DOCSLIB.ORG

Episode 43 Appendicitis Controversies

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Episode 43 Appendicitis Controversies EPISODE #43: APPENDICITIS & DIVERTICULITIS - EMERGENCYMEDICINECASES.COM EPISODE 43: ADULT APPENDICITIS CONTROVERSIES WITH DR. Appendicitis STEINHART & DR. DUSHENSKI Alvarado score NOT Laboratory Values: recommended by our experts as - WBC > 10: (Pos Likelihood Clinical Decision Scores: 1) ALVARADO score: it underperforms in elderly, Ratio (+LR)) = 2.4; (MANTRELS) children and women, and Neg LR = 0.25) as good or Migration of pain RLQ (1) physician judgment may better than any single clinical Anorexia (1) outperform the score. history/physical factor(2) N/V (1) 2) Appendicitis Inflammatory - Sensitivity of WBC increases Tenderness in RLQ (2) Response Score with duration of illness Rebound pain (1) Vomiting (1) - Combining WBC and CRP Elevated temp >= 37.3 (1) Pain right inferior fossa (1) increases predictive power Leukocytosis >=10 (2) Rebound tenderness (1-3) - Urinalysis – in appendicitis, Shift of WBC to left (1) Temp >=38.5 (1) inflamed appendix can abut Score of 7 or more has positive PMN (1-2) the ureter and cause ureter LR of 4.0. Score of less than 7 WBC (1-2) CRP (1-2) inflammation, resulting in a has negative LR of 0.2. Score 0-4 is low probability of significant WBC (don’t appendicitis, 9-12 high probability. assume UTI!) History and Physical Examination - Migration of pain, RLQ pain, psoas sign, fever, pain before vomiting, rebound tenderness all increase likelihood of appendicitis Does Delay in Dx Increase the Rate of - Recurrent pain decreases the likelihood of Appendix Perforation? appendicitis but does not rule it out - Delay in seeking care is a risk factor for perforation - Pain while traveling over speed bumps increases the - Multiple studies have shown that in-hospital delay to likelihood of appendicitis (3) OR <12 h does not affect perforation rates (5,6). - DRE has limited role in diagnosis of acute, undifferentiated abdominal pain (4) - Important to consider pelvic exam in females with undifferentiated abdominal pain. Remember, cervical motion tenderness does not rule out appendicitis! - Atypical presentations: obese, immunocompromised, extremes of age, diabetics Imaging for Appendicitis Factors Affecting Imaging: Fig 1: Distended appendix on found to be non-inferior to 1. Duration of Pain: Ultrasound emergency appendectomy. - Ultrasound sensitivity However, associated with increases with duration of One option after equivocal increased risk for recurrent pain ultrasound for appendicitis: disease. - CT sensitivity unchanged with observe patient for 8hrs, then re- - Candidates for medical duration of pain examine +/- re-ultrasound management (decision best (remember that ultrasound made in conjunction with 2. Body Habitus: sensitivity increases with time) surgical colleagues): Early, - Ultrasound accuracy is non-perforated, < 24h from increased in slim patients CT Scan: onset of symptoms, no - CT accuracy is increased in - Contrast may increase appendicolith or masses obese patients sensitivity (8) causing persistent obstruction 3. Number of ultrasounds done - IV contrast: accentuates of the appendix at your institution for appendicitis periappendiceal and luminal inflammation Modalities: - Oral contrast: demarcates References Ultrasound: appendix from surrounding (click for abstract) - First line in: young, non-obese structures, opacifies ileocecal patients with symptoms > 12h portion of bowel in 45-60min 1) Andersson. 2004. Br J Surg, - Dependent on operator skill. - Rectal contrast: also helps 91(1): 28-37 More impact of patient’s body demarcate appendix, can habitus. Bowel gas can hinder administer just prior to CT, 2) Cardall et al. 2004. Acad image acquisition thereby reducing time to wait Emerg Med, 11(10):1021-7. - Diagnostic Criteria: for CT (9). 3) Ashdown et al. 2012. BMJ, - Non-compressible - Studies have failed to 345: e8012. appendix demonstrate reduction in - No peristalsis negative appendectomy rate 4) Kessler & Bauer. 2012. J - Diameter > 6mm in men despite increased CT Emerg Med, 43)6):1196-204. - Other suggestive findings: use - Appendicolith 5) Ingraham et al. 2010. Arch - Hyperechoic fat Treatment Surg, 145(9): 886-92. - Free fluid in males 6) Clyde et al. 2008. Am J Surg, - Appendix not visualized (7): Antibiotics: 195(5): 590-2. - Indicator for observation - No good evidence for routine vs. further imaging administration of antibotics in 7) Steward et al. 2012. J Clin - NPV 85-95% ED for appendicitis Ultrasound, 40(8): 455-61. - Consider your pre-test - Patients should receive 8) Chiu et al. 2013. Acad Radiol, probability and other prophylactic antibitoics within 20(1): 73-8. ultrasound findings 60min window prior to 9) Rao et al. 1997. Am J incision Raoentgenol, 169(5): 1275-80. - Consider antibiotics if there is delay to OR 10) Vons et al. 2011. Lancet, 377(9777): 1573-9. Medical vs Surgical Management: SUBSCRIBE TO EMCASES - Oral antibiotics vs. immediate OR for acute, uncomplicated appendicitis (10). Amox-Clav .
Load more

Recommended publications
  • Print This Article
    International Surgery Journal Lew D et al. Int Surg J. 2021 May;8(5):1575-1578 http://www.ijsurgery.com pISSN 2349-3305 | eISSN 2349-2902 DOI: https://dx.doi.org/10.18203/2349-2902.isj20211831 Case Report Acute gangrenous appendicitis and acute gangrenous cholecystitis in a pregnant patient, a difficult diagnosis: a case report David Lew, Jane Tian*, Martine A. Louis, Darshak Shah Department of Surgery, Flushing Hospital Medical Center, Flushing, New York, USA Received: 26 February 2021 Accepted: 02 April 2021 *Correspondence: Dr. Jane Tian, E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Abdominal pain is a common complaint in pregnancy, especially given the physiological and anatomical changes that occur as the pregnancy progresses. The diagnosis and treatment of common surgical pathologies can therefore be difficult and limited by the special considerations for the fetus. While uncommon in the general population, concurrent or subsequent disease processes should be considered in the pregnant patient. We present the case of a 36 year old, 13 weeks pregnant female who presented with both acute appendicitis and acute cholecystitis. Keywords: Appendicitis, Cholecystitis, Pregnancy, Pregnant INTRODUCTION population is rare.5 Here we report a case of concurrent appendicitis and cholecystitis in a pregnant woman. General surgeons are often called to evaluate patients with abdominal pain. The differential diagnosis list must CASE REPORT be expanded in pregnant woman and the approach to diagnosing and treating certain diseases must also be A 36 year old, 13 weeks pregnant female (G2P1001) adjusted to prevent harm to the fetus.
    [Show full text]
  • General Signs and Symptoms of Abdominal Diseases
    General signs and symptoms of abdominal diseases Dr. Förhécz Zsolt Semmelweis University 3rd Department of Internal Medicine Faculty of Medicine, 3rd Year 2018/2019 1st Semester • For descriptive purposes, the abdomen is divided by imaginary lines crossing at the umbilicus, forming the right upper, right lower, left upper, and left lower quadrants. • Another system divides the abdomen into nine sections. Terms for three of them are commonly used: epigastric, umbilical, and hypogastric, or suprapubic Common or Concerning Symptoms • Indigestion or anorexia • Nausea, vomiting, or hematemesis • Abdominal pain • Dysphagia and/or odynophagia • Change in bowel function • Constipation or diarrhea • Jaundice “How is your appetite?” • Anorexia, nausea, vomiting in many gastrointestinal disorders; and – also in pregnancy, – diabetic ketoacidosis, – adrenal insufficiency, – hypercalcemia, – uremia, – liver disease, – emotional states, – adverse drug reactions – Induced but without nausea in anorexia/ bulimia. • Anorexia is a loss or lack of appetite. • Some patients may not actually vomit but raise esophageal or gastric contents in the absence of nausea or retching, called regurgitation. – in esophageal narrowing from stricture or cancer; also with incompetent gastroesophageal sphincter • Ask about any vomitus or regurgitated material and inspect it yourself if possible!!!! – What color is it? – What does the vomitus smell like? – How much has there been? – Ask specifically if it contains any blood and try to determine how much? • Fecal odor – in small bowel obstruction – or gastrocolic fistula • Gastric juice is clear or mucoid. Small amounts of yellowish or greenish bile are common and have no special significance. • Brownish or blackish vomitus with a “coffee- grounds” appearance suggests blood altered by gastric acid.
    [Show full text]
  • ACUTE Yellow Atrophy Ofthe Liver Is a Rare Disease; Ac
    ACUTE YELLOW ATROPHY OF THE LIVER AS A SEQUELA TO APPENDECTOMY.' BY MAX BALLIN, M.D., OF DETROIT, MICHIGAN. ACUTE yellow atrophy of the liver is a rare disease; ac- cording to Osler about 250 cases are on record. This affection is also called Icterus gravis, Fatal icterus, Pernicious jaundice, Acute diffuse hepatitis, Hepatic insufficiency, etc. Acute yellow atrophy of the liver is characterized by a more or less sudden onset of icterus increasing to the severest form, headaches. insomnia, violent delirium, spasms, and coma. There are often cutaneous and mucous hiemorrhages. The temperature is usually high and irregular. The pulse, first normal, later rapid; urine contains bile pigments, albumen, casts, and products of incomplete metabolism of albumen, leucin, and tyrosin, the pres- ence of which is considered pathognomonic. The affection ends mostly fatally, but there are recoveries on record. The findings of the post-mortem are: liver reduced in size; cut surface mot- tled yellow, sometimes with red spots (red atrophy), the paren- chyma softened and friable; microscopically the liver shows biliary infiltration, cells in all stages of degeneration. Further, we find parenchymatous nephritis, large spleen, degeneration of muscles, haemorrhages in mucous and serous membranes. The etiology of this affection is not quite clear. We find the same changes in phosphorus poisoning; many believe it to be of toxic origin, but others consider it to be of an infectious nature; and we have even findings of specific germs (Klebs, Tomkins), of streptococci (Nepveu), staphylococci (Bourdil- lier), and also the Bacillus coli is found (Mintz) in the affected organs. The disease seems to occur always secondary to some other ailment, and is observed mostly during pregnancy (about one-third of all cases, hence the predominance in women), after Read before the Wayne County Medical Society, January 5, I903.
    [Show full text]
  • The Abnormal Presentation of Complicated Appendicitis Goubeaux C* and Adams J Removed
    Open Access Journal of Family Medicine Case Report The Abnormal Presentation of Complicated Appendicitis Goubeaux C* and Adams J removed. Heritage College of Osteopathic Medicine, Ohio University, Dublin, OH 43016, USA Discussion *Corresponding author: Craig Goubeaux, Heritage Acute appendicitis is one of the most common pathologies in College of Osteopathic Medicine, Ohio University, Dublin, medicine with more than 250,000 cases reported per year [5]. The OH 43016, USA lifetime prevalence is reported to be between 7-8% [5,7]. Diagnosis is Received: January 31, 2019; Accepted: March 12, typically based on a careful clinical history and physical examination 2019; Published: March 19, 2019 [1.7]. The signs and symptoms classically associated with appendicitis are periumbilical pain initially that migrates to right lower quadrant, The Case rebound tenderness, low-grade fever, anorexia, and elevated white A 60-year-old white male presented to our family practice with a blood cell count. chief complaint of isolated right upper quadrant (RUQ) abdominal There are pathologies that may mimic appendicitis such as an pain. It began one week prior after suspected food poisoning with anomalous congenital band, Meckel’s diverticulitis, spontaneous one episode of vomiting. The pain was a constant, dull ache ranging urinary extravasation, renal artery thrombosis or renal infarction between 1-5/10. It did not limit his activities as a farmer. He used [3]. Additionally, a mobile cecum is a congenital anomaly that may NSAIDs to help with the pain. During the past week all other review of systems were negative. Vitals signs were within normal lead to abnormal presentation of appendicitis which occurs in about limits.
    [Show full text]
  • Acute Abdomen
    Acute abdomen: Shaking down the Acute abdominal pain can be difficult to diagnose, requiring astute assessment skills and knowledge of abdominal anatomy 2.3 ANCC to discover its cause. We show you how to quickly and accurately CONTACT HOURS uncover the clues so your patient can get the help he needs. By Amy Wisniewski, BSN, RN, CCM Lehigh Valley Home Care • Allentown, Pa. The author has disclosed that she has no significant relationships with or financial interest in any commercial companies that pertain to this educational activity. NIE0110_124_CEAbdomen.qxd:Deepak 26/11/09 9:38 AM Page 43 suspects Determining the cause of acute abdominal rapidly, indicating a life-threatening process, pain is often complex due to the many or- so fast and accurate assessment is essential. gans in the abdomen and the fact that pain In this article, I’ll describe how to assess a may be nonspecific. Acute abdomen is a patient with acute abdominal pain and inter- general diagnosis, typically referring to se- vene appropriately. vere abdominal pain that occurs suddenly over a short period (usually no longer than What a pain! 7 days) and often requires surgical interven- Acute abdominal pain is one of the top tion. Symptoms may be severe and progress three symptoms of patients presenting in www.NursingMadeIncrediblyEasy.com January/February 2010 Nursing made Incredibly Easy! 43 NIE0110_124_CEAbdomen.qxd:Deepak 26/11/09 9:38 AM Page 44 the ED. Reasons for acute abdominal pain Visceral pain can be divided into three Your patient’s fall into six broad categories: subtypes: age may give • inflammatory—may be a bacterial cause, • tension pain.
    [Show full text]
  • Missed Appendicitis Diagnosis: a Case Report Jocelyn Cox, Bphed, DC1 Guy Sovak, Phd2
    ISSN 0008-3194 (p)/ISSN 1715-6181 (e)/2015/294–299/$2.00/©JCCA 2015 Missed appendicitis diagnosis: A case report Jocelyn Cox, BPhEd, DC1 Guy Sovak, PhD2 Objective: The purpose of this case report is to highlight Objectif : Cette étude de cas vise à souligner la nécessité and emphasize the need for an appropriate and thorough d’une liste appropriée et détaillée de diagnostics list of differential diagnoses when managing patients, as différentiels lors de la gestion des patients, car il n’est it is insufficient to assume cases are mechanical, until pas suffisant de supposer que les cas sont d’ordre proven non-mechanical. There are over 250,000 cases mécanique, jusqu’à la preuve du contraire. Il y a plus de of appendicitis annually in the United States. Of these 250 000 cas d’appendicite par an aux États-Unis. Parmi cases, <50% present with classic signs and symptoms of ces cas, < 50 % présentent des signes et des symptômes pain in the right lower quadrant, mild fever and nausea. classiques de douleur dans le quadrant inférieur droit, It is standard for patients who present with appendicitis de fièvre légère et de nausées. Il est normal qu’un to be managed operatively with a laparoscopic patient qui se présente avec une appendicite soit géré appendectomy within 24 hours, otherwise the risk of par une intervention chirurgicale (appendicectomie complications such as rupture, infection, and even death par laparoscopie) dans les 24 heures, sinon le risque increases dramatically. de complications, telles que rupture, infection et décès, Clinical Features: This is a retrospective case report augmente considérablement.
    [Show full text]
  • Imaging of Acute Appendicitis in Adults and Children
    Diagnostic Imaging Imaging of Acute Appendicitis in Adults and Children Bearbeitet von Caroline KEYZER, Pierre Alain Gevenois 1. Auflage 2011. Buch. IX, 256 S. Hardcover ISBN 978 3 642 17871 9 Format (B x L): 19,3 x 26 cm Gewicht: 688 g Weitere Fachgebiete > Medizin > Sonstige Medizinische Fachgebiete > Radiologie, Bildgebende Verfahren Zu Inhaltsverzeichnis schnell und portofrei erhältlich bei Die Online-Fachbuchhandlung beck-shop.de ist spezialisiert auf Fachbücher, insbesondere Recht, Steuern und Wirtschaft. Im Sortiment finden Sie alle Medien (Bücher, Zeitschriften, CDs, eBooks, etc.) aller Verlage. Ergänzt wird das Programm durch Services wie Neuerscheinungsdienst oder Zusammenstellungen von Büchern zu Sonderpreisen. Der Shop führt mehr als 8 Millionen Produkte. Clinical Presentation of Acute Appendicitis: Clinical Signs—Laboratory Findings—Clinical Scores, Alvarado Score and Derivate Scores David J. Humes and John Simpson Contents Abstract Appendicectomy is the most commonly performed 1 Clinical Presentation ............................................... 14 emergency operation worldwide with a lifetime risk 1.1 History........................................................................ 14 of appendicitis of 8.6% in males and 6.7% in 15 1.2 Examination ............................................................... females (Flum and Koepsell 2002; Addiss et al. 2 Laboratory Investigations....................................... 16 1990). The diagnosis of acute appendicitis is 3 Scoring Systems ......................................................
    [Show full text]
  • Case Report Perforated Acute Appendicitis Misdiagnosed As Colonic Perforation in Colon Cancer Patients After Colonoscopy: a Report of Two Cases and Literature Reviews
    Int J Clin Exp Pathol 2017;10(6):7256-7260 www.ijcep.com /ISSN:1936-2625/IJCEP0050313 Case Report Perforated acute appendicitis misdiagnosed as colonic perforation in colon cancer patients after colonoscopy: a report of two cases and literature reviews Kaiyuan Zheng, Ji Wang, Wenhao Lv, Yongjia Yan, Zhicheng Zhao, Weidong Li, Weihua Fu Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China Received January 23, 2017; Accepted May 9, 2017; Epub June 1, 2017; Published June 15, 2017 Abstract: Free gas in the abdominal cavity usually indicates that the perforation of the gastrointestinal tract from many factors including perforated ulcer, tumor perforation and severe infection, etc. But the pneumoperitoneum in perforated acute appendix secondary to the colonoscopy was rare relative. We reported two colon cancer patients with signs of abdominal free air after the operation of colonoscopy, considered the diagnosis of colon perforation at first, but eventually they were confirmed as perforated appendicitis. This report highlights that purulent perforated appendicitis should be considered especially for elderly patients with colon tumor presenting as signs of pneumo- peritoneum after the endoscopic operation. Keywords: Pneumoperitoneum, perforated appendicitis, colon cancer perforation, colonoscopy Introduction Acute perforated appendicitis is one of the common causes of acute abdomen and is Pneumoperitoneum is defined as free gas ap- needed emergency surgery. Its incidence was pears in the abdominal cavity, is usually caused higher in elderly population [6]. However, acute by the perforation of the alimentary tract sec- appendicitis following the operation of colonos- ondary to pathological or iatrogenic factors, but copy as a rare complication, with a consider- caused by purulent perforated appendix was ed incidence of 0.038%, and the appendix is rare relative.
    [Show full text]
  • Positive Psoas Sign in a Disabled Child-Not Always Appendicitis, Seldomly Due to Duodenal Perforation by Sharp Foreign Body
    Case Report Published: 01 Aug, 2019 SF Journal of Radiology and Clinical Diagnosis Positive Psoas Sign in a Disabled Child-Not Always Appendicitis, Seldomly due to Duodenal Perforation by Sharp Foreign Body Klein E1*, Merhav G1, Kassis I2 and Ilivitzki A1 1Department of Radiology, Rambam Health Care Campus, Haaliya Hashniya 8 st, Haifa, Israel 2Pediatric Infectious Disease Unit, Rambam Health Care Campus, Haaliya Hashniya 8 st, Haifa, Israel Abstract We present a rare cause for "positive psoas sign" secondary to duodenal perforation by an ingested wooden skewer in a disabled 13 years old male. The unreliable clinical evaluation made the appreciation of a "positive psoas sign" obscured. We highlight the possible occurrence of this pathology in young or disabled children, and the importance of CT leading to this diagnosis, with the utilization of multiplane MIP reconstructions. This case also points that the psoas muscle is a long structure in the retroperitoneum, and irritation of its upper most part may also present as positive psoas sign. Keywords: Psoas sign; Psoasabscess; Skewer; Perforation; Missed diagnosis Case Report A 13 years old male is seen in the pediatric emergency room (ER) due to new onset of limp on the right lower limb, nausea and agitation. His past medical history consists of prematurity with severe psychomotor delay including mental retardation as a sequalae. Past surgical history consists of fundoplication procedure due to diaphragmatic hernia and feeding jejunostomy which was thereafter closed. Medical history was negative for any recent illness with fever, nothing to support food poisoning OPEN ACCESS or any trauma. Physical examination revealed a positive psoas sign, with no tenderness upon deep palpation of the abdomen, and additional point tenderness upon palpation of the distal femur.
    [Show full text]
  • Abdominal Pain
    10 Abdominal Pain Adrian Miranda Acute abdominal pain is usually a self-limiting, benign condition that irritation, and lateralizes to one of four quadrants. Because of the is commonly caused by gastroenteritis, constipation, or a viral illness. relative localization of the noxious stimulation to the underlying The challenge is to identify children who require immediate evaluation peritoneum and the more anatomically specific and unilateral inner- for potentially life-threatening conditions. Chronic abdominal pain is vation (peripheral-nonautonomic nerves) of the peritoneum, it is also a common complaint in pediatric practices, as it comprises 2-4% usually easier to identify the precise anatomic location that is produc- of pediatric visits. At least 20% of children seek attention for chronic ing parietal pain (Fig. 10.2). abdominal pain by the age of 15 years. Up to 28% of children complain of abdominal pain at least once per week and only 2% seek medical ACUTE ABDOMINAL PAIN attention. The primary care physician, pediatrician, emergency physi- cian, and surgeon must be able to distinguish serious and potentially The clinician evaluating the child with abdominal pain of acute onset life-threatening diseases from more benign problems (Table 10.1). must decide quickly whether the child has a “surgical abdomen” (a Abdominal pain may be a single acute event (Tables 10.2 and 10.3), a serious medical problem necessitating treatment and admission to the recurring acute problem (as in abdominal migraine), or a chronic hospital) or a process that can be managed on an outpatient basis. problem (Table 10.4). The differential diagnosis is lengthy, differs from Even though surgical diagnoses are fewer than 10% of all causes of that in adults, and varies by age group.
    [Show full text]
  • Crohn's Disease Manifesting As Acute Appendicitis: Case Report and Review of the Literature
    Case Report World Journal of Surgery and Surgical Research Published: 20 Jan, 2020 Crohn's Disease Manifesting as Acute Appendicitis: Case Report and Review of the Literature Terrazas-Espitia Francisco1*, Molina-Dávila David1, Pérez-Benítez Omar2, Espinosa-Dorado Rodrigo2 and Zárate-Osorno Alejandra3 1Division of Digestive Surgery, Hospital Español, Mexico 2Department of General Surgery Resident, Hospital Español, Mexico 3Department of Pathology, Hospital Español, Mexico Abstract Crohn’s Disease (CD) is one of the two clinical presentations of Inflammatory Bowel Disease (IBD) which involves the GI tract from the mouth to the anus, presenting a transmural pattern of inflammation. CD has been described as being a heterogenous disorder with multifactorial etiology. The diagnosis is based on anamnesis, physical examination, laboratory finding, imaging and endoscopic findings. There have been less than 200 cases of Crohn’s disease confined to the appendix since it was first described by Meyerding and Bertram in 1953. We present the case of a 24 year old male, who presented with acute onset, right lower quadrant pain, mimicking acute appendicitis with histopathological report of Crohn’s disease confined to the appendix. Introduction Crohn’s Disease (CD) is a chronic entity which clinical diagnosis represents one of the two main presentations of Inflammatory Bowel Disease (IBD), and it occurs throughout the gastrointestinal tract from the mouth to the anus, presenting a transmural pattern of inflammation of the gastrointestinal wall and non-caseating small granulomas. The exact origin of the disease remains OPEN ACCESS unknown, but it has been proposed as an interaction of genetic predisposition, environmental risk *Correspondence: factors and immune dysregulation of intestinal microbiota [1,2].
    [Show full text]
  • MANAGEMENT of ACUTE ABDOMINAL PAIN Patrick Mcgonagill, MD, FACS 4/7/21 DISCLOSURES
    MANAGEMENT OF ACUTE ABDOMINAL PAIN Patrick McGonagill, MD, FACS 4/7/21 DISCLOSURES • I have no pertinent conflicts of interest to disclose OBJECTIVES • Define the pathophysiology of abdominal pain • Identify specific patterns of abdominal pain on history and physical examination that suggest common surgical problems • Explore indications for imaging and escalation of care ACKNOWLEDGEMENTS (1) HISTORICAL VIGNETTE (2) • “The general rule can be laid down that the majority of severe abdominal pains that ensue in patients who have been previously fairly well, and that last as long as six hours, are caused by conditions of surgical import.” ~Cope’s Early Diagnosis of the Acute Abdomen, 21st ed. BASIC PRINCIPLES OF THE DIAGNOSIS AND SURGICAL MANAGEMENT OF ABDOMINAL PAIN • Listen to your (and the patient’s) gut. A well honed “Spidey Sense” will get you far. • Management of intraabdominal surgical problems are time sensitive • Narcotics will not mask peritonitis • Urgent need for surgery often will depend on vitals and hemodynamics • If in doubt, reach out to your friendly neighborhood surgeon. Septic Pain Sepsis Death Shock PATHOPHYSIOLOGY OF ABDOMINAL PAIN VISCERAL PAIN • Severe distension or strong contraction of intraabdominal structure • Poorly localized • Typically occurs in the midline of the abdomen • Seems to follow an embryological pattern • Foregut – epigastrium • Midgut – periumbilical • Hindgut – suprapubic/pelvic/lower back PARIETAL/SOMATIC PAIN • Caused by direct stimulation/irritation of parietal peritoneum • Leads to localized
    [Show full text]