DIFFERENTIAL DIAGNOSIS cevy4 •Acute abdomen = Abdominal pain, GIT bleeding, •Dyspepsia, Diarrhoea, Hepato-Splenomegaly, Icterus cevy4 Differential diagnosis is an ability of ALL physicians lThe specific treatment of the particular disease is the ablity a physician with the particular speciality Výsledek obrázku pro treatment Výsledek obrázku pro diagnosis cevy4 The Leading Symptom vs Accompanying symtpoms le.g. lABDOMINAL PAIN lVs. lFever, Dierrhoea, Jaundice, Bleeding, Dyspepsia, Breathlessness, Vomiting, Peripheral ischaemia, … cevy4 The principle is reverse to the learning lLearning – starts with organ systems and gets deeper into different pathologies with deifferent symptoms l lDD – starts at a symptom and tries to find its origin – the diseae Výsledek obrázku pro detective cevy4 Exclude life threatening conditions lSepsis (cholangitis, bowel perforation, toxic megacolon, nephritis, appendicitis…) secondary peritonitis, lBleeding – into and outside GIT lThrombemolism….. lCritical ischaemia lHaemolytic crisis lHeart failure cevy4 The Leading Symptom Abdominal pain lSharp and hot - neuropathic lWell localised – somatic nerves affection lBlunt – inflammation, ischaemia lPulsating – innflammation, disecting aneurysm lCramps – hormonal and mineral disorders cevy4 The significance of the ACUTE ABDOMEN lUp to 20% surgically treated patients lCorrespond to a vast majority of surgical mortality and morbidity lUp to 25% with GI tumor is being diagnosed for the first time upon bleeding or obstructive acute abdomen cevy4 Definition lAs of a tradition, they are defined as life threatening episodes of abdominal symptoms arising with no prior warning. lThe term Acute abdomen or Acute abdominal pain, however comprises all even non surgical causes. cevy4 Division – should mirror the treatment lTraumatic lPenetrating –Always revise lNon-penetrating –Non-surgical approach possible lNon-traumatic linflammatory •Hollow organ - colic •Solid organ •peritonitis lObstructive - ileus •mechanic •vascular •neurogenic •pseudoobstruction lBleeding •into GIT •Out of GIT cevy4 Treatment lA shift to less invasive methods lendoskopic lEndovascular lLaparoscopy lCompletely non-surgical upon the particular cause lNon-surgical treatment possible only when 24hr diagnostics at hand (ileus, bleeding) lRaised demands for accuracy and reproducibility of imaging methods cevy4 •Inflammtory AA • • •GIT perforation • • •Surgical revision •Laparoscopic suture and drainage •Conservative in covered perforation reported • •Hollow organ inflamed, empyema, abscess • • •ATB + Drainage •– percutaneus (CT, US) -Endoscopic -If everything fails than surgical •Pimary surgical APPE, LCHCE • •Solid organ inflamed •(kidney, pancreas...) • • •-Just ATB, •-if abscess or infected necrosis thean percutaneous or endoscopic necrectomy or drainage •-Surgery as the last possibility •-Provide proper clearance of particular duct affected • • •Possibilities in inflammatory Acute Abdomen cevy4 •ileus • • •mechanic • •Obstruction remowal, early enteroclysis in intususception, spontaneous resolution in adhesions possile, •- Surgical reviosion usually inevitable • • •vascular • • •Thrombolysis if caught early •Surgical revascularisation •Or resection if possible • • •Neurogenic – both spastic and paralytic • • •Non-surgical treatment unles its failure and disease progression • • •pseudo-obstruction, Ogilwie • • •Endoscopic desuphlation and prokinetics • • •Possibilities in obstructive acute abdomen cevy4 •Bleeding into GIT • • •Varices, GD ulcer, tumours, divrticuli, AV malformations • • •endoskopy, TIPS, endovascular, surger as the last option or in a non-stabilisable patient • • •aorto-enteric fistula • •Diagnostics unaccurate – emergency surgical reviosion •- Emergency stentgraft placement reported • • •Bleeding out of GIT • • •Visceral arteries ruptured, AV malformation • •Endovascular emboisation, stentgrafts, surgery in case of failure • • •Ruptured aneurysm of AA and iliac arteries • •Emergency surgical revision (2/3 die before admission and another 2/3 after succesfull surgery – MOSF) • • • •Possibilities in bleeding acute abdomen •Always substitute for the blood loss and coagulopathy •Extrauterine pregnancy •Laparoscopy possible cevy4 Treatment of traumatic acute abdomen lPenetrting lAlways surgical reviosion lAt least using laparoscopy lNon-penetrating lNon-urgical management possible if good 24hr IC monitoring and CT accesibility lLiver trauma oudht to be managed non-surgically irresective of the degree and haemoperitoneum but a non-stabilized patient lHve in mind risk of ommitted GIT perforation – high energy trauma cevy4 Origin lPsychologic lAlimentary/Intoxication lMusculosceletal lMetabolic lBleeding lIschaemia/Thrombosis lInfection lInborn malformations lTumours l cevy4 Diagnosis lSwift and accurate lMedical history lPhysicl examination lBlood chmistry lImaging methods lDevelopment in time lBe carefull in ltoddlers lelderly lpregnant cevy4 Differential diagnosis lExtra-abdominal diseases lIHD - MI, basal pneumonia, lumbago, pulmonary embolisation, pleuritis, testis torsoin (or torqued ovary), radiculitis, herpes zoster lHematologic causes lHaemolytic crisis – liver and spleen distension, lMetabolic lUraemia, poissoning, hyper-parathyreosis, thyreotoxicosis, endometriosis, DM and alkoholic ketoacidosis, porfyria, mehtanol poissoning lOther lGI gasses, morphin withdrawal syndrome, gastro-enteritis, colitis lBlack widow bite, scorpion sting. cevy4 Defining symptom- abdominal PAIN lType lvisceral – vegetative nerves – non-localisable - distension, spasms lSomatic – somatic nerves - peritoneum lIrradiating – convergence of nerves coming from different places within the medulla lBeginning lsudden – seconds - perforation, bleeding, torsion (ovary, testes, appendix) lquick - minutes to hours - intususception, strangulation, pancreatitis, hollow organs collic lslow - inflammation - lCharacter lcolic – hollow organ obstruction lcontinual lThe pain travel lA shift of affection from the particular organ to the corrsponding peritoneum cevy4 Pain Location lEPIGASTRIUM - nn splanchnici maiores + n.X lForegut embriologically – coeliac trunc - stomach, 1st one half of duodenum, liver, pancreas. lMESOGASTRIUM - n splanchnici maiores + n.X lMidgut embriologically - AMS – periumbilical pain lappendicitis – typical shift in the location and character of the pain lHYPOGASTRIUM – pelvic sympathetic nn. + nn. splanchnici minores l Hindgut – AMI - levý tračník a níže (+ genitourinární systém) cevy4 Important medical history lMedication lBlood thinning therapy, NSAIDS, hormonální contraception lOral intake lPoissoning, diet mistakes, abuse of… lChronic diseases lGastric ucer, CKD, haematologic diseases lPreceding surgeries lRelapsses, adhesions lAccompanying symtoms lConstipation, diarrhoea, vomitus lStool, urine character, vomitus character cevy4 Physical examination l2A + 3P (Aspection, auscultation, palpation, percussion, per rectum) lPulse, Blood pressure, Body temperature, lRectal to axillary BT difference cevy4 Typical local findings on abdomen resulting from the peritoneum irritation lDéfanse musculaire – diffuse peritonitis lMurphy lKehr – phrenic nerve sign lBlumberg lRowsing lPleniés lMcBurney – McBurney spot pain lCullen – acute pancreatitis lGrey-Turner – acute pancreatitis lChandelier – pelveoperitonitis, pelvis elevation on DRE lPsoatic sign – psoatic irritation lObturator fossa sign – inner hernia cevy4 Laboratory tests lBlood count + coagulation lLEU – sign of inflammation, dehydration, ERY – deyhdration, Leukocytóza jako známka zánětu, polycytémie a riziko trombózy lBleeding – cave delay, Plt + Ery down , Leu up lPrimary or secodary coagulopathy lD-Dim – when negative thrombosis excuded lJT lhepatopathy lBile obstruction lAmylase + lipase (serum , urine) lAcute pancreatitis/ischamia (3 times serum level od 5 times inrenal insuff.) lCRP l6 hours after insult, maxumu at 48 hours l PCT (vs. IL-6) lQuite specific for becterial infection l Lactate lIschaemia, shck, affected microcirculation lPregnancy test - HCG cevy4 Fundamental imaging methods lPlain abdominal X-ray lLying vs standing position – ileus, foreign body lPlain X-ray targeted to subphrenic space lFree air = GIT perforation lBut – preceding surgery, PNO, VATS, pneumatosis cystoides lMind adhesions – prevent gas redistribution –ascension to diaphragm and detection lUS lCT – all in one examination lEndoscopy in case of GIT cevy4 Pneumoperitoneum pneumoperitoneum01 cevy4 Water levels in ileus chycené kličky cevy4 paralytický ileus01 Dilation, gathering cevy4 Prestenotic dilation in Crohn´s disease cevy4 Additional and Alternatve imaging methods lWhen still in doubt lUsually non emergency lMRI lenteroclysis lDSA lMR a CT angiography lERCP, MRCP lGamma ray imaging with stained Leu or Ery cevy4 Gamma-ray image - bleeding KRV_CEN_ cevy4 Leiomyoma of the jejunum DSA • G:\Kala-obrázky\angio - leiomyom.JPG cevy4 Lymphoma of jejunum at enteroclysis • G:\Kala-obrázky\Enteroklýza - lymfom 2.JPG cevy4 Amyloidosis enteroclysis of the ileal region cevy4 Pneumatosis cystoides v obraze enteroklýzy, bublinky plynu ve stěně PNEUMATOSA • cevy4 The Leading Symptom Diarrhoea lPsychologic lAlimentary/Intoxication lMetabolic lInfection lIBD l cevy4 The Leading Symptom Dyspepsia lPsychologic lAlimentary/Intoxication lMetabolic lInfection lIBD lMalformation/Atresia cevy4 Origin lPsychologic lAlimentary/Intoxication lMusculosceletal lMetabolic lBleeding lIschaemia/Thrombosis lInfection lInborn malformations lTumours l cevy4 The Leading Symptom Jaundice lPsychologic lAlimentary/Intoxication lMetabolic lInfection lIBD l cevy4 Origin lPsychologic lAlimentary/Intoxication lMusculosceletal lMetabolic lBleeding lIschaemia/Thrombosis lInfection lInborn malformations lTumours l cevy4 The Leading Symptom hepato-spleno megaly lHematologic lOncohematologic lCardiologic lInfection l cevy4 Origin lPsychologic lAlimentary/Intoxication lMusculosceletal lMetabolic lBleeding lIschaemia/Thrombosis lInfection lInborn malformations lTumours l cevy4 The Leading Symptom GIT bleeding cevy4 Origin lPsychologic lAlimentary/Intoxication lMusculosceletal lMetabolic lBleeding lIschaemia/Thrombosis lInfection lInborn malformations lTumours l cevy4 Causes cevy4 mesenterika2 Trombóza a. mesenterica částečná cevy4 Leiomyom jejuna střevo 3 cevy4 Karcinom sigmatu tumor střeva cevy4 Hemoperitoneum Hemoperitoneum 4 cevy4 Biliární ileus P1300005 cevy4 Srůsty cevy4 Rupturující aneurysma břišní aorty v CT obraze 17