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Home , Acute abdomen, Organomegaly

LESSON 13 ACUTE

Objectives By the end of this lesson, you should be able to: 1. Define 2. Describe the causes of acute abdomen 3. Describe the assessment of a patient with acute abdomen 4. List the criteria for admission of a patient with acute abdomen 5. Describe emergency treatment of acute abdomen 6. List the Medicolegal issues Definition of acute abdomen • The term acute abdomen refers to a sudden, severe that is less than 24 hours in duration. • It represents a rapid onset of severe symptoms that may indicate life-threatening intra-abdominal pathology. • It is in many cases a medical or a surgical emergency, requiring urgent and specific diagnosis and treatment. • Pain is usually a feature but is not always the case. • A pain-free acute abdomen is more likely in the elderly, in children and in the third trimester of pregnancy.

• The differential diagnosis is extremely wide and definitive diagnosis is often difficult. This is due to the many different organs within the peritoneal cavity and the potential for referred pain. • The clinical scenario can change rapidly and conclusions previously reached by yourself or colleagues may need to be revised as events evolve. • A failure to be open-minded and revise a previous diagnosis is often at the of medicolegal claims relating to patients with an acute abdomen. classification of causes of acute abdomen

• Classification of causes can be done according to site of pain • Another way to consider the causes of an acute abdomen is by classifying them according to the area of the abdomen most affected by pain

CAUSES OF ACUTE ABDOMEN ACCORDING TO SITE OF PAIN Assessment of patient with acute abdomen Initial impression/observation • Does the patient look ill, septic or shocked? • Are they lying still (think ), or rolling around in agony (think intestinal, biliary or renal )? • Assess and manage Airway, Breathing and Circulation as a priority (ABC). • If there are signs that the patient is shocked or acutely unwell, assess quickly but carefully and arrange any early investigations. • Admit the patient quickly.

History The history should cover the following points: • Demographic details, occupation, recent travel, history of recent abdominal trauma • Pain: – Onset (including whether new pain or previously experienced) – Site (ask patient to point), localised or diffuse – Nature (constant/intermittent/colicky) – Radiation – Severity – Relieving/aggravating factors (e.g. if worsened by movement/coughing suspect active peritonitis; is relieved by sitting forward)

Associated symptoms – and nature of vomitus (undigested food or bile suggests upper GI pathology or obstruction; feculent vomiting suggests lower GI obstruction) – Haematemesis or melaena – GIT bleeding – Stool/urine colour – New lumps in abdominal region/groins – Eating and drinking - including when was last meal? – Bowels - including presence of diarrhoea, and ability to pass flatus – Fainting, dizziness or palpitations – Fever/rigors – Rash or itching – Urinary symptoms – Recent weight loss

Past medical and surgical history/medication

• Past medical and surgical history/medication • Gynaecological and obstetric history: – Contraception (including IUCD use) – LMP – History of STIs/PID – Previous gynaecological or tubal – Previous – Vaginal bleeding – Drug history and allergies - including any complementary medication

Physical examination

• Pulse, temperature and blood pressure. • Assess respiratory rate and pattern. Patients with peritonitis may take shallow, rapid breaths to reduce pain. • If altered consciousness check Glasgow Coma Scale (GCS) or AVPU scale (Alert, Voice response, Pain response, Unconscious).

Glasgow Coma Scale Eye movement – 4 Spontaneous opening 4 Opening to verbal command 3 Opening to pain 2 No eye opening 1 Motor function – 6 • Spontaneous purposeful movement 6 • Purposeful movement to command 5 • Localizes pain 4 • Flexes to pain 3 • Extend to pain 2 • No movements 1 Verbal response – 5 • Normal speech 5 • Confused 4 • Utters words coherent but meaningless words 3 • Utters non coherent words 2 • No response 1 Inspection: – Look for evidence of anaemia/ – Look for visible peristalsis or . – Look for signs of bruising around the umbilicus (Cullen's sign - can be present in haemorrhagic pancreatitis and ectopic pregnancy) or flanks (Grey Turner's sign - can be present in retroperitoneal haematoma). – Assess whether patient is dehydrated (skin turgor/dry mucous membranes). Auscultation: – Auscultate abdomen in all four quadrants. – Absent bowel sounds suggest paralytic ileus, generalised peritonitis or intestinal obstruction. High-pitched and tinkling bowel sounds suggest sub-acute intestinal obstruction. – Intestinal obstruction can also present with normal bowel sounds. – If there is reason to suspect aortic aneurysm, listen carefully for abdominal and iliac bruits.

Percussion: – Percuss the abdomen to assess whether swelling/distension might be due to bowel gas or . – Patients who display tenderness to percussion are likely to have generalised peritonitis and this should act as a red flag for serious pathology. – Assess for and fluid thrill. – Percussion can also be used to determine size of an /extent of . Palpation: – Palpate the abdomen gently, then more deeply, starting away from the pain and moving towards it. – Feel for masses, tenderness, involuntary guarding and organomegaly (including the bladder). – Test for rebound tenderness. – Examine the groins and umbilicus for evidence of herniae. – Always examine the scrotum in men as pain may be referred from unrecognised testicular pathology. – Check supraclavicular and groin lymph nodes.

Further examination: – Perform rectal or pelvic examination as needed. – Check lower limb pulses if there could be an abdominal aortic aneurysm. – In a woman of child-bearing age, assume that she is pregnant until proven otherwise - perform a pregnancy test. – Examine any other system that might be relevant, e.g. respiratory, cardiovascular.

Investigation The following tests are often used but can be non-specific and must be interpreted in the clinical context and with appropriate medical/surgical expertise: 1. Haemogram - FBC, Hb 2. Biochemistry - UEC, LFTs, serum amylase, RBS, INR and clotting, and occasionally serum calcium 3. Group and crossmatch 4. Blood cultures 5. Pregnancy test in women of child bearing age 6. Urinalysis 7. Imaging – Plain Abdominal Xray (AP supine and lateral decubitus), CXR (erect looking for gas under the diaphragm), IVP, CT, U/S scan 8. Consider ECG and cardiac enzymes – heart disease 9. Peritoneal lavage if history of abdominal trauma

Criteria for admission • All patients with acute abdomen should be admitted • Patients less severe abdominal pain but cannot take oral fluids or who have severe persistent • Patient with less pain but have significant co- morbidity such as diabetes or ischaemic heart disease • Patient who are febrile • Patient who are pale • Clear documentation is needed.

Red flags that raise suspicion of serious pathology 1. Hypotension 2. Confusion/impaired consciousness 3. Signs of 4. Systemically unwell/septic-looking 5. Signs of dehydration 6. Rigid abdomen 7. Patient lying very still or writhing 8. Absent or altered bowel sounds 9. Associated testicular pathology 10.Marked involuntary guarding/rebound tenderness 11.Tenderness to percussion 12.History of haematemesis/melaena or evidence of latter on PR examination

Special situations Children • Pain etiology in children varies with age • History and examination can be difficult. Pregnancy • Always consider ectopic pregnancy in women of child-bearing age. • Causes of acute abdomen in late pregnancy are different and require expert combined obstetric, gynaecological and surgical evaluation.

Older patients • Tend to show less specific symptoms and signs and present later in the course of their illness. • Morbidity and mortality high. • Should have specialized review by surgeon early • Aortic aneurysm and bowel ischaemia are more prevalent in the elderly. • Angiodysplasia of the colon is more common and can cause GI bleeding. • Medical causes of abdominal pain are encountered more frequently. • The 'Top 5' medical causes in the elderly are: – Inferior MI – Lower-lobe pneumonia/Pulmonary Embolism causing pleurisy – or Hyperosmolar Non-Ketotic Coma (HONK) – – Inflammatory Bowel Disease (IBD) • Biliary tract disease, including , is the most common indication for surgery in older patients with abdominal pain.

Medicolegal pitfalls and tips

1. Careful documentation of the clinical situation and decision- making process is essential. 2. Failure to appreciate the severity of illness through not assessing vital signs/taking heed of general condition. 3. Failing to take note of history from carers/parents in a patient who now seems relatively well, particularly in children. 4. Failure to examine adequately or to document findings. 5. Failure to examine for a bladder, herniae or check scrotum. 6. Failure to carry out rectal or vaginal examination when it is indicated. 7. Failing to explain the reason for an intimate examination, leading to an accusation of impropriety.

Medicolegal pitfalls and tips cont… 9. Treating children as little adults and not considering paediatric-specific diagnoses. 10. Failing to make concrete follow-up arrangements or advising a patient of when they should seek further assessment, when managing patients in the community. 11. Delayed consult senior colleague 13. Giving drugs which may mask symptoms and signs. 14. When pain outstrips signs, consider gut or AAA. 15. Don't rely on a normal test result to discount pathology if the clinical condition suggests otherwise. 16. Failing to consider pregnancy or conduct a pregnancy test. 17. Be ready to re-assess your initial diagnosis, or a colleague's diagnosis, where the clinical situation has changed.

Emergency care of suspected acute abdomen 1. Keep patient nil by mouth. 2. Apply oxygen as appropriate. 3. Set an IV line with draw blood for GXM, and appropriate blood test and start on IV fluids should be started immediately 4. Consider passing an NG tube if severe vomiting, signs of intestinal obstruction or extremely unwell with danger of aspiration. 5. Analgesia: previous practice was to withhold analgesia until surgical review. One recent review showed that opiate administration may alter findings, but these changes result in no significant increase in management errors. Another study showed that morphine safely provides analgesia without impairing diagnostic accuracy

Emergency care cont…. 6. Antiemetic: avoid using this as a symptomatic treatment without making a diagnosis 7. Antibiotics: if suspect systemic sepsis, peritonitis, severe UTI. IV cephalosporin plus metronidazole are commonly used in acutely unwell patients in whom peritonitis is suspected. 8. Arrange urgent surgical or gynaecological review as appropriate. 9. Arrange investigations such as ECG if medical cause likely. 10 Admit: if you consider that surgery is likely, if unable to tolerate oral fluids, for pain control, if medical cause possible or if IV antibiotics required.

Conclusion  Definition acute abdomen  Causes of acute abdomen  Assessment of a patient with acute abdomen History Examination Investigations Criteria for admission  Special situations  Acute abdomen in children  Acute abdomen in the elderly  Describe emergency medical treatment of a patient with acute abdomen  Medicolegal issues

10/30/2015