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anil on Jan 12, 2012 Says :

The management of Acute abdomen is nicely shown

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fedasaj12, favourited this 1 Years ago.

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Art of Approaching Acute Abdomen… Dr.S.Easwaramoorthy MS FRCS (Edin) FRCS (Eng) FRCS (Glas) Consultant Surgeon, Lotus hospital, Erode Honorary Faculty, PMCH, Perundurai Examiner, Royal College of surgeons of Edinburgh Top- 10 Points for General Practice Tambaram IMA 21.01.12

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‘Doc, Which of them has an acute abdomen!’

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‘Great Wars are won not by Air strikes and Laser Guided missiles but by the Army Men. Acute abdomen is diagnosed and managed not by Scans and blood tests but by Clinical Instinct And Common Sense!

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Approach to Abdominal pain…

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Take Pain to Elicit Pain History Quality Site Character Shifting Pain of Appendicitis Radiating Pain of Ureteric Colic Key Message 1 Quantity Visual Analog Score

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Art of Bed Side Assessment Inspect Palpate/ Percuss Auscultate God gave you ears, eyes and hands: Use them on the patient in That order’! William Kelsey Fry 1889-1963 Key Message 2 Rebound Tenderness Release Sign

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Let Us Recognize the Clinical Patterns ‘Shock/Catastrophe’ AAA/Ectopic/Pancreatitis ‘Hole’ Generalised peritonitis ‘Itis’ Appendicitis/Cholecystitis ‘Block’ Mechanical/Functional bowel obstruction Medical illness DKA/Pneumonia Key Message 3

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Shock/Catastrophe 40 yr lady/ sudden severe abdominal pain Hypovolumic Shock/Soft but tender abdomen Serum amylase/US abdomen/ Diagnosis: Acute Severe Gall stone pancreatitis AAA/Ectopic/Pancreatitis

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Clinical Pattern: 2 ‘Shock/Catastrophe’ AAA/Ectopic/Pancreatitis ‘Hole’ Generalised peritonitis Duodenal ulcer perforation Enteric perforation Sigmoid diverticular perforation

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‘Hole’ 62/M\Sudden onset of Severe abdominal pain Lying Still Stone like Silent abdomen X ray chest : Pneumoperitoneum Oversew Perforation of DU Laparotomy Vs Laparoscopy

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Clinical Pattern: 3 ‘Shock/Catastrophe’ AAA/Ectopic/Pancreatitis ‘Hole’ Generalised peritonitis ‘Itis’ Appendicitis/Cholecystitis

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Localized Peritonitis Appendicitis Cholecystitis Guarding & Local Tenderness Mc Burney’s tenderness Murphy’s sign

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Even a dentist can diagnose classic appendicitis But…

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Variable Position of Appendix

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Psoas sign

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DD for Appendicitis Children Gastroenteritis Mesenteric adenitis Meckel’s Intussusception Henoch-Schonlein purpura Lobar Pneumonia Adult Ureteric colic Perf DU Pancreatitis Crohn’s UTI Adult Female Ovary Twisted cyst Mid cycle pain Tube Ectopic Salpingitis Uterus Endometriosis Elderly Diverticulitis Ca caecum Intestinal obstruc Mesenteric Ischemia

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Clinical Pattern: 4 ‘Shock/Catastrophe’ AAA/Ectopic/Pancreatitis ‘Hole’ Generalised peritonitis ‘Itis’ Appendicitis/Cholecystitis ‘Block’ Intestinal obstruction

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‘Block’ Intestinal obstruction Symptoms Colicky pain Distension Vomiting Constipation Signs Distension BS : Increased Band/adhesions Intussusception

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Intestinal obstruction Pearls of Wisdom Useful Tips: Small bowel Vs Large bowel Scarred abdomen Vs Virgin abdomen Never forget to look for Femoral hernia Mechanical Vs Functional bowel obstruction True/Pseudo obstruction

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Small or Large bowel

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Virgin Abdomen Vs Scarred Abdomen Strangulated Hernia Crohn’s/TB Intussusception Cancer

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In cases of Acute abdomen Never forget to look for Femoral Hernia Tenth Compartment..

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Clinical Pattern:5 ‘Shock/Catastrophe’ AAA/Ectopic/Pancreatitis ‘Hole’ Generalised peritonitis ‘Itis’ Appendicitis/Cholecystitis ‘Block’ Mechanical/Functional bowel obstruction Medical illness DKA/MI

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Know the value & Limitation of FBC Normal White cell count will not rule out Appendicitis Raised CRP is in favour of sepsis Key Message 4

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Understand the value of laboratory results in Acute abdomen Serum amylase > 1000 units to diagnose pancreatitis Renal Parameters Paralytic ileus Low serum albumin Wound Healing Urine Pus cells : UTI pregnancy test : Ectopic Pregnancy Key Message 5

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Role of Imaging in Acute Abdomen X ray Chest Abdomen Erect , Supine, KUB US abdomen CT abdomen MRI Visceral Angiogram Etc… Key Message 6

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Role of Xrays X ray abdomen Erect Multiple Fluid Levels X ray abdomen Supine Dilated loops X ray Chest Pneumoperitoneum

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Role of US in Acute Abdomen Gall Stones Appendicitis Normal US abdomen will not Exclude acute appendicitis!

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CT Abdomen Free gas Fluid in the abdomen Solid viscera Liver/Spleen Kidney Hollow viscus Retroperitoneum AAA Pancreatitis

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Recognize Pancreatitis Hide him from Surgeon! Diagnosis of Pancreatitis Serum Amylase and Lipase US abdomen, Contrast CT abdomen Management of Pancreatitis Medical Management Surgical Management Pancreatic Pseudo cyst Infected Pancreatic Necrosis Pancreatic abscess etc Key Message 7

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Risk Reduction Pre operative optimization will avert any intra operative catastrophe! Fluid & Electrolyte correction Analgesics and Antibiotics Bowel Preparation etc Key Message 8

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When to Operate? Urgent Surgery Perf DU/Strangulated bowel Surgery Next day Ac Appendicitis/Obstructed Ca colon Surgery at a later date Appendicular mass Conservative Pancreatitis, Paralytic ileus Key Message 9 Decision to operate is not difficult but the decision not to operate is! Because it needs courage and wisdom

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Role of laparoscopy in Acute Abdomen Well Establised Acute appendicitis Cholecystitis Ectopic/Ovarian cyst Evolving Closure of perf DU Obstructed Hernia Blunt Injury abdomen Better avoided Bowel obstruction Unstable patients Key Message 10 Feasibility is not an indication

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Conclusion 5 clinical patterns of acute abdomen Pre op Optimization And let us remember, Clinical Decision Making is an Art Knowledge, Experience & Instinct

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Rely on your expertise and instinct rather than Scans and tests! So next time, when you see a patient with acute abdomen…

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Thank You Long Live IMA

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art of managing acute abdominal pain in adults
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