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    1 : Assessment and Management Acute Abdomen
    2 : There is surely no greater wisdom than well to time the beginning and onset of things. Bacon,On Delay
    3 : 11/6/2013 fiaz fazili 3 Acute Abdomen Dr Fiaz Maqbool Fazili SURGEON ACUTE CARE- (EMEREGNCY &TRAUMA) LAPAROSCOPY King Fahd Hospital Medina Munawarah Kingdom of Saudi Arabia Assessment and Management MBBS;MS;MAMS(Aust)FICA(USA)FICS(USA)
    4 : What is Acute Abdomen –definition Def; Severe abdominal pain which ensue in patient who have been previously well ,and which last as long as six hours ,are caused by conditions of surgical importance .(there are exceptions ) REF -Cope early Dx of acute Abdomen) # Acute abdominal pain (AAP): of less than 1 week’s duration. The term “acute abdomen” denotes any sudden spontaneous non-traumatic disorder whose chief manifestation is in the abdominal area. “any serious acute intra-abdominal condition attended by pain, tenderness, and muscular rigidity, and for which emergency surgery must be considered.” Stedman’s Medical Dictionary, 27th Edition
    5 : Acute abdomen –magnitude of problem & WHY Evaluation is challenge? Most common cause of surgical presenting complaint encountered IN ER/ admission (5 million pts annually in USA-s/s ) 1/3 have an atypical presentation.-A specific diagnosis is not possible in approximately 30% of cases.- Among them, 14-40% patients need surgical intervention. If misdiagnosis, mortality rate 2.5 times higher than correct diagnosis in the elderly. The list of possible causes of abdominal pain is too long, From trivial like psychogenic pain to life threatening aortic dissection to –(ncluding almost anything in between) # can be an indication of a number of diseases & conditions From abdominal organs from organs and structures outside the borders of the abdominal cavity.- referred pain However, a sudden onset and severe abdominal pain is almost always caused by some type of serious intra-abdominal pathology.
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    8 : Acute Abdominal Pain No surgical causes Metabolic(medical ) Causes Diabetic Ketoacidosis Heavy Metal Poisoning Acute Porphyria Tabes Sickle Cell Crisis Acute Enteric Infections Acute Enteric Poisonings Inflammatory Bowel Disease Pancreatitis (usually) Mesenteric Adenitis 11/6/2013 fiaz fazili 8
    9 : 1. To arrive at an accurate diagnosis that leads to proper management 2.Recognize an abdominal emergency (acute abdomen) 3.Determine if it is life-threatening or potentially life-threatening conditions exist. 4.Is the problem surgically correctable? OUR PRIMARY GOAL
    10 : Problems of Haji as a patient RACE +old age problems +chronic diseases Drug usage/Systems.(Herbal;homepathy:chniese etc) Language barrier Disorientation ; DEHYDRATED :Exhaustion. (some haji fear of loosing Hajj obscure/under report history)—plus -----------------------------------------------------------------
    11 : Abdominal topography Abdomen cavity has a ast amount of space in Abdomen to hide volume Hidden portions of abdomen difficult to evaluate by hands. -Retroperitoneum/pelvis/& portions of abdomen behind subcostals Initial abdominal exam only 66%reliable; initially the signs may be so subtle to evade your attention. Haji + acute abdomen =challenge
    12 : ACUTE ABDOMEN- GENERAL PRINCIPLES Need for Prompt Diagnosis and Early Treatment-that Does Not Mean Always Surgical Interference Need for Urgent Surgery May Be So Obvious and Transfer to Surgery Is Clear Indefinite symptoms-Justification to Wait for Development of Clear Indication_(further observation) Seeking help of senior /expert is not a failure –but a plus point in your attitude
    13 : The Most Important Concept for EP in Approaching Abdominal Pain-triage plan To Differentiate Who is the patient of acute abdomen? What are the probable diagnoses you have in mind? Why do you consider such diagnosis? How do you prove it? When will you consult surgeon for operation?
    14 : DIFFERENT ORGANS/Diseases HAVE Particular Characters/presentations OF PAIN when affected TO Reach Diagnosis or D/d_We have to answer Qs? Q1.Which system? Q2.Which Organ? Q3.Which disease? Q4.Surgical or NON surgical;Medical-Gynae etc cause 5.For OR or observation WHAT MIND DOESNOT KNOW_ Eyes Don’t SEE- So what is important to reach DX? Knowledge ---of
    15 : How are you going to diagnose? BACKGROUND KNOWLEDGE Epidemiology of disease s and their presentations Anatomical of abdomen & Physiology and abd pain The History taking -The Examination of the patient Detailed history-esp pain The grouping of symptoms- The Knowledge of symptoms, local and systemic signs of an attack Order of occurrence of symptoms Differential diagnosis Investigative Help ER Treatment When TO CALL A SURGEON ??
    16 : Anatomy considerations Abdomen extends from diaphragm to pelvic cavity. Externally: Abdomen proper,+ a portion behind subcostal region* Flank, Back (*don’t forget Perineum,Axilla; groin) Internally, 3 distinct regions Intraperitoneum Pelvic cavity* Retroperitoneum* *Hidden Portions of abdomen.
    17 : Anatomical landmarks-organ location Four quadrants: Right Upper Quadrant Right Lower Quadrant Left Upper Quadrant Left Lower Quadrant Three central areas: Epigastric Periumbilical Suprapubic PERIUMBILICAL Epigastric umbilical Supra pubic LIVER Gall bladder stomach Spleen PANCREAS Appendix Caecum Kidney Kidney Sigmoid colon Urinary bladder
    18 : Abdominal Organs Solid Organs; LIVER SPLEEN *KIDNEY PANCREAS Hollow; Intestine Bile ducts Ureter Pelvic organs; Bladder; Rectum;Uterus;Ovaries; Solid &Hollow organs
    19 : Retroperitoneal structures Retroperitoneum Kidneys Ureter AORTA IVC kidney pancreas uterus
    20 : Main OBJECTIVE OF THIS LECTURE- IS Abdomen Hot (acute) or Cold? To examine the Anatomical & Physiologic background of abdominal pain As An aid to accurate interpretation of Symptoms & Signs in acute abdomen
    21 :      The pain is usually caused by one of the following mechanisms Ischemia (lack of adequate oxygenation of tissue) of the intestines or associated structures Distention of the organs or associated structures Inflammation or irritation of the peritoneal lining due to chemical or infectious substances Mechanical stretch of tissues
    22 : Analysis of pain need DATA COLLECTION 1 2 3 History Physical exam. Lab.inv. apply your medical knowledge***
    24 : Important Extra-abdominal Causes of Abdominal Pain Systemic DKA Alcoholic ketoacidosis Uremia Sickle cell disease Porphyria SLE Vasculitis Glaucoma Hyperthyroidism Toxic Methanol poisoning Heavy metal toxicity Scorpion bite Black widow spider bite Thoracic Myocardial infarction/ Unstable angina Pneumonia Pulmonary embolism Herniated thoracic disc (neuralgia) Genitourinary Testicular torison Renal colic Infectious Strep pharyngitis (more often in children) Rocky Mountain Spotted Fever Monocucleosis Abdominal wall Muscle spasm Muscle hematoma Herpes zoster
    25 : Tips ---Abdominal Pain- Pain from Hollow Viscera_is -COLICKY Crampy /paroxysmal (intermittent) often poorly localized _WHY?related to peristalsis patient writhing on exam table Pain from Peritoneal Irritation is _Dull ACHE steady/constant /cutting often localized _WHY? patient lies still with knees up
    26 : Abdominal pain can be classified Visceral Pain Somatic (Parietal) Pain Referred Pain
    27 : Visceral Pain Corresponds to the embryologic origin of the diseased organ (foregut, midgut, hindgut) - Pain Poorly localized Stimuli= ??Distention of the gut/hollow organ ?? Traction on the bowel mesentery ?? Inflammation ?? Ischemia
    28 : Parietal(Somatic) Pain Stimuli Irritation of the peritoneum Sensation Sharp, localized pain Easily described Cardinal signs Pain “tenderness” Guarding Rebound Absent bowel sounds
    29 : Refferd pain Referred pain is a type of visceral pain that is felt away from the actual affected organ site, even though the patient is complaining of discomfort or pain in that particular area Cause =neural pathways of the affected organ follow or share a central afferent (toward spinal cord) nerve pathway that may have been common during embryonic development.
    30 : Acute Abdomen
    31 : The history of pain betrays the diagnosis History of pain Site Mode of onset Nature of pain Severity Radiation Duration Factors influencing the clinical manifestation
    32 : Mode of onset Sudden onset [The patient can tell you exactly when the pain started ] The pain that start suddenly has a mechanical basis Some thing has been Ruptured Twisted Occluded
    33 : Cont’ Mode of onset Gradual Onset ( The pat. Usually responds vaguely to questions about time of onset ) Cause=Non- mechanical or chronic process
    34 : Obstruction Sudden prolonged Distention of the viscus ( constant stretching pain ) Colic pain = visceral pain Three Types ( 1 ) Biliary System = ( foregut ) Foregut pain is experienced in the epigastrium (2) Small Intestine = ( midgut ) Pain is experienced in the periumbilical region (3) Renal system = ( retroperitoneal ) Pain is felt in the flank & radiates to the groin
    36 : Example- For example, when a patient develops cholecystitis, gallbladder inflammation is experienced initially as a visceral pain in the epigastric region. Eventually, the inflammation extends to the parietal peritoneum, and the patient will experience parietal pain that lateralizes to the right upper quadrant. (parietal) Gallbladder pain may also refer to the right shoulder.(refrd)
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    38 : Important features of colic pain Pat . Is often restless & agitated during exacerbations. Pat. Does not experience a totally pain –free interlude. Colic pain is an intermittent pain . Colic pain is an visceral pain . ( not influenced by changing relationships between the peritoneal layers ) Failing to demonstrate abd guarding , tenderness ? ????
    40 : Important features of Peritonitis(somatic pain) Pat. Laying quite in bed . ( movement is limited ) Examination may demonstrate guarding , tenderness . The pain is localized over the inflamed organ . Fever , tachycardia & tachypnea are systemic manifestation for generalized inflammation .
    41 : Ischemic pain Is a somatic pain Occlusion of blood supply cause Tissue Hypoxia With metabolic changes Necrosis After 6-12 h
    42 : Factors influencing clinical manifestation (6) Drugs Many drugs influence both the character , perception & the course and effects of disease . Corticosteroids Suppress the inflammatory response Sedatives Influence pat. Recognition of problems Analgesics Decrease pain ( minimized or overlooked )
    43 : Special Questions ?_To know which system is influenced Ask questions specific to chief complaint: ABDOMEN PAIN PLUS Anorexia /Nausea/vomiting /fresh bleeding PR – MOST PROBABLY=GIT system Urinary Frequency, Urgency, Discomfort hematuria / Vaginal discharge. MOST PROBABLYGenito Urinary system
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    45 : Essential OBSERVATIONS-posture Posture may also provide some clues. The patient who has writhing movements due to renal colic , biliary colic. ( kidney /gall stone ) Pt of pancreatitis bending forwards Pt of peritonitis will stay quiet –doesn’t lie to be disturbed Pt with ischaemic pain crying asking to open him
    46 : VITAL SIGNS  Assess heart rate; respirations; skin color, temperature and condition; blood pressure and pupils. Shocked or stable.Although tachycardia is a true sign of shock, it may not be present in many patients. caution-If the patient takes beta blockers or calcium channel blockers, the heart rate may remain much lower than would be expected, even though he is truly in hypovolemic shock
    47 : The Important Physical Examination of Acute Abdomen General Facial expression, pallor, jaundice and degree of agitation Vital signs Temp > 40 °C or < 35° C ? consider abdominal sepsis Tachypnea, bradypnea or tachycardia
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    49 : Physical Examination of the Abdomen   Inspection    Auscultation     Percussion    Palpation Special Tests
    50 : Examination Abdomen –signs of acute abdomen  Tense; Tender; Rigid; not moving with respiration; Distended; with rebound tenderness BS+ _ Signs of peritonitis- Doesn’t mean all need OR
    51 : Rebound Tenderness This is An important test for peritoneal irritation. Palpate deeply and then quickly release pressure. If it hurts more when you release, the patient has rebound tenderness. .
    52 : Costovertebral Angle Tenderness CVA tenderness is often associated with renal disease. Slide showing how to eliict it Use the heel of your closed fist to strike the patient firmly over the costovertebral angles.
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    54 : Adjuvant Exams  Digital Rectal Exam Bimanual Pelvic Exam Listening to lower lung fields Examine back
    55 : Ancillary aids to clinical Diagnosis? Take help from… LABORATORY CBC with diff count LFT;KFT Amylase/lipase Urine HCG/preg test Consider chemistry panel
    56 : Free air on x ray- To detect free air depends on the volume of free air within the peritoneal cavity. Snsitivity is maximized if the patient is placed in the upright or decubitus position for 5 to 10 minutes before obtaining an upright chest or lateral decubitus film, thereby allowing small volumes of air to redistribute to and collect within nondependent areas. Volumes as small as 1 to 2 cm3 of air have been reported using this method The instillation of intraluminal water-soluble contrast media in cases of suspected perforation can also improve sensitivity [10]. Free air on xray-
    57 : Free air on xray- What is the finding /Diagnosis ?
    58 : What is the diagnosis ? Volvulus- loop of bowel
    59 : Gall stones YOUR DIAGNOSIs
    60 : What is the Diagnosis? Large bowel obstruction-Causes- cancer
    61 : What do you see in this abd x-ray Air fluid levels-Multiple Causes- A(adhesions) B (bulges), C (cancer) Dx =Small bowel obstruction- more centrally located , air-fluid levels, due to , valvulae conniventes (traverse full width of bowel),
    62 : The Roles and Diagnosis of Ultrasound for EP Perforated ulcer (X) Cholecystitis (O) Pancreatitis (O) Pyelonephritis (O) Abdominal aneurysm (O) Renal colic (O) Diverticulitis (?) Appendicitis (O) Salpingitis (O) Ovarian cyst (O) Ectopic pregnancy (O) Fecal impaction (X) Kang et al., 1989 (Appendicitis) Chern et al., 1997 (Psoas muscle abscess) Yen et al., 1999 (Renal abscess)
    63 : CT as imaging CT has become the imaging modality of choice for the evaluation of most presentations of acute abdominal pain. For example, CT can diagnose acute appendicitis with a reported sensitivity and specificity as high as 98% and 97%, respectively . I Even in situations in which plain films have a proven diagnostic accuracy,such as perforated viscus or small bowel obstruction, many physicians now opt for CT as the initial imaging study.
    64 : Common Abdominal Emergency Conditions 1.Acute cholecystitis 2. Perforated) Peptic ulcer/Ac gastritis; 3.GIT Bleed 3. Acute appendicitis 4. Acute pancreatitis 5. Small bowel obstruction 6. Colon obstruction/diverticulitis 7. Vascular occlusion-Mesentric; 8. Others –,Ectopic pregnancy;Aortic aneurysm 9. Renal or ureteric colic; Nephrolitihiasis Pyelonephritis
    65 : Commonly missed abdominal emergencies Acute Mesenteric Ischemia Intestinal Volvulus Gallstone “Ileus” Groin Hernias-obst/strangulated AAA and back pain “It’s just gastroenteritis”
    66 : Dangerous Mimics True Diagnosis Initial Misdiagnosis Appendicitis Gastroenteritis, PID, UTI Ruptured abdominal Renal colic, diverticulitis, lumbar strain aortic aneurysm Ectopic pregnancy PID, UTI, corpus luteum cyst Diverticulitis Constipation, gastroenteritis, pyelonephritis Perforated viscus PUD, pancreatitis, nonspecific abdominal pain Bowel obstruction Constipation, gastroenteritis, nonspecific abdominal pain Mesenteric ischemia Gastroenteritis, constipation, ileus small bowel obstruction Incarcerated or Ileus or small bowel obstruction strangulated hernia Shock or sepsis from Urosepsis or pneumonia (in elderly) perforation, bleed, abdominal infection
    67 : Common Pitfalls in Acute Appendicitis Rupture Appendicitis may present as diffused peritonitis or intestinal obstruction or enteritis Caution is advised in evaluating the young, the elderly, pregnant women, and women of childbearing age. The diagnosis is often elusive, and many patients proceed to perforation. When in doubt, admit the patient for observation and sequential physical examination
    68 : Common Pitfalls in Mesenteric Ischemia and Infarction Perhaps the greatest pitfall is to suspect it Pain disproportionate to physical findings –refractory to analgesia Identify high risk groups Underlying diseases: AF, Severe CHF, RHD, Coagulopathy. CT-Angiography: 82% sensitivity for mesenteric infarction vs 87.5% in angiography.(Radiology 197: 79-82, 1995) Early radiographic consultation and refusal to “wait until morning” are essential to a good outcome.
    69 : Common Pitfalls in Abdominal Aortic Aneurysm Frequently misdiagnosed, Palpable pulsatile abdominal mass ---- suspected of being an AAA, unless proved otherwise even if a mass cannot be clearly discerned. Back pain or flank pain in patients > 50 is common symptom. Peritoneal signs may not be present unless free rupture into the abdominal cavity. Misdiagnoses as renal colic or lumbosacral disk disease. Rapid bedside ultrasonography:
    70 : ER-interventions Keep pt NPO until surgical pathology is excluded Place NGT (bowel obstruction, ileus or upper GIT bleeding is suspected.or vomiting profusely A Foley catheter helpful as a guide for volume resuscitation who look sick. Incontinence is not indication for a Foley catheter Frequent re -assessments Antibiotics: indicated if infection is suspected. Narcotic analgesia (?) Timing (?) ER policy Pro: Humane; permit a more accurate history and PE. Morphine (2-5 mg IV) Con: Surgeon is hostile to this approach, consultation immediately.
    71 : DOCUMENTATION INTERVENTIONS AND PT RESPONSE Clear and legible hand writing Observations & Timing of interventions-their response Name of interventionalist Handover notes on shift change-full
    72 : Nursing Interventions & Management- DO NOT……X NO ENEMAS IF YOU SUSPECT ACUTE ABDOMEN Acute Appendictis PERITONITIS Un sure Dx NO ANALGESIA(Buscopan;Voltaren:Pethidine; till a pr dx is made)
    73 : Red flags -Extra-abdominal cause A life-threatening extra-abdominal cause of abdominal pain include chest pain, back pain, shortness of breath vaginal bleeding hemodynamic instability. . A multitude of systemic medical disorders, such as adrenal insufficiency, diabetic ketoacidosis porphyria, sickle cell pain crisis, that can present with abdominal pain
    74 : ACUTE ABDOMEN DIAGNOSIS ? – not sure If in doubt about the DX Admit him, re-examine him, and monitor him carefully, if necessary every hour for the first few hours. If he deteriorates, intervene /operate. otherwise observe Re -assess in the ward easier than in the oPD or ER department, This is especially important if you suspect him of having a strangulated Gut ,appendicitis, or a peptic ulcer.
    75 : BE AWARE ---MASKING EFFECT If a patient happens to be on Steroids, Pregnant, or Aged, any of the symptoms of an acute abdomen may be blurred , If he is on Antibiotics, they will not seal a perforated peptic ulcer, but they may diminish the signs of a perforated appendix
    76 : When to call the surgeon?  Call immediately - Obvious peritonitis Acute Abdomen+Unstable V Sign Otherwise once Work up complete in stable, less obvious CBC, coagltion profile Blood gas Electro Lytes Amylase Bilirubin(s) LFTs Imaging =s
    77 : THE INDICATIONS FOR OPERATION .... after adequate resuscitation-Always operate if there are signs of peritoneal irritation; Board-like abdomen Tender all over-,rebound, Distended-Absent bowel sounds (exclude paralytic ileus) Free air under diaphragm or perit cavity on imaging Signs of bowel ischemia Definite Diagnosis made and condition needing operation, e.g Appendicitis or perforated ulcer.
    78 : Decision to discharge Decision to discharge should be made carefully-exception rather than the rule Review of pts social setting is recommended. Elderly pts who live alone are at high risk , and admission should be considered All D/c pts should undergo a repeat examination , if possible within 24 Hrs .best option is return visit to ER in 12-24 hrs
    79 : Sample Discharge Instructions for the Patient with Abdominal Pain Pain that gets worse or moves to just one spot. Pain that gets worse if you cough or sneeze. Pain that does not get better in 24 hours. Inability to keep down liquids--especially if you are making less urine. Fainting. REPORT BACK TO HOSPITAL IF ….. Blood in the vomit or stool. High fever or shaking chills. Swelling of the abdomen. Any new or worsening problem. Remember that the ED is open 24 hours a day, every day, and we are always glad to see you.
    80 : MEDICAL ETHICS Treat a person not a disease Treat a patient as your family Be patient to a patient’s complaint Be kind and more smile Careful Explanation-respect to secrecy,privacy
    81 : Take away home points Because there are many causes of acute abdominal pain A Systematic approach by the evaluating physician is necessary to narrow the differential diagnosis. It is vital that the physician have an understanding of the mechanisms of pain generation and be familiar with the presentations of common diseases that cause abdominal pain. Recognizing the red flags in the history and physical examination initial imaging and laboratory findings helps to determine which patients may have a serious underlying disease process, and therefore warrant more expedited evaluation and treatment.
    82 : Take away home points-2 Making the correct diagnosis is never easy- It demands attention to detail in taking the history and examining the patient and clarity of thought in analyzing the information that is obtained. Investigations may help but in many places in the world there are no facilities for further investigations. The management of every patient depends entirely on the clinical skills of the doctor. Patients labelled as having NSAP does not mean that there was no cause. It does mean that our skill in making a diagnosis needs to be improved and new diagnostic tools should be used wherever necessary to improve diagnostic accuracy and better patient management.
    83 : THANK YOU

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