Dr. Shamim Ahmad BhatConsultant Emergency MedicineKing Saud Medical CityRiyadh. KSA

INTRODUCTION

Types of pain Special Populations Assessment

History Examination Investigations Differential Diagnosis

Management - overview Cases ( if time permits)

Visceral

Parietal 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?

Most Common Causes in the ED Non-specific abd pain 34% Appendicitis 28% Biliary tract dz 10% SBO 4% Gyn disease 4% Pancreatitis 3% Renal colic 3% Perforated ulcer 3% Cancer 2% Diverticular dz 2% Other 6%

WOMEN OF CHILD BEARING AGE

OLD AGE (ELDERLY PATIENTS)

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 Immunosuppressant 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

ABDOMINAL EXAMINATION

Investigations

Bedside UE

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

SOME INTRESTING AXRs

Other imaging

ULTRASOUND Biliary Disease Good for gynae complaints Rule out Ectopic pregnancy Appendicitis in children No radiation

CT ABDOMEN

CT is accurate for diagnosis of Renal colic Appendicitis Diverticulitis AAA Intra abdominal Abscesses

Mesenteric Ischaemia

Bowel Obstruction

Avoid repeated CT scans

Limit use in younger patients

Avoid where possible in pregnant females

Management

Resuscitate with ABC APPROACH 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 Elderly

Management

NPO 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 blood Tests will you order on this patient?

HB 13.8 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

NPO 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 ICD/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 OR immediately

Case 5

88 yr old female. Peri-umbilical, colicky abdominal pain for 2 days

Abdominal distension Vomits x 10 Reduced flatus 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

Labs AXR CXR CT

Management

NPO Fluid resuscitation Monitor volume status – may have large volume shifts

Correct Electrolytes Analgesia NG if vomiting IV Abs – Ceftriaxone, metronidazole

Urgent Surgical consult for OR

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 ALS Occasional alcohol

Examination

Distressed P 130 BP 80/60 RR 26 Sats 99% RA Abdomen

Non-distended Generally tender.

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 OR

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

ABC NPO IV access IVF Analgesia IV abs Urgent Surgical Consult Urgent CT mesenteric angiogram OR

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 Morphine IV titrated to pain IV fluids – maintenance only Observe

Who should we CT

CT On going 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

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 Ask for help if not sure about diagnosis/Rx

Thanks for your patience!