Acute Care Surgery > Acute Abdomen

A 45-year-old male with a known history of alcoholism is admitted with acute pancreatitis. His serum calcium is 7 mg/dL. Management is based upon which of the following?

One-fourth of calcium in serum is ionized

Alkalosis increases the ionized calcium component

Hypocalcemia may cause polyuria and polydypsia

Determination of serum albumin is necessary

Treatment should involve intravenous administration of calcium chloride

Determination of serum albumin or protein level is necessary for proper determination of serum calcium level. For every 1 g decrease of serum albumin, the serum calcium level is corrected by 0.8. Intravenous administration of calcium chloride is indicated in the presence of symptoms. Approximately 45% of serum calcium is ionized and responsible for neuromuscular stability. Half of the calcium in the blood is bound to protein, and an additional 5% is attached to substances other than protein. Alkalosis decreases the ionized component. Hypercalcemia causes polydypsia and polyuria.

A 63-year-old woman is admitted to the hospital with severe abdominal pain of 3-hour duration. Abdominal examination reveals board-like rigidity, guarding, and rebound tenderness. Her blood pressure is 90/50 mm Hg, pluse 110 bpm (beats per minute), and respiratory rate is 30 breaths per minute. After a thorough history and physical, and initiation of fluid resuscitation, what diagnostic study should be performed?

Supine abdominal x-rays

Upright chest x-ray

Gastrograffin swallow

Computerized axial tomography (CAT) scan of the abdomen

Abdominal sonogram

An upright chest x-ray will demonstrate free air below the diaphragm in about 70–75% of patients presenting with a perforated duodenal ulcer. An abdominal sonogram may demonstrate free fluid, but not free air. Although a CAT scan will show both free fluid and free air, it will take longer to perform and may delay the definitive treatment. The combination of an acute abdomen and an upright chest x-ray with free air under the diaphragm provides enough information to take the patient to the operating room for exploration.

A frail elderly patient is found to have an anterior perforation of a duodenal ulcer. He has a recent history of nonsteroidal anti-inflammatory drug (NSAID) use and no previous history of peptic ulcer disease. A large amount of bilious fluid is found in the abdomen. What should be the next step?

Lavage of the peritoneal cavity alone

Lavage and omental patch closure of the ulcer

Total gastrectomy

Lavage, vagotomy, and gastroenterostomy

Laser of the ulcer

Although surgery is generally recommended for perforation, conservative measures can be considered in select cases. A patient who has a benign clinical presentation or one who is improving, might be considered for treatment with antibiotics and nasogastric decompression.

Patients who have an acute abdomen and are hemodynamically unstable should not be observed. Board-like rigidity of the abdomen occur as a result of chemical peritonitis. These patients should have fluid and electrolyte repletion, and anitbiotics followed by surgery.

Choice of the operative procedure should be guided by the information obtained during the history, the presence of comorbid disease, and hemodynamic stability during the operation. A omental (Graham) patch will seal the ulcer, but it will not prevent recurrence.

A 55-year-old man presents with left lower quadrant (LLQ) abdominal pain of 2-day duration, associated with constipation. On physical examination, he has tenderness localized to the LLQ with fullness in that area leukocyte count is 22,000 and temperature is 101.5°F. Which would be the best diagnostic study to evaluate this man?

Diagnostic laparoscopy

Barium enema

Plain abdominal roentgenogram

Computed tomography (CT) of the abdomen/pelvis with orally (PO) and intravenous (IV) contrast

Colonoscopy

The man likely has diverticulitis. The differential includes irritable bowel, appendicitis, inflammatory bowel disease, pyelonephritis, ischemic colitis, and perforated carcinoma. Diverticulitis is an infectious complication of diverticulosis resulting from perforation of the colonic diverticulum. The resulting inflammation may be confined to the pericolonic tissue (incomplicated diverticulitis) or result in abscess, free perforation, fistulization, or obstruction (complicated diverticulitis). The clinical spectrum is correspondingly broad ranging from mild symptoms to peritonitis and sepsis. Patients with signs and symptoms of sepsis should be hospitalized and undergo diagnostic study. A CT scan is the best study to evaluate the extent of the inflammatory process as well as to exclude other pathology. Plain x-ray would not reveal specific pathology. Both barium enema and colonoscopy in the acute setting are risky and may cause free perforation and contamination of the peritoneal cavity there by converting a localized process to generalized peritonitis. Barium has the additional risk of a chemical peritonitis caused by the barium itself. Diagnostic laparoscopy is invasive and may risk spreading a localized process.

Complications of diverticulitis include:

Carcinoma of the colon

Extraintestinal manifestations such as arthritis, iritis, and skin rashes

Fistulisation to adjacent organs such as the bladder, with insueing colovesical fistula

Artheriovenous fistulae of the intestine

Sclerosing cholangitis

Diverticulitis results from acute inflammation of a colonic diverticula. The process may extend into adjacent organs (e.g., the urinary bladder and a fistula between the colon and bladder colovesical fistula may ensue). This leads to passage of colonic gas and fecal material into the bladder and urine resulting in pneumaturitis and fecaluria. Sigmoid resection and repair of the bladder fistula is indicated.

A patients CT scan reveals diverticulitis confined to the sigmoid colon. There is no associated pericolic abscess. What is best course of treatment?

Bowel rest, nasogastric suction, IV fluids, and broad spectrum antibiotics

Urgent surgical resection

Steroids

Diverting colostomy

Ileostomy

Uncomplicated diverticulitis is treated with broad spectrum antibiotics and bowel rest. Surgery is not indicated—either resection or diversion of the fecal stream by colotomy or ilestomy. Anti-inflamatory agents are not indicated in the therapy of diverticulitis. The risk of a second episode is less than 30%. After a second episode, the risk is greater than 50% and resection may be advised at this stage.

An elderly nursing home patient is brought to the hospital with recent onset of colicky abdominal pain, distension and obstipation on examination, the abdomen is markedly distended and tympanitic. There is no marked tenderness. Plain abdominal x-ray shows a markedly distended loop located mainly in the right upper quadrant. The likely diagnosis is:

Small-bowel obstruction

Large-bowel obstruction

Gallstone ileus

Mesenteric vascular occlusion

Sigmoid volvulus

This patient has sigmoid volvulus. Plain abdominal x-ray shows a massively distended loop in the right upper quadrant, because the sigmoid colon, as it progressively distends, as a result of the twist of its mesentery, has no space, in the LLQ to occupy and flips over to the largest available area—namely the right upper quadrant. Given the clinical presentation and findings, the plain abdominal x-ray is diagnostic.

A 12-year-old boy complains of pain in the lower abdomen (mainly on the right side). Symptoms commenced 12 hours before admission. He had noted anorexia during this period. Examination revealed tenderness in the right iliac fossa, which was maximal 1 cm below Mc Burney’s point. In appendicitis, where does the pain frequently commence?

In the right iliac fossa and remains there

In the back and moves to the right iliac fossa

In the rectal region and moves to the right iliac fossa

In the umbilical region and then moves to the right iliac fossa

In the right flank

In appendicitis, patients frequently note that the pain commences in the umbilical region and moves later to the right iliac fossa. Pain in the iliac fossa occurs when the overlying parietal peritoneum is involved. Patients with appendicitis typically indicate that they have anorexia. 70–80% of patients with appendicitis have vomiting.

On examination, patients presenting with appendicitis typically show maximal tenderness over which of the following?

Inguinal region

Immediately above the umbilicus

At a point between the outer one-third and inner two-thirds of a line between the umbilicus and the anterior superior iliac spine

At a point between the outer two-thirds and inner one-third of a line between the umbilicus and the anterior superior iliac spine

At the midpoint of a line between the umbilicus and the anterior superior iliac spine

This is McBurney’s point and often indicates the region where maximal tenderness can be elicited. In addition to tenderness, guarding and percussion tenderness should be sought to verify whether localized and/or general peritonitis exists.

A 28-year-old man is admitted to the emergency department complaining of pain in the umbilical region that moves to the right iliac fossa. Which is a corroborative sign of acute appendicitis?

Referred pain in the right side with pressure on the left (Rovsing) sign

Increase of pain with testiculalr elevation

Relief of pain in lower abdomen with extension of thigh

Relief of pain in lower abdomen with internal rotation of right thigh

Hyperanesthesia in the right lower abdomen

Rovsing’s sign is corroborative of acute appendicitis. The other signs are corroborative of appendicitis. Hyperesthesia is a useful sign provided that it is performed objectively. The area of hyperesthesia is a triangular area (base placed upward) in the right lower abdomen.