Michelle Giovannelli MSN, BSN, RN, APN-BC, CWS The Ohio State University Wexner Medical Center. Acute Abdomen
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1 Michelle Giovannelli MSN, BSN, RN, APN-BC, CWS The Ohio State University Wexner Medical Center Acute Abdomen
2 The Abdomen by Homer Simpson
3 Acute conditions of the Abdomen 1.Acute conditions of the abdomen require urgent treatment, often including emergency operation. 2. To determine whether or not your patient has an acute Abdomen you need to understand the anatomy of the abdomen and the symptoms of that anatomy that are pathologic.
4 Abdominal Facts The abdomen is the largest cavity in the body The abdomen contains all the digestive organs, including the stomach, intestines, pancreas, liver and gallbladder The abdomen also contains the kidneys and spleen These organs are held together loosely by the mesentery (connective tissue) that allow them to expand and slide against each other The Aorta, Inferior Vena Cava and dozens of these large vessels smaller branches travel through the abdomen The abdomen is protected by a tough layer of tissue called fascia Abdominal and back muscles and skin cover the fascia layer of the abdomen
5 Abdominal Anatomy The abdominal cavity can be broken down into 4 quadrants to help with visceral location and differential diagnosing of presenting signs and sxs RUQ Right upper quadrant RLQ Right lower quadrant LUQ Left upper quadrant LLQ Left lower quadrant
6 Abdominal Quadrants RUQ- Liver Gallbladder Duodenum Head pancrease R side stomach R sub adrenal Gland R Kidney Ascending and Transverse colon LUQ Spleen L side stomach Jejunum Proximal ilium pancreatic body and tail L Kidney L Sub adrenal gland Transverse and top of descending colon
7 Abdominal Quadrants RLQ- Cecum Appendix Ileum Ascending colon R ovary R side uterus if gravid R ureter R spermacord Bladder if full LLQ sigmoid colon Descending colon L ovary L uterine tube L ureter L spermatic cord Uterus gravid Urinary bladder if full
8 Acute Abdomen Signs and Symptoms 1.Pain 2. Swelling 3. Involuntary contraction of abdominal muscles 4. Abdominal Rigidity 5. Fever
9 Pain 1. Pain may be located in any quadrant of the abdomen 2. Pain can be continuous, intermittent, sharp, dull, achy or piercing 3. Pain can radiate from a focal site 4. Pain can have associated symptoms like nausea and vomiting 5. you can have visceral pain, parietal pain or referred pain in an acute abdomen
10 Abdominal Pain Visceral Pain Parietal or Somatic Pain: Derived from the Autonomic nervous system (sympathetic & Parasympathetic) Dull, cramping, burning pain that increases over time Pain can be intermittent or can be constant Pain does not change with movement Palpation doesn t usually change pain level Exact location of pain is ambiguous but usually pain is perceived to be in the midline below the sternum regardless of the chest/abdominal organ involved Usually presents with other autonomic phenomena ie pallor, profuse sweating, nausea, vomiting, changes in blood pressure and heart rate, GI disturbances and changes in body temperature Can cause anxiety and feelings of doom Derived from Somatic innervation (spinal nerves) Sudden, sharp, and able to pinpoint its location Pain is constant Pain increases with movement Palpation makes pain worse Referred Pain: Pain d/t overlapping stimulus in CNS from different organs caused by similar embryonic origin Pain appreciated at satellite location
11 Visceral pain Visceral pain is referred to three zones located in the midline of the abdomen. The localization of abdominal pain can help you differentiate what is wrong with the patient. 1. The epigastric zone originates by structures innervated by T6-T8 and includes the stomach, duodenum, pancreas, liver, biliary tree and associated parietal peritoneum 2. The periumbilical zone originates in structures innervated by T9-T10 and includes the small intestine, appendix and upper ureters 3. The hypogastric zone originates in structures innervated by T11-T12 and includes the colon, bladder, lower ureters and uterus
12 Pain Work-Up Questions to ask your patients who are complaining of Abdominal pain: 1. Onset (new or reoccurring) 2. Site (localized or Diffuse) 3. Nature (constant, intermittent, colicky) 4. Radiation 5. Severity 6. Relieving/Aggravating factors
13 Visceral Pain continued Epigastric zone: 1. Stomach 2. Duodenum 3. Pancreas 4. Liver 5. Biliary tree 6. Parietal peritoneum Periumbilical Zone: 1. Small intestine 2. Appendix 3. Upper ureters Hypogastric Zone: 1. Colon 2. Bladder 3. Lower ureters 4. uterus
14 Abdominal Assessment History Most diagnosis can be made by history alone so ask the right questions and listen to your patient! Include: 1. Time of onset and what were you doing when it started (day or night) (sleeping, eating, etc) 2. Mode of onset (abrupt vs gradual) 3. Location of pain (RUQ, LUQ, RLQ, LLQ, visceral zones) 4. Character of pain (constant, intermittent, colicky, etc) 5. Duration of pain (Acute vs Chronic) 6. Progression of pain (getting worse, better, same) 7. PMH (ABD surgery,stds,travel,occupation, Psych) 8. Menstral History 9. Contributing Symptoms (anorexia, vomiting, diarhea, fever)
15 Abdominal Assessment Physical Exam: 1. The physical exam should confirm the suspicions you conceived during the patient history 2. The physical exam should help you to localize area of concern 3. The physical exam should help you avoid missing extraabdominal causes of pain like heart attack Exam: 1. Observation of patients demeanor 2. Inspection of Abdomen 3. Auscultation of Abdomen 4. Palpitation of Abdomen 5. Percussion Of Abdomen
16 Abdominal Findings on Exam Murphy s sign Respiratory arrest on inspiration during palpation of the RUQ Rovsing s sign Pain referred to the RLQ on palpation of the opposite side of the ABD Obturator sign Pain with internal rotation of flexed hip Ilopsoas sign Pain with hyperextension or flexion of the hip McBurnies sign Pain 1/3 distance from umbilicus to ASIS RLQ Rebounding No pain when pushing on ABD. Pain is illicited when palpating hand is released from belly Guarding Actively or Passively protecting belly from manipulation Point tenderness Direct pain at the site of palpation.
17 Abdominal Exam: McBurnies Point
18 Abdominal Exam: Obturator Sign
19 Formulating a Diagnosis RUQ Appendicitis 1. Cholangitis 2. Cholecystitis 3. Hepatic Abscess 4. Hepatitis 5. Hepatomegaly 6. Myocardial Infarction 7. Pancreatitis 8. Peptic Ulcer Disease 9. Pericarditis 10. Pleurisy 11. Pneumonia 12. Pulmonary Embolism 13. Pyelonephritis 14. Renal Colic 15. Subphrenic Abcess 16. Dissecting Aortic Aneurysm LUQ 1. Aortic Dissection 2. Gastritis 3. Duodenal ulcer 4. Gastric ulcer 5. Intestinal Obstruction 6. Ischemic Colitis 7. LLL effusion/ empyema 8. Myocardial Infarction 9. Pancreatitis 10. Pericarditis 11. Pleurisy 12. Pneumonia 13. Pulmonary Embolism 14. Pyelonephritis 15. Splenic Infarction/ Rupture 16. Thoracic Aneurysm
20 Formulating a Diagnosis: RLQ 1. Appendicitis 2. Cholecystitis 3. Divertiulitis 4. Ectopic Pregnancy 5. Endometriosis 6. Epididymitis 7. Gastroenteritis 8. Hip Pain 9. Intestinal Obstruction 10. Leaking Aortic Aneurysm 11. Mittelschmerz 12. PID 13. Perforated Peptic ulcer 14. Psoas Abscess 15. Rectus Hematoma 16. Regional Enteritis 17. Renal Colic 18. Salpingitis 19. Torsion of Ovarian Cyst or Tumor 20. UTI LLQ 1. Diveritulosis 2. Ectopic Pregnancy 3. Endometriosis 4. Epidiymitis 5. Fecal impaction 6. Hip Pain 7. Incarcerated Inguinal Hernia 8. Intestinal Obstruction 9. Ischemic Colitis 10. Leaking Aortic Aneurysm 11. Mittelschmerz 12. Munchausen Syndrome 13. PID 14. Perforated Colon Carcinoma 15. Psoas Abcess 16. Rectus Hematoma 17. Renal Colic 18. Salpingitis 19. Torsion of Ovarian Cyst or Tumor 20. UTI
21 Questions????????
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