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Surgical Abdomen GI module Jane R. Perlman Fellowship Program Nurse Practitioner and Physician Assistant Fellowship in Emergency Medicine Jennifer S. Foster PA-C Dina Mantis PA-C Acute Abdomen – causes Acute appendicitis Acute mesenteric ischemia/ischemic colitis Perforated bowel, acute peptic ulcer or tumor Spectrum of cholecystitis Asymptomatic gallstones Biliary colic Acute Cholecystitis Choledocholithiasis Cholangitis Pancreatitis Hemoperitoneum – perforated AAA, trauma, surgery Abcess Bariatric surgery complications Acute abdomen Worry about abdominal pain in elderly, children, HIV infection, immune suppressed from steroids or chemotherapy History questions to ask: MerckManuals.com Where is the pain? What is the pain like? Have you had it before? Yes – recurrent problem such as ulcers, biliary colic, diverticulitis, mittelsherz No – think perforated ulcer, ectopic pregnancy, torsion How severe is pain? Pain out of proportion – mesenteric ischemia Does pain travel to other body parts? Right scapula – gallbladder pain Left shoulder – ruptured spleen, pancreatitis Other questions re abdominal pain: What relieves the pain? Sitting up right and leaning forward, think acute pancreatitis What other sx occur with the pain? a) vomiting before pain, then diarrhea = gastroenteritis b) delayed vomiting, no bowel movements, no gas = acute intestinal obstruction, SBO c) severe vomiting, then intense epigastric left chest or shoulder pain = perforation of esophagus Other historical questions the surgeon will want to know: Prior surgeries Surgical history, when – how recently, what, where, who did it? Also postop complications, postop course Pregnant or not Physical exam General, are they texting and talking and telling you pain is 10/10 or quiet, pale and diaphoretic? Ask patient where most tender area is, then start away from there, listen first, then percuss and palpate. Guarding or rigid? Check groin area for bulges, hernias Even if they are very tender/distended, always check for inguinal hernias Red flags Severe pain, abdominal distention Shock, tachycardic, hypotensive, diaphoretic, confusion Signs of peritonitis Tricks with this, go back and examine patient, distract them by asking a question, re-evaluate their tenderness Notice if when ask them to take deep breaths during lung exam if they do it easily and without pain or do they sit up in bed really easily and without wincing. Or are they really having pain and tenderness? Appendicitis Appendectomy most common general surgery performed in US. 7% of all surgeries annually. Most common cause of acute abdominal pain Historically: Mortality for appendicitis in 1886? 45% died! Signs and symptoms of acute appendicitis Classic Symptoms: Epigastric/periumbilical pain Brief nausea/vomiting/anorexia Pain moves to RLQ Increased pain with cough and motion Classic Signs: RLQ tenderness Rebound tenderness at Mcburney’s point – pain worse when let go Rovsing sign – pain in RLQ when push in LLQ Psoas sign/obturator sign – tests for retrocecal appendicitis. Obturator sign not a very good diagnostic tool. Non classic signs, symptoms Elderly patients, patients with dementia, pregnant women – pain may be less severe and local ttp less severe Hamburger sign – Ask patients with suspected appendicitis if they would like a hamburger or pizza/favorite food: if they are hungry, seriously question diagnosis This only lasts for a few hours Diagnosis of acute appendicitis Clinical evaluation CT findings: Thickened appendix > than 6 mm Fat stranding Cecal thickening Appendicolith No contrast in appendix Arrowhead sign – contrast in cecum forms an arrowhead pointing to the occluded appendiceal orifice Acute appendicitis Acute appendicitis Time to appendectomy and risk of perforation Study looked at time to treatment and perforation, analyzed hospital arrival time, time of diagnostic imaging, operating room start times. (Drake et al. 2014) 9048 patients Mean time from presentation to OR was 8.6 hrs 15.8% were perforated No association between time from presentation to surgery and risk of perforation Higher risk of perforation associated with: male sex, increased age, 3 or more comorbid conditions, and lack of insurance. New hypothesis, perforation is most often a prehospital occurrence, not strictly time-dependent. Acute mesenteric ischemia Interruption of blood flow Causes: Thrombus – blood clot that forms in a vein Embolism ie small piece of clot, fat, air, tumor, foreign body Low flow state Then inflammatory mediator release Infarction Interesting fact: intestinal mucosa uses 20-25% of cardiac output (high metabolic rate) Acute mesenteric ischemia Ischemia – disrupts the mucosal barrier - allows bacteria, toxins, vasoactive mediators to leaks out Within 10-12 hours, Myocardial depression, systemic inflammatory response, multiorgan failure, death Acute mesenteric ischemia 3 major blood vessels involved I: Celiac trunk, supplies esophagus, stomach, prox duodenum, liver, gallbladder, pancreas, spleen II: SMA: supplies distal duodenum, jejunum, ileum, colon to splenic flexure III: IMA: descending colon, sigmoid colon, rectum Most common areas for ischemia ? Most common area? How is acute mesenteric ischemia different from ischemic colitis? Which areas least likely to be ischemic? What test do you use to test for ischemia? Most common areas for ischemia Most common area = splenic flexure, watershed area Why? The splenic flexure is supplied by the area btwn the SMA and IMA Acute mesenteric ischemia involves clots or emboli in the bigger gut vessels Ischemic colitis is only small vessels – causes mainly necrosis and bleeding The stomach, duodenum and rectum are least likely to be ischemic because many collateral vessels. Risk factors of acute mesenteric ischemia based on cause Arterial embolus (40% of cases): CAD, CHF, Afib, valvular heart disease Arterial thrombosis: atherosclerosis DVT: hypercoagulable states, inflammatory conditions like pancreatitis Non-occlusive ischemia: Low flow states - shock, heart failure, cocaine, vasopressors Acute mesenteric ischemia: symptoms, signs Early – lots of pain, benign abdominal exam findings, abd soft, min ttp (Pain out of Proportion) Later findings signs of peritonitis, markedly ttp, guarding, rigid, no bowel sounds Stool heme postive Shock Death Diagnosis, acute mesenteric ischemia CTA (if renal function allows) might need to hydrate first Mesenteric angiogram (if renal function allows) Serum markers: creatinine kinase, lactate New test: intestinal fatty acid binding protein Early diagnosis important Very high mortality if infarction occurs Summary acute mesenteric ischemia Early diagnosis important CTA or mesenteric angiogram Surgical exploration Treatment: resuscitate – IVF, cipro/flagyl for bacterial gut translocation embolectomy, resvascularization and resection GI tract perforation Etiology: Blunt and penetrating trauma Swallowed foreign body ex toothpick Anatomical location and causes: a) esophagus – forceful vomiting aka Boerhave syndrome, iatrogenic (EGD), ingestion corrosive material b) stomach/duodenum: PUD (peptic ulcer disease) 1/3 of patients, no prior hx of ulcer sx, 20% don’t have free air on xray!!!! GI perforation, stomach cont b) stomach – PUD, ingestion corrosive material c) Intestine – strangulating obstruction, possibly acute, ex. Appendicitis, sbo, obstruction, meckel’s diverticulum ex. free air, rarely visible on xrays d) Symptoms of esophageal, gastric, duodenal perf ’s: sudden onset abrupt onset severe pain, peritoneal signs, may radiate to shoulder Symptoms of perforation (not in esophagus, stomach or duodenum) Usually small initially, omentum walls them off Pain develops gradually, may be localized, tenderness is focal too. Often exam is very distended, but NO tenderness Nausea, vomiting, anorexia common Bowel sounds quiet to absent Diagnosis of GI tract perforation Obstructive series, 50-75% show free air Abdominal ct +/- po and iv contrast, and/or rectal contrast Case study - perforation 64 yo male Hx Etoh, diabetes Recent ORIF shoulder after fall, postop had PE/DVT discharged on lovenox, coumadin Came back to ER with abdominal pain, possible SBO on xray at NH CT extensive free air Perforated colon Case study Perforated right colon Treatment – exploratory lap, right colectomy Postop septic, abdominal compartment syndrome, went back to OR for ex lap, washout Intubated, sedated for weeks, finally extubated, then transferred to floor approx HOD 20 Treatment GI tract perforation Immediate surgery, NGT, resuscitate, IV abx, typically broad spectrum, unasyn, zosyn There are cases where we’ve successfully treated patients with only IV antibiotics, bowel rest, esp. when body has walled it off. Or elderly patient, too many medical comorbidities Causes of Colon perforation Colon – causes: obstruction from colon mass, diverticulitis, IBD (Crohn’s, ulcerative colitis), toxic megacolon, constipation – stercoral ulcer. most common area to perforate = cecum. High risk greater than 13 cm, patients on prednisone or other immune suppressed patients. GI tract perforation Clinical pearl: People on steroids could still have a bad problem, even though physical exam without peritoneal signs. Case study 67 yo male PMhx: htn ER complaint: abdominal pain, rectal bleeding, nausea Wbc 18.8 CT – diffuse bowel wall thickening, inflammatory changes Colon ischemia Initial treatment in ER IV antibiotics, Zosyn or cipro/flagyl NPO IVF Case study - Flexible
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