Comprehensive Educational information on Computer Programming!: Acute Abdomen

Wednesday, January 23, 2019

Acute Abdomen


Acute, Catastrophic Abdominal Pain
Intense abdominal pain of acute onset or pain associated with syncope,hypotension,
or toxic appearance necessitates rapid yet orderly evaluation. Consider
obstruction,perforation, or rupture of hollow viscus; dissection or rupture of
major blood vessels (esp. aortic aneurysm); ulceration; abdominal sepsis; ketoacidosis; and adrenal crisis.

Brief History and Physical Examination Historic features of importance
include age; time of onset of the pain; activity of the pt when the pain began;
location and character of the pain; radiation to other sites; presence of nausea,
vomiting,or anorexia; temporal changes; changes in bowel habits; and menstrual
history. Physical exam should focus on the pt’s overall appearance [writhing
in pain (ureteral lithiasis) vs. still (peritonitis,perforation)], position (a pt leaning forward may have pancreatitis or gastric perforation into the lesser sac),
presence of fever or hypothermia, hyperventilation,cyanosis,bowel sounds,
direct or rebound abdominal tenderness,pulsating abdominal mass, abdominal
bruits,ascites, rectal blood,rectal or pelvic tenderness, and evidence of coagulopathy.

Useful laboratory studies include hematocrit (may be normal with
acute hemorrhage or misleadingly high with dehydration),WBC with differential
count,arterial blood gases, serum electrolytes, BUN, creatinine, glucose,
lipase or amylase,and UA. Females of reproductive age should have a pregnancy
test. Radiologic studies should include supine and upright abdominal
films (left lateral decubitus view if upright unobtainable) to evaluate bowel
caliber and presence of free peritoneal air,cross-table lateral film to assess aortic
diameter; CT (when available) to detect evidence of bowel perforation,inflammation, solid organ infarction, retroperitoneal bleeding, abscess, or tumor. Abdominal paracentesis (or peritoneal lavage in cases of trauma) can detect evidence of bleeding or peritonitis. Abdominal ultrasound (when available) reveals evidence of abscess,cholecystitis, biliary or ureteral obstruction, or hematoma and is used to determine aortic diameter.

Diagnostic Strategies The initial decision point is based on whether the
pt is hemodynamically stable. If not,one must suspect a vascular catastrophe
such as a leaking abdominal aortic aneurysm. Such pts receive limited resuscitation
and move immediately to surgical exploration. If the pt is hemodynamically
stable,the next decision point is whether the abdomen is rigid. Rigid
abdomens are most often due to perforation or obstruction. The diagnosis can
generally be made by a chest and plain abdominal radiograph.
If the abdomen is not rigid,the causes may be grouped based on whether
the pain is poorly localized or well localized. In the presence of poorly localized
pain,one should assess whether an aortic aneurysm is possible. If so, a CT scan
can make the diagnosis; if not,early appendicitis, early obstruction, mesenteric
ischemia,inflammatory bowel disease, pancreatitis, and metabolic problems are
all in the differential diagnosis.
Pain localized to the epigastrium may be of cardiac origin,esophageal inflammation or perforation,gastritis,peptic ulcer disease, biliary colic or cholecystitis, and pancreatitis. Pain localized to the right upper quadrant includes
those same entities plus pyelonephritis or nephrolithiasis,hepatic abscess, subdiaphragmatic absess,pulmonary embolus,or pneumonia or be of musculoskeletal origin. Additional considerations with left upper quadrant localization are infarcted or ruptured spleen,splenomegaly, and gastric or peptic ulcer.

Right lower quadrant pain may be from appendicitis,Meckel’s diverticulum, Crohn’s disease, diverticulitis,mesenteric adenitis,rectus sheath hematoma, psoas abscess, ovarian abscess or torsion, ectopic pregnancy,salpingitis,familial fever
syndromes,uterolithiasis,herpes zoster. Left lower quadrant pain may be due
to diverticulitis,perforated neoplasm, and other entities previously mentioned.

TREATMENT
Intravenous fluids,correction of life-threatening acid-base disturbances, and
assessment of need for emergent surgery are the first priority; careful followup
with frequent reexamination (when possible,by the same examiner) is
essential. The use of narcotic analgesia is controversial. Traditionally,narcotic
analgesics were withheld pending establishment of diagnosis and therapeutic
plan,since masking of diagnostic signs may delay needed intervention. However,
evidence that narcotics actually mask a diagnosis is sparse.

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