Acute Abdomen

Acute AbdomenAnatomy reviewNon-hemorrhagic abdominal painGastrointestinal hemorrhageAssessmentManagement

Abdominal AnatomyReview

Abdominal CavitySuperior border = diaphragm Inferior border = pelvisPosterior border = lumbar spine Anterior border = muscular abdominal wall

PeritoneumAbdominal cavity liningDouble-walled structureVisceral peritoneumParietal peritoneumSeparates abdominal cavity into two partsPeritoneal cavityRetroperitoneal space

Primary GI StructuresMouth/oral cavityLips, cheeks, gums, teeth, tonguePharynxPortion of airway between nasal cavity and larynx

Primary GI StructuresEsophagusPortion of digestive tract between pharynx and stomachStomachHollow digestive organReceives food from esophagus

Primary GI StructuresSmall intestine Between stomach and cecumComposed of duodenum, jejunum and ileumSite of nutrient absorption into bodyLarge intestineFrom ileocecal valve to anus Composed of cecum, colon, rectumRecovers water from GI tract secretions

Accessory GI StructuresSalivary glandsProduce, secrete salivaConnect to mouth by ducts

Accessory GI StructuresLiverLarge solid organ in right upper quadrant Produces, secretes bile Produces essential proteinsProduces clotting factorsDetoxifies many substancesStores glycogenGallbladderSac located beneath liverStores and concentrates bile

Accessory GI StructuresPancreasEndocrine pancreas secretes insulin into bloodstreamExocrine pancreas secretes digestive enzymes, bicarbonate into gutVermiform appendixHollow appendage Attached to large intestineNo physiologic function

Major Blood VesselsAortaInferior vena cava

Solid OrgansLiverSpleenPancreasKidneysOvaries (female)

Hollow OrgansStomachIntestinesGallbladder and bile ductsUretersUrinary bladderUterus and Fallopian tubes (female)

Right Upper QuadrantLiverGallbladderDuodenumTransverse colon (part)Ascending colon (part)

Left Upper Quadrant:StomachLiver (part)PancreasSpleenTransverse colon (part)Descending colon (part)

Right Lower QuadrantAscending colonVermiform appendixOvary (female)Fallopian tube (female)

Left Lower QuadrantDescending colonSigmoid colonOvary (female)Fallopian tube (female)

Acute Abdomen

Abdominal PainVisceralSomaticReferred

Abdominal PainVisceral painStretching of peritoneum or organ capsules by distension or edemaDiffusePoorly localizedMay be perceived at remote locations related to organs sensory innervation

Abdominal PainSomatic painInflammation of parietal peritoneum or diaphragmSharpWell-localized

Abdominal PainReferred painPerceived at distance from diseased organPneumoniaAcute MIMale GU problems

Non-hemorrhagic Abdominal Pain

EsophagitisInflammation of distal esophagusUsually from gastric reflux, hiatal hernia

EsophagitisSigns and SymptomsSubsternal burning pain, usually epigastricWorsened by supine positionUsually without bleedingOften temporarily relieved by nitroglycerin

Acute GastroenteritisInflammation of stomach, intestineMay lead to bleeding, ulcersCauses acid secretionChronic EtOH abuseBiliary refluxMedications (ASA, NSAIDS)Infection

Acute GastroenteritisSigns and SymptomsEpigastric pain, usually burningTendernessNausea, vomitingDiarrheaPossible bleeding

Chronic Infectious GastroenteritisLong-term mucosal changes or permanent damageDue primarily to microbial infections (bacterial, viral, protozoal)Fecal-oral transmissionMore common in underdeveloped countriesNausea, vomiting, fever, diarrhea, abdominal pain, cramping, anorexia, lethargyHandwashing, BSI

Peptic Ulcer DiseaseCraters in mucosa of stomach, duodenumMales 4x > FemalesDuodenal ulcers 2 to 3x > Gastric ulcersCauses:Infectious disease: Helicobacter pylori (80%)NSAIDSPancreatic duct blockageZollinger-Ellison Syndrome

Peptic Ulcer DiseaseDuodenal Ulcers20 to 50 years oldHigh stress occupationsGenetic predispositionPain when stomach is emptyPain at nightGastric Ulcers> 50 years oldWork at jobs requiring physical activityPain after eating or when stomach is fullUsually no pain at night

Peptic Ulcer DiseaseComplicationsHemorrhagePerforation, progressing to peritonitisScar tissue accumulation, progressing to obstruction

Peptic Ulcer DiseaseSigns and SymptomsSteady, well-localized painBurning, gnawing, hot rockRelieved by bland, alkaline food/antacidsWorsened by smoking, coffee, stress, spicy foodsStool changes, pallor associated with bleeding

PancreatitisInflammation of pancreas in which enzymes auto-digest glandCauses include:EtOH (80% of cases)Gallstones obstructing ductsElevated serum triglyceridesTraumaViral, bacterial infections

PancreatitisMay lead to:PeritonitisPseudocyst formationHemorrhageNecrosisSecondary diabetes

PancreatitisSigns and SymptomsMid-epigastric pain radiating to backOften worsened by food, EtOHBluish flank discoloration (Grey-Turner Sign)Bluish periumbilical discoloration (Cullens Sign)Nausea, vomitingFever

CholecystitisGall bladder inflammation, usually 2o to gallstones (90% of cases)Risk factorsFive Fs: Fat, Fertile, Febrile, Fortyish, FemalesHeredity, diet, BCP use

CholecystitisAcalculus cholecystitisBurnsSepsisDiabetesMultiple organ systems failureChronic cholecystitis (bacterial infection)

CholecystitisSigns and Symptoms Sudden pain, often severe, crampingRUQ, radiating to right shoulderPoint tenderness under right costal margin (Murphys sign)Nausea, vomitingOften associated with fatty food intakeHistory of similar episodes in pastMay be relieved by nitroglycerin

AppendicitisInflammation of vermiform appendixUsually secondary to obstruction by fecalithMay occur in older persons secondary to atherosclerosis of appendiceal artery and ischemic necrosis

AppendicitisSigns and SymptomsClassic: Periumbilical pain RLQ pain/crampingNausea, vomiting, anorexiaLow-grade feverPain intensifies, localizes resulting in guardingPatient on right side with right knee, hip flexed

AppendicitisSigns and SymptomsMcBurneys Sign: Pain on palpation of RLQAarons Sign: Epigastric pain on palpation of RLQRovsings Sign: Pain in LLQ on palpation of RLQPsoas Sign: Pain when patient:Extends right leg while lying on left sideFlexes legs while supine

AppendicitisSigns and SymptomsUnusual appendix position may lead to atypical presentationsBack painLLQ painCystitisRupture: Temporary pain relief followed by peritonitis

Bowel ObstructionBlockage of intestine Common CausesAdhesions (usually 2o to surgery)HerniasNeoplasmsVolvulusIntussuceptionImpaction

Bowel ObstructionPathophysiologyFluid, gas, air collect near obstruction siteBowel distends, impeding blood flow/ halting absorptionWater, electrolytes collect in bowel lumen leading to hypovolemiaBacteria form gas above obstruction further worsening distensionDistension extends proximallyNecrosis, perforation may occur

Bowel ObstructionSigns and SymptomsSevere, intermittent, crampy painHigh-pitched, tinkling bowel soundsAbdominal distensionHistory of decreased frequency of bowel movements, semi-liquid stool, pencil-thin stoolsNausea, vomiting? Feces in vomitus

HerniaProtrusion 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)

HerniaSigns and Symptoms Pain by abdominal pressurePast historyInguinal hernia may be palpable as mass in groin or scrotum

Crohns DiseaseIdiopathic inflammatory bowel diseaseOccurs anywhere from mouth to rectum35-45%: small intestine; 40%: colonRuns in familiesHigh risk groupsWhite femalesJewsPersons under frequent stress

Crohns DiseasePathophysiologyMucosa of GI tract becomes inflamedGranulomas form, invade submucosaMuscular layer of bowel become fibrotic, hypertrophiedIncreased risk develops forObstructionPerforationHemorrhage

Ulcerative ColitisIdiopathic inflammatory bowel diseaseChronic ulcers develop in mucosal layer of colonSpread to submucosal layer uncommon75% of cases involve rectum (proctitis) or rectosigmoid portion of large intestineInflammation can spread through entire large intestine (pancolitis)

Ulcerative ColitisSeverity of signs, symptoms depends on extentClassic presentationCrampy abdominal painNausea, vomitingBlood diarrhea or stool containing mucusIschemic damage with perforation may occur

DiverticulitisDiverticulaPouches in colon wallTypically in older personsUsually asymptomaticRelated to diets with inadequate fiber

DiverticulitisDiverticula trap feces, become inflamedOccasionally result in bright red rectal bleedingRupture may cause peritonitis, sepsis

DiverticulitisSigns and Symptoms Usually left-sided pain May localize to LLQ (left-sided appendicitis)Alternating constipation, diarrheaBright red blood in stool

HemorrhoidsSmall masses of veins in anus, rectumMost frequently develop when patients are in 30s or 40s; common past 50Most are idiopathic, can be associated with pregnancy, portal hypertensionCause bright red bleeding, pain on defecationMay become infected, inflamed

PeritonitisInflammation of abdominal cavity liningSigns and SymptomsGeneralized pain, tendernessAbdominal rigidityNausea, vomitingAbsent bowel soundsPatient resistant to movement

Hemorrhagic Abdominal ProblemsGastrointestinal HemorrhageIntraabdominal Hemorrhage

Esophageal VaricesDilated veins in esophageal wallOccur 2o to hepatic cirrhosis, common in EtOH abusersObstruction of hepatic portal blood flow results in dilation, thinning of esophageal veins

Esophageal VaricesPortal hypertensionHepatic scarring slows blood flowBlood backs up in portal circulationPressure risesVessels in portal circulation become distended

Esophageal VaricesSigns and Symptoms Hematemesis (usually bright red)Nausea, vomitingEvidence of hypovolemiaMelena (uncommon)

Mallory-Weiss SyndromeLongitudinal tears at gastroesophageal junctionOccur as result of prolonged, forceful vomiting, retchingCommon in alcoholicsMay be complicated by presence of esophageal varices

Peptic Ulcer DiseaseUlcer erodes through blood vesselMassive hematemesisMelena may be present

Aortic AneurysmLocalized dilation due to weakening of aortic wallUsually older patient with history of hypertension, atherosclerosisMay occur in younger patients secondary toTraumaMarfans syndrome

Aortic AneurysmUsually just above aortic bifurcationMay extend to one or both iliac arteries

Aortic AneurysmSigns and SymptomsUnilateral lower quadrant pain; low back or leg painMay be described as tearing or rippingPulsatile palpable mass usually above umbilicusDiminished pulses in lower extremitiesUnexplained syncope, often after BMEvidence of hypovolemic shock

Ectopic PregnancyAny pregnancy that takes place outside of uterine cavityMost common location is in Fallopian tubePregnancy outgrows tube, tube wall rupturesHemorrhage into pelvic cavity occurs

Ectopic PregnancySuspect in females of child-bearing age with: Abdominal pain, orUnexplained shockWhen was last normal menstrual period?Ectopic pregnancy does NOT necessarily cause missed period

Assessment of Acute Abdomen

HistoryWhere do you hurt? Try to point with one fingerWhat does pain feel like?Steady pain = Inflammatory processCramping pain = Obstructive processOnset of pain?Sudden = Perforation or vascular occlusionGradual = Peritoneal irritation, distension of hollow organ

HistoryDoes pain travel anywhere?Gallbladder = Angle of right scapulaPancreas = Straight through to backKidney/ureter = Around flank to groinHeart = epigastrium, neck/jaw, shoulders, upper armsSpleen = Left scapula, shoulderAbdominal Aortic Aneurysm = low back radiating to one or both legs

HistoryHow long have you been hurting?>6 hours = increased probability of surgical significanceNausea, vomitingHow much, How long?Consider possible hypovolemiaBlood, coffee grounds?Any blood in GI tract = emergency until proven otherwise

HistoryUrineChange in urinary habits?FrequencyUrgencyColor?Odor?

HistoryBowel movementsChange in bowel habits? Color? Odor?Bright red bloodMelena = black, tarry, foul-smelling stoolDark stoolSuspect bleedingOther causes possible (iron or bismuth containing materials)

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

Physical ExamPosition and General AppearanceStill, refusing to move = Inflammation, peritonitisExtremely restless = ObstructionGross appearance of abdomenDistendedDiscoloredConsider possible third spacing of fluids

Physical ExamVital signsTachycardia = more important sign of volume loss than falling BPRapid, shallow breathing = possible peritonitisConsider performing tilt test

Physical ExamBowel soundsAuscultate BEFORE palpatingOne minute in each abdominal quadrantAbsent sounds = possible peritonitis, shockHigh-pitched, tinkling sounds = possible bowel obstruction

Physical ExamPalpationPalpate each quadrantPalpate area of pain LASTDo NOT check rebound tenderness in prehospital settingALL abdominal tenderness significant until proven otherwise

Management Oxygen by non-rebreather maskIV LR or NSPASG (demonstrated benefit in intrabdominal hemorrhage)Keep patient from losing body heatMonitor vital signs

Management Monitor EKG

Keep patient npoAnalgesia controversialDemerol is preferred narcotic analgesic

Consider possible MI with pain referred to abdomen in patients >30 years old