ACUTEABDOMEN
ACUTE ABDOMEN
WHATISACUTEABDOMEN?The term acute abdomen refers to signs and symptoms ofabdominal pain and tenderness, a clinical presentation thatoften requires emergency surgical therapy
WHAT IS ACUTE ABDOMEN? • The term acute abdomen refers to signs and symptoms of abdominal pain and tenderness, a clinical presentation that often requires emergency surgical therapy
Box47-2Surgical Acute Abdominal ConditionsHemorrhageWHATISACUTEABDOMEN?Solid organ traumaLeaking orruptured arterial aneurysmRupturedectopicpregnancyBleedinggastrointestinaldiverticulumArteriovenousmalformationofgastrointestinal tractIntestinal ulcerationMost surgical diseases associated with anAortoduodenal fistula afteraorticvasculargraftacuteabdomenresult frominfection,HemorrhagicpancreatitisMallory-Weisssyndromeobstruction,ischemia,orperforationSpontaneousruptureof spleenInfectionAppendicitisCholecystitisMeckel's diverticulitisBecause of thepotential surgical nature ofHepaticabscessDiverticularabscessthe acute abdomen,an expeditious workupPsoasabscessisnecessaryPerforationPerforated gastrointestinal ulcerPerforated gastrointestinal cancerBoerhaave's syndromePerforateddiverticulumThe workup proceeds in the usual order-BlockageAdhesioninduction small/largebowelobstructionhistory,physical examination,laboratorySigmoidvolvulusCecalvolvulustests, and imaging studiesIncarcerated herniasInflammatoryboweldiseaseGastrointestinal malignancyIntussusceptionIschemiaBuerger's diseaseMesentericthrombosis/embolismOvariantorsionIschemiccolitisTesticulartorsionStrangulated henias
WHAT IS ACUTE ABDOMEN? • Most surgical diseases associated with an acute abdomen result from infection, obstruction, ischemia, or perforation • Because of the potential surgical nature of the acute abdomen, an expeditious workup is necessary • The workup proceeds in the usual order— history, physical examination, laboratory tests, and imaging studies
WHATISACUTEABDOMEN?Not allacuteabdomen needs surgicaltreatmentBOx47-1 Nonsurgical Causes of theAcuteAbdomenEndocrineandMetabolicCausesNonsurgical causes of an acute abdomen canUremiaDiabetic crisisbe divided into three categories, endocrineAddisoniancrisisAcuteintermittentporphyriaand metabolic, hematologic, and toxins orHereditaryMediterraneanfeverdrugsHematologic CausesSickle cell crisisAcuteleukemiaOtherblooddyscrasiasToxins and DrugsIt is important to consider thesepossibilitiesLead poisoningOtherheawymetal poisoningwhenpatient withacuteevaluatingaNarcoticwithdrawalabdominal painBlackwidowspiderpoisoning
WHAT IS ACUTE ABDOMEN? • Not all acute abdomen needs surgical treatment • Nonsurgical causes of an acute abdomen can be divided into three categories, endocrine and metabolic, hematologic, and toxins or drugs • It is important to consider these possibilities when evaluating a patient with acute abdominal pain
ANATOMYANDPHYSIOLOGYAbdominal pain is divided into visceral andparietal componentsVisceral pain tends to be vague and poorly localized to the epigastrium,periumbilicalregion, or hypogastrium, depending on its origin from the primitive foregut, midgut, orhindgut,Itisusuallytheresultofdistention of ahollowviscusParietal pain corresponds to the segmental nerve roots innervating the peritoneum andtendstobesharperandbetterlocalizedPeritonitis is peritoneal inflammation of any cause.It is usually recognized on physicaexamination by severetenderness to palpation,with or without rebound tenderness,andguardingReferred pain is pain perceived at a site distant from the source of stimulusBox47-3LocationsandCausesofReferredPainRight ShoulderLiverGallbladderRighthemidiaphragmLeftShoulderHeartTail ofpancreasSpleenLefthemidiaphragmScrotumand TesticlesUreter
ANATOMY AND PHYSIOLOGY • Abdominal pain is divided into visceral and parietal components • Visceral pain tends to be vague and poorly localized to the epigastrium, periumbilical region, or hypogastrium, depending on its origin from the primitive foregut, midgut, or hindgut, It is usually the result of distention of a hollow viscus • Parietal pain corresponds to the segmental nerve roots innervating the peritoneum and tends to be sharper and better localized • Peritonitis is peritoneal inflammation of any cause. It is usually recognized on physical examination by severe tenderness to palpation, with or without rebound tenderness, and guarding • Referred pain is pain perceived at a site distant from the source of stimulus
HISTORY -PainAdetailed and organized history is essential to formulating an accurate differentialdiagnosisandsubsequenttreatmentregimenThehistorymust notonlyfocus on the investigation of thepaincomplaints,but onpastproblemsandassociatedsymptomsaswellHow to describethe pain:OnsetCharacterLocationDurationRadiationChronologyofthepainexperienced
HISTORY-Pain • A detailed and organized history is essential to formulating an accurate differential diagnosis and subsequent treatment regimen • The history must not only focus on the investigation of the pain complaints, but on past problems and associated symptoms as well • How to describe the pain: • Onset • Character • Location • Duration • Radiation • Chronology of the pain experienced
HISTORY -PainThe intensity and severity of the pain are related to the underlying tissue damageintestinal perforationarterialembolizationwithischemiabiliary colicCholecystitisColitisBowel obstruction
HISTORY-Pain • The intensity and severity of the pain are related to the underlying tissue damage • intestinal perforation • arterial embolization with ischemia • biliary colic • Cholecystitis • Colitis • Bowel obstruction
HISTORY-PainCholecystitisHepatitisPancreatitisPerforatedulcerUreteral colicAppendicitis(maybeconstant)RupturedDiverticulitisaorticTubo-ovariananeurysmabcessorectopicpregnancyFiGURE47-4 Characterofpain-sudden,severepainFIGURE47-2Characterofpain-gradual,progressivepainBiliarycolicPerforatedulcerUreteral colicPyelonephritis,(kidney stones),renal orureteral colicSmall bowelobstructionColonicobstructionFIGURE47-3Characterof pain-colicky,crampy,intermittentpainFIGURE47-5Referredpain.Solid circles areprimary or most intensesites of pain
HISTORY-Pain
HISTORY-PainLocation and radiation is equally as important as the character of the painTissueinjuryorinflammation cantriggervisceral andsomaticpainSolid organ visceral pain in the abdomen is generalized in the quadrant of the involvedorganAsinflammationexpandstoinvolvetheperitoneal surface,parietal nervefibersfromthespineallowforfocalandintensesensationAppendicitis:diffuseperiumbilical pain shifts toan intensefocal painintheright loweabdomenatmcburney'spointPainmayalsoextendwellbeyondthediseasedsite--Referred PainLiver/gallbladder/common bileductobstruction--RadiatetorightshoulderGenitourinary--primarily in the flank region--Radiateto scrotum orlabia
HISTORY-Pain • Location and radiation is equally as important as the character of the pain • Tissue injury or inflammation can trigger visceral and somatic pain • Solid organ visceral pain in the abdomen is generalized in the quadrant of the involved organ • As inflammation expands to involve the peritoneal surface, parietal nerve fibers from the spine allow for focal and intense sensation • Appendicitis: diffuse periumbilical pain shifts to an intense focal pain in the right lower abdomen at mcburney’s point • Pain may also extend well beyond the diseased site-Referred Pain • Liver/gallbladder/common bile duct obstruction-Radiate to right shoulder • Genitourinary-primarily in the flank region -Radiate to scrotum or labia
HISTORY-PainActivities that exacerbate orrelieve the pain arealso importantEating worsen the pain: bowel obstruction/biliary colic/pancreatitis/diverticulitis/bowelperforationFoodproviderelieffromthepain:nonperforatedpepticulcerdisease/gastritisCompulsive posititon:Patients with peritoneal inflammation will avoid any activity thatstretchesorjostlestheabdomen
HISTORY-Pain • Activities that exacerbate or relieve the pain are also important • Eating worsen the pain: bowel obstruction/biliary colic/pancreatitis/diverticulitis/bowel perforation • Food provide relief from the pain: nonperforated peptic ulcer disease/gastritis • Compulsive posititon: Patients with peritoneal inflammation will avoid any activity that stretches or jostles the abdomen