© Springer International Publishing Switzerland 2016
Abe Fingerhut, Ari Leppäniemi, Raul Coimbra, Andrew B. Peitzman, Thomas M. Scalea and Eric J. Voiglio (eds.)Emergency Surgery Course (ESC®) Manual10.1007/978-3-319-21338-5_22. Leading Symptoms and Signs
(1)
Department of Surgery, Hospital General Universitario Gregorio Marañón, Madrid Head of General Surgery II and Emergency Surgery, University General Hospital Gregorio Marañón, Madrid, Spain
2.1 Generalities
2.2.1 Perforated Appendicitis
2.2.2 Colonic Perforation
2.3.2 RUQ Pain
2.3.3 LUQ Pain
2.3.4 Pain in the Hypogastrium
2.3.5 RLQ Pain
2.3.6 LLQ Pain
2.4.3 Other
2.8 Summary
Objectives
Categorize different abdominal clinical conditions in relation to the characteristics of the pain and the presence or absence of tenderness
Describe other symptoms and signs leading to acute surgical intervention
Describe the specifics of clinical diagnosis in the postoperative abdomen
2.1 Generalities
Acute abdominal pain accounts for up to 50 % of emergency surgery consultations.
All abdominal crises present with one or more of five main symptoms or signs:
Pain (often alone and inaugural)
Vomiting
Abdominal distension
Muscular rigidity
Shock
The severity and the order of occurrence of the symptoms are important for diagnosis, together with the presence or absence of fever, diarrhea, constipation, and others.
The presence of tenderness on palpation is a hallmark of potential acute abdominal problem of surgical importance, and it generally implies inflammation of the visceral peritoneum.
May be accompanied or not by muscular rigidity (defense guarding or guarding).
Several grades (maximum: boardlike rigidity typical of perforated ulcer).
Usually implies inflammation of the parietal peritoneum.
Sometimes, it takes a great deal of clinical acuity and experience to differentiate between voluntary and involuntary guarding. In the past (pre-CT-scan era), errors with this distinction have led to numerous unnecessary abdominal explorations.
Clinical expertise should not be replaced by easy availability of ultrasound (US) and CT scan; the latter is complementary and may sometimes be lacking.
2.2 Acute Generalized Abdominal Pain with Tenderness
Generalized peritonitis consists of:
Diffuse severe abdominal pain
Patient:
Who looks sick and toxic
Typically lies motionless
Has a tender abdomen with “peritoneal signs” (rebound tenderness, defense guarding, or boardlike rigidity)
The three most common causes of generalized peritonitis in adults are:
Perforated appendicitis
Colonic perforation
Perforated duodenal ulcer
An occasional patient with acute pancreatitis may present with a clinical picture mimicking diffuse peritonitis.
2.2.1 Perforated Appendicitis
Typical history: midabdominal visceral discomfort, shifting to the RLQ and becoming a somatic, localized pain, with rapid generalization and diffuse tenderness
Sometimes inaugural
Otherwise after a slow but rapid, progression
2.2.2 Colonic Perforation
The most common causes:
Colonic malignancy
The tumor (usually rectosigmoid)
Distension upstream from malignant obstruction (usually cecum)
Often after several days of unrelieved complete obstruction in a patient with a competent ileocecal valve. Presenting symptoms include tenderness of the abdomen on the right side (sign of impending perforation) and history of previous abdominal distention associated with recent onset of constipation and lack of flatus.
Peritoneal irritation and tenderness are usually diffuse.
Acute sigmoid diverticulitis.
Peritonitis is diffuse in large, non contained perforations, with free intraperitoneal gas on abdominal X-ray or CT.
2.2.3 Perforated Gastroduodenal Ulcer
Incidence has decreased drastically, with some exceptions in socioeconomically disadvantaged populations worldwide.
In the Western world, perforated duodenal ulcers (DUs) are much more common than perforated gastric ulcers (GUs), presenting at times without a previous history of peptic ulcer disease.
Signs and symptoms vary according to the time which has elapsed since perforation
Classically:
Abdominal pain
Intense.
Of sudden onset.
Located in upper abdomen.
Accompanied most often by signs of diffuse peritoneal irritation and tenderness.
May mimic acute appendicitis if spillage of gastroduodenal contents along the right gutter.
May be associated with pain on the top of the shoulder (Kehr’s sign).
The finding of “coffee ground” or fresh blood in the NG tube suggests the possibility of kissing ulcers – the anterior perforated, the posterior bleeding.
Patients:
Restless
In great pain
Have boardlike abdomen
Investigations:
Free gas under the diaphragm in about two-thirds of perforated patients, best seen on an upright chest X-ray
Differential diagnosis
Acute pancreatitis
In the absence of free air, marginal elevation of amylase (perforated ulcer can cause hyperamylasemia).
Abdominal CT scan is excellent at picking up minute amounts of free intraperitoneal gas and free peritoneal fluid.
Acute perforative appendicitis
Ruptured ectopic gestation
Acute intestinal obstruction
Diffuse peritonitis from other causes (perforated gallbladder with bile peritonitis among other more rare causes)
2.3 Localized Abdominal Pain with Tenderness (Epigastric, Umbilical, RUQ, LUQ, Hypogastric, RLQ, and LLQ)
Pain and tenderness are not always over the site of disease.
Initial pain of appendicitis may be epigastric or umbilical.
Obstructive pain arising from the transverse colon may be hypogastric.
Golden rule: examine the patient again within 2 or 3 h.
In nearly every serious case, other symptoms (such as vomiting, fever, or local tenderness, pointing more definitely to the nature of the lesion) may then be found
2.3.1 Periumbilical and Epigastric Pain
Uncommon in the absence of incarcerated umbilical hernia and omphalitis
May be due to:
Simple intestinal or biliary colic
Initial stage of small bowel obstruction
Acute pancreatitis
Or even initial stages of acute cholecystitis
2.3.2 RUQ Pain
If the chest is clear (no right basal pneumonia):
Calculous acute cholecystitis (AC)
The most common cause.
RUQ pain and tenderness (Murphy’s sign) are accompanied by systemic evidence of inflammation (fever, leukocytosis) and usually by a mild or moderate elevation of bilirubin or liver enzymes, sometimes also mild elevation of the serum amylase.
Diagnosis is usually confirmed with US.
Intramural gas, and gas within the gallbladder lumen (acute emphysematous cholecystitis), typical of AC in diabetic patients can also be seen on abdominal X-ray.
Acute Cholangitis
Characterized by Charcot’s triad (RUQ pain, fever, and jaundice).
Disproportionate pain may be due to coexisting AC.
Can progress to include confusion and septic shock (Reynold’s pentad) in the elderly patient, or when medical intervention is delayed.
Typical biochemical panel shows mildly elevated transaminases, variably elevated total bilirubin with a direct preponderance, and a disproportionately elevated alkaline phosphatase and glutamyl transferase.
Diagnosis usually confirmed by US, which, besides gallstones in the gallbladder, usually demonstrates mild intra- and extrahepatic ductal dilatation.
If no gallstones are seen, malignant periampullary biliary obstruction must be suspected.
Pyogenic liver abscess, amoebic liver abscess (in tropical climates), and hydatid disease (endemic regions) may give rise to similar signs and symptoms.
Acute Acalculous Cholecystitis
Manifestation of the disturbed microcirculation in critically ill patients.
Fever, jaundice, leukocytosis, and disturbed liver function tests are commonly present but are entirely nonspecific.
Pain may be minimal or difficult to discern because of patient status.
Early diagnosis requires a high degree of suspicion in patient with otherwise unexplained septic state or SIRS.
2.3.3 LUQ Pain
Rare
LUQ contains tail of the pancreas, fundus of the stomach, spleen and its blood vessels, splenic flexure of the colon, and upper pole of the left kidney, each of which may on occasion cause acute abdominal symptoms.
Acute Pancreatitis
One of the most common causes of pain in the LUQ.
Vomiting and retching are frequent.
Perforation (uncommon) of fundic gastric ulcer localized by adhesions
Free air is rarely seen.
Often discovered intraoperatively.
Leakage or Rupture of an Aneurysm of the Splenic Artery (Uncommon)
Tends to have a predilection for the pregnant patientRelated posts:
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