Dónal Murphy General surgical registrar The Acute Abdomen Aims What is it How it presents General vs Local causes What I am expected to do as an Intern Initial management and escalation of care ID: 918363
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Slide1
The acute Abdomen: Recognition, assessment and management
Dónal Murphy. General surgical registrar
Slide2The Acute Abdomen: Aims
What is it?
How it presents: General vs Local causes
What I am expected to do as an Intern: Initial management and escalation of care
Eg
. When should I worry and what should I do about it!
Slide3Acute Abdomen
Non traumatic cause of Sudden onset abdominal pain less than 24 hours in duration
Multiple different causes encompassing both medical and surgical areas
Trivial to life threatening
Most common presentation to Ed 334,759 cases last year
Number 2 Chest pain at 279,340
May require surgical intervention urgently to treat the patient
Slide4Abdominal Pain Pathophysiology
Parietal
pain
Sharp and better localised
Associated with pain, guarding or rebound tenderness when the parietal peritoneum is stimulated by movement, coughing or walking
Visceral PAIN
Deep, dull, aching but poorly localised
Usually felt near the midline +/- tenderness
Can be associated with inflammation or ischaemia
Referred pain
Areas supplied with same innervation
Slide5Our Challenge…
Differential Diagnosis
atypical presentation
Stable vs the sick patient
being wary to deterioration
Mimicking causes of pain
Slide6HIPOI Framework
HIPOI Video
Slide7Initial approach
Most important: go see the patient!
Big sick or little sick?
Stablisied
?:
Abc’s
Thorough history
Full body
exam
Slide8Initial approach
Review the history
Virgin abdomen vs multiple previous surgeries.?
Co-morbidities
?
What investigations have been done
what you're going to
order
Slide9investigations
Urinalysis
BHCG
ECG
FBE UEC CMP LFTs CRP
VBG?
CXR
CT + contrast
Slide10General Management
IV cannula insertion
Analgesia
NG tube?
Foley
Catether
Antibiotics?
Refer for definitive treatment vs Conservative management
Reassess Patient Regularly!
Slide11Cases
Slide12Case 1
76 year old male presenting with central abdominal pain radiating to the back
Pmhx
: HTN, PVD, t2Dm, Smoker
HR
147 BP 90/60 Sp02 94% RA RR 24
Pale, clammy and agitated
o/e: rigid abdomen, diffusely tender
Differentials?
Slide13Case 1 – whats next
Supplemental Oxygen
Two large bore IVC’s
Bloods
Group and cross match
Fluid challenge
?
Imaging? – Fast Scan vs CT
Rapid referral for surgical management – who needs to be called?
Slide14Case 1 – whats next
Slide15Help?!
Slide16Case 2
21 year old female presenting with a 12 hour history of right iliac fossa pain
Pmhx
Nil
Vomit x1 , poor appetite
HR110, BP 115/70, Spo2 100% RA RR 18, T38.5
o/e Looks a little unwell
Involuntary guarding and rebound tenderness in RIF
Slide17Case 2 - Investigations
Bloods
Hb
130, WCC 12, CRP 22
Urine FWT
leuks
+ Nitrites 0 Blood 0
Bhcg
negative
Imaging?
Slide18Case 2 - Management
IV
Abx
Prep for theatre
After care
Slide19Case 3
64 year old man presenting with Left Iliac Fossa Pain for 1/7
assoc
with lethargy malaise and some vomiting.
Pmhx
:
HTn
,
GoRD
, IHD on aspirin and Beta blockerVitals: HR 80 BP 110/80 SPo2 97% on RA, T 38.6 RR 16
o/e Looks uncomfortable but not unwell
rebound tenderness and guarding in the LIF
Slide20Case 3 - Investigations
Bloods
Hb
140 WCC 16 CRP 80
Diagnosis? – Diverticulitis?
Ddx
?
Imaging? - CT
Slide21Case 3 – Continued
4 hours later Paged for Rapid review
Worsening abdominal pain
Vitals RR 28, BP 97/60, HR 95, t 39, spo2 97% 2L
o/e looks unwell,
rigoring
, rigid abdomen, chest sounds clear.
Slide22Case 3 –
VBG? –
Ph
7.4 Po2 70 Pco2 30 lactate 2.0,
Hb
140
What do we think is going on?
CXr
Management
Stabilise the patient – ABC
Repeat CT vs Straight to theatre
Slide23Case 4
63 year old lady presenting with 4 hours of central abdominal pain and bilious vomiting, BNO 4/7
PMHX: Lap Cholecystectomy, Gastric band, Low Anterior resection for Ca.
Vitals HR 115 BP 90/65 RR 22 Spo2 97% RA T 37
o/e Looks miserable, Abdomen distended, No rigidity,
unconfortable
but not tender, ongoing large vomiting
Slide24Case 4 - Mangement
Initial investigations
Stabilise the patient
Drip and suck
Slide25Case 4
Urine Clear
Bloods:
Hb
128, WCC 14, CRP 60, K 3.0
Imaging AXR vs CT
NGT is placed and I
mproves
with a fluid challenge
Trial of Conservative management
Vs
Adhesiolysis
Slide26Thank you – Questions?
References
https://lifeinthefastlane.com/investigations/axr-interpretation
/
Ray S, Patel M,
Parmar
H. Management of acute abdomen: Study of 110 cases.. IAIM, 2016; 3(2):
18-24
Australian Hospital Statistics AIHW
https
://
www.aihw.gov.au/getmedia/981140ee-3957-4d47-9032-18ca89b519b0/aihw-hse-194.pdf.aspx?inline=true
http://teachmesurgery.com/general/presentations/acute-abdomen/