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Acute abdomen: | Acute abdomen: | ||
<div style="width: 85%;"> | |||
<small> | |||
{| Class="wikitable" style="border: 2; background: none;" | |||
! colspan="2" rowspan="3" |Classification of acute abdomen | |||
based on the etiology | |||
! rowspan="3" |Presentation | |||
! colspan="6" |Symptoms | |||
! colspan="8" rowspan="1" | '''Signs''' | |||
! rowspan="3" | '''Lab findings''' | |||
! rowspan="3" |Preferred diagnostic test | |||
! rowspan="3" |Additional findings | |||
|- | |||
! rowspan="2" |Fever | |||
! rowspan="2" |Jaundice | |||
! rowspan="2" |Nausea/ | |||
Vomiting | |||
! rowspan="2" |Diarrhea | |||
! rowspan="2" |Constipation | |||
! rowspan="2" |Abdominal | |||
Pain | |||
Location | |||
! rowspan="2" |General | |||
Appearance | |||
! rowspan="2" |Bowel Sounds | |||
! colspan="2" |Abdominal tenderness | |||
! rowspan="2" |Shifting dullness | |||
! rowspan="2" |Rigidity | |||
! rowspan="2" |Rebound tenderness | |||
! rowspan="2" |Shock | |||
|- | |||
!Superficial | |||
!Deep | |||
|- | |||
! rowspan="8" |Common causes of peritonitis | |||
!Primary peritonitis | |||
!Spontaneous bacterial peritonitis | |||
!✔ | |||
!✔/✘ | |||
!✔/✘ | |||
!✘ | |||
!✘ | |||
!diffuse | |||
!lies supine motionless | |||
tense abdomen due to ascites | |||
!diminished | |||
!✔ | |||
!✘ | |||
!✔ | |||
!✘ | |||
!✘ | |||
! | |||
!Ascitic fluid PMN>250cells/mm3 | |||
Single organism on culture of the ascitic fluid | |||
!ascitic fluid PMN count | |||
!Altered mental status usually seen. | |||
|- | |||
! rowspan="7" |Inflammatory disorders and perforations causing Secondary peritonitis | |||
!Perforated gastro-duodenal ulcers | |||
!✔ | |||
!✘ | |||
!✔ | |||
!✘ | |||
!✘ | |||
!right upper quadrant | |||
!Scaphoid, tense abdomen | |||
!✘ | |||
!✔ | |||
!✘ | |||
!✘ | |||
!✔ | |||
!✔ | |||
! | |||
!Fulfillment of 2/3 runyon's criteria: | |||
glucose < 50mg/dl | |||
total protein > 1g/dl | |||
LDH ascites > normal LDH serum | |||
!upright chest x-ray, CT scan | |||
! | |||
|- | |||
!Acute cholangitis | |||
!✔ | |||
!✔ | |||
!✘ | |||
!✘ | |||
!✘ | |||
!Right upper quadrant | |||
!Toxic look | |||
!normal | |||
!✘ | |||
!✘ | |||
!✘ | |||
!✘ | |||
!✘ | |||
! | |||
! | |||
!Ultrasound, CT, ERCP, MRCP, PTC | |||
!Charcot triad ( RUQ pain, jaundice,fever) | |||
Reynold pentad ( RUQ pain, jaundice,fever, confusion,shock) | |||
|- | |||
!Acute cholecystitis | |||
!✔ | |||
! | |||
!✔ | |||
!✘ | |||
!✘ | |||
!Right upper quadrant or epigastrium may radiate to the right shoulder or back | |||
! | |||
! | |||
!✔ right upper abdomen | |||
!✘ | |||
!✘ | |||
!✘ | |||
!✘ | |||
! | |||
! | |||
!Ultrasound | |||
!Murphy's sign (pain on inspiration causing a cessation of breathing) may be present | |||
|- | |||
!Acute pancreatitis | |||
!✔ | |||
! | |||
!✔ | |||
! | |||
! | |||
!midepigastrium, right upper quadrant, diffuse, or, infrequently, confined to the left side with a band-like radiation to the back | |||
! | |||
! | |||
!✔epigastrium | |||
!✘ | |||
!✘ | |||
!✘ | |||
!✘ | |||
! | |||
!Serum amylase/lipase | |||
!CT scan | |||
! | |||
|- | |||
!Acute appendicitis | |||
!✔ | |||
! | |||
! | |||
!✘ | |||
!✘ | |||
!vague periumbilical initially that eventually localises to right lower quadrant | |||
! | |||
! | |||
!✔right lower quadrant | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
!CT scan, ultrasound | |||
! | |||
|- | |||
!Acute diverticulitis | |||
!✔ | |||
!✘ | |||
!✔ | |||
!✔/✘ | |||
!✔/✘ | |||
!Left lower quadrant pain | |||
! | |||
! | |||
!✔left lower quadrant | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
!CT scan | |||
!leukocytosis | |||
|- | |||
!Acute salpingitis | |||
!✔ | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
|- | |||
! colspan="2" rowspan="4" |Hollow Viscous Obstruction | |||
!small Intestinal obstruction | |||
! | |||
! | |||
!✔ | |||
! | |||
! | |||
!periumbilical and crampy, with paroxysms of pain occurring every 4-5minutes.Pain progresses from crampy to constant and more severe indicating impending strangulation | |||
!Dissension of the abdomen | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
!Flat and upright film, CT scan | |||
! | |||
|- | |||
!Volvulus | |||
! | |||
! | |||
!✔ | |||
! | |||
!✔ in sigmoid volvulus | |||
!steady pain, with a superimposed colicky component | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
|- | |||
!Biliary Colic | |||
! | |||
! | |||
!✔ | |||
! | |||
! | |||
!right upper quadrant | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
!CT scan | |||
!hepatomegaly and a palpable gallbladder(courvoisier sign) pancreatic head tumor | |||
|- | |||
!Renal Colic | |||
! | |||
! | |||
! | |||
! | |||
! | |||
!colicky and radiates to the flank or groin | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
!Hematuria | |||
|- | |||
! rowspan="4" |Vascular disorders | |||
! rowspan="2" |Ischemic | |||
!Mesenteric ischemia | |||
! | |||
! | |||
!✔ | |||
! | |||
! | |||
!severe periumbilical pain out of proportion to physical examination findings | |||
!Soft duffy fullness | |||
! | |||
!Severe pain out of proportion to examination | |||
! | |||
! | |||
! | |||
! | |||
! | |||
!increased lactic acid and leukocytosis | |||
!Abdominal x-ray, CT Angiogram, MRI | |||
! | |||
|- | |||
!Acute ischemic colitis | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
!CT scan, | |||
Colonoscopy | |||
! | |||
|- | |||
! rowspan="2" |Hemorrhagic | |||
!Ruptured abdominal aortic aneurysm | |||
!✘ | |||
!✘ | |||
!✘ | |||
!✘ | |||
!✘ | |||
!variable depending on the location of the rupture(proximal or distal aorta) | |||
!toxic | |||
!normal | |||
!✘ | |||
!✘ | |||
!✘ | |||
!✘ | |||
!✘ | |||
!✔ | |||
!White blood cell count, fibrinogen, D-dimer, troponin T, N-terminal pro-brain natriuretic peptide, and high-sensitivity C-reactive protein | |||
!abdominal ultrasound and computed tomography (CT) of abdomen are most useful | |||
!patients presenting with abdominal/back/flank pain, hypotension, pulsatile mass should undergo emergency surgery. cullen sign(bruising around the umbilicus) | |||
|- | |||
!Intraabdominal or Retroperitoneal hemorrhage | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
!Grey turner sign(bruising in the flank) | |||
|- | |||
! rowspan="3" |Gynecologic Causes | |||
! rowspan="2" |Ovarian Cyst Complications | |||
!Torsion | |||
! | |||
! | |||
!✔ | |||
! | |||
! | |||
!lower abdominal pain | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
|- | |||
!Rupture | |||
! | |||
! | |||
! | |||
! | |||
! | |||
!focal,unilateral lower abdominal pain accompanied by light vaginal bleeding | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
! | |||
!measurement of human chorionic gonadotropin and alpha-fetoprotein | |||
!transvaginal ultrasonography | |||
! | |||
|- | |||
! colspan="2" |Ruptured Ectopic Pregnancy | |||
!✘ | |||
!✘ | |||
!✔/✘ | |||
!✘ | |||
!✘ | |||
!lower abdominal quadrant and pelvis | |||
!toxic look | |||
!normal | |||
!✘ | |||
!✘ | |||
!✘ | |||
!✘ | |||
!✘ | |||
! | |||
!urine b-hcg +, | |||
!transvaginal ultrasonography and serial testing of hCG | |||
!Amenorrhea and vaginal bleeding. | |||
|} | |||
</div> | |||
</small> | |||
{{WH}} | |||
{{WS}} |
Latest revision as of 16:24, 16 February 2017
Acute abdomen:
Classification of acute abdomen
based on the etiology |
Presentation | Symptoms | Signs | Lab findings | Preferred diagnostic test | Additional findings | |||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Fever | Jaundice | Nausea/
Vomiting |
Diarrhea | Constipation | Abdominal
Pain Location |
General
Appearance |
Bowel Sounds | Abdominal tenderness | Shifting dullness | Rigidity | Rebound tenderness | Shock | |||||||
Superficial | Deep | ||||||||||||||||||
Common causes of peritonitis | Primary peritonitis | Spontaneous bacterial peritonitis | ✔ | ✔/✘ | ✔/✘ | ✘ | ✘ | diffuse | lies supine motionless
tense abdomen due to ascites |
diminished | ✔ | ✘ | ✔ | ✘ | ✘ | Ascitic fluid PMN>250cells/mm3
Single organism on culture of the ascitic fluid |
ascitic fluid PMN count | Altered mental status usually seen. | |
Inflammatory disorders and perforations causing Secondary peritonitis | Perforated gastro-duodenal ulcers | ✔ | ✘ | ✔ | ✘ | ✘ | right upper quadrant | Scaphoid, tense abdomen | ✘ | ✔ | ✘ | ✘ | ✔ | ✔ | Fulfillment of 2/3 runyon's criteria:
glucose < 50mg/dl total protein > 1g/dl LDH ascites > normal LDH serum |
upright chest x-ray, CT scan | |||
Acute cholangitis | ✔ | ✔ | ✘ | ✘ | ✘ | Right upper quadrant | Toxic look | normal | ✘ | ✘ | ✘ | ✘ | ✘ | Ultrasound, CT, ERCP, MRCP, PTC | Charcot triad ( RUQ pain, jaundice,fever)
Reynold pentad ( RUQ pain, jaundice,fever, confusion,shock) | ||||
Acute cholecystitis | ✔ | ✔ | ✘ | ✘ | Right upper quadrant or epigastrium may radiate to the right shoulder or back | ✔ right upper abdomen | ✘ | ✘ | ✘ | ✘ | Ultrasound | Murphy's sign (pain on inspiration causing a cessation of breathing) may be present | |||||||
Acute pancreatitis | ✔ | ✔ | midepigastrium, right upper quadrant, diffuse, or, infrequently, confined to the left side with a band-like radiation to the back | ✔epigastrium | ✘ | ✘ | ✘ | ✘ | Serum amylase/lipase | CT scan | |||||||||
Acute appendicitis | ✔ | ✘ | ✘ | vague periumbilical initially that eventually localises to right lower quadrant | ✔right lower quadrant | CT scan, ultrasound | |||||||||||||
Acute diverticulitis | ✔ | ✘ | ✔ | ✔/✘ | ✔/✘ | Left lower quadrant pain | ✔left lower quadrant | CT scan | leukocytosis | ||||||||||
Acute salpingitis | ✔ | ||||||||||||||||||
Hollow Viscous Obstruction | small Intestinal obstruction | ✔ | periumbilical and crampy, with paroxysms of pain occurring every 4-5minutes.Pain progresses from crampy to constant and more severe indicating impending strangulation | Dissension of the abdomen | Flat and upright film, CT scan | ||||||||||||||
Volvulus | ✔ | ✔ in sigmoid volvulus | steady pain, with a superimposed colicky component | ||||||||||||||||
Biliary Colic | ✔ | right upper quadrant | CT scan | hepatomegaly and a palpable gallbladder(courvoisier sign) pancreatic head tumor | |||||||||||||||
Renal Colic | colicky and radiates to the flank or groin | Hematuria | |||||||||||||||||
Vascular disorders | Ischemic | Mesenteric ischemia | ✔ | severe periumbilical pain out of proportion to physical examination findings | Soft duffy fullness | Severe pain out of proportion to examination | increased lactic acid and leukocytosis | Abdominal x-ray, CT Angiogram, MRI | |||||||||||
Acute ischemic colitis | CT scan,
Colonoscopy |
||||||||||||||||||
Hemorrhagic | Ruptured abdominal aortic aneurysm | ✘ | ✘ | ✘ | ✘ | ✘ | variable depending on the location of the rupture(proximal or distal aorta) | toxic | normal | ✘ | ✘ | ✘ | ✘ | ✘ | ✔ | White blood cell count, fibrinogen, D-dimer, troponin T, N-terminal pro-brain natriuretic peptide, and high-sensitivity C-reactive protein | abdominal ultrasound and computed tomography (CT) of abdomen are most useful | patients presenting with abdominal/back/flank pain, hypotension, pulsatile mass should undergo emergency surgery. cullen sign(bruising around the umbilicus) | |
Intraabdominal or Retroperitoneal hemorrhage | Grey turner sign(bruising in the flank) | ||||||||||||||||||
Gynecologic Causes | Ovarian Cyst Complications | Torsion | ✔ | lower abdominal pain | |||||||||||||||
Rupture | focal,unilateral lower abdominal pain accompanied by light vaginal bleeding | measurement of human chorionic gonadotropin and alpha-fetoprotein | transvaginal ultrasonography | ||||||||||||||||
Ruptured Ectopic Pregnancy | ✘ | ✘ | ✔/✘ | ✘ | ✘ | lower abdominal quadrant and pelvis | toxic look | normal | ✘ | ✘ | ✘ | ✘ | ✘ | urine b-hcg +, | transvaginal ultrasonography and serial testing of hCG | Amenorrhea and vaginal bleeding. |