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Dr. Matthew Smith Emergency Specialist. An approach to abdominal pain. Types of pain Special Populations Assessment History Examination Investigations Differential Diagnosis Management - overview Cases ( if time permits). Types Of Pain. Visceral Parietal Pain. Visceral Pain. - PowerPoint PPT Presentation
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AN APPROACH TO ABDOMINAL PAIN
Dr. Matthew SmithEmergency Specialist
Types of pain Special Populations Assessment
History Examination Investigations Differential Diagnosis
Management - overview Cases ( if time permits)
VisceralParietal Pain
Types Of Pain
Visceral Pain
Stretching of nerve fibres of walls or capsules of organs Crampy Dull Achy
Often unable to lie still
Bilateral innervation
Parietal Pain
Parietal peritoneum irritated Usually anterior abdominal wall Localised to the dermatome
superficial to the site of painful stimulus
Course
Referred Pain
Examples of referred pain?
Special Populations
Elderly
May lack physical findings despite having serious pathology
As patients age increases diagnostic accuracy declines
Risk of Vascular Catastrophes Assume surgical cause until proven otherwise 30-40% of geris with abdo pain need surgery Biliary tract Disease is the commonest cause Age > 65 need to think of reasons not to CT! Mortality is 7% in the over 80’s - equivalent to
AMI!
Elderly Patient think Nasties! AAA Ischaemic Gut Bowel Obstruction Diverticulitis Perforated Peptic
Ulcer Cholecystitis Appendicitis
Women of Childbearing Age
Must Ascertain whether PREGNANT ALL WOMEN OF CHILDBEARING AGE
WITH ABDO PAIN NEED BHCG Gravid uterus displaces intra-
abdominal organs making presentations atypical
Pregnant women still get common surgical abdominal conditions
History
What are the key points of the abdominal pain history?
History
HPC Pain
Provocative Palliative Quality Radiation Symptoms associated
with Timing Taken for the pain
Consultations/ Presentations
Associated Symptoms – Gastro – intestinal Genito-urinary Gynaecologic
History
PMH DM HT Liver Disease Renal Disease Sexually Transmitted Infections
PSH Abdominal Surgery Pregnancies
Deliveries/ Abortions/ Ectopics Trauma
History
Meds NSAIDs Steroids OCP/ Fertility Drugs Narcotics Immunosuppressants Chemotherapy agent
ALLS Contrast Analgesic
High Yield Questions
Which came first – pain or vomiting? How long have you had the pain? Constant or intermittent? History of cancer, diverticulosis, gall
stones,Inflammatory BD? Vascular history, HT, heart disease or
AF?
Examination
Lots of information from the end of the bed Distressed vs. non distressed Lying still - peritonitis Writhing – Renal Colic
Vital Signs NEVER ignore abnormal vital signs! Always document as part of your
assessment
Investigations
Bedside UA
Blood? Leucocyte Esterase and nitrites Urine HCG
ECG – anyone with upper abdominal pain or elderly
Bloods ALL WOMEN OF CHILDBEARING AGE NEED
BHCG What are your differentials? Avoid machine gun approach!
Radiology
CXR –?perforation ?Extra abdominal pathology ?Complications of intra-abdominal disease
Which of the following is NOT an indication for plain abdominal imaging?
1. Bowel Obstruction2. Constipation3. Tracking Renal Calculi4. Foreign Body
Other imaging
USS Biliary Disease Good for gynae complaints Rule out Ectopic pregnancy Appendicitis in children No radiation
CT is accurate for diagnosis of Renal colic Appendicitis Diverticulitis AAA Intraabdominal
Abscesses Mesenteric
Ischaemia Bowel Obstruction
Avoid repeated CT scans
Limit use in younger patients
Avoid where possible in pregnant females
Imaging Dose (mSV) CXR equivalents
Pelvic XR 0.6 6
Abdominal XR 0.7 7
CT abdo-pelvis 14 140
CT aortogram 24 240
Management
Resuscitate Large bore access N Saline bolus 20ml/kg x 2 if shocked If bleeding think hypotensive resuscitation All should be NBM until provisional diagnosis Ensure normothermia
Maintenance fluids and fluid balance Analgesia doesn’t mask signs
Use a the pain scale Morphine titrated to pain. Normally 0.1mg/Kg Paracetamol adjunct NSAIDs for renal colic
Correct Electrolytes Thromboprophylaxis
Cases
Case 1
21 year old female 24 hour history of vague peri-
umbilical abdominal pain. Moved down to the RIF. Now constant and sharp. Associated with 2x vomits and feels
flushed No appetite Normal Bowels
What clinical signs may lead you to a diagnosis of appendicitis?
Lie stillRIF tendernessReboundRovsig’s signPsoas Sign
Imaging?
AXR rarely useful
USS Not as good as CT Good for female to exclude gynae pathology If appendix is visualised is useful
CT Only if there is doubt about diagnosis Sensitivity up to 98% High radiation dose Diagnose other pathology if no appendicitis Elderley
Management
NBM Analgesia Anti-emetic if necessary Maintenance fluids IVABs – e.g. Ceftriaxone, Gentamicin
and Metronidazole Surgical Referral
Case 2
40 yr old obese female RUQ pain Pain is constant nausea, vomiting fevers and chills
PMH Asthma MEDS OCP SH
Drinks 2 std / week Smokes 20/day Nil drugs
On Examination
Looks distressed. Not jaundiced T 38 C P 120 BP 100/60 RR 20 Sats 98% RA Tender in the RUQ
and Murphy’s positive.
What bloods will you order on this patient?
HB 138 WCC 16.0 Neuts 12.4 Lymph 1.6
EUC Normal Bil 9 (<18) ALP 450 (30-130) GGT 320 (<60) ALT 41 (5-55) AST 30 (5-55) Amylase 28 (<120) Lipase 40 (<60)
Management
NBM IVF IV abs –Ampicillin + Gentamicin Analgesia +- anti emetic Refer to surgeons
Case 3
52 yr old alcoholic Constant epigastric pain radiating to
the back. Worsening over the past 2 days
Improved with sitting up and forwards
Nausea and vomiting Bowels OK
PMH Chronic Airways LimitationAlcoholic Gastritis
MEDS Thiamine 100 mg daily
SH Boarding house residentDrinks 4 litres wine/daySmokes 20/day
Looks unwell and dehydrated
T38.4C P105 BP 130/70 RR 18 Sats 93% RA
Reduced AE L base
Tender Epigastrium and RUQ
No guarding/ rebound
What blood tests will you order?
Blood Results
Biochem Na 129 K 4.0 Cr 62 Ur 8.0
Amylase 1080 (<120) Lipase 950 (<60)
Bil 11 ( 18) GGT 900 (<60) ALP 200 ( < 140) AST 300 (5-55) ALT 250 (5-55) LDH 800( 105-333)
Glucose 15 Alb 23 Ca (Corr) 2.0
Haem HB 114 WCC 17 Coags Normal
What imaging will you perform ( if any)?
CXR
Imaging
CT Confirms diagnosis Identifies
complications Help’s grade severity Not always necessary
in ED
USS Poor visualisation of
pancreas Good for looking at
gall stones/ biliary tree dilatation
CXR Look for
complications Pleural Effusion,
Atelectasis, ARDS
Management
O2 NBM IVF Analgesia +-Antibiotics (controversial) Correct Electrolytes Thromboprophylaxis IDC/Art-line/CVC depending on severity Surgical Admit +_ ICU review
Causes
G all stones E toh T rauma S teroids M umps A utoimmune S corpion Bites H yperlidaemia/hypercalcaemia/hypothermia E RCP D rugs
Case 4
27 yr old female 6/40 LIF constant severe sharp pain Radiating to the back Light bright red PV spotting Feels light headed
PMH IVF Previous D+C x 2 Ovarian Cysts
MEDS Nil
SH Lives with partner Non-smoker Non-Drinker
On Examination
Looks unwell. Pale, diaphoretic, restless P 150 BP 70/40 RR 26 Sats 98% RA Tender and guarding in the LIF PV
Bright red blood spotting L adnexal tenderness ++
How do you manage this patient? Panic! ( don’t!) Call for senior help Large bore IV access x 2 (16 G or
larger) Urgent Cross Match Fluid resuscitation Call O+G urgently Needs OT immediately
Case 5
88 yr old female. Peri-umbilical, colicky abdominal pain for
2 days Abdominal distension Vomits x 10 Reduced flatus and NOB for 2 days. PMH
Cholecystectomy appendectomy TAH BSO Hypertension
On examination
Looks distressed Lying Still T 37.5 P 110 sinus BP 150/80 RR 18 Sats 98% RA Abdomen
Distended Generally tender No guarding rebound or rigidity High pitched bowel sounds
Investigations
Investigations
EUC/CMP/FBP AXR CXR CT
Management
NBM Fluid resuscitation Monitor volume status – may have large
volume shifts Correct Electrolytes Analgesia NG if vomiting IV Abs – Amp+Gent+Met Urgent Surgical consult for OT
Small Bowel
Adhesions Hernias Polyps Lymphoma Adenocarcinoma Gall Stones Inflammatory BD
Large Bowel
Almost never adhesions or hernia
CARCINOMA Diverticulitis Sigmoid Volvulus Faecal Impaction
Case 6
73 yr old male presents with sudden onset of central abdominal pain radiating to the back. He also reports weakness to both legs
PMH HT Hypercholesterolemia Current smoker 30/day
MEDS Aspirin 100mg Daily Perindopril 5 mg Daily Atorvastatin 10 mg Daily
SH Lives Alone Fully independent with ADLS Occasional alcohol
Examination
Distressed P 130 BP 80/60 RR 26 Sats 99% RA Abdomen
Non-distended Generally tender
Reduced power 3/5 to hip flexors
Bedside Ultrasound
9cm
Management of ruptured AAA Senior help ABC Large Bore IV Access x 2 Hypotensive resuscitation Analgesia Ensure O neg available Ensure normothermia Urgent Vascular Consult To OT
Last Case!
85 yr old male. Nursing home resident
Central Abdominal Pain Sudden onset. Severe PMH
Dementia MI
MEDS Clopidogrel 75 mg Daily Metoprolol 25 mg BD Perindopril 5 mg daily
SH Mild dementia Forgetful Requires some assistance with bathing
and toileting Feeds Self Walks with frame Non-smoker Non-drinker
Examination
Looks dry and emaciated P 120- 140 BP 110/70 RR 30 Sats 96% RA T 37.4 C Abdomen
Generally tender No guarding rigidity or rebound
ECG
Differential?
ABG
pH 7.10 pCO2 15 P02 80 Bic 8 BE -15 Lactate 10.2
Management
02 NMB IV access IVF Analgesia IV abs Urgent Surgical Consult Urgent CT mesenteric angiogram OT
Take Home Message
Exclude life threatening pathology BHCG in female of child bearing age Be mindful of radiation exposure Beware of Abdominal pain in the
Elderly Never ignore abnormal vital signs
Mesenteric Ischaemia
Surgical Emergency Small bowel has warm ischaemic time
of 2-3 hours Rapidly progresses to gangrene, septic
shock and death Need high index of suspicion to
diagnose it Severe pain but little tenderness on
examination
Case 7
40 yr old male presents with sudden onset of severe R loin to groin pain. Excruciating pain.Coming in waves. Feels nauseated and has vomited x 2.
Patient is agitated, pacing around the room, unable to sit still.
Screaming in pain. P 120 sinus BP 160/80 T 37.0 C RR 18
Sats 99% RA R renal angle tender
Differential Diagnosis?
Renal Colic Pancreatitis Cholecystitis Appendicitis Ruptured/leaking AAA
UA Erythrocytes ++++ No leucocytes No nitrites
Investigations
UA EUC FBC (other bloods if diagnosis unclear) CT KUB
Management
Analgesia NSAID e.g. PR indomethacin 100 mg 1st
line Morphine IV titrated to pain IV fluids – maintenance only Observe
Who should we CT
CT Ongoing pain Impaired renal function Fever Diagnosis not clear
Indications for admission
Infection Impaired Renal Function Pain ongoing– needing IV opiates Stone > 5mm Obstruction/hydronephrosis on CT Stag horn Calculus on CT
ECG
What does the ECG show?1. Sinus Tachycardia2. VT3. VF4. Rapid Atrial Fibrillation5. No idea!
ECG