Properties In Evaluation Of The Acute Abdomen
14 PRIORITIES IN EVALUATION OF THE ACUTE ABDOMEN
Alden H. Harken M.D.
1. What is the surgeon’s responsibility when confronted by a patient with an acute abdomen?
Show answer
1. To identify how sick the patient is
2. To determine whether the patient (a) needs to go directly to the operating room, (b) should be admitted for resuscitation or observation, or (c) can be sent safely home
2. Which is the most dangerous course?
Show answer
To send the patient home.
3. Is it important to make the diagnosis in the emergency department?
Show answer
No. Frequently time spent confirming a diagnosis in the emergency department is lost to inhospital resuscitation or treatment in the operating room. The only patient who needs a relatively firm diagnosis is a patient who is to be sent home.
4. If the essential goal is not to make the diagnosis, what should the surgeon do?
Show answer
1. Resuscitate the patient. Most patients do not eat or drink when they are getting sick. Most patients are depleted of at least several liters of fluid. Fluid depletion is worse in patients with diarrhea or vomiting.
2. Start a big IV line.
3. Replace lost electrolytes (see Chapter 7).
4. Insert a Foley catheter.
5. Examine the patient (frequently).
5. Are symptoms and signs uniquely misleading in any groups of patients?
Show answer
Yes. Watch out for the following groups:
* The very young, who cannot talk.
* Diabetics, because of visceral neuropathy.
* The very old, in whom, much as in diabetics, abdominal innervation is dulled.
* Patients taking steroids, which depress inflammation and mask everything.
* Patients with immunosuppression (a heart or kidney transplant patient may act cheerful even with dead or gangrenous bowel).
6. Summarize the history needed.
Show answer
1. The patient’s age. Neonates present with intussusception; young women present with ectopic pregnancy, pelvic inflammatory disease, and appendicitis; the elderly present with colon cancer, diverticulitis, and appendicitis.
2. Associated problems. Previous hospitalizations, prior abdominal surgery, medications, heart and lung disease? An extensive gynecologic history is valuable; however, it is probably safer to assume that all women between 12 and 40 years old are pregnant.
3. Location of abdominal pain. Right upper quadrant: gallbladder or biliary disease, duodenal ulcer. Right flank: pyelonephritis, hepatitis. Midepigastrium: duodenal or gastric ulcer, pancreatitis, gastritis. Left upper quadrant: ruptured spleen, subdiaphragmatic abscess. Right lower quadrant: appendicitis (see Chapter 37), ectopic pregnancy, incarcerated hernia, rectus hematoma. Left lower quadrant: diverticulitis, incarcerated hernia, rectus hematoma. Note: Cancer, unless it obstructs (colon cancer), and bleeding (diverticulosis) typically do not hurt.
4. Duration of pain. The pain of a perforated duodenal ulcer or perforated sigmoid diverticulum is sudden, whereas the pain of pyelonephritis is gradual and persistent. The pain of intestinal obstruction is intermittent and crampy. Note: Although the surgeon is rotating through a gastrointestinal service, the patient may not know this and may present with urologic, gynecologic, or vascular pathology.
Comments
Leave a Reply
Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
