The Physiology of Abdominal Pain PowerPoint Presentation

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Acute Abdomen and Appendix Xu Xiao M.D. Ph.D. Department of Hepatobiliary and Pancreatic Surgery The First Affiliated Hospital, College of Medicine, Zhejiang University 1

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Part Ⅰ Acute Abdomen 2

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Definition of acute abdomen Acute abdominal pain the patient feel pain anywhere between chest and groin. This is often referred to the stomach region or belly sudden, severe abdominal pain that is less than 24 hours in duration medical emergency in many cases, requiring urgent and specific diagnosis. Several causes need surgical treatment 3

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Classification Physiology of abdominal pain Diagnosis Differential diagnosis Treatment 4

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Classification Internal acute abdomen Refers to the existing medical disease which can induce abdominal pain with no surgical or gynecological indications, abdominal pain can be alleviated after existing medical disease control with the comprehensive examination and dynamic observation Such as acute myocardial infarction, acute mesenteric lymphadenitis, abdominal purpura, abdominal epilepsy, acute non-specific appendicitis Surgical acute abdomen Refers to the existing abdominal pain caused by some diseases which need surgical treatment 5

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Classification of surgical acute abdomen Peritonitis is the most specific term Five types Perforation: perforated ulcer, intestinal perforation Parenchymatous organic rupture: hepatorrhexis, splenic rupture Inflammatory: acute peritonitis, appendicitis Obstruction: intestinal obstruction Strangulation: mesenteric thrombosis 6

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The Physiology of Abdominal Pain Visceral Pain The most common form of pain Manifestation of damaged or injured internal organs Many forms of visceral pain are particularly prevalent in women and are associated with their reproductive life period pains, labour pain or postmenopausal pelvic pain For both men and women, pain of internal origin is the number one reason to consult a doctor pain 7

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Parietal Pain Corresponds to the segmental nerve roots innervating the peritoneum Tends to be sharper and better localized Caused by pneumonia; empyema; pneumothorax; tuberculosis; neoplasm; or the accumulation of fluid resulting from heart, liver, or kidney disease Aggravated by respiration and thoracic movements The Physiology of Abdominal Pain 8

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Referred Pain (sometimes referred to as reflective pain) Referred pain is a term used to describe the phenomenon of pain perceived at a site adjacent to or at a distance from the site of an injury‘s origin. One of the best examples : myocardial infarction (heart attack): pain is often felt in the neck, shoulders, and back rather than in the chest, the site of the injury surface areas of referred pain from different visceral organs The Physiology of Abdominal Pain 9

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Common Causes of Acute Abdomen Appendicitis Peritonitis Bowel Perforation Pancreatitis Diverticular disease Cholecystitis Perforating gastric/duodenal ulcer Ruptured ectopic pregnancy Ruptured or hemorrhagic ovarian cyst Pelvic inflammatory disease Abdominal aortic aneurysm Tubo-ovarian abscess 10

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Diagnosis History Physical examination Laboratory Findings Imaging studies Diagnostic laparoscopy Atypical patients 11

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History Type of onset Sudden - rupture of viscus, mesenteric thrombosis Gradual - cholecystitis, appendicitis Quality Dull - initial epigastric pain of appendicitis Sharp - renal or biliary colic or obstruction of gut Aching - pelvic inflammatory disease Pleuritic - intensified by breathing Lancinating - acute pancreatitis Tearing - dissecting aneurysm 12

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Frequency & duration History Intensity Severe - rupture of viscus or blood in the peritoneal cavity Moderate - RLQ appendiceal mild peptic ulcer, without perforation Features Pulsatile - abdominal aneurysm Continuous - acute pancreatitis Transient pain of short duration which does not recur is usually insignificant. The longer the duration the more likely a surgical condition 13

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History Factors which intensify or relieve pain Relation to meals - peptic ulcer pain relieved by food, cholecystitis pain aggravated by fatty meal Posture jack-knifing - leg drawn up to decrease peritoneal irritation in suppurative appendicitis Motion - any movement causes intense pain in generalized peritonitis and the patient lies motionless 14

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History Associated nausea and vomiting Nausea & vomiting - reflex, or irritative non-specific vomiting occurs in many conditions Such as acute appendicitis, anorexia always occurs and vomiting, if it occurs, usually follows abdominal pain rather than preceding it, as in gastroenteritis Repeated vomiting of large amounts occurs in gut obstruction, is often bile stained and may become fecal 15

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History Diarrhea Most occur with acute gastroenteritis or food poisoning May also occur with appendicitis or other focal inflammatory lesions of the gut Constipation or obstipation With complete small bowel obstruction - unrelenting constipation (obstipation) Progressive constipation with carcinoma of the large bowel Gas stoppage with decreased or absent bowel sounds - paralytic ileus 16

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Physical Examination Overall appearance ( Facial expression, diaphoresis, pallor, and degree of agitation) Inspection: scars, hernias, masses Palpation : The most critical step Tenderness Rigidity and guarding Board-like abdomen Rebounding pain 17

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Physical Examination Auscultation Hyperactive BS(bowel sound) , hypoactive BS or silent BS Percussion   Digital examination of rectum A routine part of the physical examination Check for problems with organs or other structures in the pelvis and lower belly 18

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Laboratory Findings WBC-DC (differential counting ) The total leukocyte count and percentage of polymorph nuclear cells are usually elevated in acute inflammatory conditions Whereas early in the course of intestinal obstruction there may be no significant alterations Urinalysis Blood in the urine suggest disease of the urinary tract and can also result from an inflamed appendix lying in proximity to the ureter or bladder In dehydration the specific gravity of the urine may be increased, and the red cell and hemoglobin values 19

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Amylase, lipase Serum amylase values in excess of 500 units are significant and levels of 1500-2000 units or more are not unusual in the early stages of severe acute pancreatitis. β-HCG (human chorionic gonadotrophin) – woman of childbearing age Bilirubin, ALT, AST, Alkaline phosphatase Laboratory Findings 20

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Imaging Studies Standing CXR and KUB Ultrasound for solid organs CT of abdomen for abscess, free air, vessel, tumor and ischemia bowel Angiography: Especially in non-diagnostic ischemia bowel 21

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Imaging Studies Gastric ulcer 22

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Imaging Studies 23

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Imaging Studies Pneumoperitoneum 24

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Imaging Studies Incomplete intestinal obstruction 25

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Imaging Studies Cholecystitis Pancreatitis Effusion A buildup of fluid 26

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Imaging Studies Gall stone 27

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Imaging Studies Hemorrhage of large hepatocellular carcinoma TACE (Transcatheter Arterial Chemoembolization ) 28

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Imaging Studies Biliary ascariasis 29

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Diagnostic Laparoscopy A high sensitivity and specificity Decreased morbidity and mortality Decreased length of stay Decreased overall hospital costs 30

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Atypical Patients Pregnancy Acute Abdomen in the Critically Ill Immunocompromised Patients With Acute Abdomen Acute Abdomen in the Morbidly Obese 31

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(1) Pregnancy The underlying pregnancy has symptoms similar with acute abdomen, including abdominal pains, nausea, vomiting, and anorexia Pregnancy can alter the presentation of some disease processes and make the physical examination more challenging because of the enlarged uterus in the pelvis Pregnancy can alter the laboratory findings, such as white blood cell counts Pregnancy can influence the doctor’s decision to perform typical imaging studies because of concern about radiation exposure to the developing fetus The reasons for delayed diagnosis 32

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(1) Pregnancy Most common surgical diseases seen in pregnancy Appendicitis Appendicitis is the most common nonobstetric disease requiring surgery, occurring in 1 of 1500 pregnancies Biliary tract disorders Surgery for biliary disease occurs in 1 to 6 per 10,000 pregnancies. Symptoms of pain, nausea, and anorexia are the same as in nonpregnant patients Bowel obstructions Bowel obstructions are much less common, occurring in about 1 or 2 per 4000 deliveries 33

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(2)Acute Abdomen in the Critically Ill The reasons for delayed diagnosis Many of the underlying diseases and treatments encountered in the intensive care unit can predispose to acute abdominal disease Critically ill patients are often unable to appreciate symptoms to the same degree as healthy peers because of nutritional or immune compromise, narcotic analgesia, or antibiotic use 34

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(3) Immunocompromised Patients With Acute Abdomen The reasons for delayed diagnosis Most common Immunocompromised Patients Immunocompromised patients have variable presentations with acute abdominal diseases. The variability is highly correlated to the degree of immunosuppression Elderly, malnourished, and diabetic patients Transplant recipients on routine maintenance therapy Cancer patients; renal failure patients HIV patients 35

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(4) Acute Abdomen in the Morbidly Obese The reasons for delayed diagnosis Alterations in the signs and symptoms of peritonitis in the morbidly obese Exam findings can also be difficult to confirm distention or intra-abdominal mass because of the size and thickness of the abdominal wall. Abdominal imaging is also adversely affected by obesity 36

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Effective management of acute abdominal pain involves a careful history taking, ultrasound, electrocardiography and blood tests. Computed tomography of abdominal organs and visceral vessels is probably important already at the beginning of the diagnostic work up Treatment for Acute Abdomen 37

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Treatment Algorithms (1) CT, computed tomography; NG, nasogastric tube; NL, normal study; OR, operation Algorithm for the treatment of acute-onset severe, generalized abdominal pain 38

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Treatment of gradual-onset severe, generalized abdominal pain. Treatment Algorithms (2) CT, computed tomography; ERCP, endoscopic retrograde cholangiopancreatography; LFTs, liver function tests 39

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Algorithm for the treatment of right upper quadrant abdominal pain Treatment Algorithms (3) CT, computed tomography; ERCP, endoscopic retrograde cholangiopancreatography; LFTs, liver function tests; NL, normal study; US, ultrasound. 40

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Algorithm for the treatment of left upper quadrant abdominal pain Treatment Algorithms (4) CT, computed tomography 41

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Algorithm for the treatment of right lower quadrant abdominal pain Treatment Algorithms (5) CT, computed tomography; hx, history; OR, operation; UTI, urinary tract infection 42

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Algorithm for the treatment of left lower quadrant abdominal pain Treatment Algorithms (6) CT, computed tomography 43

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Preparation for emergency operation IV access Antibiotic infusions Nasogastric tube Foley catheter bladder drainage Hydroelectrolytic equilibration Crossmatched blood available 44

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Summary Acute abdomen remains a challenging part of a surgeon's practice KEY: A patient with an acute abdomen is an EMERGENCY, and it is IMPERATIVE to get a correct diagnosis Although advances in imaging techniques, a careful history and physical examination remain the most important part of the evaluation Perform a laparoscopy or laparotomy for diagnosis with a good deal of uncertainty as to the expected findings 45

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Case Study 20-Year-Old Male with Abdominal Pain for 18 Hours Pain started in the Mid-Abdomen Constant Anorexia, Nausea, and Vomiting First Episode No Diarrhea, Dysuria Pain Now Seems Worse in the Right Lower Abdomen History 46

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Case Study Lying flat, avoids moving Afebrile Abdomen tender mostly in the RLQ Significant guarding Positive Roving's Sign Physical Exam 47

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Case Study WBC 14*109/L AST,ALT Normal Amylase, Lipase Normal Urine Culture Negative CT scan Lab Data Further Testing Diagnosis? 48

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Part Ⅱ Appendix Appendicitis Appendiceal Abscess 50

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Appendicitis Reginald Fitz first described acute and chronic appendicitis in 1886 It has been recognized as one of the most common causes of severe acute abdominal pain worldwide Appendicitis is a condition characterized by inflammation of the appendix Vermiform appendix All cases require removal of the inflamed appendix, either by Laparotomy or laparoscopy. Untreated, mortality is high, mainly because of peritonitis and shock 51

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Appendicitis Anatomy and position Pathophysiology Diagnosis Differential Diagnoses Treatment Outcome 52

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Anatomy and position Anatomy A closed-ended, narrow tube up to several inches in length that attaches to the cecum like a worm The inner lining of the appendix produces a small amount of mucus that flows through the open center of the appendix and into the cecum The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies Position The vermiform appendix has no constant position The appendix is more often found in the pelvic rather than the retrocaecal position pelvic Pre-ileal post-ileal retrocaecal Para-caecal 53

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Pathophysiology Acute appendicitis is thought to begin with obstruction of the lumen Obstruction can result from food matter, adhesions, or lymphoid hyperplasia Mucosal secretions continue to increase intraluminal pressure 54

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Pathophysiology Acute simple appendicitis Acute purulent appendicitis Acute gangrenous appendicitis 55

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Diagnosis History Physical Examination Laboratory Studies Radiography Diagnostic Laparoscopy 56

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History Primary symptom: abdominal pain Pain beginning in epigastrium or periumbilical area that is vague and hard to localize Associated symptoms: indigestion, discomfort, flatus, need to defecate, anorexia, nausea, vomiting Migration of pain from initial periumbilical to RLQ was 64% sensitive and 82% specific Anorexia is the most common of associated symptoms Vomiting is more variable, occuring in about ½ of patients 57

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Physical Examination Findings depend on duration of illness prior to exam Early on patients may not have localized tenderness With progression there is tenderness to deep palpation over McBurney’s point McBurney’s Point: just below the middle of a line connecting the umbilicus and the ASIS （anterior superior iliac spine) Rectal exam: pain can be most pronounced if the patient has pelvic appendix 58

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Physical Examination Roving's sign Pain in RLQ with palpation to LLQ A sign of appendicitis. If palpation of the lower left quadrant of a person's abdomen results in more pain in the right lower quadrant, the patient is said to have a positive Rovsing's sign and may have appendicitis 59

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Physical Examination Psoas sign Place patient in L lateral decubitus and extend R leg at the hip. If there is pain with this movement, then the sign is positive. Occasionally, an inflamed appendix lies on the Psoas muscle and the patient will lie with the right hip flexed for pain relief. 60

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Physical Examination Obturator sign Passively flex the R hip and knee and internally rotate the hip. If there is increased pain then the sign is positive If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internally rotating the hip. This maneuver will cause pain in the hypogastrium 61

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Laboratory Studies WBC The white blood cell count is elevated with more than 75% neutrophils in most patients A completely normal leukocyte count and differential is found in about 10% of patients with acute appendicitis A high white blood cell count (>20,000/mL) suggests complicated appendicitis with either gangrene or perforation Urinalysis Be helpful in excluding pyelonephritis or nephrolithiasis Microscopic hematuria is common in appendicitis Gross hematuria is uncommon and may indicate the presence of a kidney stone 62

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Radiography Plain abdominal radiographs Ultrasonography Computed tomography (CT) CT：best choice based on availability and alternative diagnoses CT：greater sensitivity, accuracy, predictive value 63

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CT scan of the abdomen or pelvis in a patient with acute appendicitis may reveal an appendicolith (arrow) CT typically shows a distended appendix (arrow) with diffuse wall-thickening and periappendiceal fluid (arrowhead) CT scanning 64

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Diagnostic Laparoscopy A direct examination of the appendix A survey of the abdominal cavity for other possible causes of pain. Primarily for women of childbearing age in whom preoperative pelvic ultrasound or CT scan 65

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Diagnostic Algorithm Algorithm for the evaluation and management of patients with possible acute appendicitis based on surgical assessment of clinical probability of the diagnosis 66

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Diagnostic Algorithm Algorithm summarizing the treatment of acute appendicitis 67

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Differential Diagnoses Two type : A: required surgery B: not required surgery Required surgery Perforation of gastrointestinal tract ulcer, tumor, diverticulitis Obstetrics and gynecologic disease: ectopic pregnancy, ovarian torsion Meckel’s diverticulitis Tumor Not required surgery Pelvic inflammation Mesenteric adenitis: at exploration a normal appendix and enlarged lymph nodes in the mesentery Viral &bacterial gastroenteritis Pneumonia, pleurisy 68

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Treatment Surgical removal of appendix is definitive treatment Incision Incision over the point of maximal tenderness,generally at McBurny point McBurney’s incision, tansvers skin incision , 3—6cm long Process The taenia of the colon are followed to the base of the appendix Mesoappendix is divided between clamps and ligated The base of appendix is divided and ligated 0.5cm from caceum and inverted using a purse-string Suspected case Admit the patient to hospital for further observation 12-24hrs 69

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Open Appendectomy (OA) Location of possible incisions for an open appendectomy Division of the mesoappendix cecum Anterior cecal artery 70

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B. Ligation of the base and division of the appendix C. Placement of purse-string suture or Z stitch D. Inversion of the appendiceal stump Open Appendectomy (OA) 71

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Location of port sites for laparoscopic appendectomy Division of the mesoappendix using the harmonic scalpel Laparoscopic Appendectomy (LA) 72

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Placement of an absorbable Endoloop encircling the base of the appendix Division of the appendix between Endoloops Placement of the appendix into a specimen bag before removal of the appendix with the umbilical port Laparoscopic Appendectomy (LA) 73

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Antibiotic thearpy The differentiation between simple appendicitis and gangrenous appendicitis/perforated appendicitis with peritonitis should determine the length of antibiotic administration 74

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Appendiceal Abscess An abscess in the peritoneal cavity resulting from the spread of infection in acute appendicitis, especially with perforation of the appendix. Also called periappendiceal abscess. Imaging studies are useful both in confirming the diagnosis and in evaluating the size of any abscess present Those patients with smaller abscesses or phlegmon and who are not sick may be successfully managed initially with antibiotics alone. Patients who continue to have fever and leukocytosis after several days of nonoperative treatment are likely to require appendectomy during the same hospitalization, whereas those who improve promptly may be considered for interval appendectomy 75

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Diagnostic Algorithm Algorithm for the management of appendiceal abscess 76

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Outcomes The mortality rate after appendectomy is less than 1%. Surgical site infections are the most common complications seen after appendectomy. Small bowel obstruction occurs in less than 1% of patients after appendectomy for uncomplicated appendicitis and in 3% of patients with perforated appendicitis who are followed for 30 years. The risk for infertility following appendectomy in childhood appears to be small. There are rare reports of appendicocutaneous or appendicovesical fistulas after appendectomy, typically for perforated appendicitis. 77

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Thanks ! 78