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lies motionless, and hasan extremely tender abdomenwith ‘peritoneal
signs’ consisting of board-like rigidity, rebound-tenderness, and
involuntarydefense-guarding.Surprisinglyenough, less experienced
cliniciansoccasionallymissthediagnosisentirely.Thisisespecially
common in the geriatric patient who may have weak abdominal
musculatureor may not exhibit theclassicalperitoneal signs. The most
common error in the physical examination of a patient with acute
abdominalpainisroughand‘deep’palpationoftheabdomen,whichmay
elicit severe tenderness even in a patient without any abdominal
pathology.Palpation oftheabdomen shouldbe very gentle,and should
not hurt the patient. We appreciate that at this stage of your surgical
careeryoudonotneedadetailedlectureontheexaminationoftheacute
abdomen. Forgive us, however, for emphasizing that the absence of
rebound tenderness means nothing and that a good way to elicit
peritonealirritationisbyaskingthepatienttocough,shaking(gently)his
bed,orbyverygentlepercussionoftheabdomen—startingawayfrom
the painful area and slowly moving towards it. The deliberate
demonstration of the clinical sign of rebound tenderness is cruel,
unnecessaryandtobedeplored.
The three most common causes of generalized peritonitis in
adultsareaperforatedulcer( Chapter18),colonicperforation(
Chapter28), and perforated appendicitis( Chapter 23). Classically,
with exceptions listed below and in the individual chapters, the
management of a patient with diffuse peritonitis is an emergency
operationwithinafewhours(surgerytonight),afterabriefperiodofpreoperativeoptimizationasoutlinedin Chapter6.
Animportantexceptiontothismanagementoptionisthepatient
with acute pancreatitis. While most patients with acute pancreatitis
present with mild epigastric tenderness, the occasional patient may
present with a clinical picture mimicking diffuse peritonitis ( Chapter
19). As a precaution against misdiagnosing these patients, it is
essentialpracticealwaystomeasuretheserumamylase(orlipase)
inanypatientpresentingwithsignificantabdominalsymptoms (
Chapter4).Note,however,thatamylase/lipaselevelsarenotcompletely
reliable but abdominal CT would establish the diagnosis in doubtful
cases.An exploratory laparotomy in a patient suffering from acute
severe pancreatitis may lead to disaster; believe us — as we
discovered in the pre-imaging era, when we were young and
aggressive.Remember:Godputthepancreasinthebackbecause
hedidnotwantsurgeonsmessingwithit.
Localizedperitonitis
Inthepatientwithlocalizedperitonitis,theclinicalsignsareconfinedto
onequadrantoftheabdomen.Onceyouhavedecidedwhichquadrantis
the problem, there are only a few possible diagnoses from which to
choose. Like the French Chief ofPolice saidin themovie Casablanca:
“Round up the usual suspects.” In the right lower quadrant (RLQ) the
most common cause of localized peritonitis is acute appendicitis (
Chapter23).Intherightupperquadrant(RUQ)itisacutecholecystitis(
Chapter 20), and in the left lower quadrant (LLQ) it is acute
diverticulitis ( Chapter 28). Peritonitis confined to the left upper
quadrant(LUQ)isuncommon,making thisquadrant the‘silent one’.Oh
well,notalwayssosilent:youcanseetheoccasionalcolonicdiverticulitis
or tumor perforationwith abscess high in the descending colon, or the
‘funny’ splenic problems such as splenic infarct, but usually these are
onlydiscoveredwithCT.
Asa general rule, localizedperitonitis israrelyan indication for
an emergency operation — ‘tonight!’. As you will learn from the
relevantchaptersmostepisodesofacutediverticulitiscanbemanaged
withoutanoperation( Chapter28).Themajorityofpatientswithacute
cholecystitis should undergo cholecystectomy ‘tomorrow’, or within 72
hours — but, in general, the sooner the better ( Chapter 20). Even
acuteappendicitisisnolongerconsideredadireemergency—inmost
casestheoperationcanbepostponeduntilthemorning( Chapter23).
Buy a copy of this book as a gift toyour ER docs so thatthey too will
understand…
What to do ifthediagnosis is uncertain? Yes, evenin thisera of
instantUSorCTimagingthiscanhappen!And,obviously,thissituation
isnotsorareifyoupracticeawayfrommodernimagingtechnology.You
should then admit the patient for observation, hydrate him with
intravenous fluids, give antibiotics (e.g. if the diagnosis of acute
cholecystitis or diverticulitis is entertained), and conduct serial physical
exams. Do not omit analgesia! Condemning the patient to suffer
long periods of untreated pain in order “not to mask signs and
symptoms of an undiagnosed abdominal disaster” is an outdated
practice.Instead,providesmalldoses(1-4mg)ofi.v.morphine.
REMEMBER:ailmentsgetbetterwithtime,truesurgicalproblems
getworsewithtime.Thustimeisasuperbdiagnostician;whenyou
returntothepatient’sbedsideafterafewhoursyoumayfindallthe
previously missing clues. Of course, after you have consulted the
relevantchaptersinthisbook .
Inwomenoffertileage,lowerabdominalperitonitis,ontherightorleft
side, commonly tends to be gynecological in origin, and is usually
managedconservatively( Chapter35).
Intestinalobstruction
The clinical pattern of intestinal obstructionconsists ofcentral,
colicky abdominal pain, distension, vomiting and constipation (
Chapters21and27).
As a general rulethe earlierand morepronounced the vomiting, the
moreproximalthesiteofobstructionislikelytobe.Butthemoremarked
the distension, the more distal is the site of obstruction. Thus, vomiting
and colicky pain are more characteristic of small bowel obstruction,
whereas constipation and gross distension are typical of colonic
obstruction. However, the distinction between these two kinds of
obstructionusuallyhingesontheplainabdominalX-ray—thatis,ifyour
ERdocstillbothersobtainingitpriortothe‘obligatoryCT’.
There are twomanagement options forthese patients: a trial of
conservative treatment, or operative treatment after adequate
preparation. The major problem with intestinal obstruction is not in
makingthediagnosisbutindecidingontheappropriatecourseofaction.
Ifthepatient has a history of previous abdominalsurgeryand presents
withsmall bowelobstruction butwithout signsof peritonitis,theworking
diagnosis is ‘simple’ adhesive small bowel obstruction. The initial
management of these patients is conservative, with intravenous fluids
andnasogastrictubedecompression.Iftheobstructioniscomplete(e.g.
no gas in the colon above the rectum), the chances of spontaneous
resolution are small and some surgeons would opt for an operative
intervention.Inthepresenceofclinicalfeaturesofintestinalcompromise
—fever,peritonitis,andelevatedwhitebloodcellcount,theindicationfor
operationismorepersuasive.But,asalways,inreallifethingsaremuch
morecomplicatedsopleaseread Chapter21.
Thereareafewclassicpitfallswithsmallbowelobstruction:
•
The ‘virgin’ abdomen (no previous abdominal surgery): here,
typicallyadhesionmaynotbetheunderlyingcause.Thinkoutside
oftheboxandgetaCTofthe‘black box’,i.e.the abdomen.In
thesecasesthereisoftenatreatablecausefortheobstruction,and
itmakesyoufeelgoodatoperationtohavefoundit.
•
Themissedgroinhernia.Theelderlyladywithnoprevioussurgical
history who presents with small bowel obstruction due to an
incarceratedfemoralhernia.Alwaysexaminethegroin!Insiston
patients having their pants and underpants off. The fact that
modernERdocstendtodiagnoseincarceratedinguinalherniasonly
on CT is sad. But we want you to detect such hernias on
examination,priortoCT,whichthenbecomesunnecessary.
•
Thesilentcecalcancer.Thepatientwithalleged‘simple’adhesive
small bowel obstruction who improves on conservative treatment
andisdischarged,onlytocomebacklaterwithalargetumormass
intherightcolon.Thesecancerscanactasaballvalve,causing
intermittentdistalobstructionoftheileocecalvalve.
•
The gallstone ileus. The elderly lady whose partial small bowel
obstruction resolves and recurs intermittently and is finally
diagnosedasgallstoneileus.Alwayslookforairinthebileducts
onplainabdominalX-rays. If you don’t think about ityou will
missit!
•
The post-gastric surgery patient, who presents with intermittent
episodes of obstruction originating from a bezoar in the terminal
ileum.
Unlike small bowel obstruction, colon obstruction is almost
alwaysan indicationforsurgery—‘tonight’or ‘tomorrow’but usually
‘tomorrow’.A plain abdominal X-ray cannot reliably distinguish between
functionalcolonicpseudo-obstruction (Ogilvie’ssyndrome) or chronic
megacolon and a mechanical obstruction. Thus, these patients usually
needadditional imaging (contrastenema,CT) or fiberoptic colonoscopy
toclinchthediagnosis( Chapter27).
Theabdominal‘wastebasket’
•
Non-specific abdominal pain (NSAP). Many patients with acute
abdominalpainundergoaclinicalexaminationandalimitedwork-up
—whichtodayinmanycentersmayincludeaCTscan—onlytobe
labeled as “non-specific abdominal pain” (NSAP), and then
discharged.NSAPisaclinicalentity,albeitanill-definedone.Itisa
typeofacuteabdominalpainthatissevereenoughtobringapatient
to seek medical attention. The patient’s physical examination and
diagnostic work-up are negative, and the pain is self-limiting and
usuallydoesnotrecur.Itisimportanttokeepinmindthatinan
ER setting, more than half of patients presenting with acute
abdominal pain have NSAP, with acute appendicitis, acute
cholecystitisand‘gynecologicalcauses’,beingthecommonest
‘specific’conditions.Butthe exactpathology youseedependsof
course on your geographical location and pattern ofpractice. Just
rememberthatpatientsdischargedhomelabeledwithadiagnosisof
NSAP have an increasedprobability of asubsequent diagnosis of
abdominalcancerorotherlingeringsurprisepathologies.Therefore,
elective investigations may be indicated so try to follow-up these
patients.
•
Importantmedicalcauses.While thereisa largenumberof non-
surgical causes of acute abdominal pain, two must be kept
constantly in your mind: inferior wall myocardial infarction and
diabetic ketoacidosis. A laparotomy for porphyria or even basal
pneumoniaisanunfortunatesurgical(andmedicolegal)occurrence,
butinadvertentlyoperatingonapatientwithanundiagnosedinferior
wallMI ordiabeticketoacidosis maywell be alethal mistake.Asa
surgeon you should strive to be a better physician than the
internists,andwouldn’titbefuntoshowthema‘medical’diagnosis
theyhadmissed!
Exploratory laparotomy or laparoscopy for the acute
abdomen?
Manyofus,oldfarts,wereraisedonthedictumthatclinicalperitonitis
is an indication for abdominal exploration. Many of you, promising
emergingstars,are nurturedwiththeconceptof “letusinsertacamera
andseewhat’sgoingon”.
Thenotionsthat“peritonitisisanindicationforoperation”andthat“only
skin separates us from the diagnosis” developed before the days of
modernabdominal imaging;but isthis stilltrue today,justifyingopening
the abdomen or inserting a scope, without resonable evidence of a
surgical pathology necessitating an operation? We do notthink so. We
believe that modern abdominal imaging has revolutionized
emergency abdominal surgery, and that if you have immediate
accesstoabdominalCTand/orultrasoundyouhavetouseit.This,
aswillbediscussedinmanyofthefollowingchapters,willavoidan
operation in many patients, or make operative treatment less
invasive and more specific. Thanks to the abdominal CT the
abdomenisnolongerablackbox.Useabdominalimagingliberallyfor
thebenefitofyourpatients—especiallywhenthediagnosisisnotclearly
evident. It is OK to operate on a young man with classcial features of
acute appendicitis without a pre-operative CT; but a woman of childbearing age needs abdominal imaging (to exclude gynecological
conditions) and so do elderly patients in whom other pathologies are
morelikely.Thisisalljustcommonsensereally.
Thesurgeonwhostrivesforperfection
Needssomebasisforpatientselection
Hewouldliketobesure
There’sagoodchanceforcure
Beforehebeginstheresection.
ElwoodG.Jensen
Yes,what’scommoniscommonandwhat’srareisrare,butrare
thingscanbelethal—alwayskeeptheminmind!
Whoshouldlookafterthe‘acuteabdomen’andwhere?
Everybody’sbusinessisnobody’sbusiness.
The majority of patients suspected of having an acute abdomen or
otherabdominalemergency donot requireanoperation.Nevertheless,
it is you — the surgeon — who should take, or be granted, the
leadershipin assessing, excluding or treatingthis condition,or at
leastplayamajorroleinleadingthemanagingteam.Toemphasize
howcrucialthisissueis,wededicateanentiresectionofthischaptertoit
—althoughitsscopewouldfitintoaparagraph.
Figure3.2.“Whoisresponsible?”
Unfortunately, in real life, surgeons are often denied the primary
responsibility. Too often we see patients with mesenteric ischemia
rottingawayinmedicalwards,thesurgeonbeingconsulted“toevaluate
theabdomen”, only when thebowelis dead, and the patientissoonto
be. A characteristic scenario is a patient with an abdominal surgical
emergency, admitted underthe care ofnon-surgeons who undertake a
seriesofunnecessary,potentiallyharmful andexpensive diagnosticand
therapeutic procedures. Typically, internists, gastroenterologists,
infectious-disease specialists and radiologists are involved, each
prescribing his own wisdom in isolation (many treating the patient for
‘CRPitis’ or ECOUO — elevated CRP of unknown origin...) ( Figure
3.2).When,finally,thesurgeoniscalledin,hefindstheconditiondifficult
to diagnose, partially treated or maltreated. Eventually, the indicated
operationis performed, but too late and thus carries a higher morbidity
andmortality.Theetiologyofsuchchaosisnotentirelyclear.Motivesof
power,egoandfinancialconsiderationsaresurelyinvolved;itispolitically
correcttocallthisa‘systemfailure’.
Theteamapproachtotheacutelyillsurgicalpatientshouldnotbe
discarded. The team, however, should be led and coordinated by a
generalsurgeon.Heistheonewhoknowstheabdomenfromwithinand
without. He is the one qualified to call in consultants from other
specialties,toordervaluabletests,tovetothosethataresuperfluousand
wasteful. And, above all, he is the one who will eventually decide that
enough is enough and the patient needs to be taken to the operating
room.
Whenyoudecidedtobecomeageneralsurgeonyoubecamethe
captainoftheship,navigatingthedeepoceanoftheabdomen.Do
notabandonyourshipwhilethestormrageson!
Continuity of care is a sine qua non in the optimal care of the
acuteabdomen as theclinical picture, which may changerapidly,is a
majordeterminantinthechoice oftherapy andits timing.Such patients
needtobefrequentlyreassessedbythesameclinician,whoshouldbea
surgeon.Anydeviationfromthismaybehazardoustothepatient;thisis
ourpersonalexperience and that which is repeated adnauseum in the
literature. Why don’t welearn? The place for the patient with an acute
abdominal condition is on the surgicalfloor,surgical intensivecare unit
(ICU), or in the operating room and under the care of a surgeon —
yourself.Don’tduckyourresponsibilities!
Only10or20yearsago,whenwewereresidents,an‘acuteabdomen’
andclinicalevidenceofperitonitismandatedanoperation.Todayweare
smarter. Judicioususe of diagnostic modalities (see Chapter 4) and
betterunderstandingofthenaturalhistoryofvariousdiseaseprocesses
allowus todecrease mortalityand morbidityby beinglessinvasive and
moreselectiveand,ingeneral,toachievemorebydoingless.
Thekeyforthe‘best’outcomeoftheacuteabdomenis:
Operateonlywhennecessary,anddotheminimumpossible.
Donotdelayanecessaryoperation,anddothemaximumwhenindicated.
“The concept thatone citizen will layhimself horizontal
andpermitanothertoplungeaknifeintohim,takeblood,
give blood, rearrange internal structures at will,
determineultimatefunction,indeed,sometimeslifeitself
—thatresponsibilityisawesomebothintrueandinthe
currentlydebasedmeaningofthatword.”
AlexanderJ.Walt
1
AsherHirshberg,MD,contributedtothischapterinthefirsteditionofthisbook.
Chapter4
Rationaldiagnosticprocedures
MosheSchein,PaulN.Rogers,AriLeppäniemi,DannyRosinand
JonathanE.Efron
1
Toopen an abdomenand search fora lesion as lightlyas
one would open a bureau drawer to look for the laundry,
may mean lack of mental overwork to the surgeon, but it
meanshorrortothepatient.
J.ChalmersDaCosta
To see what is in front of one’s nose needs a constant
struggle.
GeorgeOrwell
The 21st century brought bad news to the surgical cowboys. In the
goodolddaysyouexaminedthepatient,observedthesystemicsignsof
infection or inflammation, poked theabdomen withyour delicatehands
andnoted“peritonitis”andhurrah—“takehimtotheOR”,youexclaimed
with gusto, bathing in the admiration of the nurses and the envy of the
non-surgeons — Gee, what a clinician! But these days even the born
cowboys have to feign being tame farmers: in the vast majority of
casesonecannowonlygototheORwithanestablisheddiagnosis!
When treating a patient with acute abdominal pain it is tempting to
make extensive use of ancillary investigations. This leads to the
emergence of ‘routines’ in the emergency room (ER) whereby every
patient with acute abdominal pain undergoes a series of blood tests,
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