Abdomen Agudo

Dr. Miguel ngel Ros Trejo

Fecha: 07 / Ene / 13

DEFINICIN
Signos y sntomas de dolor abdominal y rigidez
Manejo quirrgico
Causas NO quirrgicas / NO intra-abdominales
DX CORRECTO

Manejo apropiado

Edad
Joven apendicitis
Adulto - biliar, oclusin, isquemia, diverticulitis

Townsend: Sabiston Textbook of Surgery, 18th ed

CAUSAS
ABDOMEN AGUDO NO QUIRRGICO
Endocrino / Metablica
Uremia
DM descontrolada
Porfiria

Hematolgica
Cls falciformes
Leucemia aguda
Discrasias sangunea

Drogas
Envenenamiento plomo
Supresin
Picadura viuda negra

Townsend: Sabiston Textbook of Surgery, 18th ed

CAUSAS
ABDOMEN AGUDO QUIRRGICO
Infeccin
Apendicitis
Colecistitis
Diverticulo Meckel
Absceso heptico
Absceso psoas

Hemorragia
Trauma rgano slido
Aneurisma arterial
Embarazo ectpico roto
Divertculo sangrante
MAV
Pancreatitis hemorrgica
Sx Mallory- Weiss

Isquemia
Trombosis mesentrica
Torsin ovario / testculo
Colitis isqumica
Hernia estrangulada

Oclusin
Adherencias
Vlvulo sigmoides / ciego
Hernia encarcelada
Enfermedad inflamatoria
intestinal
Intususcepcin
Cncer GI

Townsend: Sabiston Textbook of Surgery, 18th ed

Perforacin
Ulcera GI
Cncer
Sx Boerhaave
Divertculo

ANATOMA / FISIOLOGA
Dolor Visceral
Vago, poco localizado
Epigastrio, mesogastrio, hipogastrio (origen)
Por distensin viscera hueca

Dolor Parietal
Agudo, Localizado
Races nerviosas segmentarias inervan peritoneo

Dolor referido
Distante a fuente estmulo

Townsend: Sabiston Textbook of Surgery, 18th ed

ANATOMA / FISIOLOGA
Bacterias / Qumicos irritantes estimulan peritoneo

Aumento flujo
Aumento permeabilidad
Exudado fibrinoso
Parlisis intestinal

Adherencias (localiza inflamacin)

Townsend: Sabiston Textbook of Surgery, 18th ed

FISIOLOGA
Peritonitis
Inflamacin peritoneo
Resistencia a la palpacin, con o sin rebote
Principalmente a proceso inflamatorio (Enterobacterias o
anaerobio)
NO inflamatorio (pancreatitis)

Townsend: Sabiston Textbook of Surgery, 18th ed

ESTUDIO
Interrogatorio
Antecedentes: HF, PP, GO
Medicamentos / Drogas

Examen fsico
Laboratorios
Imagen

Townsend: Sabiston Textbook of Surgery, 18th ed

INTERROGATORIO
Dolor
Inicio
Sbito: perforacin intestinal, embolizacin arterial
Progresivo: inflamacin (colecistitis, oclusin intestinal)
Caractersticas
Intermitente: oclusin intestinal, clico biliar
Continuo: procesos inflamatorios
Localizacin / Irradiacin

Townsend: Sabiston Textbook of Surgery, 18th ed

 Gradual, progresivo

Sbito, severo

Townsend: Sabiston Textbook of Surgery, 18th ed

Intermitentes, clico

INTERROGATORIO

Townsend: Sabiston Textbook of Surgery, 18th ed

INTERROGATORIO
Dolor
Sntomas asociados
Vmito: dolor, oclusin, ileo
Alteracin hbito intestinal
Oclusin
Hematoquezia
Melena

Townsend: Sabiston Textbook of Surgery, 18th ed

INTERROGATORIO
Dolor
Exacerbantes
Alimento: oclusin, pancreatitis, diverticulitis, perforacin
Movimiento
Atenuantes
Alimento: ulcera no perforada
Reposo

Townsend: Sabiston Textbook of Surgery, 18th ed

EXPLORACIN FSICA
Inspeccin

Posicin
Cicatrices
Tumor, hernia
Eritema

Auscultacin
Peristalsis
Tono
Soplos

oclusin (metlico)
Estenosis arterial + 75% o MAV

Townsend: Sabiston Textbook of Surgery, 18th ed

EXPLORACIN FSICA
Percusin
Timpnico / Mate
Oclusin
Perforacin
Ascitis

Palpacin

Inicio alejado sitio del dolor

Organomegalia
Tacto rectal
Exploracin Ginecolgica

Townsend: Sabiston Textbook of Surgery, 18th ed

EXPLORACIN FSICA
Signos

Murphy
Blumberg
McBurney
Psoas
Rovsing
Obturador
Capurro
Giordano

Townsend: Sabiston Textbook of Surgery, 18th ed

LABORATORIOS
BH
Leucocitosis / bandemia

ES, BUN, Creat

Vmito, diarrea

Amy, Lipasa
Pancreatitis, perforacin, isquemia

PFH
Va biliar

EGO
GCh

Townsend: Sabiston Textbook of Surgery, 18th ed

IMAGENOLOGA
Radiografas
5% apendicolitos
90% nefrolitiasis

Townsend: Sabiston Textbook of Surgery, 18th ed

10% litiasis vesicular

Townsend: Sabiston Textbook of Surgery, 18th ed

Fox JC. Emergency and Critical Care Imaging. Emerg Med Clin N Am 2008; 26: 787812

IMAGENOLOGA
Ultrasonido
Colecistitis
Coledocolitiasis ??
tero y anexos
Limitantes
Aire
Operador dependiente

Townsend: Sabiston Textbook of Surgery, 18th ed

IMAGENOLOGA
TAC
Intestino y mesenterio
S: 69 95%
> en rganos slidos

Townsend: Sabiston Textbook of Surgery, 18th ed

E: 95 100%

IMAGENOLOGA
TAC
Apendicitis
Oclusin intestinal
Isquemia intestinal

Townsend: Sabiston Textbook of Surgery, 18th ed

LAPAROSCOPA DX

Alta sensibilidad y especificidad

Tx mltiples patologas
Disminucin morbi-mortalidad
Disminucin EIH
Disminucin costos

Townsend: Sabiston Textbook of Surgery, 18th ed

PATOLOGA QUIRRGICA
EF
PIA > 30mmHg
Resistencia involuntaria
Hemorragia GI requiere +4 PG s/estabilizacin

Rx

Dilatacin intestinal
Pneumoperitoneo
Extravasacin medio contraste
Oclusin vascular (angiografa)
Engrosamiento pared intestinal

Townsend: Sabiston Textbook of Surgery, 18th ed

PATOLOGA QUIRRGICA
Lavado peritoneal diagnstico
INESTABLE
1000 mL

> 500 leu / mm3

> 100,000 eritros / mm3
Tincin Gram (+)
Sangre
Fibras vegetales
Creatinina > Cr plasmtica

Townsend: Sabiston Textbook of Surgery, 18th ed

Bilis
Heces

PREPARACIN
Mayor dao por retraso en Tx quirrgico

Acceso IV
Correccin ES
SNG
Foley
Antibitico
Gram (-) y anaerobios

Hemoderivados

Townsend: Sabiston Textbook of Surgery, 18th ed

ESPECIALES
Embarazo
Apendicitis

Sntomas embarazo
Leucocitosis normal
USG: S 100%
E:96%
RM

Falso Positivo 15 35%

Prdida:
3 5 % NO complicada
20% Complicada

Townsend: Sabiston Textbook of Surgery, 18th ed

ESPECIALES
Embarazo
Patologa biliar
Qx: 2do trimestre o postparto

Oclusin intestinal
Adherencias
Vlvulo
3 periodos
16 20 SDG
32 36 SDG
Postparto

Townsend: Sabiston Textbook of Surgery, 18th ed

ESPECIALES
Crticamente enfermo

Isquemia mesentrica
Sx Ogilvie
Ulcera
Colecistitis alitisica
Pancreatitis

Townsend: Sabiston Textbook of Surgery, 18th ed

ALGORITMOS
LOCALIZACIN
HCD

Townsend: Sabiston Textbook of Surgery, 18th ed

ALGORITMOS
HCI

FII

Townsend: Sabiston Textbook of Surgery, 18th ed

ALGORITMOS
FID

Townsend: Sabiston Textbook of Surgery, 18th ed

CONCLUSIONES
Historia clnica y EF LO + IMPORTANTE
Evaluacin dirigida
Apoyo con Imagenologa
Retraso en Tx incrementa morbi-mortalidad

Townsend: Sabiston Textbook of Surgery, 18th ed

DUDAS,
PREGUNTAS