The Acute Abdomen – Differential Diagnosis and Evaluation

From a 2014 lecture by Dr Steven O’Day:
Involuntary guarding is worrisome and the sign of an acute abdomen.
Neutropenic enterocolitis (typhilitis)
 – complication of chemo, bone marrow transplant
 – 5% in this population
 – transmural inflammation of the bowel usu in the ileocecal region
 – dx: CT scan
 – on CT, wall > 1 mm, diameter > 7 mm
 – Signs:  Obturator, psoas, Rovsing’s, Dunphy signs (Dunphy’s sign – pain w coughing or movement)
 – Y. enterocolitica enteritis can mimic appendicitis
 – Perforated appendicitis:  can be tx with IR and abx (IV, then PO) – similar to diverticular abscess; recurrence only 10%
RLQ pain DDx includes:  tubo-ovarian abscess, inguinal-femoral hernias, cecal volvulus – including appy.
Choledochal cyst – seen in kids, can turn cancerous, so remove
Hepatic adenomas > 4 cm should be removed, higher risk of malignant transformation
Perforated gastric or duodenal ulcers – plugged with patch of omentum
 – don’t do vagotomies or acid-reducing surgeries anymore
Splenic artery aneurysms – repair/exclude if > 2 cm, mortality 35-50% if rupture.  Higher risk of rupture if the woman becomes pregnant.
Sigmoid volvuli:  risks include hx of constipation, persons on psychogenic meds (!)
       – tx is to get endoscopy to decompress the volvulus
Diverticular abscesses:  Hinchey classification:  type 1 can be tx with antibiotics.  Larger or more complicated often have to be drained by IR or surgery.
Howship-Romberg sign:  pain in the ipsilateral thigh and knee caused by obturator nerve compression, occurs in 50% of obturator hernias.
Spigelian hernia:  bowel pokes through at the arcuate line, where there is no posterior rectus sheath, and can get entrapped below the rectus abdominus – hard to find on exam, CT for dx.
Hernias should be fixed if:  symptomatic, not clearly reducible, any hx of obstructive symptoms.
Ogilvie’s syndrome:  acute colonic pseudo-obstruction.  Often pts on chronic narcotics.  Tx:  IVF resuscitation, neostigmine x 2 doses; if fails, endoscopic decompression; perforation rate 3-15%.
Surgical complications of bariatric surgery:
– Peterson’s hernia (small bowel twists around itself)
– internal hernia
– slipped band
– marginal ulcers
– anastamotic leak
Abdominal compartment syndrome:  bladder pressure > 20 mmHg suggests abdominal hypertension; mortality is high.  Sxs include decreased venous return, increased peak pressure, pulmonary HTN, decreased renal perfusion, hepatic dysfunction.
Vascular causes of acute abdomen:  acute mesenteric ischemia, chronic mesenteric ischemia, non-occlusive mesenteric ischemia, SMV clot, ruptured aneurysms, ruptured AAA, aortic dissection, inflammatory and mycotic aneurysms

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