Acute Abdomen & Peritonitis

What condition is primary peritonitis commonly seen with?

*Cirrhosis*, advanced liver disease, nephrotic syndrome, SLE

What is included in pre-op management after the initial assessment?

*Resuscitation*: give fluids. Give pain meds: even if going the route of observation w/ serial exam. ABX. NGT: if distended abdomen or vomiting. Foley catheter. Prepare people for the worst: warn them of the possibility of the bag.

How do you dose Colase?

100 mg PO BID for constipation

How do you dose IV morphine?

2-4 mg IV q 2 hr PRN pain

How do you dose Vicodin (APAP + hydrocodone)?

5/300 1 tablet PO q 4-6 hr PRN pain. If you say to take 2 tablets, then specify q 6hr or 1 tablet q 4 hr.

How do you dose Percocet (APAP + oxycodone)?

5/325 1 tablet PO q 4-6 hr PRN pain

How do you dose Zofran?

8 mg SL or IV q 6 hr PRN nausea

What is spontaneous bacterial peritonitis?

A type of primary peritonitis. >90% are caused by mono-microbial infection and you treat with ABX, not surgery. You can diagnose based on peritoneal fluid analysis for C&S. Imaging will show free fluid without free air. This clinically looks like secondary peritonitis.

How do you treat secondary peritonitis?

ABX: broad range and modify post-op after C&S are available. Continue these until patient has remained afebrile with normal WBC. Surgical correction of cause of peritonitis.

What is one of the most frequent reasons for out-patient ER visits?

Abdominal pain

What imaging should you get for acute abdomen?

Abdominal x-ray: flat and upright w/ a PA and upright CXR to look at bowel gas pattern and free air. Abdominal US: GB. Pelvic US: ectopic pregnancy, ovarian cyst, PID, torturous ovary. *CT scan of abdomen AND pelvis*: look at all organs for abscess, free air, fluid, mass, pneumotosis - *GOLD STANDARD*

What are important considerations when working up an acute abdomen?

Accurate and complete H&P to guide the choice of initial diagnostic studies. Try to hold analgesics until after the initial evaluation is done. Serial exams by the same provider are important for the patients that don't go directly to the OR

What are *local* findings of peritonitis?

Acute Abdomen. Abdominal tenderness. Rebound tenderness. Guarding. Rigidity. Distension. Diminished bowel sounds. Free air

What are causes of gradual, steady abdominal pain?

Acute cholecystitis, acute cholangitis, acute hepatitis, appendicitis, acute salpingitis, diverticulitis.

What are causes of rapid onset of severe, constant abdominal pain?

Acute pancreatitis, mesenteric thrombosis, strangulated bowel, ectopic pregnancy.

What does costovertebral angle tenderness indicate?

Acute pyelonephritis

What should be included in the past surgical history info?

Ask if they have: gallbladder (doesn't rule out CBD stones), appendix (doesn't rule out appendicitis), uterus, ovaries. History of ruptured viscous or peritonitis? Mode of operations? Complications with anesthesia?

What should you have done before getting an outpatient surgeon consult?

Basic, initial workup should be complete including US (radiographs), and LFTs for possible chronic cholecystitis.

What are causes of abrupt, excruciating abdominal pain?

Biliary colic, ureteral colic, MI, perforated ulcer, ruptured aneurysm.

What conditions are associated with pain onset in *hours*?

Biliary disease, appendicitis, diverticulitis, SBO, PUD

What organs are possibly affected if you have epigastric pain?

Biliary, cardiac, gastric, pancreas, esophagus, vascular

What type of meds are important to consider for a surgical abdomen case?

Blood thinners, ASA, NSAIDs (GI bleed, perf ulcer), OCP (ectopic, clotting, hepatic adenoma), steroids (infection, blunt inflammation, less severe pain aka blunted presentation)

What conditions can present as generalized abdominal pain?

Bowel obstruction, mesenteric ischemia, peritonitis, sickle cell crisis

What labs may be included in an abdominal pain workup?

CBC w/ diff, serum electrolytes, BUN & creatinine, liver panel, amylase/ lipase, pregnancy test, UA, cardiac enzymes, lactic acid, ABGs, clotting studies, stool studies.

What labs should you get for peritonitis?

CBC w/ diff. Cross-match. ABG and electrolytes. BUN & Creatinine. Blood clotting profile. Liver and renal function tests. Blood and urine cultures before starting ABX. Peritoneal fluid before starting ABX if possible.

What are different "general conditions" we might observe patients in?

Calm, writhing, bending forward, rigidly motionless (peritonitis) or diminished responsiveness

What causes secondary peritonitis?

Can occur after perforation, inflammatory, infectious or ischemic injuries of the GI or GU systems. It results from bacterial contamination from within the viscera or from external sources like trauma. Ex: appendicitis, perforated gastroduodenal ulcers, acute salpingitis, diverticulitis, bowel perforation, trauma, ischemic bowel, acute necrotizing pancreatitis.

What organs are possibly affected if you have left upper quadrant pain?

Cardiac, gastric, colon, pancreatic, renal, vascular, splenic, pulmonary

What organs are possibly affected if you have umbilical pain?

Colonic, gastric, vascular

What organs are possibly affected if you have suprapubic pain?

Colonic, gynecologic, renal

What organs are possibly affected if you have left lower quadrant pain?

Colonic, gynecologic, renal, rectus sheath hematoma

What organs are possibly affected if you have right lower quadrant pain?

Colonic, gynecologic, renal, rectus sheath hematoma (can come from anticoagulants)

How should we order a CT scan of the abdomen and pelvis?

Contrast or no contrast. PO vs IV vs both PO would differentiate between bowel and abscess. IV would enhance the wall of the abscess.

What meds can be put in a PCA?

Dilaudid (heavy duty), morphine, fentanyl (peds)

What causes visceral pain?

Distention and stretch of organs is the primary signal for pain. Mediated by autonomic nerves: sympathetic and parasympathetic. Receptors for visceral pain are located in the mucosa or muscularis in hollow visceral and visceral peritoneum. Location corresponds to dermatomes.

What are signs of intestinal obstruction?

Distention, visible peristalsis (late), hyperperiastalsis early on and then quiet abdomen later, diffuse pain without rebound tenderness, hernia or rectal mass in some.

What are signs of paralytic ileus?

Distention; minimal bowel sounds; no localized tenderness

What are causes of intermittent, colicky abdominal pain with crescendo free intervals?

Early pancreatitis (rare), small bowel obstruction, inflammatory bowel disease

What do you inspect for in the abdominal exam?

Expose from the nipples to below the inguinal region to look for: distention, scar (correlate w/ PSH?), scaphoid and contracted, visible peristalsis, masses or hernias

What are *systemic* findings associated with peritonitis?

Fever, chills, rigors, tachycardia, diaphoresis, tachypnea, restlessness, dehydration, oliguria, disorientation, shock

What are the general categories of the physical exam?

General condition. Systemic signs. Vitals. HEENT exam. Cardiac exam: afib. Pulmonary exam: lower lobe pneumonia. Skin exam: yellowing. Extremity exam. GU exam. Rectal exam. Inspection, Auscultation, Palpation, Percussion. Coughing to elicit pain. Specific signs noted.

What should you palpate the abdomen for?

Hernias, involuntary guarding or rebound tenderness indicating peritoneal inflammation. Begin exam away from area of cough tenderness and work toward it.

What conditions can present as pain anywhere on the abdominal wall?

Herpes zoster, muscle strain, hernia

What are vital signs that might indicate that an abdominal pain patient is unstable and may need surgery?

Hypotensive, tachycardia, tachypnea, febrile

What conditions are associated with pain onset in *days*?

IBD

What should you do pre-op for secondary peritonitis?

IVF to replace massive transfer of fluid into peritoneal cavity. Consider central venous catheter. May need cardiovascular agents. May need mechanical ventilation. Start empiric ABX. Consider arterial line.

What is angiography used for in acute abdomen?

Identify mesentaric ischemia and identify and possibly stop bleeding.

What does bump tenderness over the lower costal ribs indicate?

Inflammatory condition affecting the diaphragm, liver, spleen or adjacent structures.

What does pain in the shoulder indicate?

Irritation of the diaphragm by blood, pus, gastric contents, or stool.

What questions should you ask yourself before getting an inpatient surgery consult?

Is patient sick or not? Is diagnosis medically or surgically managed? Who do you consult first? Have you done work-up needed for them to properly assess patient?

What type of infection is seen with fecal spillage and secondary peritonitis?

It can be associated w/ a bacterial load of 10^12 or more of organism. Most commonly gram negative and anaerobic bacteria: E. coli, Strep proteus, Enterobacter, Klebsiella, Bacteroides fragilis, cocci and clostridia

What is the omentum and what role does it play in peritonitis?

It is a well-vascularized, pliable, mobile double fold of peritoneum and fat that is involved in control of peritoneal inflammation and leaking viscus or area of infection. Peritonitis is the inflammatory or suppurative response of this peritoneal lining to a direct irritant.

What is Kehr sign?

Left shoulder pain associated with hemoperitoneum

What should you percuss the abdomen for?

Listen for tympanic vs dull sound. Tympanic indicates air (possibly obstruction) and dull indicates fluid (ascites or bowel obstruction). Tenderness on percussion.

What should be included in the HPI for abdominal pain?

Location of pain at onset and presentation. Radiation. Quality of pain at onset and presentation. Severity of pain at onset and presentation. Duration of Pain. *Rate of onset and progression of pain*: Explosive (within sec), rapidly progressive (1-2 hr), gradual (over several hrs). Constant or Intermittent pain. Timing. Context. Modifying Factors (better/worse): including response to narcotics in ED. Associated sx: N/V and which came first pain or sx? (more worrisome if pain comes first; if V first, think gastritis) Loss of appetite, diarrhea, constipation/obstipation, bloating Signs or symptoms of jaundice.

What should you look for in the HEENT exam?

Lymph nodes and sclera color for any jaundice

What causes parietal pain?

Mediated by somatic nerves. Direct irritation of parietal peritoneum by pus, bile, blood, urine, and GI secretions. This leads to more precisely localized pain.

What should be included in PMH for abdominal pain?

Meds. Allergies. Complete medical history: past surgical history, cardiac issues (CAD, afib), pulmonary issues, GI issues (IBD, PUD), GYN issues (STD, menstruation), Diabetes. Social history: travel. Family history: IBD, sickle cell, AAA. Alcohol, drugs, tobacco. Pregnancy. *At very least get AMPLE

What is parietal pain?

More intense, acute, sharp and better localized. AKA somatic pain

Would coughing elicit pain from colic?

No, because colic is more of a visceral pain

What are signs of ischemic or strangulated bowel?

Not distended until late, variable bowel sounds, severe pain but little tenderness, rectal bleeding in some.

What is referred pain?

Noxious sensations perceived at a site distant from that of a strong primary stimulus. It usually arises from a deep structure. Example: shoulder pain after laparoscopic surgery from trapped gas under the diaphragm

What is Rovsing's sign?

Pain at McBurney's point with palpation of LLQ. This is associated with acute appendicitis.

What is Murphy's sign?

Pain at right upper quadrant with inspiration causes patient to cease inspiration. This might indicate an inflamed gallbladder.

What is spreading/ shifting pain?

Pain that parallels the course of the underlying condition like appendicitis pain moving from periumbilical to RLQ. Visceral pain shifting to parietal pain indicates extension of underlying process. This is why we should ask about pain at onset vs during presentation.

What is Iliopsoas sign?

Pain when hip passively extended or actively flexed against resistance. This might indicate a psoas abscess.

What are the different peritoneal signs?

Pain with bed bump, push w/ stethoscope, shake pelvis from side to side, rebound tenderness, involuntary guarding, rigidity. If intra-abdominal catastrophe is the cause of the peritonitis, light palpation is all you need.

What is the obturator sign?

Pain with internal rotation of the flexed thigh. This may indicate an obturator hernia where a loop of bowel is caught in obturator canal.

What are possible systemic signs seen with abdominal pain?

Pallor, coolness, tachypnea, diaphoresis

What are signs of GI bleed?

Pallor, shock, distention, pulsatile (aneurysm) or tender (ectopic) mass, rectal bleeding in some.

What are signs of peritonitis?

Patient laying motionless, absent bowel sounds (late sign), cough and rebound tenderness, guarding or rigidity

What conditions are associated with pain onset in *minutes*?

Perforated viscera, testicular or ovarian torsion, ruptured AAA, ectopic pregnancy, pancreatitis, mesenteric ischemia

What should you auscultate the abdomen for?

Peristaltic rushes or a silent abdomen

What PE findings mean you should consult a surgeon?

Peritonitis, incarcerated hernia, tender abdomen w/ high fever or hypotension, suspected ischemia. Any radiographic findings that may require surgery. If you completely work-up a stable patient but are unable to come to a definitive diagnosis.

What is a nickname for the omentum?

Policeman of the abdomen

What are the different anatomic regions of the abdomen?

RUQ, LUQ, RLQ, LLQ. Periumbilical, epigastric, suprapubic/pelvic

What should you look for with the rectal exam?

Rectal tenderness, masses, abscess, blood or occult blood

What are the signs of a perforated viscus?

Scaphoid, tense abdomen, diminished bowel sounds (late sign), loss of liver dullness, guarding or rigidity

What is visceral pain and what causes it?

Slow onset of deep, generalized, dull, poorly localized and protracted pain. Typically caused by organ swelling (stretching)

What is an acute abdomen?

Sudden, severe abdominal pain that may be benign/ self-limited or a surgical emergency.

What does referred pain feel like?

Superficial, sharp, localized and persistent. Usually arises from a deep structure.

What are signs of an inflammed mass or abscess?

Tender mass (abd, pelvic, rectal), bump tenderness, special signs: Murphy's, obturator, psoas

What causes peritonitis?

The peritoneal cavity is normally sterile but it can dispose of a small number of bacteria. Peritonitis occurs if this defense mechanism is overwhelmed by massive or continued contamination.

What do you think about if patient is writhing around in terrible pain, but your exam does not correlate with this type of pain?

Think mesenteric ischemia which is an emergent surgical case.

What is primary peritonitis?

This occurs in the absence of GI perforation and is usually caused by hematogenous spread but can occasionally be transluminal or direct bacterial invasion.

What would localized pain with coughing indicate?

This would be a type of peritoneal pain

What are invasive studies we can order for acute abdomen?

Upper endoscopy (EGD). Colonoscopy: colon and termnial ileum. Angiography. Paracentesis (needle into abd cavity on someone with ascites for fluid aspiration). Diagnostic laparoscopy. Exploratory laparotomy.

What does secondary peritonitis d/t a perforated PUD look like?

Usually no bacteria in the first 12 hrs. The initial peritonitis is d/t chemical irritation. After 12 hrs you can have gram positive, gram negative or possibly fungal infection.

What organs are possibly affected if you have right upper quadrant pain?

biliary, colon, hepatic, pulmonary, renal