Evaluation and management of the surgical abdomen

Abstract

Purpose of review The aim of this study was to describe important features of clinical examination for the surgical abdomen, relevant investigations, and acute management of common surgical problems in the critically ill. Recent findings Lactate remains a relatively nonspecific marker of gut ischemia. Dual energy computed tomography (DECT) scan can improve diagnosis of bowel ischemia. Further evidence supports intravenous contrast during CT scan in critically ill patients with acute kidney injury. Outcomes for acute mesenteric ischemia have failed to improve over time; however, increasing use of endovascular approaches, including catheter-directed thrombolysis, may decrease need for laparotomy in the appropriate patient. Nonocclusive mesenteric ischemia remains a challenging diagnostic and management dilemma. Acalculous cholecystitis is managed with a percutaneous cholecystostomy and is unlikely to require interval cholecystectomy. Surgeon comfort with intervention based on point-of-care ultrasound for biliary disease is variable. Mortality for toxic megacolon is decreasing. Summary Physical examination remains an integral part of the evaluation of the surgical abdomen. Interpreting laboratory investigations in context and appropriate imaging improves diagnostic ability; intravenous contrast should not be withheld for critically ill patients with acute kidney injury. Surgical intervention should not be delayed for the patient in extremis. The intensivist and surgeon should remain in close communication to optimize care.

Point of care biliary ultrasound in the emergency department (BUSED) predicts final surgical management decisions

“…Point-of-care ultrasound (POCUS) in the ED has seen growing use in the diagnosis and management of gallbladder disease. [2][3][4] The diagnostic accuracy of biliary POCUS has been previously evaluated in multiple studies. Compared with history, physical examination, and laboratory tests, biliary POCUS is the best performing bedside test for acute biliary disease.…”

“…It frequently results in emergency department (ED) presentation and admission for surgery. Point-of-care ultrasound (POCUS) in the ED has seen growing use in the diagnosis and management of gallbladder disease 2–4. The diagnostic accuracy of biliary POCUS has been previously evaluated in multiple studies.…”