The Surgical Approach to the Acute Abdomen

Posted by e-Medical PPT Thursday, September 29, 2011
The acute abdomen refers to the clinical situation in which an acute change in the condition of the intraabdominal organs, usually related to inflammation or infection, demands immediate and accurate diagnosis.
The Acute Abdomen
Abdominal pain is one of the most frequent reasons to visit physician offices and emergency rooms
Most patients are found to have self limited conditions
A subset of patients harbor serious intraabdominal disease that requires urgent  surgical or medical intervention
Early diagnosis is the key to improving outcomes
An accurate history and complete physical examination are more important than any diagnostic test
The history should be obtained with the abdomen bare, with attention to how the patient positions himself and moves
Early evaluation by experienced physicians is important, as once the initial evaluation is done analgesia may be given
Antibiotics should not be given until a working diagnosis is made
Serial examinations by the same physician during the patient’s work up determines disease progression or resolution

Peritoneal Signs
Palpation and Percussion – BE GENTLE
Rebound – please do not perform this test
Causes unexpected and unnecessary pain
Does not add information to an examination after percussion
Rigidity
not present in pelvic inflammation or obstruction, unreliable

Abdominal Pain
Acute abdominal pain is the hallmark of an acute abdomen
It may originate from any organ in the abdominal cavity
Understanding the mechanisms of pain production and the physiology of pain perception allow for more accurate diagnoses
Pain may be visceral, somatic or referred
Visceral pain is characterized by dullness, poor localization, cramping, burning or gnawing
Visceral pain is mediated by autonomic (sympathetic and parasympathetic) nerves
The location of the pain corresponds to the dermatomes of the organs involved
Sensory neuroreceptors for visceral pain are located in the mucosa or muscularis of hollow viscera, on the visceral peritoneum and within the mesentery
These receptors respond to mechanical and chemical stimuli
Stretch is the primary mechanical signal for pain
The parietal peritoneum has an entirely somatic innervation
Somatic pain is more intense and well localized
Somatic innervation is mediated by the spinal nerves
A transition from visceral to somatic pain indicates extension of the underlying process

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