Danil Hammoudi.MD

Sinoe Medical Association

 

 

 

Surgical Abdomen

 

 

 

 

 

 

 

 

 

 

 

ABDOMINAL PAIN


THE FIRST QUESTION IS: IS IT A SURGICAL ABDOMEN OR NOT

THE CLINICAL PRESENTATION AND SIGNS USUALLY WILL GIVE YOU THE ANSWER WITH THE RELATION TO THE AGE , THE SEX OF THE PATIENTS

SOME DIFFERENTIAL WILL BE MORE THINKS FOR CATEGORIES THAN OTHERS [Surgical problems of the abdomen are different in many ways in elderly patients compared with those in younger patients. Diagnosis, particularly in emergencies, is more difficult because sensation is not as acute as in younger patients, and pathophysiologic reactions (eg, pain, tenderness, response to inflammation) are not as quick or effective. Thus, minimal symptoms may accompany a potentially fatal intestinal perforation, and the first sign may be free subphrenic gas on a plain abdominal x-ray.]

IS IS AFTER OR WITHOUT TRAUMA , FAR FROM FOOD INTAKE OR AFTER FOOD INTAKE ASSOCIATED OR NOT WITH FEVER , THE DURATION THE IRRADIATION AND THE OTHER SYMPTOMS SPECIFIC WITH EACH OF THE CASES

acute abdomen as "any serious acute intra-abdominal condition attended by pain, tenderness, and muscular rigidity, and for which emergency surgery must be considered." [Stedmanís Medical Dictionary, 27th Edition]

(Determine whether the patient has an acute "surgical" [i.e., requiring surgery] abdomen): Always starting with the ABC no matter what.

A. What are the patient's vital signs? Orthostatic blood pressure and pulse changes help ascertain the patient's volume status. Fever occurs in inflammatory conditions. Tachycardia and hypotension would suggest circulatory or septic shock from perforation, hemorrhage, or fluid loss into the intestinal lumen or peritoneal cavity.

B. Where is the pain located? When did the pain begin? Sudden onset suggests perforated ulcer, mesenteric occlusion, ruptured aneurysm or ruptured ectopic pregnancy. What is the quality of pain? Intestinal colic occurs as cramping abdominal pain interspersed with pain-free intervals.

C. Are there any associated symptoms? Vomiting may result from intestinal obstruction or could result from a visceral reflex caused by pain.

D. If the patient is a woman, what is her menstrual history?

E/ with any previous surgery , post op immediate and far, without any previous abdominal surgery

F/ after trauma or not after trauma

G/far from a meal close to a meal

 

 

 

Acute abdomen should be suspected in patients who complain of only minimal abdominal pain. Peritonitis caused by perforation of the sigmoid, stomach, or duodenum may be present even if the patient has only slight abdominal tenderness. Vascular lesions (eg, mesenteric artery thrombosis) also are common. With appendicitis, acute cholecystitis, and strangulated hernias, the interval between onset and gangrene may be only a few hours.

The physical examination is extremely important. Old incisional scars raise the likelihood of intestinal obstruction. An examination of potential hernia sites is essential. Absence of bowel sounds indicates aperistalsis, a serious finding that requires other diagnostic tests be performed expeditiously.

The major indications for emergency surgery are perforation of a viscus, appendicitis, intestinal obstruction, and massive hemorrhage. Acute cholecystitis often requires urgent surgery.

Most elective surgery is for malignant disease. Excluding hernia repairs, > 90% of abdominal procedures involve the colon, gallbladder, and stomach; with effective medical treatment for peptic ulcer disease, operations on the colon and gallbladder now predominate.

Generally, the elderly tolerate a single operation well, provided the offending lesion is removed. However, complications from second or third operations performed soon after the first carry a high mortality rate. Staged procedures should be spaced apart to allow complete recovery. These considerations are particularly important in gastrointestinal (GI) disorders.

 

 

 


CHARACTERISTIC PHYSICAL FINDINGS IN THE ACUTE ABDOMEN

Peritonitis

Generalized guarding, tenderness, rebound tenderness, hypoactive or absent bowel sounds

Appendicitis

Right lower quadrant tenderness, guarding and rebound, discrete tenderness at McBurney's point, peak age 10-20.

Acute cholecystitis

Right upper quadrant tenderness and guarding, positive Murphy's sign, may radiate to right scapula.

High Small Bowel obstruction

Severe vomiting, dehydration, no distention

Low Small Bowel obstruction

Distention, hyperactive and high pitched bowel sounds, vomiting.

Bowel Infarction

Pain out of proportion to tenderness, rectal bleeding if venous infarction.

Ruptured aortic aneurism

Pulsatile tender mass, hypotension, back pain

Pancreatitis

Steady, severe, LUQ and epigastric pain radiating to the back; pain less when sits forward; decreased BS; diffuse tenderness.


Exam of the Abdomen

The major components of the abdominal exam include: observation, auscultation, percussion, and palpation. While these are the same elements which make up the pulmonary and cardiac exams, they are performed here in a slightly different order (i.e. auscultation before percussion) and carry different degrees of importance. Pelvic, genital, and rectal exams, all part of the abdominal evaluation, are discussed elsewhere.

Think Anatomically: When looking, listening, feeling and percussing imagine what organs live in the area that you are examining. The abdomen is roughly divided into four quadrants: right upper, right lower, left upper and left lower. By thinking in anatomic terms, you will remind yourself of what resides in a particular quadrant and therefore what might be identifiable during both normal and pathologic states.

Quadrants of the Abdomen

Topical Anatomy of the Abdomen

By convention, the abdominal exam is performed with the provider standing on the patient's right side.

Observation: Much information can be gathered from simply watching the patient and looking at the abdomen. This requires complete exposure of the region in question, which is accomplished as follows:

  1. Ask the patient to lie on a level examination table that is at a comfortable height for both of you. At this point, the patient should be dressed in a gown and, if they wish, underwear.
  2. Take a spare bed sheet and drape it over their lower body such that it just covers the upper edge of their underwear (or so that it crosses the top of the pubic region if they are completely undressed). This will allow you to fully expose the abdomen while at the same time permitting the patient to remain somewhat covered. The gown can then be withdrawn so that the area extending from just below the breasts to the pelvic brim is entirely uncovered, remembering that the superior margin of the abdomen extends beneath the rib cage.

Draping the Abdomen

  1. The patient's hands should remain at their sides with their heads resting on a pillow. If the head is flexed, the abdominal musculature becomes tensed and the examination made more difficult. Allowing the patient to bend their knees so that the soles of their feet rest on the table will also relax the abdomen.
  2. Keep the room as warm as possible and make sure that the lighting is adequate. By paying attention to these seemingly small details, you create an environment that gives you the best possible chance of performing an accurate examination. This is particularly important early in your careers, when your skills are relatively unrefined. However, it will also stand you in good stead when examining obese, anxious, distressed or otherwise challenging patients.

While observing the patient, pay particular attention to:

  1. Appearance of the abdomen. Is it flat? Distended? If enlarged, does this appear symmetric or are there distinct protrusions, perhaps linked to underlying organomegaly? The contours of the abdomen can be best appreciated by standing at the foot of the table and looking up towards the patient's head. Global abdominal enlargement is usually caused by air, fluid, or fat. It is frequently impossible to distinguish between these entities on the basis of observation alone (see below for helpful maneuvers). Areas which become more pronounced when the patient valsalvas are often associated with ventral hernias. These are points of weakening in the abdominal wall, frequently due to previous surgery, through which omentum/intestines/peritoneal fluid can pass when intra-abdominal pressure is increased.

Various Causes of Abdominal Distension

The photo above left illustrates an obese abdomen, above right illustrates an abdomen enlarged secondary to hepatomegaly, and the photo at the bottom illustrates an abdomen filled with ascites.


Umbilical Hernia


Same umbilical hernia while patient
performs valsalva maneuver.

  1. Presence of surgical scars or other skin abnormalities.
  2. Patient's movement (or lack thereof). Those with peritonitis (e.g. appendicitis) prefer to lie very still as any motion causes further peritoneal irritation and pain. Contrary to this, patients with kidney stones will frequently writhe on the examination table, unable to find a comfortable position.

Auscultation: Compared to the cardiac and pulmonary exams, auscultation of the abdomen has a relatively minor role. It is performed before percussion or palpation as vigorously touching the abdomen may disturb the intestines, perhaps artificially altering their activity and thus bowel sounds. Exam is made by gently placing the pre-warmed (accomplished by rubbing the stethoscope against the front of your shirt) diaphragm on the abdomen and listening for 15 or 20 seconds. There is no magic time frame. The stethoscope can be placed over any area of the abdomen as there is no true compartmentalization and sounds produced in one area can probably be heard throughout. How many places should you listen in? Again, there is no magic answer. At this stage, practice listening in each of the four quadrants and see if you can detect any "regional variations."

Abdominal Auscultation

What exactly are you listening for and what is its significance? Three things should be noted:

  1. Are bowel sounds present?
  2. If present, are they frequent or sparse (i.e. quantity)?
  3. What is the nature of the sounds (i.e. quality)?

As food and liquid course through the intestines by means of peristalsis noise, referred to as bowel sounds, is generated. These sounds occur quite frequently, on the order of every 2 to 5 seconds, although there is a lot of variability. Bowel sounds in and of themselves do not carry great significance. That is, in the normal person who has no complaints and an otherwise normal exam, the presence or absence of bowel sounds is essentially irrelevant (i.e. whatever pattern they have will be normal for them). In fact, most physicians will omit abdominal auscultation unless there is a symptom or finding suggestive of abdominal pathology. However, you should still practice listening to all the patients that you examine so that you develop a sense of what constitutes the range of normal. Bowel sounds can, however, add important supporting information in the right clinical setting. In general, inflammatory processes of the serosa (i.e. any of the surfaces which cover the abdominal organs....as with peritonitis) will cause the abdomen to be quiet (i.e. bowel sounds will be infrequent or altogether absent). Inflammation of the intestinal mucosa (i.e. the insides of the intestine, as might occur with infections that cause diarrhea) will cause hyperactive bowel sounds. Processes which lead to intestinal obstruction initially cause frequent bowel sounds, referred to as "rushes." Think of this as the intestines trying to force their contents through a tight opening. This is followed by decreased sound, called "tinkles," and then silence. Alternatively, the reappearance of bowel sounds heralds the return of normal gut function following an injury. After abdominal surgery, for example, there is a period of several days when the intestines lie dormant. The appearance of bowel sounds marks the return of intestinal activity, an important phase of the patient's recovery. Bowel sounds, then, must be interpreted within the context of the particular clinical situation. They lend supporting information to other findings but are not in and of themselves pathognomonic for any particular process.

After you have finished noting bowel sounds, use the diaphragm of your stethoscope to check for renal artery bruits, a high pitched sound (analogous to a murmur) caused by turbulent blood flow through a vessel narrowed by atherosclerosis. The place to listen is a few cm above the umbilicus, along the lateral edge of either rectus muscles. Most providers will not routinely check for bruits. However, in the right clinical setting (e.g. a patient with some combination of renal insufficiency, difficult to control hypertension and known vascular disease), the presence of a bruit would lend supporting evidence for the existence of renal artery stenosis. When listening for bruits, you will need to press down quite firmly as the renal arteries are retroperitoneal structures. Blood flow through the aorta itself does not generate any appreciable sound. Thus, auscultation over this structure is not a good screening test for the presence of atherosclerosis or aneurysmal dilatation.

Percussion: The technique for percussion is the same as that used for the lung exam. First, remember to rub your hands together and warm them up before placing them on the patient. Then, place your left hand firmly against the abdominal wall such that only your middle finger is resting on the skin. Strike the distal interphalangeal joint of your left middle finger 2 or 3 times with the tip of your right middle finger, using the previously described floppy wrist action (see under lung exam). There are two basic sounds which can be elicited:

  1. Tympanitic (drum-like) sounds produced by percussing over air filled structures.
  2. Dull sounds that occur when a solid structure (e.g. liver) or fluid (e.g. ascites) lies beneath the region being examined.

*Special note should be made if percussion produces pain, which may occur if there is underlying inflammation, as in peritonitis. This would certainly be supported by other historical and exam findings.

Abdominal Percussion

What can you really expect to hear when percussing the normal abdomen? The two solid organs which are percussable in the normal patient are the liver and spleen. In most cases, the liver will be entirely covered by the ribs. Occasionally, an edge may protrude a centimeter or two below the costal margin. The spleen is smaller and is entirely protected by the ribs. To determine the size of the liver, proceed as follows:

  1. Start just below the right breast in a line with the middle of the clavicle, a point that you are reasonably certain is over the lungs. Percussion in this area should produce a relatively resonant note.
  2. Move your hand down a few centimeters and repeat. After doing this several times, you will be over the liver, which will produce a duller sounding tone.
  3. Continue your march downward until the sound changes once again. This may occur while you are still over the ribs or perhaps just as you pass over the costal margin. At this point, you will have reached the inferior margin of the liver. The total span of the normal liver is quite variable, depending on the size of the patient (between 6 and 12 cm). Don't get discouraged if you have a hard time picking up the different sounds as the changes can be quite subtle, particularly if there is a lot of subcutaneous fat.
  4. The resonant tone produced by percussion over the anterior chest wall will be somewhat less drum like then that generated over the intestines. While they are both caused by tapping over air filled structures, the ribs and pectoralis muscle tend to dampen the sound.
  5. Speed percussion, as described in the pulmonary section, may also be useful. Orient your left hand so that the fingers are pointing towards the patients head. Percuss as you move the hand at a slow and steady rate from the region of the right chest, down over the liver and towards the pelvis. This maneuver helps to accentuate different percussion notes, perhaps making the identification of the liver's borders a bit more obvious.

Percussion of the spleen is more difficult as this structure is smaller and lies quite laterally, resting in a hollow created by the left ribs. When significantly enlarged, percussion in the left upper quadrant will produce a dull tone. Splenomegaly suggested by percussion should then be verified by palpation (see below). The remainder of the normal abdomen is, for the most part, filled with the small and large intestines. Try percussing each of the four quadrants to get a sense of the normal variations in sound that are produced. These will be variably tympanitic, dull or some combination of the above, depending on whether the underlying intestines are gas or liquid filled. The stomach "bubble" should produce a very tympanitic sound upon percussion over the left lower rib cage, close to the sternum.

Percussion can be quite helpful in determining the cause of abdominal distention, particularly in distinguishing between fluid (a.k.a. ascites) and gas. Of the techniques used to detect ascites, assessment for shifting dullness is perhaps the most reliable and reproducible. This method depends on the fact that air filled intestines will float on top of any fluid that is present. Proceed as follows:

  1. With the patient supine, begin percussion at the level of the umbilicus and proceed down laterally. In the presence of ascites, you will reach a point where the sound changes from tympanitic to dull. This is the intestine-fluid interface and should be roughly equidistant from the umbillicus on the right and left sides as the fluid layers out in a gravity-dependent fashion, distributing evenly across the posterior aspect of the abdomen. It should also cause a symmetric bulging of the patient's flanks.
  2. Mark this point on both the right and left sides of the abdomen and then have the patient roll into a lateral decubitus position (i.e. onto either their right or left sides).
  3. Repeat percussion, beginning at the top of the patient's now up-turned side and moving down towards the umbilicus. If there is ascites, fluid will flow to the most dependent portion of the abdomen. The place at which sound changes from tympanitic to dull will therefore have shifted upwards (towards the umbillicus) and be above the line which you drew previously. Speed percussion (described above) may also be used to identify the location of the air-fluid interface. If the distention is not caused by fluid (e.g. secondary to obesity or gas alone), no shifting will be identifiable.

Shifting Dullness

Realize that there has to be a lot of ascites present for this method to be successful as the abdomen and pelvis can hide several hundred cc's of fluid that would be undetectable on physical exam. Also, shifting dullness is based on the assumption that fluid can flow freely throughout the abdomen. Thus, in cases of prior surgery or infection with resultant adhesion formation, this may not be a very useful technique. Palpation can also be used to check for ascites (see below).

Palpation: First warm your hands by rubbing them together before placing them on the patient. The pads and tips (the most sensitive areas) of the index, middle, and ring fingers are the examining surfaces used to locate the edges of the liver and spleen as well as the deeper structures. You may use either your right hand alone or both hands, with the left resting on top of the right. Apply slow, steady pressure, avoiding any rapid/sharp movements that are likely to startle the patient or cause discomfort. Examine each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel.

  1. Start in the right upper quadrant, 10 centimeters below the rib margin in the mid-clavicular line. This should insure that you are below the liver edge. In general, it is easier to detect abnormal if you start in an area that you're sure is normal. Gently push down (posterior) and towards the patient's head with your hand oriented roughly parallel to the rectus muscle, allowing the greatest number of fingers to be involved in the exam as you try to feel the edge of the liver. Advance your hands a few cm cephelad and repeat until ultimately you are at the bottom margin of the ribs. Initial palpation is done lightly.

Abdominal Palpation

  1. Following this, repeat the examination of the same region but push a bit more firmly so that you are interrogating the deeper aspects of the right upper quadrant, particularly if the patient has a lot of subcutaneous fat. Pushing up and in while the patient takes a deep breath may make it easier to feel the liver edge as the downward movement of the diaphragm will bring the liver towards your hand. The tip of the xyphoid process, the bony structure at the bottom end of the sternum, may be directed outward or inward and can be mistaken for an abdominal mass. You should be able to distinguish it by noting its location relative to the rib cage (i.e. in the mid-line where the right and left sides meet).

Rib Cage

  1. You can also try to "hook" the edge of the liver with your fingers. To utilize this technique, flex the tips of the fingers of your right hand (claw-like). Then push down in the right upper quadrant and pull upwards (towards the patient's head) as you try to rake-up on the edge of the liver. This is a nice way of confirming the presence of a palpable liver edge felt during conventional examination.

Hooking Edge of the Liver

  1. Place your right hand at the inferior and lateral border of the ribs, pushing down as you push up from behind with your left hand. If the right kidney is massively enlarged, you may be able to feel it between your hands.
  2. Now examine the left upper quadrant. The normal spleen in not palpable. When enlarged, it tends to grow towards the pelvis and the umbilicus (i.e. both down and across). Begin palpating near the belly button and move slowly towards the ribs. Examine superficially and then more deeply. Then start 8-10 cm below the rib margin and move upwards. In this way, you will be able to feel enlargement in either direction. You can use your left hand to push in from the patient's left flank, directing an enlarged spleen towards your right hand. If the spleen is very big, you may even be able to "bounce" it back and forth between your hands. Splenomegaly is probably more difficult to appreciate then hepatomegaly. The liver is bordered by the diaphragm and can't move away from an examining hand. The spleen, on the other hand, is not so definitively bordered and thus has a tendency to float away from you as you palpate. So, examine in a slow, gentle fashion. The edge, when palpable, is soft, rounded, and rather superficial. Repeat the exam with the patient turned onto their right side, which will drop the spleen down towards your examining hand.
  3. Exploration for the left kidney is performed in the same fashion as described for the right. Kidney pain, most commonly associated with infection, can be elicited on direct examination if the entire structure becomes palpable as a result of associated edema. This is generally not the case. However, as the kidney lies in the retroperitoneum, pounding gently with the bottom of your fist on the costo-vertebral angle (i.e. where the bottom-most ribs articulate with the vertebral column) will cause pain if the underlying kidney is inflamed. Known as costo-vertebral angle tenderness (CVAT), it should be pursued when the patient's history is suggestive of a kidney infection (e.g. fever, back pain and urinary tract symptoms).

Posterior

View: Location of the Kidneys


Gross Retroperitoneum Anatomy

  1. Examine the left and right lower quadrants, palpating first superficially and then deeper. A stool filled sigmoid colon or cecum are the most commonly identified structures on the left and right side respectively. The smooth dome of the bladder may rise above the pelvic brim and become palpable in the mid-line, though it needs to be quite full of urine for this to occur. Other pelvic organs can also occasionally be identified, most commonly the pregnant uterus, which is a firm structure that grows up and towards the umbillicus. The ovaries and fallopian tubes are not identifiable unless pathologically enlarged.
  2. Finally, try to feel the abdominal aorta. First push down with a single hand in the area just above the umbillicus. If you are able to identify this pulsating structure with one hand, try to estimate its size. To do this, orient your hands so that the thumbs are pointed towards the patient's head. Then push deeply and try to position them so that they are on either side of the blood vessel. Estimate the distance between the palms (it should be no greater then roughly 3 cm). This is, admittedly, a crude technique. Remember also that the aorta is a retorperitoneal structure and can be very hard to appreciate in obese patients. There have been no reports of anyone actually causing the aorta to rupture using this maneuver, so don't be afraid to push vigorously.

Vascular Anatomy

What can you expect to feel? In general, don't be discouraged if you are unable to identify anything. Remember that the body is designed to protect critically important organs (e.g. liver and spleen beneath the ribs; kidneys and pancreas deep in the retroperitoneum; etc.). It is, for the most part, during pathologic states that these organs become identifiable to the careful examiner. However, you will not be able to recognize abnormal until you become comfortable identifying variants of normal, a theme common to the examination of any part of the body. It is therefore important to practice all of these maneuvers on every patient that you examine. It's also quite easy to miss abnormalities if you rush or push too vigorously, so take your time and focus on the tips/pads of your fingers.

Examining for a fluid wave: When observation and/or percussion are suggestive of ascites, palpation can be used as a confirmatory test. Ask the patient or an observer to place their hand so that it is oriented longitudinally over the center of the abdomen. They should press firmly so that the subcutaneous tissue and fat do not jiggle. Place your right hand on the left side of the abdomen and your left hand opposite, so that both are equidistant from the umbillicus. Now, firmly tap on the abdomen with your right hand while your left remains against the abdominal wall. If there is a lot of ascites present, you may be able to feel a fluid wave (generated in the ascites by the tapping maneuver) strike against the abdominal wall under your left hand. This test is quite subjective and it can be difficult to say with assurance whether you have truly felt a wave-like impulse.

Assessing for a fluid wave

The abdominal examination, like all other aspects of the physical, is not done randomly. Every maneuver has a purpose. Think about what you're expecting to see, hear, or feel. Use information that you've gathered during earlier parts of the exam and apply it in a rational fashion to the rest of your evaluation. If, for example, a certain area of the abdomen was tympanitic during percussion, feel the same region and assure yourself that there is nothing solid in this location. Go back and repeat maneuvers to either confirm or refute your suspicions. In the event that a patient presents complaining of pain in any region of the abdomen, have them first localize the affected area, if possible with a single finger, pointing you towards the cause of the problem. Then, examine each of the other abdominal quadrants first before turning your attention to the area in question. This should help to keep the patient as relaxed as possible and limit voluntary and involuntary guarding (i.e. superficial muscle tightening which protects intra-abdominal organs from being poked), allowing you to gather the greatest amount of clinical data. Make sure you glance at the patient's face while examining a suspected tender area. This can be particularly revealing when evaluating otherwise stoic individuals (i.e. even these patients will grimace if the area is painful to the touch). The goal, of course, is to obtain relevant information while generating a minimal amount of discomfort.

Findings Commonly Associated With Advanced Liver Disease: Chronic liver disease usually results from years of inflamation, which ultimately leads to fibrosis and interference with function. The inflamatory response can be driven by a number of different processes, most commonly chronic alcohol use, viral hepatitis (B or C) or hemachromatosis (the complete list is much longer). After many years (generally greater then 20) of chronic insult, the liver may become unable to perform some or all of its normal functions. There are several clinical manifestations of this dysfunction. While none are pathonomonic for liver disease, in the right historical context they are very suggestive of underlying pathology. Some of the most common findings are described and/or pictured below.

  1. Hyperbilirubinemia: The diseased liver may be unable to conjugate or secrete bilirubin appropriately. This can lead to
    1. Icterus - Yellow discoloration of the sclera.
    2. Jaundice - Yellow discoloration of the skin.
    3. Bilirubinuria - Golden-brown coloration of the urine.
  2. Ascites: Portal vein hypertension results from increased resistance to blood flow through an inflamed and fibrotic liver. This can lead to ascites, accumulation of fluid in the peritoneal cavity.
  3. Increased Systemic Estrogen Levels: The liver may become unable to process particular hormones, leading to their peripheral conversion into estrogen. High levels promote:
    1. Breast development (gynecomastia).
    2. Spider Angiomata - dilated arterioles most often visible on the skin of the upper chest.
    3. Testicular atrophy.
  4. Lower Extremity Edema: Impaired synthesis of the protein alburmin leads to lower intravascular oncotic pressure and resultant leakage of fluid into soft tissues. This is particularly evident in the lower extremities.


Icterus

 

Ascites

 

Jaundice

 

 

Gynecomastia

 

Spider

 

 

 

 

 

Plan:

The initial goal in evaluating a patient with abdominal pain is to determine whether or not surgical treatment is indicated to prevent further morbidity.

A. The abdominal films can help differentiate between:


                                 Differentiating medical and surgical disorders

                                 The exploratory laparotomy

 


1. Several diagnoses can cause a surgical abdomen, the most life-threatening considerations are perforated or ruptured viscus, intraabdominal hemorrhage, and necrosis of a viscus, (e.g., necrosis of an intraabdominal viscus due to intussusception, volvulus, strangulated hernia, or ischemic colitis). Other specific conditions that may not cause an acute "surgical" abdomen should be considered: pancreatitis, intraabdominal abscess, peptic ulcer disease or gastritis, pyelonephritis, renal stones, infectious gastroenteritis, ovarian cyst, tumor and salpingitis.

2. Among the elderly and those on steroids, abdominal pain may be mild despite the presence of an acute abdomen. One should not underestimate the seriousness of mild abdominal pain in the elderly, especially if it is associated with acute confusion, fever, an elevated WBC or a metabolic acidemia.

B. Laboratory tests to consider are a CBC with a differential, amylase, liver function, urinalysis, and pregnancy test.

C. Flat and upright abdominal films. These films can be readily obtained and may provide important information. Observe for the following: gas pattern, evidence of bowel dilation, air-fluid levels, presence or absence of air in the rectum, pancreatic calcifications, biliary and renal calcifications, aortic calcifications, loss of psoas margin.

D. Observation. With the exception of those conditions that require urgent surgical exploration, most cases of abdominal pain can be initially managed with close observation, correction of any fluid or electrolyte disturbances, and judicious use of analgesics.

In general, any patient on a medical service developing acute abdominal pain should receive an evaluation by a general surgeon. In those cases in which mechanical obstruction is suspected or vomiting is present, nasogastric decompression should be initiated. Patients who appear in septic or circulatory shock should receive vigorous intravenous volume replacement, cultures, empiric antibiotics and be in an ICU setting.

 

 

 

 

 

 

 

 

 

 

Hereditary Angioedema: Abdominal attacks cause severe pain, nausea, vomiting, and watery diarrhea. Some patients require hospitalization for low blood pressure, dehydration, and pain management. As noted above, abdominal attacks can mimic a surgical abdomen and many patients have been subjected to unnecessary exploratory surgery.

 


Peritonitis

Infection

Usual Organisms

Therapy (Alternatives)

Spontaneous bacterial peritonitis (primary). 

Enterobacteriaecea   (includes  E.coli, serratia, klebsiella, enterobacter, citrobacter);  S. pneumo, enterococci, anaerobes (<1%)

Zosyn 3.375 grams IV every 6 hours or Timentin 3.1 grams ivpb every 6 hours  or Unasyn 3 grams IV every 6 hours  or Cefotaxime 2 grams  IV every 8 hours  or Ceftriaxone 2g ivpb q24h  or Ofloxacin 400mg IV q12h or Ciprofloxaxin 400mg IV q12h or  levofloxacin 500mg IV qd or Imipenem 500mg IV every 6 hours

"Secondary"  bowel perforation, ruptured appendix etc.

Enterobacteriaecea   (includes  E.coli, serratia, klebsiella, enterobacter, citrobacter);  S. pneumo, enterococci, bacteroides, pseudomonas.

Single drug therapy: Timentin 3.1 grams IV every 6 hours  or Unasyn 1.5 to 3 grams IV every 6 hours  or Zosyn 3.375 grams IV every 6 hours or  imipenem 500mg IV every 6 hours  or cefotetan 1-2 grams IV q12h. 

Combination therapy: [Cefotaxime 2 grams every 6 to 8 hours  or  ceftriaxone 2 grams IV once daily   or  piperacillin  3 to 4 grams IV every 6 hours  or  azactam 1-2 grams IV every 6 or 8 hours   or ciprofloxacin 400mg IV every 12 hours ]  Clindamycin 600mg ivpb every 6 to 8 hours  or  Flagyl 500mg ivpb every 6 to 8 hours.          Penicillin allergic patient: [Ciprofloxacin 400mg IV every 12 hours + Flagyl 500mg IV every 6 to 8 hours]   // or   [ Azactam  + Flagyl] 

Peritonitis is a common clinical problem that occurs in patients with end-stage renal disease treated by peritoneal dialysis (PD). Although the incidence of continuous ambulatory peritoneal dialysis (CAPD) peritonitis varies from center to center

1.        CLINICAL PRESENTATION

Diagnosis of Peritonitis in CAPD Patients: In patients with cloudy fluid and/or abdominal pain and/or fever, a sample of the dialysate effluent should be obtained for laboratory evaluation, including a cell count with differential, Gram stain, and culture. An elevated dialysate cell count of white blood cells (WBC) > 100/mm3, of which at least 50% are polymorphonuclear neutrophils (PMN), is supportive of the diagnosis of peritonitis and calls for immediate initiation of therapy. In asymptomatic patients with only cloudy fluid, it is reasonable to delay initiation of therapy until the results of the cell count and differential and Gram stain are available, as long as these studies can be performed expeditiously (i.e., within 2 to 3 hours). If there is no increase in the peritoneal WBC count, the differential does not show a predominance of PMN, and no bacteria are seen on Gram stain, immediate therapy is not indicated. Similarly, if >10% of peritoneal leukocytes are eosinophils and the Gram stain is negative, immediate antimicrobial therapy is usually unnecessary. Patients with cloudy fluid accompanied by abdominal pain and/or fever require prompt initiation of empiric therapy that should be delayed no more than one hour for cell count, differential, and Gram stain results. Neither the differential nor the magnitude of the WBC elevation has been shown to be helpful in predicting the causative organism. A Gram stain is positive in 9% to 40% of peritonitis episodes, and, when positive, is predictive of eventual culture results in approximately 85% of cases. A Gram stain is particularly useful in the early recognition of fungal peritonitis. Culture of dialysate effluent should always be performed prior to initiation of therapy, but treatment should not be delayed while waiting for culture results.

Diagnosis of Peritonitis in APD Patients: Patients on various forms of APD require a modified approach to diagnosis and treatment of peritonitis. These patients receive a period of consecutive, relatively short exchanges during the night and may have only a partial exchange or a dry abdomen during the day. Peritonitis diagnostic criteria were established based on clinical experience with CAPD patients whose dwell times are 4 ­ 6 hours long. Concerns have been raised that the shorter dwell times of APD patients with suspected peritonitis could result in misleadingly low dialysate cell counts and falsely negative cultures. In pediatric patients, 70% of whom are treated with APD, this has not been the case. For more than a decade, CAPD peritonitis diagnostic and treatment criteria and methods have been successfully applied to the management of pediatric patients receiving APD, with only minor modifications (see Kuizon et al., 1995). The following recommendations are based on this pediatric experience, and may prove useful in the management of adults on APD. Data on peritonitis diagnosis and treatment in adults on APD are not available. Cloudy fluid remains the hallmark of peritonitis in APD-treated patients. Occasionally, the initial drain of the "stagnant" fluid that has been present in the abdomen all day in patients with only partial or dry daytime exchanges will appear cloudy in the absence of peritonitis. The WBC may exceed 100/mm3, but mononuclear cells will predominate. More important, dialysate rapidly clears with initiation of peritoneal dialysis. If cloudy fluid and/or abdominal pain and/or fever is/are observed at any point in the daily APD treatment cycle, a sample of dialysate effluent should be obtained for cell count and differential, Gram stain, and culture, as with CAPD patients. If the fluid is very turbid, the initial sample is sufficient for study, regardless of the length of the dwell time that produced it. In equivocal cases, or in patients with systemic or abdominal symptoms in whom dialysate appears to be clear, a second exchange is performed with a dwell time of at least one hour. Longer exchanges, approximating the four- to six-hour exchanges of CAPD, have not been necessary to establish the diagnosis of peritonitis in pediatric APD patients. Using this technique, the incidence of culture-negative peritonitis has remained approximately 20%, similar to that reported in pediatric CAPD patients.

Diagnosis of Peritonitis in Pediatric Patients: The clinical presentation of peritonitis in pediatric patients is similar to that in adult patients, with cloudy fluid the predominant initial finding (see Fine et al., 1983; Warady et al., 1984; and Watson et al., 1986). Fever is common in infants and young children with peritonitis; occasionally a febrile child will have clear dialysate effluent, only to have the following drained exchange appear cloudy. Infants may become anorexic or vomit during the early stages of developing peritonitis, but this is usually only appreciated in retrospect.

As with adults, pediatric patients with suspected peritonitis, including all febrile pediatric patients, should have cell count with differential, Gram stain, and culture performed on dialysate. In addition, febrile infants 24 months of age with apparent peritonitis should have a peripheral blood culture obtained; infants appear to be less capable of keeping bacterial infections sequestered within the peritoneal cavity than older patients, and a positive blood culture will dictate more extensive therapy. Although early reports suggested that a peritoneal WBC count of 50/mm3 was sufficient to support the diagnosis of peritonitis in children, common practice now is to require the same supportive laboratory criteria as are used in adult patients.

 

Pasteurella multocida Peritonitis

A 62-year-old man with Laennec's cirrhosis presented to Janeway Medical Service with fever and abdominal pain. On physical exam, he had tense ascites (Figure 8).

Figure 8

He underwent a paracentesis which revealed orange-colored, cloudy, thick fluid (Figure 9). Laboratory analysis of the ascitic fluid revealed several thousands polymorphonuclear neutrophils with gram-negative coccobacilli seen on gram stain. Cultures of the ascitic fluid and of blood later grew Pasteurella multocida.

Figure 9

Pasteurella multocida is a common inhabitant of many health animals including cats, where carrier rates of up to 90% have been documented. According to published case reports, cloudy orange fluid, as seen in this case, is characteristic of Pasteurella spontaneous bacterial peritonitis. The organism is usually sensitive to penicillin and cephalosporins as well as fluoroquinolones which may be used for spontaneous bacterial peritonitis prophylaxis. Upon further questioning, this gentleman did admit to exposure to cats in his home.

This Image of Osler shows Pasteurella multocida peritonitis.

Presented by the Janeway Firm: Steven Mast, MD, Assistant Chief of Service, 1997-98.

Figure 1 - Layers of the abdominal wall, inguinal canal and their relations to the spermatic cord and testies. © C. Salici

Figure 2 - Anatomy of the inguinal canal and relationship to the pelvic bone. © C. Salici

Nobody should be able to examine an abdomen better than a general surgeon," remarked a program director to his residents. In spite of tremendous advances in diagnostic technologies, physical examination remains the most important tool surgeons possess for assessing the acute abdomen, injured or otherwise. In this era in which homeland security threats are a reality and any community hospital can turn into a ground zero facility receiving mass casualties, it is imperative that all general surgeons be up to date with the most effective and reliable methods of assessing the acutely injured abdomen.

Penetrating Abdominal Trauma (PAT)

Basic to a discussion of PAT are the 3 main anatomic areas of the abdomen: (1) anterior abdomen, (2) thoraco-abdomen, and (3) flank/back. The anatomical limits and special considerations are outlined in Table 1.

Table 1. Anatomical Divisions of the Abdomen to Consider in the Assessment of PAT

Area

Anatomical Limits

Special Considerations

Anterior abdomen

Costal margins to the groin creases and laterally to the anterior axillary lines

Highest likelihood of requiring laparotomy, especially if there is significant evisceration

Thoraco-abdomen

4th intercostal space anteriorly and 7th intercostal space posteriorly down to costal margins

Need for operative intervention in specialized circumstances

Flank/back

Iliac crests to tip of scapula, laterally to anterior axillary line on either side

Large muscles protect this area, especially against stab wounds

Over the years, we have learned that "Everyone with a hole in the abdomen doesn't need a laparotomy" and that even the negative laparotomy has significant associated morbidity.[1] A recent study suggested that the incidence of negative or nontherapeutic laparotomy is 15% to 30%, and the complication rate is as high as 41%.[2] Complications include atelectasis, hypertension, pleural effusion, pneumothorax, and ileus, as well as long-term complications such as small bowel obstruction secondary to adhesions. Overall, up to 30% of stab wounds lack kinetic energy and do not penetrate the abdominal cavity. This percentage is even higher in obese victims. One center has reported managing up to 29% of abdominal gun shot wound victims nonoperatively.[3] Again, in obese patients, the bullet may violate only superficial tissues, mimicking signs of local peritonitis. The trick is to determine who needs to go to the operating room (OR) emergently,[4] and then to select the appropriate diagnostic tests for patients that don't. Indications for emergent laparotomy in patients with PAT are:

The following diagnostic modalities may be used in hemodynamically stable patients who do not meet the above criteria:

Serial physical exams are optimally performed by the same individual at 6-hour intervals over a 24-hour period for injuries of the anterior abdomen and over a 36-hour period for injuries of the back/flank.[5] In the non-intoxicated or nondrugged patient, a false-negative rate of </= 5% and a negative laparotomy rate of 2.5% have been reported.

Local wound exploration is optimally performed on the patient who is nonobese and cooperative. If the fascia is penetrated, then in the appropriate circumstances a diagnostic peritoneal lavage (DPL) should be performed.[6] However, the abdominal wound may hemorrhage into the peritoneum, increasing the false-positive rate.

Computerized tomography (CT) scan with triple contrast (oral, intravenous, and rectal) is highly accurate as most organs, including the hollow viscus, can be well evaluated.[7]

Diagnostic laparoscopy was used to evaluate 40 patients; 20 were found to be normal, obviating the need for further surgery, 10 had a hemoperitoneum and nontherapeutic laparotomy, and 10 had therapeutic laparotomy.[8] As the skills and instruments of laparoscopic surgeons continue to improve, it may be assumed that this technique will be more frequently used.[9,10] However, the cost of laparoscopy may be prohibitive. An early study showed that the cost of a diagnostic laparoscopy equaled the cost of a 4-day hospital stay in a patient with a negative laparotomy.[11]

Surgeon-performed focused abdominal sonogram for trauma (FAST)[12] is increasing, even for penetrating thoracic[13] and cardiac trauma.[14] In certain circumstances it is intuitively reliable. For example, the patient with a small stab wound in the right upper quadrant but with no fluid in Morrison's pouch on FAST suggests no or minimal hepatic trauma. Conversely, significant fluid in Morrison's pouch indicates a greater degree of hepatic injury and the need for further evaluation and intervention.

Specific considerations for management of hemodynamically stable patients with abdominal injuries due to PAT are outlined in Table 2.

Table 2. Management of Stab and Gunshot Wounds to the Abdomen

Type of Injury

Type of Wound

Assessment/Intervention

Right thoraco-abdominal
(The liver is the major organ of concern.)

Stab and gunshot

Serial abdominal exams

CT scan with contrast; if positive blush, then angiogram and embolization if required

Generally, management of handgun injuries confined to the liver is similar to that of blunt liver trauma.

Left thoraco-abdominal
(The esophagus, stomach, transverse colon, and diaphragm are the areas of concern.)

Stab and gunshot

Due to the organs involved, intervention is more frequent.

If FAST results are positive, then proceed to laparotomy.

Anterior abdominal
(The hollow viscus, mesentery, and omentum are the areas of concern.)

Stab

Positive FAST* -- serial abdominal exams

Negative FAST* -- local wound exploration

Gunshot

Positive FAST* -- exploratory laparotomy vs diagnostic laparoscopy

Negative FAST* -- serial abdominal exams

If patient has concomitant hematuria, a CT scan with cystogram is recommended.

Back/flank
(The spinal column, great vessels, kidneys, and retroperitoneum are the areas of concern.)

Stab and gunshot

Serial abdominal exams for at least 36 hours or triple-contrast CT scan. If results are positive, perform laparotomy; if negative, do serial abdominal exams. (Longer observation period required)

*FAST is unreliable in very obese patients; therefore, perform diagnostic peritoneal lavage.

Take-home Messages

Blunt Abdominal Trauma (BAT)

Historically, the mix of trauma patients at most centers is two thirds BAT and one third PAT, and the relative predominance of BAT is increasing.[15] Data from Westchester Medical Center in New York show a 4:1 ratio of BAT to PAT.[16] BAT may be even more predominant in community hospitals and in children. Motor vehicle accidents are the most common cause of BAT. With improving availability and ability of interventional radiology techniques, nonoperative management has become a more successful option for the patient with BAT.

After basic Advanced Trauma Life Support protocols have been instituted, the algorithm in Figure 1 is recommended as a basis for assessment of BAT. Timing is of the essence, and thus, patients need to proceed through this algorithm in an "ICU on Wheels" setting. One must remain flexible in its usage. For example, in a patient with a serious open pelvic fracture and hypotension, it would make sense to rule out intra-abdominal injury using FAST, externally fixate the pelvis in the trauma bay or OR, and then proceed to angiogram/embolization.

Figure 1. Algorithm for assessing BAT
*Where indicated.

FAST is an excellent screening tool to identify the presence (or absence) of fluid in the abdomen, which aids in determining patient disposition.[17] An unresponsive patient with a positive FAST should go to the OR. A stable patient (ie, patient responds to resuscitation without hypotension or significant tachycardia) may be taken for a CT scan to determine the extent of organ damage. This approach prevents unnecessary operations for organ injuries that can be safely managed nonoperatively.

FAST does have its limitations, however. Patients with pelvic fractures, spine fractures, or lower chest injuries (even rib fractures) need additional testing, as these injuries increase the false-negative rate for FAST.[18] A recent international consensus conference recommended the following interventions based on FAST[19]:

Hepatic and Splenic BAT

Over the years, the CT scan has dramatically improved our ability to safely practice nonoperative management, especially in patients with splenic and hepatic trauma. However, CT images only provide a snapshot of how structures appeared at the exact moment of the scan, and it must be appreciated that as the resuscitation proceeds, the intra-abdominal situation may change.

Nonoperative management of splenic trauma has been well evaluated. Most recently it has been shown in a multi-institutional study that patients with injuries classified as grade 3 or higher with hemoperitoneum had the highest failure rate of nonoperative management, about 11%.[20]

Angio-embolization is an excellent therapeutic option for splenic injuries.[21] Recent data suggest that contrast extravasation on the initial CT scan is the best predictor of a positive angiogram and need for embolization.[22] Patients who benefit most from splenic angio-embolization are those with grade 2 and 3 injuries.[23] The highest failure rate (about 40%) is in patients with an arteriovenous fistula.[24] Few centers actually practice selective embolization of the more distal splenic vessels. According to Thomas Scalea, MD, FACS, at the R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, this technique is performed at his institution only if there are 3 or fewer injuries to the spleen. Most centers practice proximal coiling of the main splenic artery. The long-term effects of this approach are not known, but it is thought that a spleen with 30% functional mass can provide adequate immunologic function and that the spleen can remain viable via collateral circulation. However, the counterargument is that occlusion of the splenic artery prevents the spleen from acting as a filter for encapsulated bacteria.

Given this argument, the panel had no consensus on whether to immunize patients who have had proximal splenic artery coiling. They did, however, agree on the need for operative intervention if the patient needed more than 2 units of blood transfusion without associated injuries.

Repeating a CT scan prior to discharge from the hospital is also recommended, as vasospasm at the time of injury may mislead the surgeon to underestimate the extent of splenic injury. In positive cases, a "second look" angiogram may be indicated.[25]

Applying the same arguments to BAT to the liver, it is known that angiogram[26] followed by selective embolization has good results, especially in grade 3-4 hepatic injuries.[27] There are also data to support attempting to angio-embolize the liver before operating on devastating liver injuries to prevent excessive exsanguination.[28] Similarly, angio-embolization also has a role as an adjunct to laparotomy in controlling persistent exsanguination after bringing the patient out of the OR.[29]

Take-home Messages

Mass Casualty Situations

According to the current definition of a disaster, the catastrophic event has a cultural effect on the target population; in other words, ordinary people are required to work and respond to extraordinary circumstances.[30] Surgeons, by virtue of their training and the nature of their work (eg, during a trauma resuscitation), are frequently required to act in similar circumstances, albeit for brief periods of time. Recent data suggest that physicians and nurses react differently than administrators and planners in the event of an acute calamity.[31] Surgeons play an important role, not only in managing victims of such tragedies, but also in disaster preparedness.

Some important concepts that may help us better understand and prepare for such situations are:

Mass casualty -- number of injured persons overwhelms existing resources to care for them. The 9/11 attack on the World Trade Center changed the world as we know it, but did not produce mass casualties.

Over-triage -- minimally injured patients are transferred to trauma centers, taxing resources that could be better spent on the critically wounded.

Critical mortality rate --

(Nonsalvageable patients transferred to expectant care are excluded in this equation.)

Such events can produce large numbers of "walking wounded" who require minimal medical attention. The severely injured victims most likely suffer polytrauma, and isolated abdominal trauma is rare. Incidence of abdominal trauma among hospitalized victims of the 9/11 attacks was only 6%[32]; similarly, the bombing at the Centennial Olympic Games in Atlanta, Georgia, yielded few significant intra-abdominal injuries.[33] On the basis of their experiences with the above tragedies, the presenters suggested the following methods for evaluating and managing patients:

Surgeons in charge - At Bellevue Hospital on 9/11, a surgical attending was physically present and in command of the following areas: triage, emergency department (ED) resuscitation area, OR, intensive care units, and general care areas.

Maintain a log book - At Grady Memorial Hospital during the Centennial Olympic Games bombing, a log of all severely injured patients was kept by the surgical triage officer to track patients and monitor resource utilization.[34]

Surgeon's exam - Of the approximately 200 victims admitted to the Bellevue Hospital ED on 9/11, two thirds were admitted to the medical side. Each of these patients received an abdominal physical exam by a surgical chief resident, and no abdominal injuries were missed.

Optimal use of abdominal injury screening tools -- A quick, surgeon-performed right upper quadrant ultrasound can be performed to rapidly evaluate the abdomen.[35] Similarly, simple kits (eg, scalpel, 2 retractors and pickups) may be assembled and utilized to perform rapid DPL, thus preventing unnecessary CT scanning, which can be reserved for evaluation of patients with traumatic brain injury.

Strategies to effectively deal with potential mass casualty situations nationwide are as follows:

Take-home Messages