Surgery - GI (CMPP)

Acute severe abdominal pain is almost always a symptom of

intra-abdominal disease

How fast does gangrene and perforation take to form in bowels with lack of blood

6 h

Types of Abdominal Pain

Visceral

Somatic/parietal

Referred

Visceral pain

Pain caused by distention, inflammation, or ischemia by stimulating the receptor neurons, or by direct involvement (tumor infiltration) of sensory nerves

What innervates abdominal viscera

autonomic nerve fibers

Characteristics of Visceral Pain

Slower onset,

vague, dull,

nauseating

What innervates parietal peritoneum

somatic nerves

Somatic (parietal) pain

direct irritation of parietal peritoneum by pus, bile, urine, or GI secretions from infectious, chemical, or inflammatory processes

Characteristics of Somatic Pain

More acute

sharp

Well-localized

Referred pain

Pain perceived distant from its source

Why does referred pain occur

convergence of nerve fibers at the spinal cord

Scapular pain can be referred pain from

biliary colic

Groin Pain can be referred pain from

Renal Colic

Shoulder pain can be referred pain from

blood, air, or peritoneal fluid irritating the diaphragm

Peritonitis

any abdominal condition that causes marked inflammation

Common Causes of Peritonitis

Acute perforation,

appendicitis,

diverticulitis,

intestinal obstruction,

pancreatitis,

PID,

acute mesenteric ischemia,

ectopic pregnancy

Infectious

Spontaneous bacterial peritonitis (SBP)

What can cause infectious peritonitis

ascitic fluid

indwelling shunt, drain,

catheter in the peritoneal cavity

Spontaneous bacterial peritonitis (SBP)

peritoneal cavity infected by bloodborne bacteria

How can peritonitis be a life-threat

causing severe dehydration and electrolyte imbalances

ARDS can develop rapidly

Liver failure,

kidney failure,

DIC

What is important HPI features for abdomen pain

Pain location and characteristics

History of similar symptoms

Anorexia

N/V/D

Blood in stools

Known medical conditions

Prior surgeries

Pregnant

prescription and illicit drugs and ETOH

When starting to palpate for abdominal pain, when should you palpate the symptomatic area

Last

What special tests are done in the abdomen exam

Jolt test or cough test for rebound tenderness

Referred rebound

Rovsing's

Murphy’s sign

Iliopsoas and obturator signs

Cutaneous hyperesthesia

Shifting dullness and fluid wave

CVA tenderness

What are red flags for abdominal pain

Severe pain

Signs of shock

Signs of peritonitis

Abdominal distention

A distended abdomen with boroborgymi in rashes often indicates

SBO

What are indicators abodminal pain can be SBO

Distention,

surgical scars,

tympany to percussion,

borborygmi in rushes

Severe abdomen pain, silent abdomen, and patient lying as still as possible is likely

peritonitis

A patient with abdominal pain, shock, and vaginal bleeding is likely to have

ruptured ectopic pregnancy

A patient with abdominal pain with Grey Turner and Cullen Sign is likely

Hemorrhagic pancreatitis

A patient wtih abdomen pain, back pain, and shock is likely

Ruptured AAA

Patient writhing and unable to get comfortable due to abdominal pain is a indicator for

obstructive mechanism (renal or biliary colic)

Patient with previous abdominal surgery is more likely to have

obstruction caused by adhesions

Patient with h/o generalized atherosclerosis and abodmen pain is likely

MI,

AAA,

mesenteric ischemia

Patients with abdominal pain and HIV is more likely to be

infectious cause

What testing should be done for abdominal pain

EKG

CXR in upper quadrant pain

CBC,

CMP,

UA

Lipase

hCG

EGD for UGI bleeding

Consider US

Abdominal Series XR

CAT

When is US done for abdomen pain

suspected biliary tract disease

ectopic pregnancy (transvaginal)

suspected appendicitis in children

Can detect AAA

When is XR done for abdominal pain?

suspected perforation or obstruction

Test of Choice for Abdominal Pain

CAT w/ PO and IV contrast

When is a non-contrast CT done for abdomen pain

Renal Stones

Treatment for Abdominal Pain

moderate doses of IV analgesics for pain

Other treatment depends on cause

Mesenteric ischemia

Interruption of intestinal blood flow by embolism, thrombosis, or low-flow state

What causes abdominal pain in Mesenteric ischemia

mediator release, inflammation, and ultimately infarction

Treatment of Mesenteric ischemia

embolectomy,

revascularization of viable segments,

resection

Sometimes vasodilators helpful

What can occur with acute perforation of the GI

gastric or intestinal contents into the peritoneal space

Presentation of acute perforation of the GI

sudden with severe pain quickly followed by peritonitis and signs of shock

dx for acute GI perforations

imaging showing “free air” in the abdomen

tx for acute GI perforations

Fluid resuscitation,

antibiotics,

surgical repair

Appendicitis

Acute inflammation of the vermiform appendix

Presentation of Appendicitis

abd pain and tenderness, and anorexia

dx of Appendicitis

◦Clinical diagnosis supplemented by CT or US

tx of Appendicitis

surgical removal of the appendix

Most common cause of acute abd pain requiring surgery

Appendicitis

Hernia

Protrusion of abdominal contents through an acquired or congenital area of weakness or defect in the abdominal wall

Incarcerated Hernia

A hernia that cannot be reduced

Presentation of Incarcerated Hernia

Gradually increasing pain

Nausea and vomiting

Tender at hernia site

Overlying skin may be erythematous

Peritonitis

guarding, and rebound

Most Common GI Hernia

Inguinal hernia

Stragulated Hernia

compromised blood supply

Treatment of incarcerated / strangulated hernia

urgent surgical repair

Hesselbach triangle

A triangle made up of rectus abdominus, inferior epigastric vessles, and inguinal ligament

Most common site for direct inguinal hernias

Most common type of inguinal hernia

Indirect inguinal hernia

What causes Indirect inguinal hernia

Most are congenital

Caused by failure of the processus vaginalis to close

Most Common Site for Indirect inguinal hernia

Superior and lateral to epigastric vessels

R > L

What causes Direct inguinal hernia

Caused by weakness in the floor of the inguinal canal

Most Common Site of Direct inguinal hernia

Hesselbach triangle

Risk Factors for Direct inguinal hernia

age,

obesity,

heavy lifting,

coughing (COPD, smoking),

chronic constipation,

straining,

ascites,

pregnancy,

peritoneal dialysis,

poor nutrition

Least Common Abdominal Hernia

Femoral

Femoral Hernia

intra-abdominal tissue, such as a loop of the small intestine or fatty tissue, pushes through a weakened area of the abdominal wall into the narrow femoral canal

Who tends to get femoral hernia

Women

Most Common Type of Abdominal hernia to be incarceration/strangulation

Femoral

Pantaloon hernia

both direct and indirect components

Characteristics of a Pantaloon hernia

Features both a direct sac and an indirect sac on one side.

Separated in the middle by the inferior epigastric artery and vein.

Presents as a combined bulge in the groin area

Treatment of Pantaloon Hernia

surgical repair

Spigelian hernia

Uncommon type of abdominal wall hernia where tissue or part of the intestine pushes through a weak spot in the Spigelian fascia

Spigelian fascia

Band of connective tissue sitting beside the rectus muscle

Lateral border of rectus muscle, adjacent to linea semilunaris

Where do Spigelian hernia tend to form

Below arcuate line

Treatment for Spigelian hernia

Surgically corrected

Cause of epigastric hernia

Weakening of Linea alba

Cause of umbilical hernia

Congenital

Obesity

Abdominal distension,

Pregnancy

Cause of incisional hernia

Infection,

Tension,

Technique

Diastasis Recti

Two rectus muscles are separated by an abnormal distance

Common with pregnancy

Ileus

Temporary arrest of intestinal peristalsis

Cause of Ileus

Abdominal surgery (#1)

peritoneal inflammation,

metabolic disturbances,

drugs

Presentation of Ileus

Nausea, vomiting,

vague abdominal discomfort

Minimal peristalsis and nontender abdomen unless caused by inflammation

dx of Ileus

X-ray diagnosis

May need contrast-enhanced CT to differentiate from obstruction

Ileus

tx of Ileus

NGT

IVFs,

NPO,

replace electrolytes

> 1 week, undergo laparoscopy

Intestinal obstruction

Mechanical impairment or complete arrest of passage of intestinal contents

Presentation of Intestinal obstruction

Cramping pain,

vomiting,

obstipation,

not passing flatus

dx of Intestinal obstruction

Clinical diagnosis and confirmed by abdominal x-ray

tx of Intestinal obstruction

NGT,

IVFs,

bowel rest

May need surgery (esp if complete obstruction)

Most Common Causes of Intestinal obstruction

adhesions,

hernias,

tumors

Complications of Bowel Obstruction

volume depletion

bowel ischemia,

infarction,

perforation

Patients with recurrent obstruction from adhesions should get

an NGT trial rather than immediate surgery

SBO without prior abdominal surgery often caused by

tumor

Most likely cause of bowel obstruction without previous surgery

Small bowel = hernia

Larger bowel = cancer

Most likely cause of bowel obstruction with previous surgery

Small bowel = adhesions

Large bowel = cancer

How does bowel obstruction appear on XR

Air-fluid levels

Distended loops of small bowl

Distal decompression

Large bowel obstruction

What is the threshold for dilation on XR

cecum greater than 9 cm

colon greater than 6 cm.

How does LBO appear on XR

peripheral framing with haustra that do not cross the entire lumen.

Shows an empty, gas-free distal colon or rectum

colonic distension with peripheral gas patterns.

primary definitive diagnostic tool for LBO

CT