Transcript Medical causes of acute abdomen

MEDICAL CAUSES OF
THE ACUTE ABDOMEN
Dr. T.H De Klerk
Critical Care
12 May 2014
DEFINITION
• The term, acute abdomen, is the medical
slang word that denotes an acute, serious
abdominal condition, usually treated best
by surgical operation.
• More appropriately referred to as a
“surgical abdomen”.
EPIDEMIOLOGY
• Acute abdominal pain comprises 5% of all
emergency medicine consultations (USA)
• 18-25% of these patients are admitted to
hospital
• 10% of those admitted require surgery
• 8% of admissions are purely medical
cases
ANATOMY AND PHYSIOLOGY
• Visceral pain – poorly localised to mainly
the midline
• Parietal pain - better localised to a
dermatomal distribution
• Referred pain – certain structures share
central pathways due to their specific
embryonic development
• Central pain – from thalamic and cortical
structures
HISTORY
• Time course – hyperacute (seconds),
acute (minutes) and gradual (hours)
• Location – often misleading, e.g.
cholecystitis
• Radiation, exacerbating and relieving
factors and associated symptoms
• Surgical conditions- pain generally
preceeds vomiting
• Non-surgical conditions – vomiting
generally preceeds pain
• Fever, vomiting, diarrhoea, leucocytosis
are unhelpful
BACKGROUND
• Risk factors, e.g. DM, HPT, vascular or
cardiac disease
• Previous surgical procedures - risk for
obstruction
• Previous similar episode (consider medical
cause)
• Familial disease
• Age group specific diseases, e.g.
appendicitis in the young, or diverticulitis in
the elderly
CLINICAL EXAMINATION
• Must be seen in the context of patient’s
history and risk factors
• 2004 Israel study: more than 600 patients
evaluated for acute abdomen clinically vs
CT diagnosis 37% correlation between the
groups, 8% of patients underwent surgery
unnecessarily due to incorrect diagnosis
• The art of the abdominal examination: time
very important, recurrent re-evaluation
• Abdominal x-rays: dilated bowel loops,
intra-peritoneal air
• Abdominal ultrasound & CT scan: confirm
diagnosis and plan further management
CATEGORIES OF MEDICAL
CAUSES
• Referred pain – adjacent structures
• Lung: pneumonia, pleuritis, pulmonary
embolus/infarct, empyema,
pneumothorax
• Heart: myocardial infarction,
myocarditis, pericarditis, congestive
cardiac failure
• Oesophagus: oesophagitis, spasm,
rupture
• Pelvis: PID, ovarian/testicular torsion,
follicular rupture, ovarian
hyperstimulation syndrome
MEDICAL CAUSES CONTINUED
• Metabolic
• Adrenal insufficiency – gastric dysmotility,
serositis
• DKA - gastritis, gastric distension, ileus
• Thyrotoxicosis – unknown, probably ileus
• Porphyria – visceral autonomic neuropathy
• Hypercalcaemia – ileus, increased gastrin
which leads to gastritis, pancreatitis,
ureterolithiasis
• Hyperlipidaemia – pancreatitis
• Uraemia – ileus, gastritis
• Haemochromatosis - SBP
MEDICAL CAUSES CONTINUED
• Infection
• Toxins – tetanus, botulism
• Dysentry – shigella, salmonella,
campylobacter, amoebiasis
• Severe gastroenteritis – giardiasis,
isospora belli
• Mesenteric lymphadenitis – yersinia,
extrapulmonary TB, CMV
• Infestations – helminths,
schistosomiasis, obstruction
• Infiltration – malaria, EBV
• Translocation - SBP
MEDICAL CAUSES CONTINUED
• Vascular
• Arterial – mesenteric ischaemia and
infarction, dissection (abdominal pain
out of proportion to clinical findings)
• Vasculitis – large vessel: Takayasu,
medium vessel: PAN, small vessel:
Wegeners
• Coagulopathy – arterial and/or venous
thrombosis, primary e.g. APLS,
secondary e.g. malignancy
• Specific vascular syndromes, e.g.
Budd-Chiari, portal vein thrombosis
MEDICAL CAUSES CONTINUED
• Haematological
• Acute leukaemia, lymphoma –
infiltration, tumour necrosis
• Haemolytic anaemia, Sickle cell
anaemia, polycythaemia vera –
vascular spasm and/or thrombosis
• Haemophilia – abdominal wall
haematomas
MEDICAL CAUSES CONTINUED
• Drugs and toxins
• Mucosal irritants and corrosives – iron,
mercury, NSAIDs
• Ileus – anticholinergics, narcotics
(opioid bowel syndrome)
• Bowel ischaemia – cocaine,
amphetamines, ergotamines
• Heavy metals – lead, arsenic
• Biological – black widow spider:
hyperstimulation of NMJ
MEDICAL CAUSES CONTINUED
• Neurological
• Central – abdominal migraine,
abdominal epilepsy,
• Neuropathies – tabes dorsalis,
secondary to syphilis. Radiculopathy:
degenerative spine disease, disc
herniation, post-herpetic neuralgia
MEDICAL CAUSES CONTINUED
• Miscellaneous
• Lactose intolerance
• Eosinophillic gastroenteritis
• SLE – pancreatitis, serositis, vasculitis
• Periodic fever syndromes
• Radiation enteritis
• Glaucoma
• Angioedema – C1-esterase inhibitor
deficiency, ACE inhibitors
SPECIAL POPULATION GROUPS
• Pregnancy – abdominal examination difficult,
uterus obscures rest of abdomen
• Neurological disease – no pain sensation,
quadroparesis, inability to communicate – delirium,
dementia
• ICU patients – altered pain perception, 38% of
patients with peritonits have peritoneal signs.
Consider acalculus cholecystitis
• Post-procedural patients
• vena cava filters which migrate, fracture,
thrombose etc
• PEG tubes – peri-stomal leakage
• Biopsies – subcapsular haematoma
• Immunocompromised
• Blunted inflammatory response
• Organ transplants lack nerve
innervation
• Opportunistic infections, e.g. PCP,
CMV
• Weakening of connective tissue, e.g.
corticosteroids and bowel wall
perforation
• Drugs: ARV’s (pancreatitis, lactic
acidosis), Chemotherapeutic agents,
e.g. vincristine
• Neutropenic enterocolitis (typhlitis)
• Elderly patients
• Immunosenescence – decreased
immunosurveillance, decreased
antibodies and T cells, decreased
pyrogen response
• GI tract – decreased motility and
secretion
• CNS – dementia, delirium, decreased
peripheral sensation
• Increased amount of chronic diseases
• Increased drug usage – decreased pain
and sympathetic response, increased
drug interactions, e.g. digoxin toxicity
REMEMBER…
• An atypical presentation of a common
condition is much more likely than the
typical presentation of an uncommon
condition
REFERENCES
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Ragsdale L, Southerland L. Acute Abdominal Pain in
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Fields JM, Dean AJ. Systemic Causes of Abdominal
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Chang CC, Wang SS. Acute Abdominal Pain in the
Elderly. Int J Gerontol. 2007 Jun;1(2):77-82.
Gajic O, Urrutia LE, Sewani H, Schroeder DR, Cullinane
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