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20 Moshe Schein
resolution are small, and some surgeons would opt for an operative intervention.
In the presence of clinical peritonitis, fever, and elevated white blood cell count,
the indication for laparotomy is clear-cut ( see > Chap. 21).
There are three classical pitfalls with small bowel obstruction:
The obese elderly lady with no previous surgical history who presents with
small bowel obstruction, where an incarcerated femoral hernia can easily
be missed if not specifically sought
The elderly patient with a “simple” adhesive small bowel obstruction who
improves on conservative treatment and is discharged only to come back
later with a large tumor mass in the right colon
The elderly lady whose “partial” small bowel obstruction “resolves and
recurs” intermittently and is finally diagnosed as gallstone ileus
The patient with a history of previous gastric surgery who presents with
intermittent episodes of obstruction originating from a bezoar in the
terminal ileum
Unlike small bowel obstruction, colon obstruction is always an indication
for surgery—“tonight or tomorrow” but usually tomorrow. A plain abdominal
X-ray cannot make the diagnosis since functional colonic pseudo-obstruction
(Ogilvie’s syndrome) or chronic megacolon cannot reliably be distinguished from
a mechanical obstruction. Thus, these patients usually undergo either fiber-optic
colonoscopy or a contrast enema (with or without CT) to clinch the diagnosis.
The management option for these patients is operation after adequate preparation (> Chap. 25).
Important Medical Causes
While there is a large number of nonsurgical causes that may result in acute
abdominal pain, two must be kept constantly in your mind: inferior wall myocardial infarction (MI) and diabetic ketoacidosis. A laparotomy for porphyria or even
basal pneumonia is an unfortunate surgical (and medicolegal) occurrence, but
inadvertently operating on a patient with an undiagnosed inferior wall MI or diabetic ketoacidosis may well be a lethal mistake. As a surgeon, you should strive to
be a better physician than the internists, and wouldn’t it be fun to show them a
“medical” diagnosis they had missed.
Wherever you practice, you may be exposed to a growing number of HIVpositive patients suffering from AIDS, who are susceptible to a large number of
abdominal conditions, which can produce or mimic an “acute abdomen.” In
(> Chap. 36) we tell you how to deal with these patients, most of them being best
treated without an operation.
3 The Acute Abdomen 21
Conclusion
The multiple etiologies of the acute abdomen converge to five distinct and
well-defined clinical patterns, each of which is associated with a specific management option. You should be familiar with these patterns and with the various management options. You should also keep in mind the classical pitfalls inherent in
this common surgical condition to avoid gross errors in the surgical care of such
patients. After all, you already have enough cases to present at the morbidity and
mortality (M & M) meeting, don’t you (> Chap. 59)?
CT is the KING!
Many of us were raised on the dictum that clinical peritonitis is an indication
for abdominal exploration (be it by laparotomy or laparoscopy). The notions that
“peritonitis is an indication for operation” and that “only skin separates us from
the diagnosis” developed before the days of modern abdominal imaging, but is this
still true today? We do not think so. We believe that modern abdominal imaging
has revolutionized emergency abdominal surgery, and that if you have immediate
access to abdominal CT or ultrasound, you have to use it. This—as is discussed in
many of the following chapters—will avoid an operation in many patients or make
operative treatment less invasive and more specific. Thanks to the abdominal CT,
the abdomen is no longer a black box. Use abdominal imaging liberally for the
benefit of your patients—especially when the diagnosis is not clearly evident. It is
okay to operate on a young man with classical features of acute appendicitis without a preoperative CT, but a woman of childbearing age needs abdominal imaging
(to exclude gynecological conditions) and so do elderly patients, in whom other
pathologies are more likely. All this is just common sense really.
“It is as much an intellectual exercise to tackle the problems of belly ache as to
work on the human genome.” (Hugh Dudley)
Yes, what’s common is common and what’s rare is rare but rare things can be
lethal—always keep them in mind!
Who Should Look After the “Acute Abdomen” and Where?
Everybody’s business is nobody’s business.
The majority of patients suspected of having an acute abdomen or other abdominal emergency do not require an operation. Nevertheless, it is you—the
22 Moshe Schein
surgeon—who should take, or be granted, the leadership in assessing, excluding, or
treating this condition or at least play a major role in leading the managing team.
To emphasize how crucial this issue is, we dedicate an entire section of this chapter
to it—although its scope would fit into a paragraph.
Unfortunately, in “real life,” surgeons are often denied the primary responsibility. Too often, we see patients with mesenteric ischemia (> Chap. 23) rotting
away in medical wards, the surgeon being consulted “to evaluate the abdomen”
only when the bowel is dead, and the patient is soon to be. A characteristic scenario is a patient with an abdominal surgical emergency, admitted under the care
of nonsurgeons who undertake a series of unnecessary, potentially harmful, and
expensive diagnostic and therapeutic procedures. Typically, internists, gastroenterologists, infectious disease specialists, and radiologists are involved, each prescribing personal wisdom in isolation (> Fig. 3.2). When, finally, called in, the
surgeon finds the condition difficult to diagnose, partially treated, or maltreated.
Eventually, the indicated operation is performed, but too late, thus carrying
higher morbidity and mortality. The etiology of such chaos is not entirely clear.
Motives of power, ego, and financial considerations are surely involved.
The team approach to the acutely ill surgical patient should not be discarded. The team, however, should be led and co-ordinated by a general surgeon.
The surgeon is the one who knows the abdomen from within and without. The
surgeon is the one qualified to call in consultants from other specialties, to order
valuable tests and to veto those that are superfluous and wasteful. And, above all,
the surgeon is the one who will eventually decide that enough is enough, and the
patient needs to be taken to the operating room.
Fig. 3.2. “Who is responsible?”
3 The Acute Abdomen 23
When you decided to become a general surgeon you became the captain of
the ship, navigating the deep ocean of the abdomen. Do not abandon your ship
while the storm rages on!
Continuity of care is a sine qua non in the optimal care of the acute abdomen as the clinical picture, which may change rapidly, is a major determinant in
the choice of therapy and its timing. Such patients need to be reassessed frequently by the same clinician, who should be a surgeon. Any deviation from this
may be hazardous to the patient; this is our personal experience and that which
is repeated ad nauseum in the literature. Why don’t we learn? The place for the
patient with an acute abdominal condition is on the surgical floor, in the surgical
intensive care unit (ICU), or in the operating room and under the care of a surgeon—yourself. Don’t duck your responsibilities!
Only 10 or 20 years ago, when we were residents, an acute abdomen and
clinical evidence of peritonitis mandated an operation. Today, we are smarter.
Judicious use of diagnostic modalities (see > Chap. 4) and better understanding
of the natural history of various disease processes allow us to decrease mortality
and morbidity by being less invasive and more selective and, in general, to
achieve more by doing less.
The key for the “best” outcome of the acute abdomen is:
Operate only when necessary and do the minimum possible
Do not delay a necessary operation and do the maximum when indicated
Advice: When you finish this book, go and buy yourself Cope’s Early Diagnosis
of the Acute Abdomen. Zachary Cope, who died in 1974, published the first edition
of his book in 1921. The current edition is the 20th! You cannot be a real general
surgeon without reading this book. Or can you?
Rational Diagnostic Procedures
1
Moshe Schein
Believe nobody—question everything.
“To open an abdomen and search for a lesion as lightly as one would open a
bureau drawer to look for the laundry, may mean lack of mental overwork to the
surgeon, but it means horror to the patient.” (J. Chalmers Da Costa, 1863–1933)
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), by which every patient with acute abdominal
pain undergoes a plain X-ray of the abdomen (AXR) and a series of blood tests,
which typically include a complete blood count, routine blood chemistry, and
serum amylase. These “routine” tests have a very low diagnostic yield and are not
cost effective. However, they are also an unavoidable part of life in the ER and are
often obtained before the surgical consultation.
For some patients who on examination have a clear-cut diffuse peritonitis,
no imaging may be necessary because a laparotomy is indicated. But, what
appears clear-cut to the experienced surgeon may be less so for you. Bear in mind
the following caveats:
Intestinal distension, associated with obstruction or inflammation (e.g., en-
teritis or colitis) may produce diffuse abdominal tenderness—mimicking “peritonitis.” The “whole” clinical picture as well as the AXR will guide you toward the
proper diagnosis (> Chaps. 21 and 25).
Acute pancreatitis may present with clinical acute peritonitis. You should
always obtain a serum amylase or lipase level in every patient with significant
abdominal pain to avoid falling into the not-so-uncommon trap of unnecessarily
and dangerously operating on acute pancreatitis (> Chap. 19).
Clostridium difficile enterocolitis should be considered in any patient who
receives or has recently received any quantity of antibiotics. This may present—from
the beginning—as an acute abdomen without diarrhea. Here, the optimal initial
management is medical and not a laparotomy; sigmoidoscopy or computed tomography (CT) may be diagnostic (> Chap. 24).
4
1
Asher Hirshberg, MD, contributed to this chapter in the first edition of the book.
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_4, © Springer-Verlag Berlin Heidelberg 2010
25
26 Moshe Schein
Chest X-ray
A chest X-ray (CXR) is routinely obtained to search for free air under the diaphragms, which is demonstrated in the majority of patients with perforated peptic
ulcer (> Chap. 18) but less frequently when colonic perforation is the underlying
problem (> Chap. 25). Remember that free air is better seen on an erect CXR than
AXR. Free intraperitoneal air is not always caused by a perforated viscus, and it is
not always an indication for a laparotomy. There is a long list of “nonoperative”
conditions that may produce free intraperitoneal air, such as a tension pneumothorax or even vigorous cunnilingus (oral sex). So, rather than being dogmatic,
look at the whole clinical picture.
Any textbook tells you that lower lobe pneumonia may mimic an acute abdomen, so think about it. Obviously, findings such as lung metastases or pleural
effusion may hint at the cause of the abdominal condition and influence treatment and prognosis. Pneumothorax, pnenumomediastinum, or pleural effusion
may be associated with spontaneous esophageal perforation—Boerhaave’s syndrome (> Chap. 15), which can present as an acute abdomen. The value of a CXR
in blunt or penetrating abdominal injury is obvious. A pre-operative CXR may
also be requested by the anesthesiologists, especially after you have inserted a
central venous line or indeed for no reason at all.
In addition, rarely, what looks to you on chest radiography like free air
under the right diaphragm is not free air but bowel (usually the hepatic flexure
of the colon) interposed between the liver and diaphragm. This entity is named
after the Austrian radiologist who described it: Dr. Chilaidiiti. If asymptomatic,
it is termed the Chilaidiiti sign. When symptoms are attributed to it (subcostal
pain, constipation, respiratory distress), it becomes the Chilaidiiti syndrome. We
have never encountered this “syndrome,” but others claim an occasional need
for its operative treatment with “colopexy” or colectomy. In uncertain cases,
abdominal CT shows the free air to be in the colon.
Plain Abdominal X-ray
The plain AXR is the classical surgeon’s X-ray as only surgeons know the true
value of these simple and cheap radiographs. Radiologists can look at and talk
about AXRs forever, searching for findings that could justify “additional” imaging
studies. We surgeons need only a few seconds to decide whether the AXR is “nonspecific,” namely, does not show any obvious abnormality, or shows an abnormal
gas pattern or abnormal “opacities.” Unfortunately, in many of today’s “modern”
ERs the humble AXR is bypassed in favor of the high-tech CT. In fact now, for many
(but it is hoped not for you), the CT supplants the AXR as well as proper history
4 Rational Diagnostic Procedures 27
taking and physical examination. Do not forget that we operate on patients and
not on CT abnormalities (see > Chap. 5 for discussion of AXR in detail).
Abdominal Ultrasound
Abdominal ultrasound (US) is a readily available diagnostic modality in most
places. Its reliability is operator dependent; the ideal situation is when the US is
performed and interpreted by an experienced clinician—a surgeon. US is very accurate in the diagnosis of acute cholecystitis (> Chap. 20.1); it is also used by gyne-
cologists to rule out acute pelvic pathology in female patients (> Chap. 33) and to
demonstrate an acutely obstructed kidney caused by a ureteric stone (> Chap. 34).
A noncompressible tubular structure (a “small sausage”) in the right lower quadrant may be diagnostic of acute appendicitis, but as discussed in > Chap. 28, you do
not always need abdominal imaging to reach this diagnosis. US is useful in demonstrating intra-abdominal fluid—be it ascites, pus, or blood, localized or diffuse. In
blunt abdominal trauma, FAST (focused abdominal sonography for trauma) has
emerged as a serious rival to diagnostic peritoneal lavage (> Chap. 39.1).
Abdominal Computed Tomography
The use of the CT scan in the acute abdomen remains a subject of some
controversy. While it is true that a CT scan should not be part of the management
algorithm in many patients with acute abdominal pain, the new spiral CT technology is nevertheless immediately available, very powerful, and thus extremely
tempting to use, especially by less-experienced clinicians.
A case in point is acute diverticulitis (> Chap. 26). Once the clinical pattern
of localized peritonitis in the lower left quadrant has been identified, initial management is conservative. A CT may show the inflammatory process and even a
paracolic abscess but will not distinguish between diverticulitis and a localized
perforation of a colonic tumor. In any case, this will not alter the approach because most surgeons would still opt for a trial of intravenous antibiotics as the
initial treatment modality for this clinical pattern (> Chap. 26).
The true role of the CT, where it can really make a critical difference, is with
“clinical puzzles.” Not infrequently, the surgeon encounters a patient with acute
abdominal pain that does not fit any of the clinical patterns described in > Chap. 3.
The patient is obviously sick, but the diagnosis remains elusive. Occasionally,
there may be a suspicion of acute intra-abdominal pathology in an unconscious
patie nt. Unde r th ese circ umst anc es, C T may b e very help ful in ident if ying a n int raabdominal problem. It is even better in excluding the last by being absolutely
28 Moshe Schein
normal. Finally, CT is frequently indicated in patients with blunt abdominal trauma
as discussed in > Chap. 39.1.
Judicious and selective use of CT may help in avoiding surgery altogether—
where previously “negative” or “exploratory” or “nontherapeutic” operations
would have been performed. It may suggest that alternative percutaneous treatment is possible, and even if operation is still indicated, CT may dictate the
optimal incision and approach (> Chap. 10). CT has a definite role in the post-
laparotomy patient as discussed in > Chaps. 48–52. For detailed discussion on
the interpretation of abdominal CT, see > Chap. 5.
A Word of Caution
For most patients with acute abdominal pain, unnecessary ancillary investigations are merely a resource problem and a waste of time. But, for two types of
surgical problems, unnecessary imaging is often lethal:
Acute mesenteric ischemia is the only life-threatening abdominal con-
dition that cannot be easily classified into one of the five clinical patterns
described in > Chap. 3. Because of this, and because the window of oppor-
tunity to salvage viable bowel is so narrow, you must have this diagnosis constantly embedded in the back of your mind. The best chance to salvage these
patients is to identify the clinical picture of very severe abdominal pain
with few objective findings in the appropriate clinical context (> Chap. 23)
and to proceed directly to mesenteric angiography. Needless to say, if the patient
has diffuse peritonitis, no imaging is necessary, and the next step is an urgent
laparotomy. The tragedy in these patients is the inability of even an experienced
clinician to make his or her mind up regarding the need for urgent angiography.
As a result, the patient is sent for a long series of irrelevant imaging studies, and
the opportunity to salvage viable bowel is lost.
The second condition for which the abuse of imaging is often lethal is with
a ruptured abdominal aortic aneurysm (AAA) (> Chap. 41). The first problem
occurs in patients with a known aneurysm and a history of abdominal or back
pain associated with hypotension who are subjected to an unnecessary CT that
merely delays definitive treatment. The second problematic scenario arises as a
result of the fact that a ruptured AAA may not present as abdominal pain and
shock but merely as severe abdominal or back pain, and it may not be easily palpable in an obese patient. When the possibility of a contained rupture is raised in
a hemodynamically stable patient, the one and only ancillary investigation that
is required is an urgent CT scan of the abdomen. Unfortunately, too many times
these patients spend several hours in the ER, waiting for the results of irrelevant
blood tests and progressing slowly along the imaging path from AXRs, which
are usually nondiagnostic, to US, which shows the aneurysm but usually cannot
4 Rational Diagnostic Procedures 29
diagnose a rupture, to a long wait for unnecessary contrast material to fill the
bowel in preparation for a “technically perfect” CT scan. The tragic consequence
of these delays is a dramatic hemodynamic collapse either before or during an
abdominal CT scan.
Contrast Studies: Barium Versus Water-Soluble Contrast
A caveat: in emergency situations do not use barium! Radiologists prefer
barium because of its superior imaging qualities, but for us—surgeons—barium
is an enemy. Bacteria love barium for it protects them from the peritoneal macrophages; a mixture of barium with feces is the best experimental recipe for the
production of intractable peritonitis and multiple intra-abdominal abscesses.
Once barium leaks into the peritoneal cavity, it is very difficult to remove. Barium
administered to the gastrointestinal tract from above or below tends to stay there
for days—distorting any subsequent CT or arteriography.
A gastrointestinal contrast study in the emergency situation has only two
queries to answer:
Is there a leak, and if so, where?
Is there an obstruction, and if so, where?
For these purposes Gastrografin is adequate. Use Gastrografin in upper gastrointestinal studies to document or exclude gastric outlet obstruction or treat
small bowel obstruction (> Chap. 21) or use a Gastrografin enema to diagnose
colonic obstruction or perforation. Unlike barium, Gastrografin is harmless should
it leak into the peritoneal cavity. Try to operate on a colon full of barium: a clamp
slides off, a stapler misfires, and you—not the radiologist—are the one left to clean
the mess. Take some advice from our bitter experience: ordering a Gastrografin
study is not enough; you must personally ensure that barium is not used.
A piece of general advice: do communicate with the radiologists and radiographers. As Leo Gordon said: “The quality of the X ray ordered is directly propor-
tional to the specificity of the clinical information supplied to the radiologist.”
Blood Tests
As stated, “routine labs” are of minimal value. In addition to amylase level,
the only “routines” that can be supported are white cell count and hematocrit.
Elevated white cell count denotes an inflammatory response. Be aware, however,
that acute cholecystitis or acute appendicitis can be present even when the white
cell count is within normal range. Its elevation, however, supports the diagnosis.
Low hematocrit in the emergency situation signifies a chronic or subacute anemia;
30 Moshe Schein
it does not reflect on the magnitude of any acute hemorrhage. Liver function tests
are of some value in patients with right upper quadrant pain, diagnosed to have
acute cholecystitis or cholangitis (> Chaps. 20.1 and 20.2). Serum albumin on ad-
mission is a useful marker of the severity of the acute or acute-on-chronic disease
and is also of proven prognostic value. When operating, for example, on someone
with albumin levels of 1.5 g%, you know that you have to do the minimum and to
expect troubles after the operation.
Whichever tests are ordered, either by you or by someone else on your behalf (usually the ER doctor), be aware that the significance of the results should
never be judged in isolation but considered as part of the whole clinical picture.
Unnecessary Tests
Unnecessary testing is plaguing modern medical practice. Look around you
and notice that the majority of investigations being ordered do not add much to the
quality of care. These unnecessary tests are expensive and potentially harmful. In
addition to the therapeutic delay they may cause, be familiar with the following paradigm: the more nonindicated tests you order, the more false-positive results are
obtained, which in turn compel you to order more tests and lead to additional,
potentially harmful, diagnostic and therapeutic interventions. Eventually, you lose
control.
What are the reasons for unnecessary tests? The etiology is a combination of ignorance, lack of confidence, and laziness. When abdominal emergencies are initially assessed by nonsurgeons who do not “understand” the
abdomen, unnecessary imaging is requested to compensate for ignorance.
Junior clinicians who lack confidence tend to order tests “just to be sure—not
to miss” a rare disorder. And, experienced clinicians occasionally ask for an
abdominal CT over the phone to procrastinate. Isn’t it easier to ask for a CT
rather than to drive to the hospital in the middle of the night, or having to interrupt the golf game, and examine the patient? (“Let’s do the CT and decide in
the morning…”)
An occasional surgical trainee finds it difficult to understand “what’s wrong
with excessive testing?” “Well,” we explain, “Why do we need you at all? Let us
all go home instead, and instruct our ER nurses to drive all patients with abdominal pain through a predetermined line of tests and imaging modalities.”
But, patients are not cars on a production line in Detroit. They are individuals
who need your continuous judgment and selective use of tests.
Be careful before adopting an investigation claimed to be “effective” by others. You read, for example, that in a Boston ivory tower, routine CT of the abdomen has been proven cost effective in the diagnosis of acute appendicitis. Before
succumbing to the temptation to order a CT for any suspected acute appendicitis,
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