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Welcome. Today we'll discuss diseases of the peritoneum.
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So we'll start with a case.
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A 38-year-old man with no past medical history presents to the emergency department
with four hours of severe right lower quadrant abdominal pain.
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The night before, he noticed a dull ache around his umbilicus.
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The pain steadily worsened and is now associated with nausea and vomiting.
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Vitals are notable for temperature of 39.2, heart rate 125 and blood pressure 92/50.
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Physical exam reveals diffused tenderness to palpation
throughout the abdomen with rebound and involuntary guarding.
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Lab studies reveal a white cell count of 18,000 and lactate 3.1.
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Bedside ultrasound shows peritoneal fluid in the right lower quadrant.
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So, what is the best next step in management?
Let's point out some key features here.
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He has had periumbilical pain that then progressed to acute severe right lower quadrant pain.
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He does have signs of sepsis with his temperature of 39,
his tachycardia and his relative hypotension.
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He also has physical exam findings that are suggestive of an acute abdomen.
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In addition, his labs are somewhat concerning.
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So he has a leukocytosis with an elevated lactase.
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So, let's talk a bit about the acute abdomen.
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The acute abdomen is what we call the condition when patients have peritonitis.
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They may come in with unstable vital signs.
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They will often have abdominal rigidity or involuntary guarding upon palpation of the abdomen.
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They may have rebound tenderness which is when letting go of palpation
causes more pain than palpation itself.
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And they may have pain that worsens with any minimal movement.
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So, a typical physical exam finding that I find to be most helpful
is when you bump the bed that the patient is on and they --
if they have extreme pain with just that minimal movement,
you can suspect that they have the acute abdomen.
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It's important to remember that the acute abdomen is an emergency.
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If you're concerned for any of these physical exam findings that we just described,
you should emergently talk to surgery for surgical exploration.
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One of the most common causes of the acute abdomen is acute appendicitis.
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This happens when there is inflammation of the appendix which is a vestigial organ.
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It often occurs from obstruction from a fecalith.
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Patients classically present with right lower quadrant pain that begins around the umbilicus
and then migrates to the right lower quadrant pain.
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However, note this is not always present.
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They may often have a lack of appetite or anorexia, nausea and vomiting,
and they may have fevers and chills if this is a late presentation of appendicitis
or if they have developed perforation.
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So, there are several physical exam maneuvers that you will frequently be tested
on in relation to acute appendicitis. The first is McBurney's point.
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This is the point we use to describe maximal tenderness about one third the distance
from the anterior superior iliac spine measured to the umbilicus.
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You may also do a maneuver called Rovsing's sign.
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This is when palpation of the left lower quadrant elicits pain in the patient's right lower quadrant.
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Another exam maneuver you may check is the Psoas sign.
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This is when you passively flex the patient's right hip and this elicits right lower quadrant pain.
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Alternatively, you can do the obturator sign which is when you flex
and internally rotate the patient's right hip which then elicits right lower quadrant pain.
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These latter two findings work because they bring the inflamed appendix against the muscle
that is named in each side and thus elicits pain in that area.
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So, although you will often hear this on tests, Rovsing's, psoas and obdurator signs
are actually poorly sensitive, clinically speaking when looking for acute appendicitis.
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But if you happen to find one of them,
they are highly specific for appendicitis, so can be helpful.
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So now let's get to the diagnosis of this disease.
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The diagnosis depends mostly on imaging. CT abdomen is the preferred method of diagnosis.
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Here, you can see an example of a CT abdomen
showing an inflamed appendix where the arrow is.
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And this patient also incidentally has an abdominal aortic aneurysm as labeled by the AAA.
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This is probably unrelated to this current presentation.
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For those patients who -- in whom you are trying to avoid radiation exposure,
you might do an ultrasound or MRI.
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In addition, now, point of care ultrasound at the bedside
is becoming more and more frequently used and can provide a rapid evaluation.
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If you detect free fluid in the pelvis, you might suspect acute appendicitis.
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So, treatment depends on whether it is perforated or non-perforated.
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Once you have perforation, this is an emergency
and requires exploratory laparotomy and appendectomy.
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Nonperforated appendicitis can be treated with immediate appendectomy.
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And in certain cases in which surgical risk is too high, you may do intravenous antibiotics
and do percutaneous drainage of the abscess.
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So now let's return to our case.
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A 38-year-old man coming in with periumbilical pain
that then progressed to severe right lower quadrant pain
should prompt you to think about appendicitis.
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He has signs of sepsis, so that's -- he meets SIRS criteria with a known source.
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He has a physical exam signs concerning for an acute abdomen.
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And his high white count with elevated lactate
should prompt you to think about perforated appendicitis.
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So the best next step in management would be an emergency surgical consultation
for surgical exploration and washout of the abdomen.