AcuteAbdomenStuartDanovitch,MDWashingtonVAMedicalCenter11/981急性腹痛英文AcuteAbdomen-ConundrumIfIoperateandtheproblemisnotsurgical,patientexposedtounnecessaryrisk,anesthetic,etc.Risksgreaterwithconcomitantillness,olderageIfIdonotoperateandproblemissurgical,patientatriskbecauseofwrongtherapy.Againtheolderpatientisundergreaterburden.11/982急性腹痛英文ACaricature-SurgeryAcutepainSeptic&toxicBoard-likeabdomenAbsentbowelsoundsWBC25,000Freeairunderdiaphragm11/983急性腹痛英文ACaricature-NoSurgeryTrivialpainRobustappearanceSoftabdomenwithnoguardingNormalbowelsoundsNormalWBCNormalpainanduprightfilmsofabdomen11/984急性腹痛英文AcuteAbdominalPain

Non-surgicalEmergenciesMesentericAdenitisAcuteEntericInfectionsAcuteEntericPoisoningsInflammatoryBowelDiseasePancreatitis(usually)11/985急性腹痛英文AcuteAbdominalPain

MetabolicCausesDiabeticKetoacidosisHeavyMetalPoisoningAcutePorphyriaTabesSickleCellCrisis11/986急性腹痛英文AcuteAbdominalPain

ClinicalPhenomena2/3ofattackstypical,1/3atypicalAcutecholecystitisandperforatedDUarerare,<20yearsAcutediverticulitisrate,<30years80%ofpatientswithbowelobstructionhadprevioussurgery75%ofpatientswithcholecystitishadpreviousattacks11/987急性腹痛英文AcuteAbdominalPain

ConfoundingClinicalFeaturesPerforatedduodenalulcer50%ofpatientshadnopreviouspain50%ofpatientshadbowelsoundsDiverticulitis40%ofpatientsvomited30%ofpatientshaveupperpainObstruction40%ofpatientshavenodistension11/988急性腹痛英文AcuteAbdominalPain

AncillaryDiagnosticStudiesCBCUrineAmylasePlainabdominalfilmsParacentesisandlavageRadionuclideScans11/989急性腹痛英文AcuteAbdominalPain

TheWBCin570patientsDiagnosis Sensitivity% Specificity%Appendicitis() 91 21Cholecystitis() 78 11Obstruction() 56 8Gastroenteritis(N) 49 11OtherNon-surgical(N) 62 82PredictivevalueofWBCforsurgicalcondition 29%PredictivevalueofWBCfornon-surgicalcond 93%11/9810急性腹痛英文AcuteAbdominalPain

SensitivityofRoentgenFindings-249Patients %Abnormal

Appendicitis 48 Cholecystitis 64 Pancreatitis 60 IntestinalObstruction 98 PerforatedUlcer 6011/9811急性腹痛英文AcuteAbdominalPain

SpecificityofRoentgenFindings-249Patients

Diagnostic 24% Helpful 18% NotHelpful 57% Misleading 1%11/9812急性腹痛英文DiagnosisofPancreatitis

Amylase-What’sRightCheapQuickNon-invasiveAdecentfirstapproximation11/9813急性腹痛英文DiagnosisofPancreatitis

Amylase-LackofSpecificityOrgannon-specificDiseasenon-specific11/9814急性腹痛英文DiagnosisofPancreatitis

HeterogeneityofSerumAmylase40%pancreatic60%salivaryIftotalactivitydoublesduetopancreatitis,p-isoenzymemust3.5x.11/9815急性腹痛英文DiagnosisofPancreatitis

TimingofEnzymeMeasurement%ActivityDaysTrypsin Lipase P-amylase T-amylase 0 100 100 100 100 1-2 100 100 100 75 3-4 100 85 70 35 5-7 55 55 3515Eckenfeld,ArchPathLabMed,198611/9816急性腹痛英文AcuteAbdominalPain

TheSerumAmylasein37Patients Amylase AmylaseNLPancreatitis (23) 17 6Nopancreatitis (14) 7 7Sensitivity Specificity +PV -PV 74 50 71 54 11/9817急性腹痛英文AcuteAbdominalPain

FrequencyofDiagnosesin1000PatientsUnknown 41% Cholecystis 4%UrinaryTract 9% IntestinalObst 2.5%Gastroenteritis 7% Constipation 2%PID 7% Misc 7%11/9818急性腹痛英文AcuteAbdominalPain

DiagnosticErrors-1000Patients

False+AssessmentPre-op--20Patients Pre-op Post-op

Appendicitis-7 MesentericAdenitis-1

EctopicPregnancy-5 PID-5

“Acute”Abdomen-5 Nothing-13

Diverticulitis-2 Pyelonephritis-1

Tubp-ovarianAbscess-311/9819急性腹痛英文AcuteAbdominalPain

DiagnosticErrors-1000Patients

False-AssessmentPre-op--11Patients InitialDx Post-op

Endometriosis-1 Appendicitis-8

Gastroenteritis-4 Obstruction-3

UTI-1

Uncertain-511/9820急性腹痛英文AcuteAbdominalPain

Sagaof1190Admissions Etiology %

Nonspecific 35

Appendicitis 17

IntestinalObstruction 15

GU 6

GB 5

Diverticulitis 4

PUD 3

Pancreatitis 2

Miscellaneous 1311/9821急性腹痛英文AcuteAbdominalPain

Sagaof1190Admissions EffectofAge >60(40%) <60(60%)

Nonspecific 23 43

Appendicitis 4 25

IntestinalObstruction 28 6 GU 3 8

IB 9 3

Diverticulitis 9 <1

PUD 4 1

Pancreatitis 4 2

Miscellaneous 16 1111/9822急性腹痛英文Computer-AidedDiagnosis

ofAcuteAppendicitis

FavoringDx AgainstDx

WBC NormalWBC

RLQlocation Othersites

Pain<12hrs >48hrs

Vomiting NoNausea

Rebound,Guarding Female 11/9823急性腹痛英文Computer-AidedDiagnosis

ofAcuteAppendicitis

ReliabilityofDecisionRules %

NegativeLapRate 15

Sensitivity 90

Specificity 91

+PredictiveValue 80

-PredictiveValue 9511/9824急性腹痛英文DecisionAnalysisinManagement

ofAcuteAbdominalPain

%Error

-lap +lap Computer Surgery 13 0 0

Nosurgery 5 2 11

Uncertain 11 0 31

Lapcontraind 4 5 2011/9825急性腹痛英文Diagnosis

SmallBowelObstructionAttribute RelativeRiskHxPrevioussurgery 12.1ColickyPain 2.5DistensiononPE 13.1AbnormalBowelSounds 9.011/9826急性腹痛英文AcutePancreatitis-PathogenesisBernard’sDictum

Noenzymes,NoPancreatitis11/9827急性腹痛英文AcutePancreatitis-Pathogenesis

MechanismsLimitingIntrapancreaticEnzymeActivationStorageandsecretionasproenzymesPancreatictrypsininhibitorspH(8-9.5);Ca(<1mM)abetdegradationMesotrypticdigestionofenzymesPlasmaanti-trypsins11/9828急性腹痛英文AcutePancreatitis-Pathogenesis

HypothesisforIntrapancreaticEnzymeActivationActivationActivationbythrombin,plasminLysosomalcathepsinEnterokinase11/9829急性腹痛英文AcutePancreatitis-Pathogenesis

InVivoEnzymeActivationAscitesandsurgicalfindingsphospholipaseelastaselysosomalenzymes[;as,aamto-trypticactivityBloodenzymes-activeandinactive11/9830急性腹痛英文EtiologyofAcutePancreatitis Cause %

Gallstones 40 EtOH 40 Hyperlipemia,Drugs, 10

Trauma,Tumor,Infection

Idiopathic 1011/9831急性腹痛英文DrugsAssociatedwith

AcutePancreatitis

Azathioprine L-Asparaginase Diuretics -methyldopa Pentamidine Captopril Sulfonamides Procaninamide

6-MP Nitrofurantoin11/9832急性腹痛英文DiagnosisofPancreatitisProblems

Symptomsnon-specificLaboratorynon-specificNogoldstandard11/9833急性腹痛英文DiagnosisofPancreatitisAppropriateclinicalcircumstance3-foldamylaseactivityReturntonormalinoneweekNogutperforationorinfarctiontrypsiongen,lipase,pancreaticisoamylase11/9834急性腹痛英文DDxofPancreatitisPerforatedviscusIntestinalobstructionMesentericvasculareventsAcutecholecystitisPID11/9835急性腹痛英文DDxofPancreatitisCluethatamylaseisnotduetopancreatitisinsickpatientsrenalfailureearlybacteremianormalcalciumdeteriorationinptwithcalcifiedglandrisingamylaseafter48hrs11/9836急性腹痛英文DiagnosisofPancreatitis

PancreaticImaging Sensitivity Ultrasound 35

CT 65

CT(Severe) 95-10011/9837急性腹痛英文DiagnosisofPancreatitis

%ConcordanceofAmylaseandImaging Amylase

<200u >200U NormalCT 12 20

AbnCT 20 48 Spechler,DigDisSci,1983