abdominal pain - edited

8/8/2019 Abdominal Pain - Edited

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ACUTE ABDOMINAL PAIN

Non-Traumatic

Acute Chronic

Subacute

Sick orUnstable


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ACUTE ABDOMINAL PAIN

Why?

Principal ChiefComplaint

Admission Rates (18-42%; 63%)

Benign/ Serious Acute Pathology?


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ABDOMINAL PAIN

Visceral

Autonomic

Parietal

Somatic


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VISCERAL PAIN

Spasm / Distension/

Stretch

Poorly Localized

Steady Ache/Vague

Discomfort

B/L Innervation

Midline Pain Appendiceal

Distension T10


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VISCERAL PAIN

Foregut (Stomach, Duodenum, Bile Tract)

Epigastric Region

Midgut (Small Bowel, Appendix,Cecum)

Periumbilical Region

Hindgut (Colon) Suprapubic Region


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PARIETAL PAIN

Irritation of Parietal

Peritoneum

Localized

Sharp

Superficial

Dermatome


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ABDOMINAL PAIN

Disease Evolution:

Visceral Pain Symptoms Parietal Pain Signs

Tenderness

Guarding Rigidity

Rebound


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CRITICAL ACTIONS

Airway

Breathing

Circulation

IV

O2

Monitor & Support


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CRITICAL ACTIONS

Does this patient have a surgical

abdomen?

Rapid evolution Sudden deterioration

Unstable Vital Signs, Fever, Dehydration

Peritonitis & Obstruction


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CRITICAL ACTIONS

Surgical Abdomen

Stability DDx Dx & Tx

Transfer to Acute Care Facility


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HISTORICAL FEATURES

Most Important Clue

Narrow the DDx


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CHARACTER

Quality

Adjective

Sharp,Dull,Cramp

Intensity/ Severity

0-10 Pain Scale

Comparison to Previous Pain


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ONSET/ DURATION

When did this pain first begin?

Gradual/Sudden?

Frequency?

Constant/ Intermittent?

Waxing/Waning?


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LOCATION/ RADIATION

Where is the pain?

Does it stay in one place?

Does the pain radiate anywhere else?


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EXACERBATING/ RELIEVING

FACTORS

Ingestion?

Defecation?

Micturition?

Inspiration?

Exhalation?

Position/ Movement?

Palpation?

Exertion?

Valsalva?

Intercourse?


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(MEMORY AIDE)

CHARACTER

ONSET

LOCATION

DURATION

EXACERBATING

RELIEVING


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ASSOCIATED SYMPTOMS

Gastrointestinal Anorexia

Nausea/ Vomiting

Diarrhea/Constipation

BRBPR/ Melena Stool Color/Size Change

Genitourinary Dysuria/Hematuria

Frequency/Urgency

Incontinence

Gynecologic LMP/ Menses

Fertility/Contraception

Discharge/STDs

General Fever/Chills

Weight Loss/Gain

Vascular MI/ IHD/CM/CHF

AFib/ Anticoagulation


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PAST MEDICAL HISTORY

Past Medical History

Past Surgical History

Family History

Medications (current/ recent)

NSAIDs, Antibiotics

Allergies

Social History Habits, Occupation,Sick/ Toxic Exposures

Travel, Living Circumstances


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PHYSICAL EXAMINATION


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ANALGESIA

Reasonable/ Humane

Alters Physical Exam, but SAFE

Facilitates H&P?

75% EPs

Wolfe JM, Lein DY, Lenkoski K, et al: Analgesic administration to patients

with an acute abdomen: A survey of emergency physicians. Am J EmergMed 18:250, 2000.

Ranji SR,Goldman LE,Simel DL,Shojania KG: Do opiates affect the clinicalevaluation of patients with acute abdominal pain? JAMA 296:1764. 2006

Manterola C, Astudillo P, Losada H, et al: Analgesia in patients with acuteabdominal pain. Cochrane Database Syst Rev 2007; :CD005660


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Vital Signs

Temperature

Respiratory Rate Oxygen Saturation

Blood Pressure (Supine/Erect)

Heart Rate (Supine/Erect)

-Blockers,Elderly


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General

Facial Expression

Diaphoresis

Degree of Agitation

Mobility

Skin

Pallor

Jaundice

HEENT Icterus

Exudate

Chest

Wheeze/ Rhonchi/ Rales

CV

Murmurs/ Rubs/Gallops Back

CVA TTP

Genital

Discharge

Rash

Testicular TTP


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ABDOMINAL EXAMINATION

Inspection Distension (air/ fluid)

Scars

Masses

Auscultation Absent

Diminished Hyperactive

Palpation Guarding

Rigidity

Rebound Organomegaly

Masses

Percussion Air/ Fluid

Organomegaly


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ABDOMINAL EXAMINATION

Pelvic Examination

Discharge

Masses Tenderness (Uterine, Adnexal)

Rectal Examination

Melena, Maroon, Bloody Stool

Impaction


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LABORATORY TESTS

FBC, with differential

Electrolytes, BUN, Creatinine, Glucose

Liver Function Tests

Lipase

Urinalysis

Pregnancy Test

Fever/ Unstable Vitals Blood/ Urine Cx


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RADIOLOGY TESTS

CXR (Erect, Lateral Decubitus) Consolidation, PTX,Effusion, Free Air

AXR (Erect,Supine, Lateral Decubitus) Free Air, Obstruction

Ultrasound Mass, Free Air, AAA,Stones, Obstruction,Hemorrhage

CT SCAN (+/- PO, PR, IV Contrast) Edema, Infection, Mass, AAA,Stone,SBO, Obstruction,

Hemorrhage


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DIFFERENTIAL DIAGNOSIS

8 Emergent Causes:

Obstruction

MI

Ectopic Pregnancy

AAA

Mesenteric Ischemia

Appendicitis Perforated Peptic Ulcer

Splenic Rupture


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Final DiagnosisFinal Diagnosis Proportion of >10,000Proportion of >10,000

NSAP 34%

Appendicitis 28%

Biliary Tract Disease 10%

Small Bowel Obstruction 4%

Acute Gynecologic Disease 4%

Pancreatitis 3%

Renal Colic 3%

Perforated Peptic Ulcer 3%Cancer 2%

Diverticular Disease 2%

Other (


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Final DiagnosisFinal Diagnosis 50 50--YearsYears < 50< 50--yearsyears

Bile Tract Disease 21% 6%

NSAP 16% 40%

Appendicitis 15% 32%

Bowel Obstruction 12% 2%

Pancreatitis 7% 2%

Diverticular Disease 6%


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GASTROINTESTINAL

Appendicitis

Biliary Tract Disease

Small Bowel Obstruction

Acute Pancreatitis

Diverticulitis


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GENITOURINARY

Renal Colic

Acute Urinary Retention


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GYNECOLOGIC

Acute Pelvic Inflammatory Disease

Ectopic Pregnancy


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VASCULAR

Abdominal Aortic Aneursym

Mesenteric Ischemia

Ischemic Colitis


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EXTRA-ABDOMINAL

DIAGNOSES

Cardiac

Pulmonary

Abdominal Wall Toxic

Infectious

Metabolic Neurogenic


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NONSPECIFIC ABDOMINAL PAIN

(NSAP) Largest Single Group

Diagnosis of Exclusion

Nausea Mid-Epigastric/ Lower Half of Abdomen

Absent- Mild Tenderness

RLQ/ Mid-Epigastrium

Laboratory Tests WNL; Occasional WBC

Abdominal Radiographs WNL/ Nonspecific

SERIAL RE-EXAMINATION; CLOSE FOLLOW-UP


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SPECIAL CONSIDERATIONS

Pediatric

Elderly

Immunocompromised

Pregnant


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TREATMENT

Hypotension

Antiemetics

Antibiotics Analgesia


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DISPOSITION

Indications for Admission:

Ill-appearing

Elderly/ Immunocompromised

Unclear Diagnosis

Intractable Pain/ Vomiting

Acute/ Chronic AMS

Poor Compliance

Un-domiciled/ Shelter/ Social-Support

Alcohol/ Drug Use


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SUMMARY

Most Benign; Identify Serious

Etiologies

Acutely Ill & Unstable

Transfer Assess for Surgical Abdomen

Stratify into Groups 1-4

High Clinical Suspicion for SpecialPopulations


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QUESTIONS


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Every woman with abdominal

pain has what until provenotherwise?

Ectopic Pregnancy

Every woman of childbearing age must

have a (-) urine pregnancy test

If(+), obtain an U/S and serum -hCG


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What is the number one

cause of the acute abdomen

in pregnancy?

Appendicitis


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All patients with RLQ, RUQ, or

epigastric pain should havewhat considered?

Appendicitis, because it is most often

misdiagnosed as gastroenteritis


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What are the most common

reasons for small bowelobstruction; for large bowel

obstruction?

Small BowelAdhesions, Hernias,

Gallstones

Large BowelCancer, Diverticulitis, &

Volvulus


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65-year-old male with renal

colic-type pain +/- hematuria;what must be ruled out?

AAA, by non-contrast CT

AAA is most often misdiagnoses as renal

colic or back pain

abdominal pain - edited

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