Priorities in Evaluation of the Acute Abdomen

1

What is the surgeon’s responsibility when confronted by a patient with an acute abdomen?

• a.

  To identify how sick the patient is (treat the patient first and then the disease).

• b.

  To determine whether the patient (1) needs to go directly to the operating room, (2) should be admitted for resuscitation or observation, or (3) can be sent safely home.

2

What is the most dangerous course in a patient with an acute abdomen?

To send the patient home.

3

Is it important to make the diagnosis in the emergency department?

No. Frequently time spent confirming a diagnosis in the emergency department (ED) is lost to in-hospital resuscitation or treatment in the operating room. The only patient who needs a relatively firm diagnosis is a patient who is to be sent home.

4

If the essential goal is not to make the diagnosis, what should the surgeon do?

• a.

  Resuscitate the patient. Most patients do not eat or drink when they are getting sick. Most patients are depleted of at least several liters of fluid. Fluid depletion is worse in patients with diarrhea or vomiting.

• b.

  Start a big intravenous (IV) line.

• c.

  Replace lost electrolytes (see Chapter 8 ).

• d.

  Insert a Foley catheter.

• e.

  Examine the patient (frequently).

5

Are symptoms and signs uniquely misleading in any groups of patients?

Yes. Watch out for the following groups:

• The very young, who cannot talk.

• Diabetics because of visceral neuropathy.

• The very old, in whom, much as in diabetics, abdominal innervation is dulled.

• Patients taking steroids, which depress inflammation and mask everything.

• Patients with immunosuppression (a heart or kidney transplant patient may act cheerful even with dead or gangrenous bowel).

6

Summarize the history needed

• a.

  The patient’s age. Neonates present with intussusception; young women present with ectopic pregnancy, pelvic inflammatory disease, and appendicitis; the elderly present with colon cancer, diverticulitis, and appendicitis.

• b.

  Associated problems. Previous hospitalizations, prior abdominal surgery, medications, heart and lung disease? An extensive gynecologic history is valuable; however, it is probably safer to assume that all women between 12 and 40 years old are pregnant.

• c.

  Location of abdominal pain.

  • i.

    Right upper quadrant: Gallbladder or biliary disease, duodenal ulcer

  • ii.

    Right flank: Pyelonephritis, hepatitis

  • iii.

    Midepigastrium: Duodenal or gastric ulcer, pancreatitis, gastritis

  • iv.

    Left upper quadrant: Ruptured spleen, subdiaphragmatic abscess

  • v.

    Right lower quadrant: Appendicitis (see Chapter 39 ), ectopic pregnancy, incarcerated hernia, rectus hematoma

  • vi.

    Left lower quadrant: Diverticulitis, incarcerated hernia, rectus hematoma

Note: Cancer, unless it obstructs (colon cancer), and is bleeding (diverticulosis) typically does not hurt.

• d.

  Duration of pain. The onset of the pain of a perforated duodenal ulcer or perforated sigmoid diverticulum is sudden, whereas the pain of pyelonephritis is gradual and persistent. The pain of intestinal obstruction is intermittent and crampy.

Note: Although the surgeon is rotating through a gastrointestinal (GI) service, the patient may not know this and may present with urologic, gynecologic, or vascular pathology.

7

Are vital signs important?

Yes. They are vital. If heart rate (HR) and blood pressure (BP) are on the wrong side of 100 (heart rate >100 beats/min, systolic blood pressure <100 mm Hg), watch out! Tachypnea (respiratory rate >16) reflects either pain or systemic acidosis. Fever may develop late, particularly in the immunosuppressed patient who may be afebrile in the face of florid peritonitis.

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