acute-abdomen.ppt

Acute Abdomenn nGeneral name for presence of signs,symptoms of inflammation of peritoneum(abdominal lining)n nAny sudden spontaneous nontraumatic disorder whose chief manifestation is an acute attack of abdominal pain and for which urgent operation may be necessary.nThe acute abdomen refers to the clinical situation in which an acute change in the condition of the intraabdominal organs,usually related to inflammation or infection,demands immediate and accurate diagnosis.The Acute Abdomenn nAbdominal pain is one of the most frequent reasons to Abdominal pain is one of the most frequent reasons to visit physician offices and emergency roomsvisit physician offices and emergency roomsn nMost patients are found to have self limited conditionsMost patients are found to have self limited conditionsn nA subset of patients harbor serious A subset of patients harbor serious intraabdominalintraabdominal disease that requires urgent surgical disease that requires urgent surgical or or medical medical interventioninterventionAcute Abdomenn nIn your textbook(Lawrence W.Way)Page 362 table 31-1 show different causes of acute abdomen.The Acute Abdomenn nEarly diagnosis is the key to improving outcomesEarly diagnosis is the key to improving outcomesn nAn accurate history and complete physical examination An accurate history and complete physical examination are more important than any diagnostic testare more important than any diagnostic testn nThe history should be obtained with the abdomen bare,The history should be obtained with the abdomen bare,with attention to how the patient positions himself and with attention to how the patient positions himself and movesmovesAnatomic Landmarksn nDivided in quadrants Divided in quadrants n nRUQ,LUQ,RLQ,LLQRUQ,LUQ,RLQ,LLQn nAnatomic:Anatomic:n nEpigastriumEpigastrium上腹部上腹部n nUmbilicalUmbilical脐部脐部n nHypogastriumHypogastrium腹下部腹下部Nine regions&Projectionspleenstomachgallbladdertransverse colonascending colonsmall intestinesigmoid colonurinary bladderileumAbdominal Painn nAcute abdominal pain is the hallmark of an acute abdomenn nIt may originate from any organ in the abdominal cavityn nUnderstanding the mechanisms of pain production and the physiology of pain perception allow for more accurate diagnosesTow Kinds of Abdominal Painn nVisceral pain is caused by distension(扩张),inflammation or ischemia(局部缺血)in hollow viscous and solid organs.n nParietal pain(体腔壁痛)is localized to the dermatome above the site of stimulus and is initially unilateral(片面的).Abdominal Painn nPain may be visceral,somatic or referredn nVisceral pain is characterized by dullness,poor localization,cramping,burning or gnawingn nVisceral pain is mediated by autonomic(sympathetic and parasympathetic)nervesn nThe location of the pain corresponds to the dermatomes of the organs involvedAbdominal Painn nSensory Sensory neuroreceptorsneuroreceptors for visceral pain are located in for visceral pain are located in the mucosa or the mucosa or muscularismuscularis of hollow viscera,on the of hollow viscera,on the visceral peritoneum and within the mesenteryvisceral peritoneum and within the mesenteryn nThese receptors respond to mechanical and chemical These receptors respond to mechanical and chemical stimulistimulin nStretch is the primary mechanical signal for painStretch is the primary mechanical signal for painAbdominal Painn nThe parietal peritoneum has an entirely somatic The parietal peritoneum has an entirely somatic innervationinnervationn nSomatic pain is more intense and well localizedSomatic pain is more intense and well localizedn nSomatic Somatic innervationinnervation is mediated by the spinal nerves is mediated by the spinal nervesn nA transition from visceral to somatic pain indicates A transition from visceral to somatic pain indicates extension of the underlying processextension of the underlying processPainn nReferred pain(Referred pain(牵涉性痛)produces symptoms,but not produces symptoms,but not signs.signs.(Take(Take cholecystitis for for example,Referred pain in the example,Referred pain in the right right shoulder and back)n nUsually lateralized(Usually lateralized(单侧性的单侧性的)n nPatterns of pain are based on Patterns of pain are based on embryologic sharing of embryologic sharing of dermatomesdermatomesAbdominal Painn nReferred pain is perceived as pain distant from the Referred pain is perceived as pain distant from the involved organinvolved organn nIt is due to a convergence of visceral afferent neurons It is due to a convergence of visceral afferent neurons with somatic afferent neurons from different anatomic with somatic afferent neurons from different anatomic regionsregionsn nReferred pain is well localizedReferred pain is well localizedMultiple Faces of Painn nPain can be characterized as:Pain can be characterized as:n nSharp Sharp 急剧的急剧的n nStabbing Stabbing 刺穿的刺穿的n nBurningBurningn nHeavyHeavyn nDiffuse Diffuse 弥散弥散n nDull Dull 钝的钝的Diagnosisn nHistoryHistoryCharacterization of painCharacterization of pain Location?Duration Location?Duration 持续时间?Other symptomsOther symptoms Nausea,vomiting?Bloody?Nausea,vomiting?Bloody?Age and SexAge and Sex 1.newborns,infants,children,adults,elderly.1.newborns,infants,children,adults,elderly.2.female and male.2.female and male.gynecology gynecology妇科妇科obstetricsobstetrics产科产科 urologyurology泌尿科泌尿科Abdominal Examinationinspection,auscultation,palpation,percussionInspection望诊n nDescription of Description of abdominal abdominal habitushabitus体型体型n nscaphoidscaphoid舟状的舟状的,n nFlatFlatn nRotundRotund圆的圆的n nScarsScars伤疤伤疤,wounds,wounds,erythemaerythema红斑红斑n nAnatomic ConfinesAnatomic Confines Generally we couldnt find gastrointestinal pattern and peristalsis in normal people.Gastrointestinal obstruction：gastral pattern intestinal pattern peristalsisSmall bowel obstruction colon obstructionAuscultation听诊n nListen with stethoscopeListen with stethoscope听诊器n nNot necessary in all quadrantsNot necessary in all quadrantsnbowel sound,borborygmus 肠肠鸣音鸣音 normal:4-5 times/minnormal:4-5 times/minn nQuantitativeQuantitativen nAbsentAbsentn nDecreasedDecreasedn nHyperactiveHyperactive活动过强的n nQualitativeQualitativen nNormalNormaln nGGurgling soundurgling sound气过水声气过水声n nBell soundBell sound金属音金属音n nObstructiveObstructiven nBruitsBruitsPercussion叩诊n nAbdomen Abdomen n nTympaniticTympanitic气鼓的 gasgasn nDull fluidDull fluidn nLiver SpanLiver Spann nmid clavicular line by mid clavicular line by conventionconventionn nBladder,UterusBladder,Uterus子宫n nRising out of the pelvisRising out of the pelvisn nPercussion is also a very Percussion is also a very sensitive sign of sensitive sign of peritonitisperitonitisPalpationl lPrepare the patientPrepare the patientn nwarn themwarn themn nmake them comfortablemake them comfortablen ntake tension off the abdominal walltake tension off the abdominal walln nPillow or bend the kneesPillow or bend the kneesn nExpose the entire abdomenExpose the entire abdomenn nXiphoidXiphoid 剑突 to pubis to pubis 耻骨Palpationn nNote the patients attitude Note the patients attitude n n(physically and(physically and emotionally)emotionally)n nWatch their eyes as you touch Watch their eyes as you touch themthemn nAfter percussion:After percussion:n nSoftly at firstSoftly at firstn nDeeperDeepern nLUQ(LUQ(leftleft upper quadrant)upper quadrant)-RUQ(RUQ(right upper quadrant)right upper quadrant)note liver edgenote liver edgen nThen LLQ Then LLQ left lower left lower quadrantquadrant-RUQ-RUQ right right lower quadranttenderness压痛压痛,rebound tenderness反跳痛反跳痛muscular tension肌紧张肌紧张rigidity（board-like rigidity）Sign of Sign of acute diffuse peritonitis tenderness rebound tendernesstenderness rebound tenderness1.Gastritis or gastric ulcerGastritis or gastric ulcer2.Duodenal ulcer2.Duodenal ulcer3.3.PancreatitisPancreatitis or tumor or tumor4.4.CholecystitisCholecystitis cholelithiaisischolelithiaisis5.appendicitis5.appendicitis6.Disease of intestine6.Disease of intestine7.Disease of urinary bladder,uterus7.Disease of urinary bladder,uterus8.8.IleocecalIleocecal junction junction9.sigmoid9.sigmoid10.spleen,splenic flexure of colon10.spleen,splenic flexure of colon11.liver,hepatic flexure of colon11.liver,hepatic flexure of colon12.pancreatitis12.pancreatitisant.Sup.spineMcBurney pointTenderness Point of nephric duct and Kidneyhypochondriummiddle nephric duct pointCosta-carinal point肋腰点肋腰点Upper nephric duct pointventral aspect Back sideCosta-lumbar pointArea of Abdominal Auscultationliverpancreasespleengurgling soundabdominal aortaarteria renalisBowel SoundAuscultation of bowel sounds can provide information about the Auscultation of bowel sounds can provide information about the motion of air and liquid in the gastrointestinal tract.motion of air and liquid in the gastrointestinal tract.Normal 4-5/min Active 10/min Hyperactive mechanic intestine obstruction Hypoactive Absent paralytic intestine obstructionLaboratory Studiesn nComplete blood count Complete blood count 全血细胞计数全血细胞计数n nUrinalysisUrinalysis尿检验尿检验n nSerum amylaseSerum amylase血清淀粉酶血清淀粉酶n nLiver function studiesLiver function studiesn nHCG(HCG(human human chorionicchorionic gonadotrophingonadotrophin)人绒毛膜促性腺激素人绒毛膜促性腺激素n nSerum electrolytesSerum electrolytesn nStool testsStool testsImaging Testsn nX rays of the X rays of the abdominal abdominal partpart n nFlat and upright Flat and upright abdominal films(the abdominal films(the most common first step)most common first step)n nAir under diaphragmatic Air under diaphragmatic musclemuscle膈肌膈肌n nCalcificCalcific钙化的钙化的densities densities(stones)(stones)n nMechanical obstruction/Mechanical obstruction/ileusileus肠梗阻肠梗阻Imaging Testsn nUltrasonographyUltrasonographyn nCT scanCT scann nSpecific organ studiesSpecific organ studiesn nIVP IVP intravenous intravenous phelographyphelography 静脉肾盂造影术静脉肾盂造影术 (造影剂造影剂constrast medium,radiopaque materials)n nAngiographyAngiographyImaging Testsn nCT:15-20%false CT:15-20%false negative for acute negative for acute perforationperforationn nPoor study for gallstonesPoor study for gallstonesn nContrast obscures kidney Contrast obscures kidney stonesstonesCommon Causesn nAppendicitisAppendicitisn nCholecystitisCholecystitisn nPancreatitisPancreatitisn nDiverticulitisDiverticulitisn nPerforated UlcerPerforated Ulcern nIBDIBDn nObstructionObstructionn nVascular EmergenciesVascular Emergenciesn nGynecologic DiseasesGynecologic Diseasesn nUrinary Tract DiseaseUrinary Tract DiseaseClinical Diagnosisn nLocation of pain by Location of pain by organorgann nRUQRUQn nGallbladderGallbladdern nEpigastrumEpigastrumn nStomachStomachn nPancreasPancreasn nMid abdomenMid abdomenn nSmall intestineSmall intestinen nLower abdomenLower abdomenn nColon,GYN pathologyColon,GYN pathologyClinical DiagnosisUndergo OperationIndication of emergency operation:n nSigns of peritonitis n nIncreasing localized abdominal tenderness n nAbdominal pain with signs of sepsis脓毒症n nAcute intestinal ischemian nCertain radiographic findingsText book P-371 table 31-5Appendicitisn nUsually due to obstruction with Usually due to obstruction with fecalithfecalith粪石n nAppendix becomes swollenAppendix becomes swollen肿胀的,inflamed gangrene,inflamed gangrene坏疽,possible perforation,possible perforationAcute Appendicitisn nPain begins periumbilical脐周围的;moves to RLQ Shift Pain,Mcburneys point.n nNausea,vomiting,anorexia食欲缺乏n nPatient lies on side;right hip,knee flexedn nPain may not localize to RLQ if appendix in odd locationn nSudden relief of pain then entire abdominal pain with peritonitis:possible perforationAppendicitisn nHistory may be classic if youre lucky70%.n nVague peri-umbilical pain is the most common symptomn nMcBurneys Pointn nHyperesthesia of the abdominal wallBowel Obstructionn nBlockage of inside of intestinen nInterrupts normal flow of contentsn nCauses include adhesions,hernias,fecal impactions嵌塞嵌塞,tumorsn ngas abdominal pain;nausea,vomiting(often of fecal matter);abdominal distension腹胀腹胀n nWe can see peristaltic wave蠕动波蠕动波,gastrointestinal form胃肠型胃肠型 on the abdominal skin from inspectionSmall Bowel Obstruction:Causesn nAdhesions 80%n nHernia 15%n nTumors,intussusception,midgut volvulus,etc.Air,Fluid or Both?n nSmall bowel can be distended by either air or fluid or bothn nFluid-filled bowel may be more significant than air-filled bowel,but often the significance is the sameSmall Bowel Obstruction:Findingsn nStep-ladder dilated bowel loops on supine viewn nStep-ladder air-fluid levels on erect/decubitus viewsn nStretch sign on supine viewn nString-of-pearls sign on erect/decubitus viewsAir Filled Small BowelFluid Filled Small BowelAir-Fluid Levelsn nAlways abnormal in small bowel,but not specific;often normal in colonn nThe height of the fluid levels,same or different,is NOT helpful in distinguishing ileus from obstructionSmall Bowel Air-Fluid LevelsSmall Bowel Obstructionn nHistoryHistoryn nPrior surgeryPrior surgeryn nHerniasHerniasn nSigns and SymptomsSigns and Symptomsn nColicky abdominal painColicky abdominal painn nNausea and vomitingNausea and vomitingn nAbdominal distensionAbdominal distensionn nRectal examRectal examn nNo peritoneal signsNo peritoneal signsObstructionClassic Small Bowel Obstruction,ErectCOLON ObstructionCausesn nCarcinoma of the colon 80%n nVolvulus 5%n nDiverticulitis 5%n nFecal impaction 5%n nEverything else 5%Colon Obstruction:Volvulus肠扭转n n5%of totaln n80%sigmoidn n20%cecumAcute Pancreatitisn nOnset is acuteOnset is acuten nAbdomen is tender,but rarely has true peritoneal signsAbdomen is tender,but rarely has true peritoneal signsn nGrey Turners sign,Cullens sign and Foxs sign are Grey Turners sign,Cullens sign and Foxs sign are infrequently seeninfrequently seenn nSerum amylase and lipase are the biochemical hallmarksSerum amylase and lipase are the biochemical hallmarksn nRansonsRansons criteria is used to torture surgical criteria is used to torture surgical housestaffhousestaff APACHE Score APACHE ScoreAcute Pancreatitisn nChest x-rays may show segmental Chest x-rays may show segmental atelectasisatelectasis,pleural,pleural effusions and an elevated left effusions and an elevated left hemidiaphragmhemidiaphragmn nKUB may show the sentinel loop and loss of the KUB may show the sentinel loop and loss of the psoaspsoas shadowshadown nCT scan with double contrast will show pancreatic CT scan with double contrast will show pancreatic edema,retroperitoneal inflammation,and areas of edema,retroperitoneal inflammation,and areas of pancreatic necrosispancreatic necrosisAcute Pancreatitispeptic ulcern nSteady,well-localized epigastric painn nMore serious when hungryn n“Burning”,“gnawing”咬的,“aching”n nIncreased by coffee,stress,spicy food,smoking,alcoholn nDecreased by alkaline food,antacidsPerforated Ulcern nFree air(80%of perforated ulcers)n nGo to ORGo to ORn nNo free air,no peritonitisn nGo to CT scan with Go to CT scan with gastrograffingastrograffinn nSubhepaticSubhepatic fluid collection fluid collectionn nFluid in the lesser sacFluid in the lesser sacPerformed pe