acute abdomen

Acute Abdomen
Anatomy review
Non-hemorrhagic abdominal pain
Gastrointestinal hemorrhage
Assessment
Management
Abdominal Anatomy
Review
Abdominal Cavity
Superior border = diaphragm
Inferior border = pelvis
Posterior border = lumbar spine
Anterior border = muscular abdominal wall
Peritoneum
Abdominal cavity lining
Double-walled structure
Visceral peritoneum
Parietal peritoneum
Separates abdominal cavity into two parts
Peritoneal cavity
Retroperitoneal space
Primary GI Structures
Mouth/oral cavity
Lips, cheeks, gums, teeth, tongue
Pharynx
Portion of airway between nasal cavity and larynx
Primary GI Structures
Esophagus
Portion of digestive tract between pharynx and stomach
Stomach
Hollow digestive organ
Receives food from esophagus
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
Accessory GI Structures
Salivary glands
Produce, secrete saliva
Connect to mouth by ducts
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
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
Major Blood Vessels
Aorta
Inferior vena cava
Solid Organs
Liver
Spleen
Pancreas
Kidneys
Ovaries (female)
Hollow Organs
Stomach
Intestines
Gallbladder and bile ducts
Ureters
Urinary bladder
Uterus and Fallopian tubes (female)
Right Upper Quadrant
Liver
Gallbladder
Duodenum
Transverse colon (part)
Ascending colon (part)
Left Upper Quadrant:
Stomach
Liver (part)
Pancreas
Spleen
Transverse colon (part)
Descending colon (part)
Right Lower Quadrant
Ascending colon
Vermiform appendix
Ovary (female)
Fallopian tube (female)
Left Lower Quadrant
Descending colon
Sigmoid colon
Ovary (female)
Fallopian tube (female)
Acute Abdomen
Abdominal Pain
Visceral
Somatic
Referred
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 organ’s sensory innervation
Abdominal Pain
Somatic pain
Inflammation of parietal peritoneum or diaphragm
Sharp
Well-localized
Abdominal Pain
Referred pain
Perceived at distance from diseased organ
Pneumonia
Acute MI
Male GU problems
Non-hemorrhagic Abdominal Pain
Esophagitis
Inflammation of distal esophagus
Usually from gastric reflux, hiatal hernia
Esophagitis
Signs and Symptoms
Substernal burning pain, usually epigastric
Worsened by supine position
Usually without bleeding
Often temporarily relieved by nitroglycerin
Acute Gastroenteritis
Inflammation of stomach, intestine
May lead to bleeding, ulcers
Causes
 acid secretion
Chronic EtOH abuse
Biliary reflux
Medications (ASA, NSAIDS)
Infection
Acute Gastroenteritis
Signs and Symptoms
Epigastric pain, usually burning
Tenderness
Nausea, vomiting
Diarrhea
Possible bleeding
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
Peptic Ulcer Disease
Craters in mucosa of stomach, duodenum
Males 4x > Females
Duodenal ulcers 2 to 3x > Gastric ulcers
Causes:
Infectious disease: Helicobacter pylori (80%)
NSAIDS
Pancreatic duct blockage
Zollinger-Ellison Syndrome
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
> 50 years old
Work at jobs requiring physical activity
Pain after eating or when stomach is full
Usually no pain at night
Peptic Ulcer Disease
Complications
Hemorrhage
Perforation, progressing to peritonitis
Scar tissue accumulation, progressing to obstruction
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
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
Pancreatitis
May lead to:
Peritonitis
Pseudocyst formation
Hemorrhage
Necrosis
Secondary diabetes
Pancreatitis
Signs and Symptoms
Mid-epigastric pain radiating to back
Often worsened by food, EtOH
Bluish flank discoloration (Grey-Turner Sign)
Bluish periumbilical discoloration (Cullen’s Sign)
Nausea, vomiting
Fever
Cholecystitis
Gall bladder inflammation, usually 2o to gallstones (90% of cases)
Risk factors
Five Fs: Fat, Fertile, Febrile, Fortyish, Females
Heredity, diet, BCP use
Cholecystitis
Acalculus cholecystitis
Burns
Sepsis
Diabetes
Multiple organ systems failure
Chronic cholecystitis (bacterial infection)
Cholecystitis
Signs and Symptoms
Sudden pain, often severe, cramping
RUQ, radiating to right shoulder
Point tenderness under right costal margin (Murphy’s sign)
Nausea, vomiting
Often associated with fatty food intake
History of similar episodes in past
May be relieved by nitroglycerin
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
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
Appendicitis
Signs and Symptoms
McBurney’s Sign: Pain on palpation of RLQ
Aaron’s Sign: Epigastric pain on palpation of RLQ
Rovsing’s 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
Appendicitis
Signs and Symptoms
Unusual appendix position may lead to atypical presentations
Back pain
LLQ pain
“Cystitis”
Rupture: Temporary pain relief followed by peritonitis
Bowel Obstruction
Blockage of intestine
Common Causes
Adhesions (usually 2o to surgery)
Hernias
Neoplasms
Volvulus
Intussuception
Impaction
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
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
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)
Hernia
Signs and Symptoms
Pain  by abdominal pressure
Past history
Inguinal hernia may be palpable as mass in groin or scrotum
Crohn’s 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

Crohn’s 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
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)
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
Diverticulitis
Diverticula
Pouches in colon wall
Typically in older persons
Usually asymptomatic
Related to diets with inadequate fiber
Diverticulitis
Diverticula trap feces, become inflamed
Occasionally result in bright red rectal bleeding
Rupture may cause peritonitis, sepsis
Diverticulitis
Signs and Symptoms
Usually left-sided pain
May localize to LLQ (“left-sided appendicitis”)
Alternating constipation, diarrhea
Bright red blood in stool
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
Peritonitis
Inflammation of abdominal cavity lining
Signs and Symptoms
Generalized pain, tenderness
Abdominal rigidity
Nausea, vomiting
Absent bowel sounds
Patient resistant to movement
Hemorrhagic Abdominal Problems
Gastrointestinal Hemorrhage
Intra-abdominal Hemorrhage
Esophageal Varicose
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
Esophageal Varicose
Portal hypertension
Hepatic scarring slows blood flow
Blood backs up in portal circulation
Pressure rises
Vessels in portal circulation become distended
Esophageal Varices
Signs and Symptoms
Hematomas (usually bright red)
Nausea, vomiting
Evidence of hypovolemia
Melena (uncommon)
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
Peptic Ulcer Disease
Ulcer erodes through blood vessel
Massive hematemesis
Melena may be present
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
Marfan’s syndrome
Aortic Aneurysm
Usually just above aortic bifurcation
May extend to one or both iliac arteries
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
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
Ectopic Pregnancy
Suspect in females of child-bearing age with:
Abdominal pain
Unexplained shock
When was last normal menstrual period?
Assessment of Acute Abdomen
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
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
History
How long have you been hurting?
>6 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
History
Urine
Change in urinary habits?
Frequency
Urgency
Color?
Odor?
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)
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
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
Physical Exam
Vital signs
Tachycardia = more important sign of volume loss than falling BP
Rapid, shallow breathing = possible peritonitis
Consider performing “tilt” test
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
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
Management
Oxygen by non-rebreather mask
IV LR or NS
PASG (demonstrated benefit in intra-abdominal hemorrhage)
Keep patient from losing body heat
Monitor vital signs
Management
Monitor ECG