Acute Abdominal Pain

ACUTE ABDOMINAL

PAINPGI Karen Cas

Acute abdominal painO Pain of less than

1 week’s duration

3 categoriesO VISCERAL PAIN

O PARIETAL PAIN

O REFERRED PAIN

Visceral PainO Usually caused by stretching of

fibers innervating the walls or capsules of hollow or solid organs, respectively.

Parietal PainO Caused by irritation of fibers that

innervate the parietal peritoneum, usually the portion covering the anterior abdominal wall.

O Can be localized to the dermatome superficial to the site of the painful stimulus

Referred painO Felt at a location distant from the

diseased organO Usually ipsilateral to the involved

organ

Abdominal Topography: “Four-quadrant approach”

Pain AttributesO P – precipitating (aggravating) /

palliating (alleviating) factorsO Q – qualityO R – radiationO S – severityO T – timing / duration / onset

Physical ExamO INSPECTION – distention, scars, massesO AUSCULTATION – normal / increased bowel

sounds, hyperactive / obstructive bowel sounds

O PALPATION – tenderness, voluntary guarding

O PELVIC EXAM – women of reproductive ageO RECTAL EXAM – stool color, +/- blood,

tenderness

CLASSIFICATIONO INTRA-ABDOMINAL

O GastrointestinalO GenitourinaryO GynecologicO Vascular

O EXTRA-ABDOMINAL

O CardiopulmonaryO Abdominal wallO ToxicO MetabolicO Neurogenic

O NON-SPECIFIC ABDOMINAL PAIN

TreatmentO HYPOTENSION

O Isotonic crystalloidO Vasoconstrictors (dopamine,

norepinephrine)O Pump failure : Dobutamine

O ANALGESICO Opioids, NSAIDs

O ANTI-EMETICO Metoclopramide

O ANTIBIOTICS

Disposition O Indication for admission:

O Appear illO Elderly or immunocompromisedO With unclear diagnosisO With reasonably unexcluded potential causes

of abdominal painO Intractable pain or vomitingO Acute or chronically altered mental statusO Inability to follow discharge or follow-up

instructionsO Lacking social supportsO Alcohol or other drug use

THANK YOU!

GastrointestinalO APPENDICITISO BILIARY TRACT DISEASEO SMALL BOWEL OBSTRUCTIONO ACUTE PANCREATITISO DIVERTICULITIS

AppendicitisO Clinical features with

predictive valueO RLQ painO Pain migration

from the periumbilical area to RLQ

O RigidityO Pain before

vomitingO Positive psoas

sign

AppendicitisO CT scan – generally preferredO ULTRASOUNDO Color flow Doppler

Biliary Tract DiseaseO Most ommon

diagnosis in ED patients ≥50 years old

O Steady post-prandial upper abdominal pain that radiates to the upper back

Biliary Tract DiseaseO ULTRASOUND is better in the

identification of Cholecystitis than in the detection of Common duct obstruction

O Cholescintigraphy (radionuclide scanning)

O MR Cholangiography

Small Bowel Obstruction

O Central issues:O Diagnosis of the

primary disorder, and

O Early detection of secondary strangulation or ischemia

O Historical features1. Previous

abdominal surgery

2. Intermittent/colicky pain

O PE findings1. Abdominal

distention2. Abnormal BS

Small Bowel Obstruction

O Ischemic bowel sec to strangulationO Extremely difficult

to detect clinically or with plain radiography

O CTO Useful in altering

the likelihood of ischemia

Acute PancreatitisO 80% caused by alcohol

or gallstones

O Steady and severe pain that extends well beyond the upper abdomen to cause generalized tenderness

O Resides deep in the belly and extends into the retroperitoneum

Acute PancreatitisO Serum lipase – begun to replace

amylase as the preferred ED screening test for suspected acute pancreatitis

O Accuracy of serum lipase in the diagnosis of acute pancreatitis is inversely related to the time elapsed between symptom onset and presentation

Acute PancreatitisO Double contrast

helical CT

O MR cholangiopancreatography (MRCP)

O ALT >150 U/L (including alcoholics)O Increased risk of

biliary pancreatitis

DiverticulitisO Pain confined to LLQ (<1/4 of cases)O Pain in lower half of abdomen (1/3 of

cases)O Generalized tendernessO Elderly

DiverticulitisO CT with colonic

contrast

O Sonography

GenitourinaryO RENAL COLIC

O ACUTE URINARY RETENTION

Renal ColicO Pain: unilateral flank,

abrupt onset, colicky, radiates to groin/testicle/labia

O Non-contrast helical CT

O Doppler UTZ + elevation of “renal resistive index” in one kidney relative to the other may identify stone in ipsilateral ureter

Renal ColicO Older patients: exclusion of an

abdominal aortic aneurysm (AAA)O (+) Anterior abd tenderness –

impacted stone at the ureterovesical junction

Acute Urinary Retention

O ACUTE URETHRAL OBSTRUCTIONO Another most common GU cause of

abd painO Distended bladderO Insertion of urethral catheter – dx & tx

Gynecologic O ACUTE PID

O ECTOPIC PREGNANCY

Acute Pelvic Inflammatory Disease

O Abnormal vaginal dischargeO Only PE finding assoc with

laparoscopic PID

O Transvaginal sonography O Positive: thickened tubal wall

O Transvaginal power dopplerO Positive: hyperemia + tubal

inflammation

Ectopic PregnancyO Pain may be absent at earlier stage

with a sentinel complaint of only vaginal bleeding

O ANY WOMAN OF CHILDBEARING AGE WHO PRESENTS TO ED W/ ABD PAIN OR ABNORMAL VAGINAL BLEEDING SHOULD RECEIVE A QUALITATIVE PREGNANCY TEST AS A SCREENING MEASURE.

Ectopic PregnancyO Transvaginal sonography

O Culdocentesis – compares poorly to TVS

Vascular O ABDOMINAL AORTIC ANEURYSM

O MESENTERIC ISCHEMIA

O ISCHEMIC COLITIS

Abdominal Aortic Aneurysm

O Tend to enlarge, become aneurysmal over years

O Triad: HYPOTENTION, ABDOMINAL/BACK PAIN, PULSATILE ABDOMINAL MASS

O Absence of abd pain – compatible with a contained leak extending to retroperitoneum

AAAO Aortic sonogram

O Non-contrast helical CT

O Helical unenhanced abdominopelvic CT

Mesenteric IschemiaO Arterial disease

O Occlusive (thrombotic/embolic)O Non-occlusive (NOMI)

Mesenteric IschemiaO Distinctions made among 4 major forms1. Embolic is abrupt; MVT is most indolent2. NOMI accompanied by low-flow state,

typically due to cardiac disease3. MVT may be more amenable to non-

invasive diagnosis with CT; in younger px; lower mortality; tx w/ immediate anticoag

4. Arteriography w/ papaverine infusion – impt in px w/ splanchnic vasoconstriction

Ischemic colitisO A disease of older patientsO Diffuse or lower abdominal visceral

painO Accompanied by diarrhea, often

mixed with bloodO Rectal sparringO Segmental portions of the mucosa

and submucosa slough

Ischemic colitisO ColonoscopyO Color doppler sonography

CardiopulmonaryO Pain of the upper half of the

abdomen (with or without tenderness)

O Chest film

O Epigastric pain + age grp CAD is prevalent

O Cardiac historyO ECG

Abdominal wallO Pain originating from the abdominal

wall may be confused with visceral pain because superficial innervation from the lower thoracic roots enter the spinal cord via the same dorsal horn as the deeper visceral afferents

O Carnett’s sign / sit-up testO (+) abdominal wall syndrome

Hernias O Defect through which intraabdominal

contents protrude, often intermittently, during transient increases in intraabdominal pressure

O UncomplicatedO Asymptomatic or at worst, aching &

uncomfortableO Significant pain: incarcerated or

strangulated

Hernias O Inguinal – most commonO Femoral hernias – women

O Sonography of the abdominal wall

ToxicO Infectious agents

irritate GI tract – crampy

O Concomitant vomiting or diarrhea

O PoisoningO Overdose

O Opioid withdrawal

O Peritoneal tendernessO InfarctionO PenetrationO Perforation

MetabolicO Anion-gap metabolic acidoses (DKA,

AKA)O Gastric distentionO Paralytic ileus

O If acidosis is resistant to standard treatment, or pain persists after normalization of pH, intraabdominal disease should be suspected

Metabolic O ENDOCRINOPATHIESO Adrenal crisis

O Thyroid stormO Hypo- and hypercalcemia

O ShockO Diffusely peritoneal

NeurogenicO Dysesthetic sensationO “hover” signO Radicular problems

O Zosteriform radiculopathyO Dysesthesia outlining a dermatome on

either side of the involved rootO Lancinating, ticlike bouts of shooting

pain or continuous burningO Vesicles

NSAPO Diagnosis of exclusionO Nausea – most common symptom

after abdominal painO Mid-epigastric and lower half of the

abdomenO Lab test usually normal / mild

leukocytosis