Dr TH De Klerk Critical Care 12 May 2014 DEFINITION The term acute abdomen is the medical slang word that denotes an acute serious abdominal condition usually treated best by surgical operation ID: 1031961
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1. MEDICAL CAUSES OF THE ACUTE ABDOMENDr. T.H De KlerkCritical Care12 May 2014
2. DEFINITIONThe term, acute abdomen, is the medical slang word that denotes an acute, serious abdominal condition, usually treated best by surgical operation. More appropriately referred to as a “surgical abdomen”.
3. EPIDEMIOLOGYAcute abdominal pain comprises 5% of all emergency medicine consultations (USA)18-25% of these patients are admitted to hospital 10% of those admitted require surgery 8% of admissions are purely medical cases
4. ANATOMY AND PHYSIOLOGYVisceral pain – poorly localised to mainly the midlineParietal pain - better localised to a dermatomal distributionReferred pain – certain structures share central pathways due to their specific embryonic developmentCentral pain – from thalamic and cortical structures
5. HISTORY Time course – hyperacute (seconds), acute (minutes) and gradual (hours)Location – often misleading, e.g. cholecystitis Radiation, exacerbating and relieving factors and associated symptomsSurgical conditions- pain generally preceeds vomitingNon-surgical conditions – vomiting generally preceeds painFever, vomiting, diarrhoea, leucocytosis are unhelpful
6. BACKGROUNDRisk factors, e.g. DM, HPT, vascular or cardiac diseasePrevious surgical procedures - risk for obstructionPrevious similar episode (consider medical cause)Familial diseaseAge group specific diseases, e.g. appendicitis in the young, or diverticulitis in the elderly
7. CLINICAL EXAMINATIONMust be seen in the context of patient’s history and risk factors 2004 Israel study: more than 600 patients evaluated for acute abdomen clinically vs CT diagnosis 37% correlation between the groups, 8% of patients underwent surgery unnecessarily due to incorrect diagnosisThe art of the abdominal examination: time very important, recurrent re-evaluation Abdominal x-rays: dilated bowel loops, intra-peritoneal airAbdominal ultrasound & CT scan: confirm diagnosis and plan further management
8. CATEGORIES OF MEDICAL CAUSES Referred pain – adjacent structures Lung: pneumonia, pleuritis, pulmonary embolus/infarct, empyema, pneumothoraxHeart: myocardial infarction, myocarditis, pericarditis, congestive cardiac failureOesophagus: oesophagitis, spasm, rupturePelvis: PID, ovarian/testicular torsion, follicular rupture, ovarian hyperstimulation syndrome
9. MEDICAL CAUSES CONTINUEDMetabolicAdrenal insufficiency – gastric dysmotility, serositisDKA - gastritis, gastric distension, ileusThyrotoxicosis – unknown, probably ileusPorphyria – visceral autonomic neuropathyHypercalcaemia – ileus, increased gastrin which leads to gastritis, pancreatitis, ureterolithiasisHyperlipidaemia – pancreatitisUraemia – ileus, gastritis Haemochromatosis - SBP
10. MEDICAL CAUSES CONTINUEDInfectionToxins – tetanus, botulismDysentry – shigella, salmonella, campylobacter, amoebiasisSevere gastroenteritis – giardiasis, isospora belli Mesenteric lymphadenitis – yersinia, extrapulmonary TB, CMVInfestations – helminths, schistosomiasis, obstructionInfiltration – malaria, EBVTranslocation - SBP
11. MEDICAL CAUSES CONTINUEDVascular Arterial – mesenteric ischaemia and infarction, dissection (abdominal pain out of proportion to clinical findings)Vasculitis – large vessel: Takayasu, medium vessel: PAN, small vessel: Wegeners Coagulopathy – arterial and/or venous thrombosis, primary e.g. APLS, secondary e.g. malignancy Specific vascular syndromes, e.g. Budd-Chiari, portal vein thrombosis
12. MEDICAL CAUSES CONTINUEDHaematologicalAcute leukaemia, lymphoma – infiltration, tumour necrosis Haemolytic anaemia, Sickle cell anaemia, polycythaemia vera – vascular spasm and/or thrombosis Haemophilia – abdominal wall haematomas
13. MEDICAL CAUSES CONTINUEDDrugs and toxinsMucosal irritants and corrosives – iron, mercury, NSAIDsIleus – anticholinergics, narcotics (opioid bowel syndrome)Bowel ischaemia – cocaine, amphetamines, ergotaminesHeavy metals – lead, arsenicBiological – black widow spider: hyperstimulation of NMJ
14. MEDICAL CAUSES CONTINUEDNeurological Central – abdominal migraine, abdominal epilepsy, Neuropathies – tabes dorsalis, secondary to syphilis. Radiculopathy: degenerative spine disease, disc herniation, post-herpetic neuralgia
15. MEDICAL CAUSES CONTINUEDMiscellaneousLactose intolerance Eosinophillic gastroenteritisSLE – pancreatitis, serositis, vasculitisPeriodic fever syndromesRadiation enteritisGlaucoma Angioedema – C1-esterase inhibitor deficiency, ACE inhibitors
16. SPECIAL POPULATION GROUPS Pregnancy – abdominal examination difficult, uterus obscures rest of abdomenNeurological disease – no pain sensation, quadroparesis, inability to communicate – delirium, dementiaICU patients – altered pain perception, 38% of patients with peritonits have peritoneal signs. Consider acalculus cholecystitis Post-procedural patients vena cava filters which migrate, fracture, thrombose etcPEG tubes – peri-stomal leakage Biopsies – subcapsular haematoma
17. ImmunocompromisedBlunted inflammatory responseOrgan transplants lack nerve innervationOpportunistic infections, e.g. PCP, CMVWeakening of connective tissue, e.g. corticosteroids and bowel wall perforation Drugs: ARV’s (pancreatitis, lactic acidosis), Chemotherapeutic agents, e.g. vincristine Neutropenic enterocolitis (typhlitis)
18. Elderly patients Immunosenescence – decreased immunosurveillance, decreased antibodies and T cells, decreased pyrogen responseGI tract – decreased motility and secretionCNS – dementia, delirium, decreased peripheral sensation Increased amount of chronic diseasesIncreased drug usage – decreased pain and sympathetic response, increased drug interactions, e.g. digoxin toxicity
19. REMEMBER… An atypical presentation of a common condition is much more likely than the typical presentation of an uncommon condition
20. REFERENCESFarthing MJG. Pearls and Pitfalls in the Diagnosis of the Acute Abdomen. Indian J Gastroenterol. 2006;25(1):33-35. Cheng EH, Mills AM. Abdominal Pain in Special Populations. Emerg Med Clin N Am. 2011;29:449-458.Ragsdale L, Southerland L. Acute Abdominal Pain in the Older Adult. Emerg Med Clin N Am. 2011;29:429-448.Fields JM, Dean AJ. Systemic Causes of Abdominal Pain. Emerg Med Clin N Am. 2011;29:195-210. Chang CC, Wang SS. Acute Abdominal Pain in the Elderly. Int J Gerontol. 2007 Jun;1(2):77-82.Gajic O, Urrutia LE, Sewani H, Schroeder DR, Cullinane DC, et al. Acute Abdomen in the Medical Intensive Care Unit. Crit Care Med. 2002;30(6):1187-1190. Mueller PD, Beneowitz NL. Toxicologic Causes of Acute Abdominal Disorders. Emerg Med Clin N Am. 1989;7:667-682.
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