Naher FY1 Learning Objectives Causes of an acute abdomen Differential Diagnosis Hx Exam Investigations Management Clinical Cases Causes of Acute Abdomen Intestinal Acute appendicitis mesenteric adenitis ID: 907820
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Slide1
Acute Abdomen Revision
Ahmed Al-
Naher
FY1
Slide2Learning Objectives
Causes of an acute abdomen
Differential Diagnosis
Hx
/Exam
Investigations
Management
Clinical Cases
Slide3Causes of Acute Abdomen
Intestinal
Acute appendicitis
, mesenteric adenitis,
mekel’s
diverticulitis,
perforated peptic ulcer
, gastroenteritis,
diverticulitis, intestinal obstruction
,
strangulated hernia
Hepatobiliary
Biliary
colic,
cholecystitis
,
cholangitis
, pancreatitis
, hepatitis
Vascular
Ruptured AAA, acute mesenteric
ischaemia
,
ischaemic
colitis
Urological
Renal colic, UTI, testicular torsion, acute urinary retention
Gynaecological
Ectopic pregnancy, ovarian cyst pathology (rupture/haemorrhage into cyst/torsion),
salpingitis
, endometriosis,
mittelschmerz
(mid-cycle pain)
Medical (can mimic an acute abdomen)
Pneumonia, MI, DKA, sickle cell crisis,
porphyria
Slide4Acute Abdomen: The Examination
Liver (hepatitis)
Gall bladder (gallstones)
Stomach (peptic ulcer, gastritis)
Hepatic flexure colon (cancer)
Lung (pneumonia)
Ascending colon (cancer,)
Kidney (stone, hydronephrosis, UTI)
Appendix (Appendicitis)
Caecum
(tumour, volvulus, closed loop obstruction)Terminal ileum (crohns, mekels)Ovaries/fallopian tube (ectopic, cyst, PID)Ureter (renal colic)
Liver (hepatitis)Gall bladder (gallstones)Stomach (peptic ulcer, gastritis)Transverse colon (cancer)Pancreas (pancreatitis)Heart (MI)
Spleen (rupture)Pancreas (pancreatitis)Stomach (peptic ulcer)Splenic flexure colon (cancer)Lung (pneumonia)
Descending colon (cancer)Kidney (stone, hydronephrosis, UTI)
Sigmoid colon (diverticulitis, colitis, cancer)Ovaries/fallopian tube (ectopic, cyst, PID)Ureter (renal colic)
Uterus (fibroid, cancer)Bladder (UTI, stone)Sigmoid colon (diverticulitis)
Small bowel (obstruction/ischaemia)Aorta (leaking AAA)
Slide5Intestinal
Slide6Intestinal (Large Bowel)
Slide7Hepatobilliary
Slide8Vascular
Slide9GU
Slide10O+G
Slide11Medical
Slide12Acute Abdomen: The History
Abdominal pain – features will point you towards diagnosis
SOCRATES
Site and duration
Onset – sudden
vs
gradual
Character – colicky, sharp, dull, burningRadiation – e.g. Into back or shoulder(Associated symptoms – discussed later)Timing – constant, coming and going
Exacerbating and alleviating factorsSeverity2 other useful questions about the pain:
Have you had a similar pain previously?What do you think could be causing the pain?
Slide13Acute Abdomen: The History
Associated symptoms
GI: bowels last opened, bowel habit (diarrhoea/constipation), PR bleeding/
melaena
, dyspeptic symptoms, vomiting
Urine:
dysuria
, heamaturia, urgency/frequencyGynaecological: normal cycle, LMP, IMB, dysmenorrhoea/menorrhagia, PV dischargeOthers: fever, appetite, weight loss, distention
Any previous abdominal investigations and findingsOther components of historyPMH e.g. Could patient be having a flare up/complication of a known condition e.g. Known
diverticular disease, previous peptic ulcers, known gallstonesDH e.g. Steroids and peptic ulcer disease/acute pancreatitisSH e.g. Alcoholics and acute pancreatitis
Slide14Acute Abdomen: The Examination
Inspection: scars/asymmetry/
distention
Palaption
:
Point of maximal tenderness
Features of peritonitis (localised
vs generalised)GuardingPercussion tenderness
Rebound tendernessMassSpecific signs (Rosvig’s sign, murphy’s sign, cullen’s sign, grey-turner’s sign)
Percussion: shifting dullness/tympanicAuscultation: bowel soundsAbsentNormalHyperactivetinklingThe above will point you to potential diagnosis
Slide15RIF Pain: APPENDICITIS
Appendix/ abscess
Pelvic inflammation/ period pain
Pancreas
Ectopic/ endometriosis
Neoplasm
Diverticulitis
IntussusseptionChrohn’s/ CystIBDTorsionIBSStones
Slide16LIF Pain: SUPERCLOTS
Sigmoid
diverticuli
,
volvulous
Ureteric colic
Pelvic inflammation/ period pain
Ectopic/ endometriosisRectal HaematomaColon cancerLeft lower pneumoniaOvarian cystTorsionStones
Slide17Acute Abdomen: Investigations
Simple Investigations:
Bloods tests (FBC, U&E, LFT, amylase, clotting, CRP, G&S/
Xmatch
, ABG)
BM
Urine dipstick
Pregnancy test (all women of child bearing age with lower abdominal pain)AXR/E-CXRECG
More complex investigations:USSContrast studiesEndoscopy (OGD/colonoscopy/ERCP)
CTMRI
Slide18AXR
Slide19Slide20Slide21Air in Abdomen
Post-op/ Post-ERCP
Perforation
Cholangitis
Abscess
Gallstone Ileus
Slide22Slide23Acute Abdomen: Indication for theatre
Urgent surgery should not be delayed for time consuming tests when an indication for surgery is clear
The following three categories of general surgical problems will require emergency surgery
Generalised peritonitis on examination (regardless of cause –
except acute pancreatitis
, hence all patients get amylase)
Perforation (air under diaphragm on E-CXR)
Irreducible and tender hernia (risk of strangulation)
Slide24Management - Conservative
Lifestyle:
Weight loss,
smoking cessation
alcohol reduction
exercise
modified diet (low fat/ high fibre)
MDT: Physio/ OT/ Nutrition Team/ Dietician/ Specialist Nurses, other specialties
Slide25Management - Medical
A - Secure airway
B – Oxygen 15L
C - Fluid Balance: large bore, IVF, catheter, bloods,
Xmatch
C - Blood Transfusion
D - Analgesia
E – IV AntibioticsE –Thromboprophylaxis?Anti-emetics/ NG aspirationSupportive nutrition/ NBMRe-assessTherapeutic procedures: ERCP
Slide26Management - Surgical
Emergency Laparotomy or
Watch+Wait
?
Monitor Pain
Serial CTs
Unstable?
E.g.:AppendicectomyCholecystectomyDefunctioning IleostomyAbscess drainage/ Necrosectomy
Slide27Clinical Scenarios
87
yr
M worsening LIF pain associated PR bleed,
tachycardic
, hypotensive
Diverticulitis, IBD,
Adenoca
Slide28Clinical Scenarios
50
yr
old obese female presents with 2 day
hx
right upper quadrant tenderness, yellow sclera and high pyrexia.
78
yr old male with fatigue, anaemia and supraclavicular lymphadenopathy. o/e you find axillary pigmentation.56 yr old female non-smoker with known primary sclerosing cholangitis, presents with change in bowel habit and PR bleed, she is found to have tender symmetrical purple shin nodules35 year old female smoker with known depression presents with generalised hypertenderness, diarrhoea and bloating sensations worse after meals
Slide29Acute Abdomen
Thin 21
y.o
. male presents with generalised
abdo
tenderness, polydipsia and sunken eyes, with reduced skin turgor.
Slide30Clinical Scenario
A 22 year old lady presents with one day history of right iliac fossa pain associated with vomiting and diarrhoea. She is normally fit and well and takes the oral contraceptive pill. She has no known allergies, does not smoke, and drinks alcohol
infrequently
Slide31What other questions would you like to ask this lady?
What are your main differential diagnoses for this lady? (make sure these include all important differentials that must be ruled out)
Slide32Questions?