ACUTE ABDOMEN

Acute Abdominal Pain Brian Piltz, MD Acute Abdominal Pain           Presentation Physiology Ddx Non-abdominal etiology History PE Labs Radiology Procedures Initial tx and pre-op preparation Definition: “Acute Abdominal Pain” • Previously undiagnosed cause • Previously well patient • Sudden onset • Less than 7d duration (usually 6hrs more likely surgical (Cope) Time vs Intensity Graphs For Acute Abdominal Pain Frequency of Specific Diagnoses in Pts With Acute Abd Pain OMGE N=10,320 Wilson N=1196 Irvin N=1190 Brewer N=1000 de Dombal N=552 Hawthorne N=496 Frequency of Specific Diagnoses in Younger and Older Pts with Acute Abd Pain in the OMGE Study Triage  Presentation Next: Physiology Labs • CBC – WBC • Absence of leukocytosis never excludes inflamm diag – HCT • Hemoconc may indicate hypovolemia – Platelets • Thrombocytopenia consistent w/ severe sepsis Labs • Electrolytes – Hypochloremic, hypokalemic met alk or “contraction alk” from GI losses – Hyperglycemia • DKA • Sepsis-induced glucose intolerance • ABG – Met acidosis w/ generalized abd pain in elderly is ischemic colitis until proven otherwise Labs • UA – UTI not always classical presentation • β-Hcg – All females are pregnant until proven otherwise • LFT – Bili and AP elev in obstruction – Transaminase elev in hepatocellular injury • Amylase/Lipase – Non-specific: mesenteric ischemia, perf duod ulcer, ruptures ovarian cyst, renal failure – Lipase more sensitive for pancreatitis  Labs Next: Radiology Radiology • • • • CXR Ultrasonography CT Contrast studies – Angiography – Upper/Lower GI series CXR Ultrasonography • • • • • • • • Hepatobiliary tree Pancreas Vascular structures Kidneys Pelvic organs Intra-abdominal fluid Pediatric pts Gynecologic abnormalities CT • Better than US in acute evaluation of presumed aortic disease • Helpful when etiology is unclear • Can identify AND localize problem Contrast Studies • Angiography – diagnose mesenteric ischemia • Upper and lower GI series – falling out of favor to preference for CT – Air enema is diagnostic and therapeutic in intussusception in children  Radiology Next: Procedures Procedures • Endoscopy – EGD useful in evaluation of GIB and epigastric pain – Colonoscopy • Potential therapy for non-strangulated sigmoid volvulus • Decompress colon • Dx IBD • Paracentesis – SBP in cirrhotic pts if ANC >500 • Laparoscopy - changing role as laparoscopic surgery techniques improve Initial Tx / Pre-op prep • • • • Prompt w/u in 1st 4-6 hrs NPO until dx is firm IV resuscitation Hemodynamic monitoring when fluid or cardiac status are in question, or when septic • NG intubation for bleeding, vomiting or signs of obstruction • Foley to monitor fluid status Decisions, decisions • Immediate surgery – Go now or resuscitate first? – What is plan B? • Admit and observe – Serial exams q2-4h during 1st 12-24 hr if no definite dx – Serial lab exams may be useful • Non-operative – Pt still needs a treatment plan for further work up or non-operative therapy .. .Acute Abdominal Pain           Presentation Physiology Ddx Non-abdominal etiology History PE Labs Radiology Procedures Initial tx and pre-op preparation Definition: ? ?Acute Abdominal... 2/3 of pts w/ acute abdominal pain have non-surgical etiology • 1/3 of pts present atypically • Pain that persists >6hrs more likely surgical (Cope) Time vs Intensity Graphs For Acute Abdominal... Diagnoses in Pts With Acute Abd Pain OMGE N=10,320 Wilson N=1196 Irvin N=1190 Brewer N=1000 de Dombal N=552 Hawthorne N=496 Frequency of Specific Diagnoses in Younger and Older Pts with Acute Abd Pain