The acute abdomen

The Acute Abdomen Yingda Li 6th Oct, 2011 Royal Melbourne Hospital

Objectives 1. Develop a rational approach to assessing and managing the acute abdomen 2. Identify ‘red flags’ on history and examination

3. Have a set of ‘rules’ as safety nets 4. Familiarise with style of questions commonly asked in exams

Overview  Definitions    

History Examination Investigations Management

 Multiple choice questions

Definitions    

Pain Acute Severe Requiring urgent attention

 Not always surgical  Not always abdominal source

Rule 1. Epigastric pain may be from supra-diaphragmatic source

Rule 2. Women of History childbearing age  Demographics    

are pregnant till Rule 3. Never proved otherwise underestimate abdominal Rule 4. Sudden pain in elderly onset pain the equals

Tempo Site, radiation perforation, Quality vascular or torsion Associated symptoms Rule 5. Vomiting  Risk factors is a key associated  Previous surgery symptom  Gynaecological history  AMPLE

Red flags

Examination  Preparation (privacy, consent, exposure, positioning, chaperone) Rule 6. Vital signs  End-of-the-bed appearance are vital  Vital signs  Look, listen, feel  PR, PV, testicular  Eponymous signs

Rule 7. Is there peritonism, is there a hernia and is there a AAA?

 Bedside tests (FWT, bhCG, ECG, BSL)  Symptoms out of proportion to signs

Investigations  

Diagnostic Pancreatic enzymes, Laboratory cardiac enzymes MSU XR, USS, CT, MR Radiology Laparoscopy, ERCP

Prognostic CRP, platelets, clotting profile CT Criteria

Supportive Inflammatory markers UEC, LFTs Lactate

Preoperative Group and screen Crossmatch

Management Resuscitation Airway Breathing Circulation General measures NBM, IV fluids, analgesia, antiemesis NGT, IDC Serial examination

Specific measures Antibiotics Open surgery, laparoscopy ERCP, image-guided percutaneous drainage, sigmoidoscopic decompression, angioembolisation

MCQs

1. 2. 3. 4. 5.

Hepatitis serology Upper abdominal ultrasound Full blood examination ERCP Liver biopsy

A. B. C. D. E.

CT kidney, ureter and bladder Ultrasound renal tract 24-hour urinary calcium excretion Plain X-ray kidney, ureter and bladder Mid-stream urine for phase microscopy