Tieman DSA- acute abdomen

Question 1

Sir Zachary Cope

Answer 1

Sir Vincent Zachary Cope MD MS FRCS (14 February 1881 – 28 December 1974) was an English physician and surgeon perhaps best known for authoring the book Cope’s Early Diagnosis of the Acute Abdomen from 1921 until 1971. New editions continue being published by editors long after his death, the most recent one being the 22nd edition, published in 2010.

Question 2

MAKING THE DIAGNOSIS

Answer 2

Directed History
Physical Examination
Suspected Diagnosis / Severity
    Labs / X-rays / Tests are Confirmatory,
    You must think of the diagnosis
Initiate therapy / Elevate level of care

Question 3

Acute Abdomen—HISTORY

Answer 3

Pain (location, character, and change)
Nausea, Anorexia
Emesis (bilious, clear, feculent, coffee grounds)
Flatus, Diarrhea, Melena
Prior Surgery
Trauma, Recent changes in Diet
Weight loss
Alcohol, Drugs, Medications
Menstrual cycle, Family history

Question 4

Acute Abdomen—PE

Answer 4

Sick or Well, Diaphoretic, pale, lethargic
Vital signs, Tachycardia, hypotension, fever
HEENT, Heart, Lungs
Abdomen- location of pain + tenderness
Guarding, Rigidity, Distention, Bowel sounds
Percussion and palpation tenderness
Referred pain, rebound, signs
Rectal Exam
? Pain out of proportion to physical exam?
Auscultation - quiet, rushes, pitch of bowel sounds

Question 5

ORIGINS OF THE GI TRACT

Answer 5

Foregut:
Esophagus, Stomach, Duodenum, Liver, Gallbladder, Pancreas, Spleen

Midgut:
Jejunum, Ileum, Right Colon, Appendix, to mid-transverse Colon

Hindgut:
Mid-transverse Colon, Descending Colon, Sigmoid Colon, Rectum, Anus

Question 6

Early Pain

Answer 6

Primarily visceral afferent pain fibers which respond to distension, increased pressure or ischemia. Not specific in location.
Foregut—Epigastrium
Midgut—Periumbilical
Hindgut—Suprapubic

Question 7

Later pain

Answer 7

Peritoneal inflammation, conducted by somatic pain fibers. More specific in location
Localized vs. Generalized Peritonitis

Question 8

How the GI tract gets sick

Answer 8

Bleeds, Obstructs, Perforates:

Infarct or Twist on blood supply
Incarcerate in hernias, internal and external
Become Infected
Rupture / Perforate
Grow tumors, benign and malignant
Strictures, Obstructs

Question 9

Foregut

Answer 9

Stomach Ulcers
Duodenal Ulcers
Gallstone
Hepatitis, Liver 
Pancreatitis
Spleen Infarcts

Question 10

Perforated Ulcer Stomach or Duodenum

Answer 10

Sudden onset of epigastric pain,
Pain spread to entire abdomen
Patient lies very still, avoids motion
Sick, tachypnic, tachycardic
Tender “boardlike” abdomen, decr. BS
75% have free air on Upright CXR,virtually all can be seen on a good CT.
Inc. Amylase lipase possible, WBC Corticosteroids and immunosuppression Mask

Question 11

Roux-en-Y Gastric Bypass

Answer 11

Most frequently performed bariatric procedure in the US
First done in 1967
Some technical modifications since (stomach is cut)
Laparoscopically since 1993

Question 12

Stones

Answer 12

Cholelithiasis infected Cholecystitis
Choledocholithiasis-Suppurative cholangitis
Gallstone Ileus –perforation into surrounding organ
Necrotic perforated GB with abscess
Gallstone Pancreatitis

Question 13

Acute Cholecystitis

Answer 13

Usually have Hx of Biliary Colic
Pain in RUQ, Epigastric, radiates to right scapula/shoulder
Dull, constant pain, Nausea, Emesis
BS decr. Tender RUQ, +/- mass, worse with deep inspiration (Murphy’s sign)
WBC, Bilirubin, LFT’s
US better than CT - thick wall, edema, stones, Rare but possible with no stones

Question 14

Suppurative Cholangitis

Answer 14

Pus in CBD—usually from partially obstructing stone
Septic,Jaundice,Confused,Febile,Tachy
Charcot’s triad
Reynold’s pentad

Any or all could be missing
Powerful Antibiotcs
Urgent CBD drainage usually with ERCP

Question 15

Acute Pancreatitis

Answer 15

Sudden onset, severe epigastric pain radiates direct to back, intolerable
Patient struggles to find comfortable position
Usually sitting up and leaning forward
Anorexia, Nausea, Vomiting
Epigastric tenderness, decreased BS
WBC inc, Amylase/ lipase incr..
CT shows inflammation of Pancreas

Question 16

Acute Small Bowel Obstruction

Answer 16

Sharp colicky pain, periumbilical, episodic
Abdominal distention, usually non-tender
Nausea, Vomiting (bilious), > yellow brown >feculent
No flatus, BS high pitched, rushes
Kub/Upr/CXR Air fluid level, no gas in colon,now CT
Adhesions,Hernia,Mass,Volvulous

Question 17

Acute Appendicitis

Answer 17

Pain in mid-abdomen, peri-umbilical migrates to RLQ in 6-8 hrs
Anorexia, nausea, vomiting
BS decr., guarding, percussion tenderness, Rovsing’s sign, Psoas sign, Obturator sign
labs may be normal or WBC incr, left shift
Gyn problems mimic appendicitis—always think gyn in female patients with RLQ pain
CT helpful (rectal contrast) (after pregnancy test)
Diagnostic laparoscopy / appendectomy

Question 18

difficulty of the dx of appendix

Answer 18

Appendicitis is the most difficult diagnosis to make on a patient that is already an inpatient.

Appendicitis is difficult to diagnosis in the very old and the very young, and delayed diagnosis has severe complications.

The two diagnoses that you will miss are the one you don’t know about, and the one that you don’t think about.

Question 19

Meckel’s Diverticulum

Answer 19

Rule of 2’s, Gastric and Pancreatic tissue
Persistence of vitelline duct on anti-mesenteric border of distal ileum
Bleeding, intestinal obstruction, diverticulitis
Similar to Appendicitis

Question 20

Pelvic Inflammatory Disease and Ectopic Pregnancy

Answer 20

RLQ pain/ Pelvic pain, often just after menses complete for PID, late or atypical menses for Ectopic Pregnancy
Rarely have Anorexia, Nausea, Vomiting
Vaginal discharge, bleeding or cervical motion tenderness
Adnexal masses—TOA or ectopic
Remember to get serum pregnancy test

Question 21

Acute Gynecologic Dz

Answer 21

Salpingitis
- usually gonococcal, periumbilical pain - RLQ, and LLQ, Vaginal discharge and CMT

Ovarian Cysts
- Sudden lower abdomen R or L, ruptured cysts may present similar to appendicitis

Ectopic Pregnancy
- Sudden lower abdominal pain, rupture of fallopian tube, +BHCG, vaginal bleeding

Question 22

Renal Calculi

Answer 22

Severe sudden, colicky abdominal pain, flank, upper abdomen, subsides and recurs
Radiates to groin, testicle, perineum as stone descends
RBC, WBC in urine
X-RAY, IVP

Question 23

Acute Diverticulitis

Answer 23

Initially lower abdominal pain, localizing to the LLQ
Fever, chills
Guarding LLQ, tender to palpation, mass
WBC
CT scan diagnostic plus to find complications of diverticulitis

Question 24

Colonic Obstruction

Answer 24

Carcinoma, Volvulus, Diverticulitis
Abdominal distention, gradual onset
No flatus
X-ray dilated colon to point of obstruction
Volvulus has sudden onset of pain, characteristic X-rays
Gastrograffin enema, or endoscopy

Question 25

Summary

Answer 25

History and Physical are essential to making the correct diagnosis

Pain location and character indicate the area of the GI tract involved—think anatomically

Use radiology and lab to confirm diagnosis, don’t rely on them to make the diagnosis