Acute Abdomen

1
Acute Abdomen
2
Acute Abdomen

• Anatomy review
• Non-hemorrhagic abdominal pain
• Gastrointestinal hemorrhage
• Assessment
• Management

3
Abdominal Anatomy

• Review

4
Abdominal Cavity

• Superior border diaphragm
• Inferior border pelvis
• Posterior border lumbar spine
• Anterior border muscular abdominal wall

5
Peritoneum

• Abdominal cavity lining
• Double-walled structure
• Visceral peritoneum
• Parietal peritoneum
• Separates abdominal cavity into two parts
• Peritoneal cavity
• Retroperitoneal space

6
Primary GI Structures

• Mouth/oral cavity
• Lips, cheeks, gums, teeth, tongue
• Pharynx
• Portion of airway between nasal cavity and larynx

7
Primary GI Structures

• Esophagus
• Portion of digestive tract between pharynx and
  stomach
• Stomach
• Hollow digestive organ
• Receives food from esophagus

8
Primary GI Structures

• Small intestine
• Between stomach and cecum
• Composed of duodenum, jejunum and ileum
• Site of nutrient absorption into body
• Large intestine
• From ileocecal valve to anus
• Composed of cecum, colon, rectum
• Recovers water from GI tract secretions

9
Accessory GI Structures

• Salivary glands
• Produce, secrete saliva
• Connect to mouth by ducts

10
Accessory GI Structures

• Liver
• Large solid organ in right upper quadrant
• Produces, secretes bile
• Produces essential proteins
• Produces clotting factors
• Detoxifies many substances
• Stores glycogen
• Gallbladder
• Sac located beneath liver
• Stores and concentrates bile

11
Accessory GI Structures

• Pancreas
• Endocrine pancreas secretes insulin into
  bloodstream
• Exocrine pancreas secretes digestive enzymes,
  bicarbonate into gut
• Vermiform appendix
• Hollow appendage
• Attached to large intestine
• No physiologic function

12
Major Blood Vessels

• Aorta
• Inferior vena cava

13
Solid Organs

• Liver
• Spleen
• Pancreas
• Kidneys
• Ovaries (female)

14
Hollow Organs

• Stomach
• Intestines
• Gallbladder and bile ducts
• Ureters
• Urinary bladder
• Uterus and Fallopian tubes (female)

15
Right Upper Quadrant

• Liver
• Gallbladder
• Duodenum
• Transverse colon (part)
• Ascending colon (part)

16
Left Upper Quadrant

• Stomach
• Liver (part)
• Pancreas
• Spleen
• Transverse colon (part)
• Descending colon (part)

17
Right Lower Quadrant

• Ascending colon
• Vermiform appendix
• Ovary (female)
• Fallopian tube (female)

18
Left Lower Quadrant

• Descending colon
• Sigmoid colon
• Ovary (female)
• Fallopian tube (female)

19
Acute Abdomen
20
Abdominal Pain

• Visceral
• Somatic
• Referred

21
Abdominal Pain

• Visceral pain
• Stretching of peritoneum or organ capsules by
  distension or edema
• Diffuse
• Poorly localized
• May be perceived at remote locations related to
  organs sensory innervation

22
Abdominal Pain

• Somatic pain
• Inflammation of parietal peritoneum or diaphragm
• Sharp
• Well-localized

23
Abdominal Pain

• Referred pain
• Perceived at distance from diseased organ
• Pneumonia
• Acute MI
• Male GU problems

24
Non-hemorrhagic Abdominal Pain
25
Esophagitis

• Inflammation of distal esophagus
• Usually from gastric reflux, hiatal hernia

26
Esophagitis

• Signs and Symptoms
• Substernal burning pain, usually epigastric
• Worsened by supine position
• Usually without bleeding
• Often temporarily relieved by nitroglycerin

27
Acute Gastroenteritis

• Inflammation of stomach, intestine
• May lead to bleeding, ulcers
• Causes
• ? acid secretion
• Chronic EtOH abuse
• Biliary reflux
• Medications (ASA, NSAIDS)
• Infection

28
Acute Gastroenteritis

• Signs and Symptoms
• Epigastric pain, usually burning
• Tenderness
• Nausea, vomiting
• Diarrhea
• Possible bleeding

29
Chronic Infectious Gastroenteritis

• Long-term mucosal changes or permanent damage
• Due primarily to microbial infections (bacterial,
  viral, protozoal)
• Fecal-oral transmission
• More common in underdeveloped countries
• Nausea, vomiting, fever, diarrhea, abdominal
  pain, cramping, anorexia, lethargy
• Handwashing, BSI

30
Peptic Ulcer Disease

• Craters in mucosa of stomach, duodenum
• Males 4x gt Females
• Duodenal ulcers 2 to 3x gt Gastric ulcers
• Causes
• Infectious disease Helicobacter pylori (80)
• NSAIDS
• Pancreatic duct blockage
• Zollinger-Ellison Syndrome

31
Peptic Ulcer Disease

• Duodenal Ulcers
• 20 to 50 years old
• High stress occupations
• Genetic predisposition
• Pain when stomach is empty
• Pain at night

• Gastric Ulcers
• gt 50 years old
• Work at jobs requiring physical activity
• Pain after eating or when stomach is full
• Usually no pain at night

32
Peptic Ulcer Disease

• Complications
• Hemorrhage
• Perforation, progressing to peritonitis
• Scar tissue accumulation, progressing to
  obstruction

33
Peptic Ulcer Disease

• Signs and Symptoms
• Steady, well-localized pain
• Burning, gnawing, hot rock
• Relieved by bland, alkaline food/antacids
• Worsened by smoking, coffee, stress, spicy foods
• Stool changes, pallor associated with bleeding

34
Pancreatitis

• Inflammation of pancreas in which enzymes
  auto-digest gland
• Causes include
• EtOH (80 of cases)
• Gallstones obstructing ducts
• Elevated serum triglycerides
• Trauma
• Viral, bacterial infections

35
Pancreatitis

• May lead to
• Peritonitis
• Pseudocyst formation
• Hemorrhage
• Necrosis
• Secondary diabetes

36
Pancreatitis

• Signs and Symptoms
• Mid-epigastric pain radiating to back
• Often worsened by food, EtOH
• Bluish flank discoloration (Grey-Turner Sign)
• Bluish periumbilical discoloration (Cullens
  Sign)
• Nausea, vomiting
• Fever

37
Cholecystitis

• Gall bladder inflammation, usually 2o to
  gallstones (90 of cases)
• Risk factors
• Five Fs Fat, Fertile, Febrile, Fortyish, Females
• Heredity, diet, BCP use

38
Cholecystitis

• Acalculus cholecystitis
• Burns
• Sepsis
• Diabetes
• Multiple organ systems failure
• Chronic cholecystitis (bacterial infection)

39
Cholecystitis

• Signs and Symptoms
• Sudden pain, often severe, cramping
• RUQ, radiating to right shoulder
• Point tenderness under right costal margin
  (Murphys sign)
• Nausea, vomiting
• Often associated with fatty food intake
• History of similar episodes in past
• May be relieved by nitroglycerin

40
Appendicitis

• Inflammation of vermiform appendix
• Usually secondary to obstruction by fecalith
• May occur in older persons secondary to
  atherosclerosis of appendiceal artery and
  ischemic necrosis

41
Appendicitis

• Signs and Symptoms
• Classic Periumbilical pain ? RLQ pain/cramping
• Nausea, vomiting, anorexia
• Low-grade fever
• Pain intensifies, localizes resulting in guarding
• Patient on right side with right knee, hip flexed

42
Appendicitis

• Signs and Symptoms
• McBurneys Sign Pain on palpation of RLQ
• Aarons Sign Epigastric pain on palpation of RLQ
• Rovsings Sign Pain in LLQ on palpation of RLQ
• Psoas Sign Pain when patient
• Extends right leg while lying on left side
• Flexes legs while supine

43
Appendicitis

• Signs and Symptoms
• Unusual appendix position may lead to atypical
  presentations
• Back pain
• LLQ pain
• Cystitis
• Rupture Temporary pain relief followed by
  peritonitis

44
Bowel Obstruction

• Blockage of intestine
• Common Causes
• Adhesions (usually 2o to surgery)
• Hernias
• Neoplasms
• Volvulus
• Intussuception
• Impaction

45
Bowel Obstruction

• Pathophysiology
• Fluid, gas, air collect near obstruction site
• Bowel distends, impeding blood flow/ halting
  absorption
• Water, electrolytes collect in bowel lumen
  leading to hypovolemia
• Bacteria form gas above obstruction further
  worsening distension
• Distension extends proximally
• Necrosis, perforation may occur

46
Bowel Obstruction

• Signs and Symptoms
• Severe, intermittent, crampy pain
• High-pitched, tinkling bowel sounds
• Abdominal distension
• History of decreased frequency of bowel
  movements, semi-liquid stool, pencil-thin stools
• Nausea, vomiting
• ? Feces in vomitus

47
Hernia

• Protrusion of abdominal contents into groin
  (inguinal) or through diaphragm (hiatal)
• Often secondary to ? intra-abdominal pressure
  (cough, lift, strain)
• May progress to ischemic bowel (strangulated
  hernia)

48
Hernia

• Signs and Symptoms
• Pain ? by abdominal pressure
• Past history
• Inguinal hernia may be palpable as mass in groin
  or scrotum

49
Crohns Disease

• Idiopathic inflammatory bowel disease
• Occurs anywhere from mouth to rectum
• 35-45 small intestine 40 colon
• Runs in families
• High risk groups
• White females
• Jews
• Persons under frequent stress

50
Crohns Disease

• Pathophysiology
• Mucosa of GI tract becomes inflamed
• Granulomas form, invade submucosa
• Muscular layer of bowel become fibrotic,
  hypertrophied
• Increased risk develops for
• Obstruction
• Perforation
• Hemorrhage

51
Ulcerative Colitis

• Idiopathic inflammatory bowel disease
• Chronic ulcers develop in mucosal layer of colon
• Spread to submucosal layer uncommon
• 75 of cases involve rectum (proctitis) or
  rectosigmoid portion of large intestine
• Inflammation can spread through entire large
  intestine (pancolitis)

52
Ulcerative Colitis

• Severity of signs, symptoms depends on extent
• Classic presentation
• Crampy abdominal pain
• Nausea, vomiting
• Blood diarrhea or stool containing mucus
• Ischemic damage with perforation may occur

53
Diverticulitis

• Diverticula
• Pouches in colon wall
• Typically in older persons
• Usually asymptomatic
• Related to diets with inadequate fiber

54
Diverticulitis

• Diverticula trap feces, become inflamed
• Occasionally result in bright red rectal bleeding
• Rupture may cause peritonitis, sepsis

55
Diverticulitis

• Signs and Symptoms
• Usually left-sided pain
• May localize to LLQ (left-sided appendicitis)
• Alternating constipation, diarrhea
• Bright red blood in stool

56
Hemorrhoids

• Small masses of veins in anus, rectum
• Most frequently develop when patients are in 30s
  or 40s common past 50
• Most are idiopathic, can be associated with
  pregnancy, portal hypertension
• Cause bright red bleeding, pain on defecation
• May become infected, inflamed

57
Peritonitis

• Inflammation of abdominal cavity lining
• Signs and Symptoms
• Generalized pain, tenderness
• Abdominal rigidity
• Nausea, vomiting
• Absent bowel sounds
• Patient resistant to movement

58
Hemorrhagic Abdominal Problems

• Gastrointestinal Hemorrhage
• Intraabdominal Hemorrhage

59
Esophageal Varices

• Dilated veins in esophageal wall
• Occur 2o to hepatic cirrhosis, common in EtOH
  abusers
• Obstruction of hepatic portal blood flow results
  in dilation, thinning of esophageal veins

60
Esophageal Varices

• Portal hypertension
• Hepatic scarring slows blood flow
• Blood backs up in portal circulation
• Pressure rises
• Vessels in portal circulation become distended

61
Esophageal Varices

• Signs and Symptoms
• Hematemesis (usually bright red)
• Nausea, vomiting
• Evidence of hypovolemia
• Melena (uncommon)

62
Mallory-Weiss Syndrome

• Longitudinal tears at gastroesophageal junction
• Occur as result of prolonged, forceful vomiting,
  retching
• Common in alcoholics
• May be complicated by presence of esophageal
  varices

63
Peptic Ulcer Disease

• Ulcer erodes through blood vessel
• Massive hematemesis
• Melena may be present

64
Aortic Aneurysm

• Localized dilation due to weakening of aortic
  wall
• Usually older patient with history of
  hypertension, atherosclerosis
• May occur in younger patients secondary to
• Trauma
• Marfans syndrome

65
Aortic Aneurysm

• Usually just above aortic bifurcation
• May extend to one or both iliac arteries

66
Aortic Aneurysm

• Signs and Symptoms
• Unilateral lower quadrant pain low back or leg
  pain
• May be described as tearing or ripping
• Pulsatile palpable mass usually above umbilicus
• Diminished pulses in lower extremities
• Unexplained syncope, often after BM
• Evidence of hypovolemic shock

67
Ectopic Pregnancy

• Any pregnancy that takes place outside of uterine
  cavity
• Most common location is in Fallopian tube
• Pregnancy outgrows tube, tube wall ruptures
• Hemorrhage into pelvic cavity occurs

68
Ectopic Pregnancy

• Suspect in females of child-bearing age with
• Abdominal pain, or
• Unexplained shock
• When was last normal menstrual period?

Ectopic pregnancy does NOT necessarily cause
missed period
69
Assessment of Acute Abdomen
70
History

• Where do you hurt?
• Try to point with one finger
• What does pain feel like?
• Steady pain Inflammatory process
• Cramping pain Obstructive process
• Onset of pain?
• Sudden Perforation or vascular occlusion
• Gradual Peritoneal irritation, distension of
  hollow organ

71
History

• Does pain travel anywhere?
• Gallbladder Angle of right scapula
• Pancreas Straight through to back
• Kidney/ureter Around flank to groin
• Heart epigastrium, neck/jaw, shoulders, upper
  arms
• Spleen Left scapula, shoulder
• Abdominal Aortic Aneurysm low back radiating to
  one or both legs

72
History

• How long have you been hurting?
• gt6 hours increased probability of surgical
  significance
• Nausea, vomiting
• How much, How long?
• Consider possible hypovolemia
• Blood, coffee grounds?
• Any blood in GI tract emergency until proven
  otherwise

73
History

• Urine
• Change in urinary habits?
• Frequency
• Urgency
• Color?
• Odor?

74
History

• Bowel movements
• Change in bowel habits? Color? Odor?
• Bright red blood
• Melena black, tarry, foul-smelling stool
• Dark stool
• Suspect bleeding
• Other causes possible (iron or bismuth containing
  materials)

75
History

• Last normal menstrual period?
• Abnormal bleeding?
• In females, lower abdominal pain GYN problem
  until proven otherwise
• In females of child-bearing age, lower abdominal
  pain ectopic pregnancy until proven otherwise

76
Physical Exam

• Position and General Appearance
• Still, refusing to move Inflammation,
  peritonitis
• Extremely restless Obstruction
• Gross appearance of abdomen
• Distended
• Discolored
• Consider possible third spacing of fluids

77
Physical Exam

• Vital signs
• Tachycardia more important sign of volume loss
  than falling BP
• Rapid, shallow breathing possible peritonitis
• Consider performing tilt test

78
Physical Exam

• Bowel sounds
• Auscultate BEFORE palpating
• One minute in each abdominal quadrant
• Absent sounds possible peritonitis, shock
• High-pitched, tinkling sounds possible bowel
  obstruction

79
Physical Exam

• Palpation
• Palpate each quadrant
• Palpate area of pain LAST
• Do NOT check rebound tenderness in prehospital
  setting
• ALL abdominal tenderness significant until proven
  otherwise

80
Management

• Oxygen by non-rebreather mask
• IV LR or NS
• PASG (demonstrated benefit in intrabdominal
  hemorrhage)
• Keep patient from losing body heat
• Monitor vital signs

81
Management

• Monitor EKG

Consider possible MI with pain referred to
abdomen in patients gt30 years old

• Keep patient npo
• Analgesia controversial
• Demerol is preferred narcotic analgesic