Acute Abdomen with Case

00:01 Welcome. Today we'll discuss diseases of the peritoneum.

00:04 So we'll start with a case.

00:07 A 38-year-old man with no past medical history presents to the emergency department with four hours of severe right lower quadrant abdominal pain.

00:16 The night before, he noticed a dull ache around his umbilicus.

00:20 The pain steadily worsened and is now associated with nausea and vomiting.

00:25 Vitals are notable for temperature of 39.2, heart rate 125 and blood pressure 92/50.

00:33 Physical exam reveals diffused tenderness to palpation throughout the abdomen with rebound and involuntary guarding.

00:41 Lab studies reveal a white cell count of 18,000 and lactate 3.1.

00:46 Bedside ultrasound shows peritoneal fluid in the right lower quadrant.

00:51 So, what is the best next step in management? Let's point out some key features here.

00:58 He has had periumbilical pain that then progressed to acute severe right lower quadrant pain.

01:05 He does have signs of sepsis with his temperature of 39, his tachycardia and his relative hypotension.

01:15 He also has physical exam findings that are suggestive of an acute abdomen.

01:20 In addition, his labs are somewhat concerning.

01:24 So he has a leukocytosis with an elevated lactase.

01:28 So, let's talk a bit about the acute abdomen.

01:32 The acute abdomen is what we call the condition when patients have peritonitis.

01:37 They may come in with unstable vital signs.

01:41 They will often have abdominal rigidity or involuntary guarding upon palpation of the abdomen.

01:48 They may have rebound tenderness which is when letting go of palpation causes more pain than palpation itself.

01:56 And they may have pain that worsens with any minimal movement.

02:01 So, a typical physical exam finding that I find to be most helpful is when you bump the bed that the patient is on and they -- if they have extreme pain with just that minimal movement, you can suspect that they have the acute abdomen.

02:16 It's important to remember that the acute abdomen is an emergency.

02:22 If you're concerned for any of these physical exam findings that we just described, you should emergently talk to surgery for surgical exploration.

02:31 One of the most common causes of the acute abdomen is acute appendicitis.

02:36 This happens when there is inflammation of the appendix which is a vestigial organ.

02:42 It often occurs from obstruction from a fecalith.

02:46 Patients classically present with right lower quadrant pain that begins around the umbilicus and then migrates to the right lower quadrant pain.

02:54 However, note this is not always present.

02:56 They may often have a lack of appetite or anorexia, nausea and vomiting, and they may have fevers and chills if this is a late presentation of appendicitis or if they have developed perforation.

03:09 So, there are several physical exam maneuvers that you will frequently be tested on in relation to acute appendicitis. The first is McBurney's point.

03:19 This is the point we use to describe maximal tenderness about one third the distance from the anterior superior iliac spine measured to the umbilicus.

03:30 You may also do a maneuver called Rovsing's sign.

03:35 This is when palpation of the left lower quadrant elicits pain in the patient's right lower quadrant.

03:42 Another exam maneuver you may check is the Psoas sign.

03:47 This is when you passively flex the patient's right hip and this elicits right lower quadrant pain.

03:53 Alternatively, you can do the obturator sign which is when you flex and internally rotate the patient's right hip which then elicits right lower quadrant pain.

04:05 These latter two findings work because they bring the inflamed appendix against the muscle that is named in each side and thus elicits pain in that area.

04:16 So, although you will often hear this on tests, Rovsing's, psoas and obdurator signs are actually poorly sensitive, clinically speaking when looking for acute appendicitis.

04:28 But if you happen to find one of them, they are highly specific for appendicitis, so can be helpful.

04:34 So now let's get to the diagnosis of this disease.

04:39 The diagnosis depends mostly on imaging. CT abdomen is the preferred method of diagnosis.

04:45 Here, you can see an example of a CT abdomen showing an inflamed appendix where the arrow is.

04:52 And this patient also incidentally has an abdominal aortic aneurysm as labeled by the AAA.

04:58 This is probably unrelated to this current presentation.

05:02 For those patients who -- in whom you are trying to avoid radiation exposure, you might do an ultrasound or MRI.

05:10 In addition, now, point of care ultrasound at the bedside is becoming more and more frequently used and can provide a rapid evaluation.

05:20 If you detect free fluid in the pelvis, you might suspect acute appendicitis.

05:25 So, treatment depends on whether it is perforated or non-perforated.

05:31 Once you have perforation, this is an emergency and requires exploratory laparotomy and appendectomy.

05:37 Nonperforated appendicitis can be treated with immediate appendectomy.

05:43 And in certain cases in which surgical risk is too high, you may do intravenous antibiotics and do percutaneous drainage of the abscess.

05:55 So now let's return to our case.

05:59 A 38-year-old man coming in with periumbilical pain that then progressed to severe right lower quadrant pain should prompt you to think about appendicitis.

06:09 He has signs of sepsis, so that's -- he meets SIRS criteria with a known source.

06:15 He has a physical exam signs concerning for an acute abdomen.

06:19 And his high white count with elevated lactate should prompt you to think about perforated appendicitis.

06:25 So the best next step in management would be an emergency surgical consultation for surgical exploration and washout of the abdomen.