Acute Abdomen/Hernias

SUGGESTED READINGS ACUTE ABDOMEN/ HERNIAS

1. Current Surgical Diagnosis & Treatment, 12th Edition, Ch. 21, 22, 23. 2. Current Surgical Diagnosis & Treatment, 12th Edition, Ch. 32.

OBJECTIVES ACUTE ABDOMEN/ HERNIAS

1. Describe a systematic approach to the history in the assessment of the acute abdomen.
2. Outline the specific ways that the physical examination is different in the assessment of the acute abdomen than it is in the benign abdomen.
3. List the differential diagnosis of localized tenderness in the epigastrium and each of the four abdominal quadrants.
4. Describe the management of the common causes of the acute abdomen.
5. Describe the role of the peritoneum in intra-abdominal inflammatory processes.
6. Describe the presentation and management of conditions that commonly present as an acute abdomen that do not require surgical therapy.
7. Provide a definition of a hernia and understand the incidence of various types of hernias.
8. Define the various locations of hernias on the abdominal wall. Understand the different types of hernias (reducible, incarcerated, strangulated, sliding) at each anatomic site.
9. Differentiate a direct, indirect, and femoral hernia of the groin and define the anatomic relationship between them.
10. Identify the types of hernia repair used for common abdominal wall hernias. Understand the potential complications of hernia repair that might be seen by primary care specialist.
11. Describe the abdominal and groin exam and the findings associated with the different types of hernias.
12. Understand the anatomy and physiologic abnormalities of the different types of diaphragmatic and hiatus hernias. Explain the long-term effects of gastroesophageal reflux disease (GERD). Describe the objectives of anti-reflux operations for

GERD. CASE HISTORIES ACUTE ABDOMEN

1. A 17-year-old female presents to the Emergency Room complaining of abdominal pain. She relates that it started yesterday afternoon and has progressed in severity. On physical examination, she is febrile with a temperature of 38.7 o C. She is tender to palpation in the right lower quadrant.

2. The Emergency Room physician asks you to evaluate a patient with a rigid abdomen. You arrive to find a 60-year-old man in significant discomfort. He relates that he has had epigastric pain for several months. On physical examination, his abdomen is rigid and his blood pressure is 90/60.

3. A 42-year-old woman presents to your office with constant right upper quadrant pain. She states that it has been present for 24 hours. She reports that prior to this time, she had intermittent pain in this area. On physical exam, she has a temperature of 38.7oC and appears moderately icteric. She is tender to palpation to the right upper quadrant.

4. A 70-year-old son transports his 90-year-old mother to the ED. Her son reports that she has been complaining of intense abdominal pain. The patient reports that the pain is located in the left lower quadrant. On physical exam, she is mildly ill appearing. She is febrile with a temperature of 39oC. She is tender in the lower abdomen on physical examination. The patient reports that her son worries too much and she doesn’t want to see a doctor because she is afraid that you will interfere with her triathlon-training schedule.

5. A 60-year-old man is presented to the Emergency Department by his relatives. They say that he has a long a complex medical history related primarily to his heart. The patient is in shock. His abdomen is distended and rigid.

6. TD is a 44-year-old male who gives a history of feeling a sudden pain in his left groin while moving a refrigerator at Best Buy. This occurred three days ago and the pain has persisted since then. He comes to the hospital with complaints of nausea and vomiting over the past two hours. Otherwise, he is healthy and does not take any medications or have any allergies. Physical exam shows him to be acutely ill and lying quietly on the gurney. His BP is 110/72, pulse 92 bpm, and temperature is 37.2° C. His chest is clear. He has some abdominal tenderness but no signs of peritoneal irritation. His left inguinal area is erythematous, tender, and has peau d’orange changes of the skin. There is a large lump (5cm) over his external ring. He vomits once during the physical exam. What is the most likely diagnosis in this patient? What is causing his vomiting? What is the natural history of this process if it is left untreated? What are the goals of an operative approach to this problem? What do you tell the patient about the possible complications of the procedure?

7. SM is a 96-year-old male who underwent a right hemicolectomy through a midline incision 32 years ago. Now he is complaining of pain in the area of the incision with a notable bulge in the region whenever he strains or coughs. A defect in the abdominal wall is palpated and felt to be 15 cm in diameter. A large hernia is protruding through the defect, but it is easily reducible. Except for mild intermittent abdominal wall pain, he has no other abdominal complaints. Past medical history is positive for CAD, CHF, A-fib, COPD, AODM, GBD, PVD, PUD, and hemorrhoids. He presents you with a list of medications and allergies that is two pages long. Physical exam of the abdomen shows a large ventral hernia that “mushrooms’ out of the abdomen. The mass is mildly tender, but is easily reducible. He asks you, “What are you going to do about this thing, doc?” What is the most likely cause of his hernia? How would you classify it?

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