Notes from the Video

What am I'm Going to Learn in this Video?

Today we're going to study something that is really the essence of general surgery...

The Acute Abdomen!

Every day I get called down in the emergency room and inevitably there is a question on a child with an acute abdomen. 

I'm a pediatric surgeon, so the differential diagnosis of an acute abdomen is a little bit different depending on age but over years of training in adult general surgery and through my fellowship and peds surgery now as an attending pediatric surgeon I've really honed my history and examination skills and I'm really excited to share those with you today.

Here is a Clinical Story...

An 8 year old girl is in the emergency room with right lower quadrant non radiating pain, it was dull in nature, it started two days ago and had been constant with no periodicity reaching a severity of 8 out of 10, aggravated by movement and pressure, releived with rest and associated with some nausea, loss of appetite and low-grade fever.

On examination she had a tender abdomen in the right lower quadrant, her labs demonstrated an elevated white cell count elevated CRP and an ultrasound showed a 12 millimeter appendix.

This history, examination, labs and some imaging gave me the diagnosis of acute appendicitis.

I took her to the operating room, I found gangrenous appendicitis, so I did a laparoscopic appendectomy which you can review in the video.

What is important about taking a proper history?

There are two questions that you need to be able to answer after you evaluate somebody with an acute abdomen:

1.). You need to know or have a pretty good idea of what's the diagnosis

2.).  You need to know if you need to perform surgery or not

What's the Best Book for History and Physical Examination?

`1.). Talley and O'Connor's Clinical Examination - I highly recommend you going and buy this book if you're a medical student or resident as it is a fantastic evaluation of the physical examination and everything that you need to know now when it comes down to doing the history. 

So what is the best way to take a history of pain in a surgical patient?

One of the surgery residents when I was at it rotating on a surgery rotation in medial school told me an acronym for the pain history and I've used it ever since, I still use it today. 

Now there are a couple of reasons why this acronym is really good! 

Number one,  I think it goes in order of the way you would logically ask questions and the way that you would deliver the bullet to your attending physician or write it in your note.

SRNOPDSARA

S = Site

R = Radiation

N= Nature

O = Onset

P = Periodictiy

D = Duration

A = Aggravating

R = Relieving

A = Associated

Check out the history I gave you above, read it out loud...it flows...SRNOPDSARA...right?

If you're presenting to your attending and it's 2:00 in the morning and you say things that are in a logical order it is very easy to listen to and also you know that that person has a process in a way that they evaluate patients and take a history and that's really important for medical students and trainees.

Let's Take Each of these History Elements into a Little More Detail!

Site

There are nine areas in the abdomen and each of these areas will have particular organs or referred pain and the subjective site will give you an idea of what's the underlying condition or reason for this patient coming in with a sick belly.

Now we don't need to go through each of these right here but later in the talk we're gonna go through each of these regions and talk about in a particular patient if they come in with pain in a particular region what should you be worried about and what questions can you ask.

Radiation

If you have pain that's radiating to that right shoulder that could be perforated, duodenal ulcer pain,  down the left shoulder and the left arm you know you might have to be thinking about a myocardial infarction, pain in the central back that's pathognomonic of acute pancreatitis but also dissecting aortic aneurisms.  As the pain gets lower on the left flank or the right flank you could start thinking about renal colic or pyelonephritis and then as it gets in the lower back start thinking about uterine pathologies, rectal pathologies.

On the front side we have biliary pain  and that's typically right upper quadrant pain that radiates in the right flank, renal colic pain is in the right flank and radiates down on the right groin.

There are a lot of these radiating patterns and teasing these out in the history can really can help you locate the organ and the pathology.

Nature

This is look at the pain's character, is it sharp or is it dull and achey.

I'll ask kids, "does it feel like I'm pinching you if I'm trying to elicit sharp pain or does it feel kind of like a dull ache" this is going to give me an idea again of what particular pathologies will give these type of presentations.  onset is when the

The sharp intermittent pain is more typical of underlying infection or abscess?  A dull and achey type pain is typical of a distended viscus like appendicitis or cholecystitis.

Onset

When did the pain begin?

If the pain started three months ago, when you first started having that right upper quadrant crampy pain after meals then it's three months and typical of biliary colic.

If it's appendicitis it was yesterday and likely it woke you up this morning of 3 a.m then that's the onset.

To me onset is looking at the very beginning of this specific type of pain.

Periodicity

Periodicity is the pattern of the pain.

Is it constant and progressive, which would be typical of acute appendicitis? For example, that periumbilical pain that started yesterday at 3 p.m. and it's been with me the whole time now it's down in the right lower quadrant, it's kind of moved but it's constant and it doesn't come and go.

When you have those pains that come and go, those can be closer to gastroenteritis or a bowel obstruction or the pain with renal colic typically is that kind of really sharp irritating pain that comes and goes,  not constant renal pathologies there is a break between episodes.

Is it a regular interval with the pain or an irregular interval?

Duration

This is different than onset.  You must ask yourself this question...when the pain comes on, how long does it last?

Do you get a break from the pain for a total of 5 minutes, do you get a break of 15 minutes?  Does the pain only come on for 30 seconds?

Knowing this will help with the differential diagnosis, so try to understand that for each patient, for example:

You know that it's easier to tease out the difference in duodenal ulcer versus gastric ulcers depending when the pain comes on and how long it lasts.  Duodenal ulcers demonstrate a delay in the onset of pain while the pain with gastric ulcer is more immediate.

Severity

How bad is the pain?

On a scale from zero to ten, ten being the worst pain you could ever imagine?

Have you ever had a pain like this before?

These questions will help kind of dial in the severity of the pain.  In addition there is one more important question....the PROGRESSION of the pain.

Did the pain start out at a three and now it's a 10 or did it start out at as a 10 and now you're feeling a little bit better?

A good example of why pattern is important is differentiating gastroenteritis from appendicitis.  Gastroenteritis usually will be quite severe and then get better and stay better.  Appendicitis is progressive and if observed overnight will get worse.  If we see a pattern when the pain get worse, and then better and then worse accompanied with SIRS, sepsis or septic shock, that is consistent with perforated appendicitis.

Aggravating

What are the things that make the pain worse? This could be everything from moving or hopping, jumping to pressure to eating and anything else you can think of to help narrow the diagnosis.

For example in appendicitis often the child might say "I felt every bump on the car ride to the hospital."

In symptomatic cholelithiasis or biliary colic often the pain will be aggravated by eating fatty meals.

Relieving

Does lying still relieve the pain? This would be typical of appendicitis, makes it feel better, whereas a renal stone lying still doesn't help at all, in fact patients with renal stones would usually be moving all over the place and that's one indication it probably isn't appendicitis.

Associated

In biliary disease associated findings may be jaundice, icteric urine or icteric sclera?

In SIRS or sepsis, any fevers, chills, rigors?

If you're suspicious of appendicitis asking about loose stools and diarrhea will give you an idea of if perforated appendicitis is possible.

SRNOPDSARA

Knowing this acronym and using it in your history and physical exams will give you a really clear bullet to communicate with your team or begin a note with an HPI.

What are some other important things to think about in the history?

There are a few other things to think about when you're taking the history...

Age

Children are gonna have a differential diagnosis that's a little bit different than an elderly person.  In a child I'm going to be thinking a little bit more like "okay could this be intussusception, or gastroenteritis or hemolytic uremic syndrome or malrotation volvulus, could there be an atresia, could there be a..."

In children I think about congenital problems as well as problems characteristic of a particular age, for example intussusception in a 2-3 year old versus pyloric stenosis in a 1month old, an atresia in a newborn or appendicitis in a 12 year old.  I'll also be thinking about dead giveaways that are concerning such as bilious emesis in a child, we must be thinking about malrotation volvulus.

In an older person that might have had previous surgery you might be thinking obstructive disease from adhesions intestinal perforation, perhaps peptic ulcer disease, biliary colic, diverticulitis and of course cancers.

Gender

Think about all of the differences between male and female organs. 

In cis-females you're going to have to pay more attention to ovarian etiologies like ovarian torsion, hemorrhagic ovarian cysts, ectopic pregnancy and endometriosis.

In cis-males you won't have those things but maybe you'll have testicular torsion or a gonadal cell tumor causing abdominal pain so an examination of the testicles during an acute abdominal exam is always indicated.

Cormorbidities

Take that patient who has atrial fibrillation, you know they have a higher chance of having a clot throw so mesenteric ischemia from an embolus now fits in your differential.  If you have somebody with HIV maybe they have an opportunistic infection causing their abdominal pain. 

Medications

Thinking about a patient's medications can give you some insight into a differential diagnosis.  If somebody is chronically taking NSAIDs you

know they have a higher risk of peptic ulcer disease or erosive gastritis.  If somebody is taking steroids they may have a higher risk of having a masked exam, sometimes they present with abdominal pain but they have a fairly benign exam and your antennae have to be more sensitive in those patients.

Bottom Line in the History for the Acute Abdomen

Your goal as a surgeon is to establish a differential diagnosis and from that differential be able to choose a management plan which could be in or out of the operating room.  If you think about age, gender, medications and comorbidities it will help you narrow that differential diagnosis and make a more effective plan.

Why is the physical exam so important in the acute abdomen?

Over the years from medical student on up through resident, fellow and attending surgeon you will hone physical examination skills so that after you take a good history you'll be able to start your physical exam, looking for particular things and. elicit signs which will really secure the diagnosis or lead to confidently order specific laboratory tests or imaging exams. 

Inspection

It all starts at inspection and I use the acronym CHANDLER.

I use CHANDLER every single day, it's become like breathing.

Color - Is the patient pale, jaundiced, grey, or are they pink and well perfused?

Hydration - Does the patient have moist or dry mucous membranes?

Alertness - Are they alert or are they confused, lethargic or sedated?

Nutrition - Are they cachectic, are they receiving enteral feeds or TPN, are they morbidly obese?

Disability - Is the patient paralyzed, in spine precautions, or are they moving all extremities?

Limbs - Are the limbs well perfused or is there pallor or cyanosis?

Extras - An evaluation of the drips and medications, Foley catheters and chest tubes, central access versus peripheral, arterial lines?

Respiratory - Is the patient in respiratory distress or are they breathing comfortably?  Are they intubated, on a non-rebreather or just room air?

As soon as I'm in the room, the Preop area, the ER or the trauma bay this is the checklist I go through every time and it helps give me a solid base to answer the all important question...

Sick or not sick?

Palpation

We begin with featherlight touch and progress with deep touch but before that we ask two very important questions...

Can I feel your abdomen?

Where does it hurt?

Here is how I do it!

After getting permission to touch the patient I always start AWAY from the pain, usually down on one knee, level with the patient and with one hand. 

Light touch with one hand allows me the ability to feel the contracting muscles of involuntary guarding or rigidity. 

Heavy touch in the beginning may lead to a "yelp" from the patient, a loss of trust and now an inability to get a good, confident physical examination.

If I need to go on to deep palpation I will but usually light palpation is all I need in the acute abdomen. 

If I'm examining for an abdominal mass I'll switch over to deep palpation and be sure that I understand where the mass is, if it is mobile or not, firm or soft and if it is most likely intra-abdominal or in the abdominal wall. 

This last point is discovered by having the patient lift their shoulders from the exam table and if I can still palpate the mass it is likely in the abdominal wall.

Also in palpation is the concept of rebound tenderness.

To elicit rebound tenderness I'll gently press into the abdomen and then release quickly, if there is pain on release this is most likely due to inflammation of the peritoneal cavity and I'm more concerned about an intra-abdominal process.

The last two comments I'll make about palpation include feeling for organomegaly, specifically hepatomegaly and splenomegaly. 

For each of these organs I'll begin inferior on the right lower quadrant and then make my way superiorly to feel for the liver, gently pressing in with the patient taking deep inhales until I can feel the liver's edge. 

For the spleen I'll also start in the right lower quadrant and make my way to the left upper quadrant, again, gently pressing in with each deep inhalation until I can feel the pleen. 

When feeling for organomegaly remember, if you start too high you may miss the organ!!

Percussion

We can use percussion in the abdomen for two main purposes. 

First we can use percussion to look for shifting dullness and get an idea if there is ascites present.  To do this I'll begin in the midline and percuss out to the flanks.  If I reach dullness then I'll keep my finger on that point and have the patient turn over on to the opposite side, percussing again may reveal a "hollow" note indicating a shift in the ascitic fluid.

The second reason to percuss is to help measure the size of the solid organs.  The liver can be measured with percussion as can the spleen.

Auscultation

I do not auscultate very often as I do not believe it adds much to my exam; however, there are some findings on auscultation which may help in your differential diagnosis.

The quiet abdomen - If I listen to the abdomen and I hear no bowel sounds it is consistent with an inflammatory process causing an ileum.

Tinkling - This is a high pitch sound which can be seen in the setting of bowel obstruction.

Venous hums - We can hear venous hums over the liver in cases of portal hypertension.

Renal bruits - Over the mid abdomen renal bruits can be heard in renal artery stenosis.

When I examine the acute abdomen I feel that inspection and palpation are the two most important skills, if you develop these skills and combine them with a solid history you can develop a very narrow differential diagnosis.

I hope this gives you a solid foundation for evaluating a patient with an acute abdomen, taking that history and performing the physical exam.