Acute Abdomen
Andreas M KluftingerMD FRCSC Kelowna General Hospital Disclosure
• Hernia Advisory Panel – Ethicon Johnson& Johnson
• Medical Director of Surgcial Weight Loss – IQuest Healthcare and Fitness Centre Objectives
• Understand the Pathophysiology and etiology of the acute abdomen
• Approch to acute abdomen in rural practice
• Case presentations Stedman's Medical Dictionary 27th Edition
“any serious acute intra-abdominal condition attended by pain, tenderness, and muscular rigidity, and for which emergency surgery must be considered." Acute Abdominal Pain
• 5-10 % of ER visits • Complex “black box” • Delays in diagnosis can increase morbidity • Excessive consultations (+/ - transport) and imaging can be costly and tax resources. • Primary assessment and triage are key History & Physical
• Onset, nature, duration, location, radiation • Aggravating and relieving factors • Associated GI or GU symptoms • Past history ( Surg and Med) • Review of Systems • Full physical exam Stereotypes of Pain Onset and Associated Pathology
•Sudden onset •Rapid onset •Gradual onset (full pain in seconds) (initial sensation to (hours) full pain over minutes or hours)
•Perforated ulcer •Strangulated hernia •Appendicitis •Mesenteric infarction •Volvulus •Strangulated hernia •Ruptured abdominal •Intussusception •Chronic pancreatitis aortic aneurysm •Acute pancreatitis •Peptic ulcer disease •Ruptured ectopic •Biliary colic •Inflammatory bowel disease pregnancy •Diverticulitis •Mesenteric lymphadenitis •Ovarian torsion or •Ureteral and renal •Cystitis and urinary retention ruptured cyst colic •Salpingitis and prostatitis •Pulmonary embolism •Acute myocardial infarction Abdominal Innervation Simplified in Thirds
Embryologic Structures Nerves Arteries Pain Location
Foregut Esophagus, Thoracic Coeliac Epigastrium stomach,3/4 splanchnics, duod,liver, gb vagus panc
Midgut ¼ duod to Thoracic SMA Periumbilical splenic flexure splanchnics, vagus
Hindgut Left colon, Pelvic IMA Hypogastrium rectum, GU splanchnics, tract lesser thoracic splanchnics Possible Causes of Pain by Location
Location of Pain Associated Diseases
Right upper quadrant Acute cholecystitis, biliary colic, acute hepatitis, duodenal ulcer, right lower (liver, kidney, gallbladder) lobe pneumonia
Right lower quadrant Appendicitis, cecal diverticulitis, ectopic pregnancy, tubo-ovarian abcess, (ascending colon, appendix, ovary, ruptured ovarian cyst, ovarian torsion fallopian tube)
Left upper quadrant Gastritis, acute pancreatitis, splenic pathology, left lower lobe pneumonia (pancreas, spleen, kidney)
Left lower quadrant Diverticulitis, ectopic pregnancy, tubo-ovarian abcess, ruptured ovarian cyst, (sigmoid and descending colon, ovarian torsion ovary, fallopian tube)
Midline or periumbilical Appendicitis (early), gastroenteritis, mesenteric lymphadenitis, myocardial ischemia or infarction, pacreatitis
Flank Abdominal aortic aneurysm, renal colic, pyelonephritis
Front to back Acute pancreatitis, ruptured abdominal aortic aneurysm, retrocecal appendicitis, posterior duodenal ulcer
Suprapubic or lower abdominal Ectopic pregnancy, mittelschmerz, ruptured ovarian cyst, pelvic inflammatory disease, endometriosis, urinary tract infection Sign Finding Association
Cullen's sign Bluish periumbilical Retroperitoneal discoloration hemorrhage pancreatitis, Grey Turner’s sign Bluish flank discoloration abdominal aortic aneurysm rupture)
Kehr's sign Severe left shoulder pain Splenic rupture Ectopic pregnancy
McBurney's sign Tenderness located 2/3 distance from Appendicitis ASIS to umbilicus on right side
Murphy's sign Abrupt interruption of inspiration on Acute cholecystitis palpation of right upper quadrant
Iliopsoas sign Hyperextension of right hip Appendicitis causing abdominal pain
Obturator's sign Internal rotation of flexed right hip Appendicitis causing abdominal pain
Chandelier sign Manipulation of cervix causes patient Pelvic inflammatory to lift buttocks off table disease
Rovsing's sign Right lower quadrant pain with Appendicitis palpation of the left lower quadrant Referred Pain
Structure Irritated Location of Referred Pain
Diaphragmatic Supraclavicular area (Kehr's sign)
Ureteral Hypogastrium, groin, inner thigh
Cardiac pain Epigastrum, jaw, shoulder
Appendix Periumbilical via T10 nerve
Duodenum Umbilical region via greater thoracic splanchnic nerve
Hiatal hernia Epigastrum via T7 and T8 nerves
Pancreas or gallbladder Epigastrum
Gallbladder and bile duct Epigastric pain that wraps around to the scapula Imaging for Appendicitis Imaging Accuracy in Appendicitis
Modality Sensitivity Specificity Pos PredValue Neg Pred Value Plain Film 10% 90% Ultrasound 85-90% 92-96% 95% 80-90% CT 95-97% 95% 97% 95-100% MRI 93% 91% 92% 100% Laboratory in Appendicitis
Test Sensitivity Neg Pred Value 1. WBC >10.5 85% 2. Neutrophils >75% 78% 94% 3. C reactive protein 93-96% 1+2 96% 1+3 92.3% 1+2+3 99.2% (81% in children) Urinalysis in Appendicitis
• 30% of appendicitis patients have some urinary syptoms • 14% have >10 WBC/hpf • 18% have > 3 RBC/ hpf Imaging in Pregnancy
• Ultrasound – Safest – Useful for fetal assessment (dates, viability, placenta, amniotic fluid) – NPV for appendicitis 80-90% – PPV for appendicitis 95% Imaging in Pregnancy Procedure Fetal Exposure Chest radiograph (2 views) 0.02-0.07 mrad Abdominal film (single view) 100 mrad Intravenous pyelography >1 rad* Hip film (single view) 200 mrad Mammography 7-20 mrad Barium enema or small bowel series 2-4 rad CT (computed tomography) scan head <1 rad or chest CT scan abdomen and lumbar spine 3.5 rad CT pelvimetry 250 mrad
No evidence of teratogenesis or fetal loss if cumulative dose < 5 rads Acute Abdomen Caused by Pregnancy
• Early pregnancy – Ruptured ectopic pregnancy – Septic abortion with peritonitis – Acute urinary retention due to retroverted gravid uterus – Torsion of the pregnant uterus • Later pregnancy – Red degeneration of myoma – Torsion of pedunculated myoma – Placental abruption, Placenta percreta – HELLP (hemolysis, elevated liver function, and low platelets) syndrome – Spontaneous rupture of the liver – Uterine rupture – Chorioamnionitis Conditions Associated with Pregnancy • Acute pyelonephritis • Acute cystitis • Acute cholecystitis • Acute fatty liver of pregnancy • Rupture of rectus abdominis muscle Case #1
• 68 male, 48 hrs RLQ pain • Quick onset, in RLQ • No nausea or anorexia • No urinary syptoms • PHx: GERD, dyslipidemia • Tender RLQ and flank with peritonism • WBC 9.2 Urine clear CT abdomen Case #2
• BW 41 yo electrician • collapsed at home with chest, abd pain • CPR by family, EHS to KGH • PHx : appe Meds: ASA • Exam: BP 60 sys, HR 100 RR 16 Chest clear Abdomen tender, acute Investigations
• Hb 108 WBC 8.9 Plts 256 • Hep panel – normal • Lipase 43 • ECG – normal • Trop < 0.1 CT with Aorta Protocol Laparotomy
• 3 litres blood • intact liver, spleen, viscera • blood from lesser sac • rupured splenic artery aneurysm at hilum • splenectomy, distal pancreatectomy • 4 units FP, 6 units RBC • Recovery uneventful