A Cute Abdomen

Goal
not exact diagnosis
but that a surgical condition exists
The general rule can
be laid down that the
majority of severe
abdominal pains that
ensue in patients
who have been
previously fairly well,
and that last as long
as six hours, are
caused by
conditions of
surgical import.
Silen W: Copes Early Diagnosis of the Acute Abdomen. 1996,p.6.
Diagnose Early
Better outcome
Pain relief (narcotics)
Antibiotics
History
Age
Onset - how long ago
sudden or gradual
Distribution - area of maximal pain
localization
radiation
Character - sharp or dull, burning,
steady or cramping
History
Nausea, vomiting, anorexia
Diarrhea, constipation, flatus, blood, tenesmus
Menstruation - where in the cycle
sexual activity
Previous episodes -
relationship to meals:
2 - 2
1
/
2
hrs = duodenal
worse with food = gastric
fatty foods = gallstones
weight loss?
Vomiting
Relationship to pain
appendicitis - pain precedes vomiting
gastroenteritis - vomiting precedes pain
Character -
feculent vomiting pathognomonic of
obstruction of distal small intestine, rare in
colonic obstruction
Physical Examination
General appearance -
restlessness = colic
immobility with knees flexed = peritonitis
Blood pressure
Pulse - too optimistic a friend to be relied upon
Respiratory rate - may suggest a thoracic origin
Temperature - could be normal, high or low
> 104
o
F (40
o
C) suggests thorax or kidney
Silen W: Copes Early Diagnosis of the Acute Abdomen, 1996,p.32.

PE: Chest
Inspection
Palpation
Percussion
Auscultation
PE: Abdomen
Inspection - distention, hernias
DONT FORGET THE FEMORAL CANAL
Auscultation
Palpation -
rigidity
area of greatest pain last
Percussion - rebound, cough tenderness
Rosvings sign
Levien: Intro to Surg 1987, p.41.
PE: Abdomen
of all the modalities of physical diagnosis
of the abdomen, auscultation is one of
the least valuable and most misleading.
Silen W: Copes Early Diagnosis of the Acute Abdomen, 1996,p.43.
PE: Pelvis
Pelvic examination -
bimanual
Rectal examination -
mass, tenderness, blood
Overreliance on laboratory tests and
radiological evaluations will very often
mislead the clinician, especially if the
history and physical examination are
less than diligent and complete.
Silen W: Copes Early Diagnosis of the Acute Abdomen, 1996,p.57.
Laboratory Tests
CBC - leukocytosis, anemia
Urinalysis - infection, blood, pregnancy
Electrolytes - renal function, dehydration
Amylase, lipase
LFTs
Radiographic Studies
Flat & upright abdomen -
air-fluid levels, distended loops, edema in
bowel wall, volvulus, fecolith
CXR - free air, lower lobe pneumonia
Contrast studies -
H
2
O soluble if perforation
disadvantage - aspiration, quality
Appendicitis
Fecolith
Young
1. Dull pain in midepigastrium
2. Nausea/vomiting follows
pain
3. Localizes to RLQ
* Anorexia
+ Fever
Leukocytosis
Reginald H. Fitz
1843 - 1913
McBurney C: NY State Med J 1889;50,676-684.
McBurney C: Ann Surg 1894;20,38-43.
McBurneys Incision
Graham RR: Surg Gynecol Obstet 1937;64,235-238.
Perforated Ulcer
Sudden onset
Previous episodes of
pain ~ 2 hrs after
eating
CXR - free air
Pancreatitis
Alcohol
Gallstones
Trauma
Hyperlipidemia
Hyperparathyroidism
Drugs - thiazide diuretics
Unknown (10%)
Pancreatitis
Excruciating pain
Fever - almost always
Ransons criteria
Grey Turner sign
Cullens sign
Cullen TS: Am J Obstet 1918;78(Sept),457.
Turner GG: Brit J Surg 1920;7(Jan),394-395.
Ransons Criteria
Admission
1. Age > 55
2. WBC > 16,000/mm
3

3. Glucose > 200 mg/100 ml
4. LDH > 350 I.U./L
5. SGOT > 250 Frankel units %
During Initial 48 Hours
1. Hematocrit fall > 10%
2. BUN rise > 5%/mg/100 ml
3. Ca
++
< 8 mg/100 ml
4. Arterial pO2 < 60 mmHg
5. Base Deficit > 4 meq/L
6. Fluid sequestration > 6 L
Ranson et al: Surg Gynecol Obstet 1974;139,69.
Amylase
Pancreatitis
Cholecystitis
High intestinal
obstruction
Acute renal insufficiency
Perforated ulcer
& others
Cholecystitis
Radiopaque gallstones (10-15%)
Pain - RUQ, colic, radiates to the
ipsalateral scapula
Pain brought on with fatty foods
US - stones, thickening, fluid, air in wall
Intestinal
Obstruction
pain - colic
Vomiting, distention
Obstipation
Auscultation - quiet to high-pitched, tinkling
rushes to borborygmi
X-ray - air-fluid levels, fixed loops
Small Bowel Obstruction
1. Adhesions (74%)

1
/
2
2
o
to gynecologic or colonic operations
2. Neoplasm (8.6%)
3. Hernias (8.1%)
most common cause in children
Inflammatory bowel disease (5.2%)
Gallstone ileus, radiation enteritis, intussusception
Unknown
Bizer et al: Surgery 1981;89,407-413.
Adynamic Ileus
2
o
to general peritonitis, severe chest injuries, after
myocardial infarction, pneumonia, operations on the
spine or abdomen, or narcotics
Auscultation - quiet, no borborygmi
Involves both small & large bowel
Gaseous distention of both small & large bowel
Large Bowel
Obstruction
1. Cancer (70%)
2. Volvulus (10%)
3. Diverticulitis (5%)
Intussusception, uremia
Volvulus
Sigmoid (most common)
Ileocecal
Transverse (rare)
Barium enema is diagnostic
& often therapeutic
Sigmoidoscopy - alternative
diagnostic & therapeutic
modality
bent inner tube sign
Diverticulitis
LLQ pain
Fever, leukocytosis
CT scan - pericolic abscess
Antibiotics, NPO, NG decompression
Operation for persistent symptoms (7 days)
or recurrent episodes
Hernias
Indirect inguinal most common in both males
& females
Femoral is more common in females
Direct inguinal, umbilical, ventral, incisional,
Spigelian, Richters, lumbar, obturator, etc.
Renal Colic
Radiopaque ureteral calculus (85-90%)
Pain radiating to the testicle or vulva
Vomiting
Microscopic hematuria
Female Disorders
Ectopic pregnancy, PID, mittelschmerz,
appendicitis
Chandelier sign
Urinalysis
Ultrasound
Laparoscopy
Mesenteric Vascular
Occlusion
Pain out of proportion to physical examination
Risk factors - atrial fibrillation, digitalis, diuretics,
cardiopulmonary bypass
Barium enema may show thumbprinting
Angiography, MRI
Mortality = 50%
Summary
not exact diagnosis
but that a surgical condition exists