1	"Javier Coronado" Javier Coronado, MD
2	Acute Abdomen Extremely diverse etiologies Diagnosis very difficult in ICU patient Complaint of pain absent in presence of intubation and/or sedation Presence must often be inferred from unexplained sepsis, hypovolemia or abdominal distension
3	Where does acute abdominal pain come from? Inflammatory Disorders (cholecystitis, appendicitis, perforated ulcer, etcetera) Colic (biliary, intestinal obstruction, renal) Vascular lesions (ruptured AAA, mesenteric ischemia, hemorrhage) Urologic/gynecologic disorders Medical disorders (sickle cell crisis, lupus serositis)
4	General Approach Evaluate patient in clinical context Obtain best history possible Example Acute abdominal pain in the setting of shock, CHF or coagulopathy may lead to suspicion of ischemic bowel Thorough physical exam Perform without sedation
5	More Principles Surgery consultations for acute abdomen Certain diagnosis suspected Unrelenting pain Diagnostic laparoscpy/laparotomy, i.e. ischemic bowel or acalculous cholecystitis Early use of computed tomography or ultrasound Disease process may already be advanced when suspected
6	Acute Abdomen in the ICU Four types Patient is critically ill postoperatively or develops postoperative complication Postoperative patient requiring critical care for unrelated condition Patient requires resuscitation preoperatively Severely ill patient that may not require surgery
7	Intra-Abdominal Abscesses Primary peritonitis Infection of peritoneal cavity without obvious source of infection Most frequently in patients with ascites Treated with broad-spectrum antibiotic(s) until cultures completed Removal of foreign body may be necessary
8	Secondary Bacterial Peritonitis Presence of purulence or gastrointestinal contents in peritoneum Caused by bowel infarction/perforation, infected gallbladder perforation, infected pancreatic pseudocyst, etcetera Enormous physiologic insult Large surface area Mortality rate of generalized peritontis is approximately 30%
9	Left Subphrenic Abscess
10	Peritonitis (continued) Treated with culture sampling, antibiotics and laparotomy or radiology-directed abscess drainage Antibiotic therapy continued until fever and leukocytosis resolved or symptoms of peritonitis/ileus disappear Single drug therapy with Unasyn or imipenem is as effective as multiple-drug regimens
11	Tertiary Peritonitis Bacterial translocation across bowel lumen secondary to increased permeability during critical illness Diagnosis of exclusion Treatment consists of ceasing unnecessary antibiotics and beginning enteral feeds if possible
12	Biliary Tract Sepsis Acute cholangitis – bacterial infection of the bile ducts Inflammatory reaction causes hydrostatic pressure to push bacteria into hepatic sinusoids resulting in bacteremia Presents with Charcot’s triad: fever, jaundice and right upper quadrant pain/tenderness Diagnosed with ultrasound, ERCP or PTC Treated with similar antibiotics as peritonitis and decompression
13	Acalculous Cholecystitis Occurs in 0.5 to 1.5% of patients in ICU for greater than one week Gallbladder infected with enteric pathogens Diagnosed with ultrasound or radionuclide scan Pericholecystic fluid Intramural gas Sloughed mucosal membrane
14	Acalculous Cholecystitis
15	Acalculous Cholecystitis Treated with cholecystectomy or cholecystostomy tube if unstable
16	Role of the Intensivist Routine supportive and preventative care Must be examined daily Communication among all physicians caring for patient Early enteral feeds Monitor postoperative complications unique to these patients
17	Postoperative Complications Wound: infection, wound infection and dehiscence/evisceration GI tract: ileus, obstruction, EC fistula, bleeding, anastamotic compromise, ischemic bowel or antibiotic-associated colitis Peritoneum: abscess, bleeding, compartment syndrome Other: postoperative pancreatitis, septicemia, acaculous cholecytsitis