Lipase: 38 10Calcium: 2 .17 (N)

On surgical arrival, therapy thus far:Obs: HR 100, BP 189/90, no new T measured, RR 24, sat 100% - worsening conditionNBMNil fluidsNil antibiotics rareNo BSL chartNo O2 therapyNo I D C(NGT occasionally required)

F indings:Severe pancreatitis secondary to choledocholithiasisICU admission


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RUQ pain differential diagnosisAcute cholecystitisBiliary colicBiliary ObstructionCholangitispancreatitisCholangiocarcinomaPancreatic carcinomaHCCLiver AbscessHepatitisD iaphragmatic abscessD iverticulitisAppendicitisD uodenitisBowel ischaemia/infarctionTumourBowel obstructionIntussusceptionIBD Renal pathologyMeckel's diverticulitis


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Symptoms attributable to biliary tract pathologyare usually the result of obstruction, infection, orboth . Obstruction can be extramural (e.g.,

pancreatic cancer), intramural(cholangiocarcinoma), or intraluminal(choledocholithiasis)


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HistoryPain

constant painbuilds in intensityradiates to the back,interscapular region,right shoulderband-like tightness ofthe upper abdomen

Association with mealspresent 50% of patientsNausea, vomiting JaundiceF ever

E xaminationpositive M urphy's sign

pain of acute cholecystitis isexacerbated by touch

Scleral/cutaneous icterus

Consider ascendingcholangitis


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LaboratoryInc WCCInc CRPD eranged L F Ts

Obstruction associated withliver dysfunction and acutecellular injuryObstruction(Pathopneumonic)

Inc Bilirubin and ALP

Lipase

ImagingPlain

15% of gallstones radiopaqueE xclude F G and pneumonia

USS (operator dependent)high specificity (>98%) andsensitivity (>95%)GS and impactionGB wallCBD dilationPericholecystic fluid

CTsensitivity about 55%Not as good for GB/GSE xclude other pathologyIdentify gangrenous GB

(MRCP/cholangiographyunavailable)


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TreatmentResuscitation

IV fluidsAnalgesia

Narcotics can cause spasm of Sphincter of OddiIV Antibiotics cover GNR, GPC, anaerobes

E nterobacteriaceae (68% incidence) - E scherichia coli, Klebsiella,E nterobacterE nterococcus species (14% incidence)Anaerobes (10% incidence) - Bacteroides species

E RCPCholecystectomy and IOC

Open

Laparoscopic


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PC:72 yo male presented to MBH at 0530F ebrile, Severe constant abdominal pain, nausea - A cu te A bdomenContacted surg PHO at 1400 (8.5 hours after presentation) for T/ F with ?acute cholecystitis for USS- acceptedtransferred from MBH ED at 2010 (14.5 hours after presentation)

PMHx:

IDD MColorectal Ca APR and colostomyHTN on beta blocker!CRIPVD bilateral BKAAppendicectomy

O/ E :Obs HR 76, BP 108/5 1, RR 18, sat 90%, T 37 .0No examination notes in HBH file

Bloods (MBH)K 5.1, Ur 19.4, Cr 220, Glu 8 .4, CRP 60, WCC 12.4, Neutro 10.44, Hb 9 1, LF Ts - OK

USS arranged 2 100ED SMO contacted Surg PHO at 2 115 (in OT with consultant until 2400 acute cholecystitis andgangrenous cholecystitis) 15.5 hours after presentation, with acute cholecystitis - SE P TIC

USSMultiple GSThickened oedematous GB wallD ilated CB D 8 .5mmAcute cholecystitis


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On surgical arrival (2400 almost 4 hours since T/ F , 18.5hours after presentation), therapy thus far

Hypotensive BP 96/54, HR 72 (beta-blocked)ID C in-situ no urine measuresNBMNo IV fluids at all (all day!)No analgesia since arriving in HBH no fluid or medication chartat HBHNo insulin (IDD M)No BSLs

No repeat bloodsSingle dose of antibiotics at MBH prior to transfer

F indings:Severely septic insulin dependent diabetic, chronic renal impaired

patient with acute cholecystitis

T/ F to RBH ICU under general surgical team


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R/LI F pain differential diagnosisD iverticulitisAppendicitisBowel ischaemia/infarctionTumourObstructionVolvulusIntussusceptionIBD AAARenal pathologyBiliary pathologyMeckel's diverticulitisPsoas abscessRectus sheath haematomaOvarian pathologyPIDMittelschmerzOvarian/testicular torsionE ndometriosisE ctopicHernia


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intestinal mucosal herniations through intestinal wall via naturalopenings created by nutrient vessels in colonic wall -pseudodiverticulumone or more become inflamed unclear process

obstruction, distension, overgrowth, vascular compromise, perforationwall erosion from increase pressure or particles, necrosis, perforation

Micro-perforation contained within pericolic fat/mesenterylarger perforations can lead to:

phlegmon/abscess formationintestinal ruptureintestinal obstructionperitonitisfistula formation

skin, bladder, vagina, small bowelhaemorrhage


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HistoryAbdominal pain

LIF usually, cramping,radiationsuprapubic/groin/back

altered bowel habitdiarrhoea/constipation

flatulencebloatingF

evers, sweats, chills,shakesNausea, vomitingurinary symptoms pneumaturia, faecaluria

E xaminationSepticTenderness

usually localised LI F (sigmoid50%, descending 40%, entire 5-10%)generalised abdominal pain,epigastric, RI Fperitonism rebound,guarding, rigidity, percussionpain

D istended, tympanicMass

phlegmonabscess

F istula

Reduced BS


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LaboratoryBloods

F BCeLF TsCRPABGLipaseBC

Urinedipstick, M/C/S, BHCG

ImagingE rect CXR

free gas, other pathology

CT abdomenpericolic fat stranding due toinflammationcolonic diverticulabowel wall thickeningsoft tissue inflammatorymasses, phlegmon, abscesses


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StagingUncomplicated or complicatedClinical staging by Hinchey'sclassification is geared towardchoosing the proper surgicalprocedure when diverticulitis iscomplicated, as follows:

Stage I disease - Small orconfined pericolic or mesentericabscessStage II disease - Large abscess,often confined to the pelvisStage III disease - Perforateddiverticulitis causinggeneralized purulent peritonitisStage IV disease - Rupture ofdiverticula into the peritonealcavity with faecalcontamination causinggeneralized faecal peritonitis

TreatmentResuscitation

IV fluids and monitoringPO/IV antibioticsAnalgesia

Surgery when:F ree-air perforation with faecalperitonitisSuppurative peritonitis secondary to aruptured abscessUncontrolled sepsisAbdominal or pelvic abscess

USS/CT-guided aspiration if possible,transanal vs transabdo (stage II)E

lective resection after recovery ifdrainage successfulF istula formationIntestinal obstructionF ailing medical therapyImmunocompromised statusRecurrent episodes of acutediverticulitis


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PC:76 yo male presents to ED at 1957, seen by SMO2/52 abdominal pains worsening

PMHx:IHD MICOA D

O/ E :Obs HR 132, BP 154/74, RR 28, sat 99%, T 38 .7- SE P TIC(T, HR, RR, WCC)HS x2, chest clearNo findings charted A cu te abdomen

BloodsBCUrine dipstickCXR


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ED SMO contacted surg PHO at 2030:Acute abdomen perforated diverticulitisbloods

WCC 15.6CRP 168

UrineModerate bloodCXR free gas

On surg PHO arrival 2 100 therapy thus far2 x IVC500ml n/saline bolus charted but not yet begunTriple antibiotics charted but not yet begunNo analgesia givenNo I D C

Laparotomy F indings:Contained perforated diverticulitis with purulent peritonitis spent 7 days in

ICU, 33 days in hospital


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the acute abdomen in the er edited

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