abdominal pain cases -...
TRANSCRIPT
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Abdominal
Cases
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The obligatory ancient Greek
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Qualities of pain
• S: Site
• O: Onset (How?)
• C: Character
• R: Radiation• R: Radiation
• A: Association
• T: Timing
• E: Exacerbation or alleviating factors
• S: Strenght
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Locations
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Assessment of the strenght pain
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Mechanisms behind the pain
• Mucosal injuries
• Smooth muscle spasm
• Capsular dystension
• Peritoneal inflammation• Peritoneal inflammation
• Direct splanchnic nerve stimulation
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How to find the cause?
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Algorithm ComplaintComplaint
History
• GI illnesses
History
• GI illnesses
Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
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Case #1
• 35 yrs old female
• 5 days ago pain in the right lower
quadrant.
• Became better, but the pain returned.
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical
• Became better, but the pain returned.Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
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Qualities of pain
• S: Epigastrial, then umbilical, then LRQ
• O: Sudden, then gone, then returned: recurring
• C: Sharp, burning
• R: Not typical• R: Not typical
• A: Nausea, vomitting, subfebrility
• T: For hours
• E: Independent from meals or bowel movements
• S: Strong
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Case #1
• Cholecystectomy
• Pyelonephritis
• Helminthiasis (no further info)
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical
• Hepatitis infectiosaPhysical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
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Laboratory findings
Hematology Kidney Liver/ Pancreas Inflammation
WBC: 16.8 Na: 133 Bi: 7.0 CRP: 4.23
Hgb: 144 K: 4.0 GOT: 36
Plt: 234 CN: 4.0 ALP: 70
Kreat: 54 LDH: 171
Amylase 27
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Ultrasound
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Dg
• Appendicitis acuta
• Surgical consultant suggested operation
• Phlegmonosus appendix was removed
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Differential dg
• Enterocolitis
• Lymphadenitis mesenterica virosa
• Extrauterinal gravidity
• Ileocolitis – M. Crohn• Ileocolitis – M. Crohn
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Case #2
• 44 yrs old female
• Epigastrial pain for more than a week
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
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Qualities of pain
• S: Epigastrial, then RUQ, hypochondrial
• O: Slowly
• C: blunt, cramps
• R: To the back• R: To the back
• A: Nausea, vomitting, fever
• T: For days
• E: Worse after meals, Nospa, Algoflex make it better
• S: 5/10
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Case #2
• Curettage
• GP evaluated her for similar
complaints. Ultrasound found
gallbladder stones.
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical gallbladder stones.Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
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Laboratory findings
Hematology Kidney Liver/ Pancreas Inflammation
WBC 9.02 Na 143 Bi: 30/5 CRP: 26.5
Hgb 127 K 3.8 GOT: 17
Plt 196 CN 3.4 ALP: 131
Creat 62 LDH: 136
Amylase 15
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Ultrasound
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Dg
• Chronic cholecystitis
• Hydrops
• Surgical consultant: delayed (a froid)
operationoperation
• Antibiotics excreted through bile (e.g.
ceftriaxon)
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Differential dg
• Acute cholecytitis
• Pancreatitis
• Duodenal ulcer
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Case #3
• 77 yrs old male
• For 7-8 days pain in the left lower
quadrant.
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
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Qualities of pain
• S: LLQ
• O: Sudden, recurring
• C: Sharp, stabbing, colicky
• R: inguinal, downwards• R: inguinal, downwards
• A: diarrhoea, faint pink, blood on paper
• T: For half an hours
• E: After meals or bowel movements
• S: 5-6/10
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Case #3
• Childhood asthma bronchiale
• Appendectomy
• In 2011 STEMI, PCI
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical
• BPH
• Atrial fibrillation, OAC
• Colonoscopy: diverticuli
Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
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Laboratory findings
Hematology Kidney Liver/ Pancreas Inflammation
WBC 6.0 Na 141 Bi 16.0 CRP 3.57
Hgb 147 K 4.2 GOT 26
Plt 280 LDH 210
Creat 113 ALP 81
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Ultrasound
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Dg
• Diverticulitis
• Antibiotics (ciprofloxacin + metronidazol)
• Surgery can be considered
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Differential Dg
• Cancer
• Complications of diverticulitis
• Inflammatory bowel disease
• Irritable bowel syndrome• Irritable bowel syndrome
• Ischemic colitis
• Helminthiasis
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Case #4
• 72 yrs old female
• For 6 months epigastric pain
• GP refers as gastritis
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
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Qualities of pain
• S: Epigastric
• O: Slowly progressing
• C: Blunt
• R: To the back of the patients• R: To the back of the patients
• A: This morning vomiting, but it is not typical
• T: For hours
• E: After meals worse, if she lies on her side and pull up her knees or bends forward it is better
• S: 7-8/10
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Case #4
• Deafness after childhood meningitis
• Cholecystectomy
• T2DM (OAD)
• For similar complaints she was evaluated
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical • For similar complaints she was evaluated two months ago, imaging a labs were negative
• One month ago endoscopy: gastritis and diverticuli
• She has lost 10 kg
Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
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Laboratory findings
Hematology Kidney Liver/ Pancreas Inflammation
WBC 7.24 Na 135 Bi 7.5 CRP 14.55
Hgb 115 K 3.8 GOT 21
Plt 244 CN 7.2 ALP 89
Creat 65 LDH 180
Amylase 66
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Ultrasound
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CT
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Dg
• CA19-9: 1936
• Pancreas head carcinoma
• FNAB: adenocc
• Palliative chemotherapy• Palliative chemotherapy
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Differential Dg
• Cholecystitis
• Peptic ulcer
• Pancreatitis
• A. mesenterica sup. obstruction, intestinal • A. mesenterica sup. obstruction, intestinal
ischemia
• Diabetic neuropathy
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Case #5
• 86 yrs old female
• For 2 weeks diffuse pain
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
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Qualities of pain
• S: LLQ, diffuse, spreading out
• O: slow
• C: Colicky, cramps, dystension
• R: To the pelvis• R: To the pelvis
• A: Constant nausea, loss of appetite, constipation for two days fever, chills
• T: For hours
• E: Watery bowel movements helps
• S: 7-8/10
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Case #4
• Relapsing atrial fibrillation
• Bradycardy VVI PM
• T2DM
• Sideropenic anemia
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical • Sideropenic anemia
• Colonoscopy two months ago showed polyposis coli, endoscope could not be passed beyond this point
• Histology: adenocc.
• She has lost 10 kg
Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
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Laboratory findings
Hematology Kidney Liver/ Pancreas Inflammation
WBC 13.96 Na 137 Bi 23.1 CRP 1.38
Hgb 159 K 3.1 GOT 24
Plt 247 CN 7.0 ALP 93
Creat 96 LDH: 255
Amylase 28
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Abdominal X-Ray
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Dg
• Ileus
• Emergency surgery
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Summary
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Typical illnesses associated with the
locations
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Useful points
• Identify the anatomical location precisely
• Character can reveal the mechanism
• Gather as many anamnestic details as possible
• Laboratory panel should be chosen carefully• Laboratory panel should be chosen carefully
• Imaging until you see clearly
• Consider extra-gastrointestinal causes
• Repeat if needed, as the disease progression itself can be meaningful