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Pitfalls and problems in the management of the acute abdomen

Weledji, Elroy P

doi: 10.4103/ijssr.ijssr_16_17
Review Article
Free
SDC

The acute abdomen is defined as the rapid onset of severe symptoms that may indicate potentially life-threatening intra-abdominal pathology which requires urgent surgical intervention. The article reviewed the pitfalls and problems in the management of the acute abdomen. The importance of simultaneous examination and resuscitation, recognizing the need for physiological support, and maintaining the rapid progress toward a diagnosis and definitive treatment are emphasized.

Department of Surgery, Faculty of Health Sciences, University of Buea, Buea, Cameroon

Address for correspondence:Elroy Weledji, Department of Surgery, Faculty of Health Sciences, University of Buea, Buea, Cameroon elroypat@yahoo.co.uk

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Introduction

The acute abdomen is defined as the rapid onset of severe symptoms that may indicate potentially life-threatening intra-abdominal pathology which requires urgent surgical intervention. The presentation of the acute abdomen describes a wide heterogeneity of patient populations, making it difficult to suggest a general treatment regimen and stressing the need of an individualized approach to decision-making. Although reassessment and changes to management may be needed, maintaining rapid progress toward a diagnosis and definitive treatment is essential in critically ill patients and diagnostic laparotomy may be necessary. Peritoneal sepsis is, however, not the sole cause of death but compounds comorbidities. 1 , 2 Many patients undergoing emergency major surgery are inherently unstable and easy prey to further complications due to preexisting organ damage (comorbidity) or the acute disease process itself. Thus, the importance of preoperative resuscitation of patients with the acute abdomen. However, a complete optimization is not always possible in the emergency setting, and thus, the mortality rate of major emergency surgery is much higher (>30%) than planned (elective) surgery (<5%). 3 , 4

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Examination and Resuscitation

Surgical peritonitis may emanate from perforation, ischemia (mesenteric or strangulation), pancreatitis, and anastomotic leakage. Although a swift history may indicate the possible pathology (e.g., conditions that start suddenly and produce signs of peritonitis are perforation of viscus, infarction, and intraperitoneal hemorrhage), simultaneous examination and resuscitation takes precedence over thorough history-taking. There are well-established specific features associated with all acute abdominal conditions but it is the ability to identify the presence (rebound tenderness) or absence of peritoneal inflammation which probably has the greatest influence on the final surgical decision. 4 However, the abdominal tenderness due to intraperitoneal blood has a different character and is less pronounced than that of peritoneal inflammation due to sepsis. In addition, it is important to note that although acute severe abdominal pain is the hallmark of the acute abdomen, a pain-free acute abdomen may occur in older people, in children, in the immunocompromised, in the last trimester of pregnancy and in the patient in the Intensive Care Unit (ICU). 2 , 5 , 6 It is, therefore, not possible to practice fully the ideal management of early diagnosis and surgery for the acute abdomen, thus reducing the morbidity and mortality to zero because patients and the disease are variable. Because infections, inadequate tissue perfusion and a persistent inflammatory state are the most important risk factors for the development of multiple organ failure, it is logical that initial therapeutic efforts are directed at their early treatment or prevention (early goal-directed therapy). 3 , 7 This is corroborated by the increased morbidity and mortality following inadequate resuscitation. 2 Anesthesia removes vascular tone and can cause catastrophic hypotension in the hypovolemic patient. Ringer lactate or Hartmann's solution or a balanced colloid solution is better than 0.9% normal saline in preventing hyperchloremic acidosis during resuscitation. Early goal-directed resuscitation during the first 6 h after recognition of septic shock has moved toward the use of whole blood as it appears to eliminate the problems of expansion of extravascular volume and marked fluid retention seen with crystalloid on a background of leaky capillaries, and also appears to provide a lower incidence of organ failure. 3 A central venous pressure between 5 cm and 10 cm H 2O and a urine output >30 ml/h are reasonable guides to the adequacy of fluid resuscitation. Patient mortality is significantly lowered following early initiation of broad-spectrum antibiotics. 8 , 9 Narcotic analgesia may assist diagnosis by relieving the patient's anxiety, but sedating a restless, agitated patient may mask an underlying sepsis. Any patient with an acute abdomen who needs high-flow oxygen or continuing fluid to maintain urine output is at high risk and need a diagnosis, monitoring and support in a high dependency unit/ICU (HDU/ICU) and definitive treatment. 10 Blood is the best resuscitation fluid for the bleeding patient who has cardiovascular instability and who requires more than 1500–2000 ml of resuscitation fluid. It is important to identify the bleeding patients (e.g., postoperative or recurrent bleeding from a peptic ulcer) who are pale and shocked and need simultaneous surgery and resuscitation. The “C” circulation stage of the primary survey assessment and treatment process (A - Airway, B - Breathing, C - Circulation, D - Dysfunction of the central nervous system, and E - exposure of the patient) is continued in theater to control hemorrhage (resuscitative laparotomy). More frequently, radiological embolization or urgent surgery will be needed to stop lesser degrees of continued hemorrhage.

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Investigations

Resuscitation is often required before investigations but it may need to be continued simultaneously with the proposed investigations. A pneumoperitoneum seen on erect chest x ray indicates a perforated viscus in only 70% of patients. Early computerized tomography (CT) or ultrasound scanning, although not with a 100% specificity or sensitivity, may reveal a source of infection or sepsis and allow simultaneous active intervention. 11 , 12 , 13 Clinical suspicion and structured reassessment alongside serial contrast-enhanced abdominal CT are needed in acute pancreatitis. Hematological tests may reveal a normal white cell count, a very low white count (neutropenia) <2000 × 10 9which is a sign of profoundly impaired host response and a raised count >20,000–25,000 as a sign of infarction. Temperature is not always raised, more often unless septicemia is present. Anemia may represent an undisclosed neoplasm or occult bleeding. Biochemistry gives a warning sign of dehydration or established renal failure (plasma urea and creatinine), and blood gases the metabolic acidosis associated with tissue perfusion and sepsis. Blood cultures are often negative in surgical infection and sepsis syndromes and may take 24–48 h to give meaningful microbiological data but may give an idea of the source of sepsis. Taking blood, urine, sputum cultures, and culturing any pus or abdominal fluid is a mandatory early step which may be useful if there is little resolution a day or two later. 4 , 5 , 10 Serum amylase is nonspecific unless >×3 upper limit of normal with classic symptoms of acute pancreatitis and only remains acutely elevated for 48 h or so. After this, C-reactive protein provides a better index of the degree of persisting inflammation although it is not specific to the pancreas. 14 Scoring systems (using hematological, biochemical, and clinical variables) offer comparative indices of disease severity but are of limited individual prognostic use. It may nevertheless be appropriately used as one of several admission criteria to a high dependency unit or ICU. The acute physiology and chronic health evaluation (APACHE II) score is widely used for all severely ill patients on ICU with a variety of disease processes. It is calculated from 12 routine physiological measurements during the first 24 h after admission, age and previous health status. APACHE II score >8 on admission predicts mortality of 11%–18%. Physiological and operative severity score for the enumeration of mortality and morbidity score is used for ward and HDU patients and the Ranson or Imrie scores of >3 are predictors of severity of acute pancreatitis. 5 , 10 , 14 The Mannheim peritonitis index is a reliable predictor of peritonitis outcome. The adverse factors include presence of organ failure, time elapsed (>24 h) before surgery, presence of malignancy, origin of sepsis, the presence of fecal, and generalized peritonitis. 15 Thus, regular reassessment and making use of the investigative options available will meet the standard of care expected by patients with acute abdominal pain.

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Principles of Management

The principles in the management of the acute abdomen are to distinguish: (1) if surgery is inevitable from the outset following diagnosis, (2) if there is no improvement or a worsening clinical condition, and (3) if the acute abdomen is responding well to conservative measures /1. Surgery is inevitable, for pathologies such as a perforated peptic ulcer, perforated intestinal typhoid, leaking aortic aneurysm, and a mesenteric ischemia which may also require a second-look laparotomy. Conservative management is limited to the resuscitation necessary in optimizing the patient's condition before operation. In the second scenario where the patient is not improving, or, has worsening clinical conditions, the initial diagnosis may have been incorrect or a complication may have supervened such as the rupture of a diverticular pericolic abscess causing generalized peritonitis. The patient would require aggressive resuscitation in ICU and optimization before surgical intervention (resection and primary anastomosis in selected patients). 16 , 17 The treatment of diverticulitis has evolved toward more conservative and minimally invasive strategies. 18 Diverticular abscesses (about 5% of patients) may require percutaneous drainage if conservative treatment (antibiotics alone) fail. 19 In purulent peritonitis of diverticular origin (Hinchey Stage III and IV), laparoscopic lavage drainage could be considered particularly in elderly, unfit patients. 18 , 19 {Table 1}

In the third scenario, the patient responding to conservative measures following a history of a gradual onset, increasingly severe abdominal pain may have pathologies such as acute cholecystitis, diverticulitis, pancreatitis which do respond to conservative medical management. However, a favorable initial response to conservative treatment may also indicate adequate resuscitation and optimization of a patient with a perforated viscus, for example, peptic ulcer, appendicitis, anastomotic leak, and now being rendered a window for surgical intervention. Any delay would lead to a loss of the benefits of resuscitation as sepsis supervenes. 1 , 20 Patients might also be considered for nonoperative treatment of their perforation or anastomotic leak with intravenous antibiotics and nasogastric suction, provided there is good reason to believe that the perforation has sealed off spontaneously, and the risks of surgery are perceived to be significantly greater than an expectant policy. They would require active observation and monitoring of vital signs particularly the pulse rate and temperature, and should have contrast radiological imaging to confirm spontaneous sealing of the perforation. 21 , 22 , 23

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Continued Optimal Organ Support in Intensive Care Unit/high Dependency Unit

Although a higher level of physiological support in ICU/HDU is anticipated from age, diagnosis, severity of the acute illness and presence of preexisting diseases, 6 , 10 surgical complications may occur on ICU and needs surgical management. Further surgical intervention for an unstable patient with a recurrent problem, for example, further sepsis in a patient with recent fecal peritonitis or a new complication, for example, acalculous cholecystitis, perforated peptic ulcer following any major surgery. Determining whether or not an unstable patient in ICU has an abdominal process which requires intervention can be difficult as the usual signs may be absent due to sedation and paralysis. Distension, appearance of wounds, stomas, drain effluent, and any systemic deterioration may give clues. Frequently, the signs will be systemic – increased inotropic requirements, onset of acute renal failure or thrombocytopenia (from severe sepsis and disseminated intravascular coagulation). Joint management (intensivist, surgeon, and the radiologist) offers the best chance of success. 10 The aim is to operate in a timely manner on as well prepared a patient as possible although it may not be able to make the patient stable until the underlying cause is dealt with. 1 Adequate treatment of the underlying cause of sepsis is vital as re-operative surgery is difficult and associated with greater morbidity and mortality. 24 Exteriorizing the bowel ends of an anastomotic leak may be necessary and safe, 25 and early tube feeding enteral nutrition (EN) should be initiated when possible. Sepsis and malnutrition will cause breakdown of a reanastomosis. 10 , 26 EN down-regulates splanchnic cytokine production, modulates the acute phase response, reduces catabolism, and preserves protein. 26 On occasion, because of difficulty in closing the abdominal wall without undue tension, it may be necessary to leave the abdomen open with moist packing (laparostomy) or with an absorbable mesh to constrain the viscera. The packing is changed every 24 h with relavage of the abdomen on the ICU, and these open wounds heal remarkably quickly if the underlying problem has been dealt with. 10 , 27 Due to immunosuppression, the most common disease processes in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patients causing the acute abdomen are cytomegalovirus (CMV) colitis, B-cell lymphoma, acute appendicitis (CMV-associated), and atypical mycobacterial infection which are quite different from those in the non-HIV population. It is crucial to have close liaison between AIDS physicians and AIDS surgeons to exclude preterminal cases and keep down negative laparotomies. 28

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Conclusions

Simultaneous examination and resuscitation takes precedence over the history of the acute abdomen. It is important to recognize and anticipate the need for a higher level of physiological support in the HDU/ICU. Although reassessment and changes to management may be needed, unstable patients require diagnosis, and definitive treatment without undue delay.

Acknowledgment

I would like to acknowledge all my patients who suffered the wrath of the acute abdomen and rendered the impetus to write this technical note from lessons learned.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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    Keywords:

    Acute abdomen; resuscitation; treatment options

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