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Acute Abdomen

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by

Patrik Tosenovsky

on 9 January 2013

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Transcript of Acute Abdomen

Patrik Tosenovsky, MD Definition

acute onset of abdominal pain severe in nature
or
severe pain lasting for
< 1 week /24 hours Types of abdominal pain:

1. VISCERAL

2. PARIETAL

3.TRANSPOSED/REFERRED definitions vary Description of the pain

1. Site
2.Time, Onset
3. Severity
4. Nature
5. Progression
6. Duration
7. Relieving/Exacerbating factors
8. Radiation Acute Abdomen Visceral pain
1. Dos not arise from all viscera (e.g., liver parenchyma - but capsule distension YES!)
2. Not specific ! (in terms of the cause -distension, ischemia, inflammation, spasm, traction)
3. Is diffuse & difficult to localize ! multiple viscera often converge onto
the same spinal cord neurons.
Thus, patterns of referred sensation from
the gallbladder,esophagus, and heart
or
from the urinary bladder
and colon overlap considerably Parietal pain

Is caused by an irritation
of the parietal pleura
...more nerves there...

- much more specific
- easily localized
- more severe Organs Poor localization! Pain patterns Pain categories:

A. Abdominal organs
- biliary tract disease
- appendix (-itis)
- large and small bowel
(obstruction, -itis)
- renal (colic, -itis)
- ovarian/uterine (ectopic,
cyst, -itis
- vascular (AAA,
thrombosis/embolus)
B. Abdominal wall/other
- hernia
- metabolic (DKA)
- cardiac/pulmonary
- other
C. Non-Specific (1/3)
- poorly identified
Physical Examination





1. Inspection - whole body!
2. Palpation
3. Auscultation Laboratory tests:

FBC (limited value)
U&E, urinalysis, dipstick
LFT, lactate
Amylase/Lipase
Troponin (?)
HCG
coags
culture (wounds, urine,
sputum etc) Radiographic assessment:
Abdominal X ray (AXR)
"gasses,masses & bones,stones"


Ultrasound (perhaps more useful)
CT/CTA (sensitive, quick, overused) Abdominal pain is the most common reason for a visit to the emergency department (ED)(7%)

The modern physician should be humbled by the fact that, despite diagnostic and therapeutic advances (computed tomography [CT], ultrasonography, and laparoscopy), the misdiagnosis rate of the most common surgical emergency, acute appendicitis, has changed little over time...



Abdominal pain is the presenting issue in a high percentage of medicolegal actions against both general and pediatric EM physicians.

Flum DR, Morris A, Koepsell T, Dellinger EP
JAMA. 2001 Oct 10; 286(14):1748-53. Pain from foregut structures,
which include the stomach,
pancreas, liver, biliary system,
and the proximal duodenum,
will be typically localized to
the epigastric region. The rest of the small bowel and
the proximal third of the colon
including the appendix are midgut
structures,

and visceral pain associated
with these organs is perceived

in the periumbilical region. Hindgut structures such as
the bladder,
and distal two-thirds of the colon,
& pelvic genitourinary organs

usually cause pain




in the suprapubic region. MIDGUT FOREGUT HINDGUT Assessment of the associated symptoms
Anorexia - in 68% of patients with appendicitis (20-44% in elderly)
Vomiting - usually in small bowel obstruction
- Bilious vomiting in an infant is always considered a harbinger
of serious abdominal illness such as intestinal malrotation,
- Blood or coffee ground emeses - caused by gastric
diseases or complications of liver disease
Bowel symptoms - diarrhea is a frequent & can be assoc. with appendic.
or mesenteric ischemia or malignancy (NOT SPECIFICIC)
- Absence of flatus is a more reliable sign than
constipation in bowel obstruction
- Bloody stool - cancer/ischemia
- Melena suggests an upper source of bleeding
The urge to defecate in a patient with acute abdominal pain has been described as a harbinger of serious disease
Past medical and surgical history,
current medications...

Many medical conditions cause
acute abdominal pain, including
diabetic ketoacidosis,
hypercalcemia,
Addison’s disease,
sickle cell crisis..

methanol poisoning ...

operations - adhesions - obstruction.......
It is preferable to have
the patient flex
the knees and hips
to allow for relaxation
of the abdominal musculature
Full transcript