ACUTE ABDOMEN. Department of Surgery Medical Student Lecture Series

Transcription

1 ACUTE ABDOMEN Department of Surgery Medical Student Lecture Series

2 Case 1 A 22-year-old man awakens with periumbilical abdominal pain followed by nonbilious vomiting. What is the most likely source of the abdominal pain?

3 Question #1 What is the most likely diagnosis? A. Perforated ulcer B. Acute appendicitis C. Perforation following bowel obstruction D. Cholecystitis E. Diverticulitis

4 Discussion 1 Learning Objective: Demographics and pathophysiology 8% of people have appendicitis during their lifetime Obstruction of the lumen is thought to be the major cause of appendicitis Appendicolith (30%) Lymphoid hyperplasia

5 Discussion 1 Learning Objective: Clinical presentation and evaluation Classic symptoms start with peri-umbilical pain, nausea and subsequent localization of the pain in at McBurney s point Exam findings include fever, tenderness over appendix, and Rovsing s sign obturator sign McBurney s Point iliopsoas sign Laboratory tests include: CBC UA beta-hcg

6 Discussion 1 Learning Objective : Radiographic imaging of appendicitis Computed Tomography signs of appendicitis: Diameter > 7 mm Circumferential wall thickening/enhancement Peri-appendiceal fat stranding/fluid Ultrasonography Distension Wall thickening CT Scan Ultrasound

7 Discussion 1 Learning Objective : Understand appendectomy operation Divide mesoappendix, divide appendiceal base

8 Case 2 A 26 year old female with a history of two prior abdominal operations presents with abdominal distension, colicy abdominal pain and no bowel function for 36 hours prior to admission. Which of the following is the initial treatment plan for this patient?

9 Question #2 What is the best initial treatment plan? A Immediate surgery is warranted when the diagnosis is made. B Nasogastric decompression for 24 hours allows spontaneous resolution in most patients. C The presence of fever, tachycardia, localized pain, or leukocytosis suggests strangulation and warrants prompt surgery. D If a small bowel resection must be performed, a stoma and mucous fistula are necessary because an anastomosis is subject to nonhealing in the face of obstruction.

10 Discussion 2 Small Bowel Obstruction Learning Objective : Demographics and pathophysiology Completeness of initial surgery is main determinant of outcome Causes of small bowel obstruction Extrinsic to bowel wall Inside bowel wall Intraluminal

11 Discussion 2 Learning Objective : Clinical presentation and evaluation Colicy abdominal pain, nausea, vomiting, abdominal distension, obstipation Signs of dehydration tachycardia, oliguria Signs of strangulation fever, leukocytosis, peritonitis Exam finds distension Laboratory evaluation: CBC BMP

12 Discussion 2 Learning Objective : Radiographic imaging Plain radiograph CT scan

13 Discussion 2 Learning Objective : Initial management Fluid resuscitation, monitor response to fluid (heart rate, urine output), electrolyte repletion Bowel rest, nasogastric tube to wall suction Partial bowel obstructions resolve 60 85% with conservative management

14 Discussion 2 Learning Objective : Decision to operate Signs of compromised intestine (fever, tachycardia, peritonitis) Failure of complete bowel obstruction to resolve with 12 to 24 hours of conservative management

15 Case 3 A 55 year old obese male presents with 48 hours of worsening LLQ pain, fevers, chills and leukocystosis. What is the best modality to confirm the diagnosis?

16 Question #3 A. Colonoscopy B. Barium Enema C. CT scan D. 3 way Abdominal X-ray E. Indium WBC scan

17 Acute Diverticulitis CT SCAN findings Wall thickness > 10mm Diverticula Pericolonic fat stranding - Uncomplicated Perforation Abscess Fistula Obstruction - Complicated - Uncomplicate d

18 Complicated: abscess + fistula

19 Definitions Diverticulum = an abnormal pouch or sac opening from a hollow organ Diverticula = pleural of diverticulum Diverticulosis = a condition characterized by the presence of numerous diverticula in the colon Diverticulitis = inflammation of a diverticulum

20 Demographics Diverticulosis 30% by age 50 66% by age 80 Younger patients tend to be male and obese Predominantly due to Western low fiber diet Diverticulitis Sigmoid Colon 95% Present with abscess 15%

21 Pathogenesis: True vs. False Diverticula True = all layers of bowel wall - congenital - Meckel s False = mucosa and submucosa protrude through muscularis externa at vasa recta and covered only by serosa - most colonic tics - obstruction causes

22 Treatment Uncomplicated = medical therapy (diet/antibiotics) 85% recover 30% recurrence (usually within first year) Complicated = surgical therapy (resection of diseased segment) patients who do not respond to or who deteriorate during medical management those with recurrent severe attacks those who have perforation with diffuse peritonitis, localized abscess, fistula formation (typically colovesical or colovaginal), and/or bowel obstruction

23 Hinchey Classification Hinchey I - localized abscess (para-colonic) Hinchey II - pelvic abscess Hinchey III - purulent peritonitis (the presence of pus in the abdominal cavity) Hinchey IV - feculent peritonitis Clinical condition + Hinchey classification determines therapy: perc drainage vs. simple laparoscopic washout vs. resection +/- ostomy

24 Hartmann Procedure Sigmoid resection End Colostomy Rectal stump closure