Health-Process-Evidence based Clinical PracticeGuidelines Acute Abdomen

Maria Cecilia T. Leyson, MD

Oliver S. Leyson, MD

Jose Maria Pingul, MD

 

Clinical Questions

1. What is an operational concept of acute abdomen?

 

Answer:any abdominal condition of acute onset from various causes involving the

intraabdominal organs that requiresimmediate/urgent intervention

 

2. What are the two general categories of acute abdomen?

Ans:  Acute Surgical abdomen

          Acute Non-Surgical Abdomen

 

3. What are reliable symptoms and signs (more than 90% certainty) that will indicate that patients with acute abdominal pain will need surgical treatment?

 

Ans: abdominal pain and tenderness with signs of peritoneal irritation

 

4. What are reliable symptoms and signs (more than 90% certainty) that a patient

has peritonitis that needs urgent celiotomy?

 

Ans: --definite (persistent, progressive) direct tenderness with at least guarding

         --abdominal rigidity

 

5. What are reliable symptoms and signs (more than 90% certainty) that a patient has

mechanical intestinal obstruction that needsurgent celiotomy?

 

Ans:

  1. Abdominal distention
  2. Fecaloid vomiting/NGT output
  3. Definite (persistent, progressive) direct
  4. Tenderness with at least guarding
  5. Abdominal rigidity

 

6. What are reliable symptoms and signs (more than 90% certainty) that a patient

has massive upper gastrointestinal bleeding that needs urgent celiotomy?

 

Ans:

  1. hemodynamic instability
  2. Massive Hematemesis/melena

 

7. What are reliable symptoms and signs(more than 90% certainty) that a patient

has massive lower gastrointestinalbleeding that needs urgent celiotomy?

 

Ans:

  1. hemodynamic instability
  2. massive hematochezia

 

8. What are reliable symptoms and signs (more than 90% certainty) that a patient with abdominal trauma needsurgent celiotomy?

 

Ans:

  1. -hemodynamic instability
  2. -definite (persistent, progressive) direct tenderness
  3. with at least guarding
  4. -abdominal rigidity

 

9. What are reliable symptoms and signs (more than 90%certainty) that a patient has perforated abdominal viscus that needs urgent celiotomy?

 

Ans:

  1. -definite (persistent, progressive) direct tenderness with at least guarding
  2. -abdominal rigidity

 

10. What are reliable symptoms and signs (more than 90%certainty) that a patient has intraabdominal abscess that needs urgent celiotomy?

 

Ans:

  1. -definite (persistent, progressive) direct tenderness
  2. with at least guarding
  3. -abdominal rigidity
  4. -fever

 

11. What are reliable symptoms and signs (more than 90%certainty) that a patient has ascending cholangitis thatneeds urgent celiotomy?

 

Ans:

  1. -RUQ abdominal (persistent, progressive)
  2. tenderness
  3. -Jaundice
  4. -Fever
  5. -Hemodynamic instability

 

12. What are reliable symptoms and signs (more than 90%occlusion that needs urgent celiotomy?

 

Ans:

-

 

 

 

13. If a paraclinical diagnostic procedure is needed in a patient with suspected peritonitis, what is the most costeffectiveprocedure?

 

Ans:

  1. -serial abdominal physical examination

 

14. If a paraclinical diagnostic procedure is needed in a patient with suspected mechanical intestinal obstruction, what is the most cost-effective procedure?

 

Ans:

  1. plain abdominal xray

 

15. If a paraclinical diagnostic procedure is needed in a patient with suspected massive upper gastrointestinal bleeding, what is the most cost-effective procedure?

 

Ans:

  1. -NGT

 

16. If a paraclinical diagnostic procedure is needed in a patient with suspected massive lower gastrointestinal bleeding, what is the most cost-effective procedure?

 

Ans:

  1. -colonoscopy

 

Endoscopy (colonoscopy or sigmoidoscopy) is the test of choice for the structural

evaluation of lower gastrointestinal bleeding. Arteriography should be reserved for

those patients with massive, ongoing bleeding when endoscopy is not feasible, or

with persistent/recurrent hematochezia when colonoscopy has not revealed a

source. There is no role for barium enema in the evaluation of acute, severe

hematochezia.

 

17. If a paraclinical diagnostic procedure is needed in a patient with suspected penetrating abdominal trauma, what is the most cost-effective procedure?

 

Ans:

  1. -wound exploration

 

18. If a paraclinical diagnostic procedure is needed in a patient with suspected perforating abdominal trauma, what is the most cost-effective procedure?

 

Ans:

  1. CXR-PA

 

 

 

 

19. If a paraclinical diagnostic procedure is needed in a patient with suspected perforated abdominal viscus, what is the most cost-effective procedure?

 

Ans:

  1. -CXR-PA

 

20. If paraclinical diagnostic procedure is needed in a patient with suspected intraabdominal abscess, whatis the most cost-effective procedure?

 

Ans:

  1. UTZ is 90 % accuracy/ cost effective
  2. CT 95% accuracy rate but not cost effective

Saber A, Intrabdominal Abscess September 2003 Or visit www.emedicine.com

 

21. If a paraclinical diagnostic procedure is needed in a patient with suspected ascending cholangitis, what is the most cost-effective procedure?

 

Ans:

  1. UTZ 95% accuracy rate

 

22. If a paraclinical diagnostic procedure is needed in a patient with suspected mesenteric vascular occlusion, what is the most cost-effective procedure?

 

Ans:

  1. CT scan diagnostic procedure of choice
  2. Duplex scan

Tessier D, William R, Mesenteric Venous Thrombosis Emedicine Instant Acsess in the minds of medicine

Dec 2002. www.emedicine.com

 

TREATMENT GOALS

23. What is the most cost-effective operative treatment (or principles of

surgical operative) for the following: Spell out the goal of treatment

before the principles and the choice.

  1. Peritonitis
  2. Mechanical intestinal obstruction
  3. Massive upper gastrointestinal bleeding
  4. Massive lower gastrointestinal bleeding
  5. Penetrating and perforating abdominal trauma
  6. Blunt abdominal trauma
  7. Perforated abdominal viscera
  8. Abdominal abscess
  9. Ascending cholangitis
  10. Mesenteric vascular occlusion

 

 

 

TREATMENT GOALS

Peritonitis

-          • Identification of cause

-          • Control the infection

1. Laparotomy

2. Peritoneal lavage

3. adequate antibiotic coverage

 

Mechanical intestinal obstruction

• Identification of cause

• Relieve the obstruction

• Restore bowel continuity (if stable)

• Massive upper gastrointestinal bleeding

• Identification of cause

• Control the bleeding

1. Laparotomy

2. Peritoneal lavage

 

Massive lower gastrointestinal bleeding

1. Laparotomy

2. Peritoneal lavage

 

Penetrating and perforating abdominaltrauma

• Identification of cause

• Control the infection/ perforation/bleeding

• Restore bowel continuity

1. Laparotomy

2. Peritoneal lavage

 

Blunt abdominal trauma

• Identification of cause

• Control the infection / bleeding

1. Laparotomy

2. Peritoneal lavage

• Repair injury (depend on severity and

affected organ)

 

Perforated abdominal viscera

• Identification of cause

• Control the infection

1. Laparotomy

2. Peritoneal lavage

3. adequate antibiotic coverage

• Restore bowel continuity

Abdominal abscess

• Identification of cause

• Control the infection

1. Laparotomy

2. Peritoneal lavage

3. adequate antibiotic coverage

 

Ascending cholangitis

• Decompression

• Relief of the obstruction (if patient is stable / cause can be identified)

• Control the infection

 

Mesenteric vascular occlusion

• Identify the underlying cause of the patients hypercoagulable state

Massive upper gastrointestinal bleeding and lower gastrointestinal bleeding

 

Goals of management

  1. resuscitation and stabilization
  2. (preventing exsanguination)
  3. identifying the anatomic level of
  4. bleeding diagnosing the cause
  5. providing specific therapy

 

24. What is the best timing for an emergency celiotomy?

 

Ans: upon diagnosis and optimization of patient usually within 6 hours

 

25. What is a rational use of antibiotics in acute surgical abdomen?

 

 

26. What is a rationale use of bowel preparation preop?

  1. To decrease the fecal/microbial load
  2. None

Baucher P, Mermillod B, Morel P, Soravia C, Does mechanical bowel obstruction have a role in preventing postoperative complications in elective colorectal surgery? Swiss Med Weekly 2004 134:69-74

 

27. What are the indications for intraabdominal drain after the abdominal

procedure?

  1. Intrabdominal drains are used as asignal drain

 

28. What is/are the most cost-effectiveprocedure in preventing celiotomy

wound infection?

 

Ans: partial wound closure

 

 

 

29. What is/are the most cost-effectiveprocedure in preventing intestinal

anastomotic leak?

 

30. What is/are the most cost-effective procedure in preventing postop

intraabdominal abscesses?

–Adequate abdominal exploration

–avoidance of retention or pockets of abscess

–Good technique in hand tying and suturing

 

31. What is/are the most cost-effective procedure in preventing abdominal

wound dehiscence?

– Proper surgical technique

– Correct apposition of fascia withadequate margins

– Continuous absorbable monofilament

 

32. What is/are the parameters to use in adequate peritoneal lavage?

– Clear peritoneal fluids

– No retained intraabdominal abscess