Durerea abdominalaCPT Jeffrey J. McInturff, MD, USADarnall Army Community HospitalFort Hood, TexasGS ACEP

IntroducereEvaluarea initiala:AnamnezaExaminarea fizicaAbdomenul acutEvaluarea pe cadraneVarsta si sarcinaDurerea iradiataConcluziiMcInturff - Abdominal Pain

Evaluarea initialaCe vezi cand intri in camera ?Atitudine confortabila -afectiune benignaAtitudine agitata -colica biliara/renalaAtitudine imobila -abdomen acutPozitie fetala -crampe gastrointestinale

McInturff - Abdominal Pain

Anamnezavarsta durereadebut,tip,localizare,severitate semne vitaleFebra?Puls si tensiunea arterialaMcInturff - Abdominal Pain

Anamneza (cont.)Simptome gastro -intestinalegreaturi ,varsaturi, diaree, meteorism,flatulenta,zgomote intestinale, aspectul scaunului,sange in scaunSistemul Reproducator al femeii:sarcina ,sangerari vaginale,scurgeri vaginale

McInturff - Abdominal Pain

Anamneza (cont.)Sistemul genito-urinardisurie, polakiurie,hematuria,senzatie imperioasa de a urina ,Aparatul respiratortuse,durere la respiratie (pleurezie)McInturff - Abdominal Pain

Examinarea fizicaInspectie Auscultatie Percutie Palpare Examenul pelvisuluiMcInturff - Abdominal Pain

Examinarea fizica (cont.)Diverse alte examinari : Sensibilitatea unghiului costo-vertebral puls femuraltuseu rectaltuseu vaginal si puncte herniarepercutia calcaneului,semnul obturatorului,semnul psoasuluiMcInturff - Abdominal Pain

Abdomenul acut si Durerea parietala Aparare musculara Semnul Blomberg Sensibilitate la percutia abdomenului si calcaneuluiMcInturff - Abdominal Pain

Durerea viscerala periombilicala

Produsa prin: - distensie: ocluzia intestinului subtire,gastroenterite,apendicite acute in prima faza - ischemie: tromboza mezentericaMcInturff - Abdominal Pain

Evaluarea pe cadraneHipocondrul dr.:Boli biliareUlcer pepticFosa iliaca dr.:Apendicite Salpingite acuteSarcina ectopica Flancuri:PielonefriteLitiaza renalaPneumoniiHipocondrul stg.:PancreatiteUlcer pepticFosa iliaca stg.:DiverticuliteSalpingite acute sSarcina ectopica Difuz sau Central:GastroenteriteAAA, Ischemie mesenterica McInturff - Abdominal Pain

Hipocondrul dreptBoli BiliareColecistite acute Colangite ascendente Colelitiaza si coledocolitiazaMcInturff - Abdominal Pain

EpigastruBoala ulceroasaDurerea epigastrica cu caracter de arsura Ulcer gastric -durerea apare imediat dupa masa Ulcer duodenal- durerea apare la doua ore dupa masaMcInturff - Abdominal Pain

EpigastruPancreatiteDurere sfasietoare Doua etiologii comune:Biliara -intalnita la varstnici.Alcoolica - intalnita la tineri Criteriile Ranson-utile in stabilirea prognosticuluiMcInturff - Abdominal Pain

Hipocondrul stangCadranul cel mai greu de diagnosticat Leziunea splenica trebuie considerata in caz de hemoragie abdominala traumaticavezi tahicardie asociata cu cresterea leucocitelor si durere in umarul stg. Considera infarctul splenic in siclemieMcInturff - Abdominal Pain

Fosa iliaca dreaptaApendiciteInitial durere periombilicala/epigastrica (durere de tip visceral) Ulterior sensibilitate in fosa iliaca dreapta(durere de tip parietal) Se poate asocia cu: greata ,varsaturi,diaree, anorexie,constipatieMcInturff - Abdominal Pain

Fosa iliaca dreapta-Apendicite (cont.)Diagnosticul este pus pa anamneza si examene fizice repetate Atat temperatura cat si leucocitele pot fi normale Examenul radiologic este rar de ajutor:Fecalitii sunt rar observati.Ajuta mai mult in diferentierea durerii de alta etiologieMcInturff - Abdominal Pain

Apendicita pelvinaDurerea viscerala de la debut este similara dar durerea parietala apare de obicei tarziu sau deloc Se poate asocia cu :polakiurie,disurie,diaree,tenesme Durerea la tuseu rectal sau semnul obturatorului pozitiv Perforeaza mai frecventMcInturff - Abdominal Pain

Fosa iliaca dreapta sau stanga Sarcina ectopicaIncidenta crescuta:1,5%din toate sarcinileDin anamneza:amenoree(80%),durere (95%),sangerare vaginala(75%)cu absenta semnelor gastrointestinale.Trebuie facut un test de sarcina si stabilita data ultimei menstruatiiEcografie pelvina. McInturff - Abdominal Pain

Fosa iliaca dreapta /stanga Boala inflamatorie pelvinaDurerea abdomino-pelvina de obicei bilaterala,ocazional unilaterala,cu debut insidios.Scurgeri vaginale si sensibilitate la tuseul vaginal( cervix sau anexe)Plus una sau mai multe din:L>10,000.Temp>38 CMasa inflamatorie la tuseul vaginal/ ecografiePuroi la punctia Douglasului/laparoscopie.McInturff - Abdominal Pain

Fosa iliaca stangaDiverticuliteDurere constanta si profunda in fosa iliaca stg cu sensibilitate si aparare localaTenesmele si sensibilitatea rectala sunt obisnuiteIritatia locala poate produce:modificari in tranzitul intestinalsimptome urinareflatulenta,greturi, varsaturi - rarLeucocitele pot fi uneori de ajutorMcInturff - Abdominal Pain

Hipogastru Infectiile tractului urinarPolakiurie ,disurie,mictiuni imperioase Intotdeauna cauta o pielonefrita Considera:piuria poate insoti o apendicitapolakiuria poate insoti o diverticulita,endometrioza,infectii intestinaleMcInturff - Abdominal Pain

VarstaVarstnici:anevrism de aorta abdominala,diverticulite,ischemii mezenterice Adolescente: dureri de ovulatie,salpingita acuta,SEU McInturff - Abdominal Pain

Ischemia mezentericaDurere abdominala surda,difuza Durerea nu este in concordanta cu gravitatea boliiDebut brusc (embolie -FiA),debut gradual (durere postprandiala) gradat se produce o scadere in greutate si o modificare a tranzitului intestinalMcInturff - Abdominal Pain

Anevrismul Abdominal AcutApare tipic la 60-70 ani Factori de risc: HTA,fumatul,hiperlipidemia,sexul masculin,DZ Triada: durere abdominala sau lombara,masa abdominala pulsatila,hTAMcInturff - Abdominal Pain

SarcinaApendiciteIncidenta: 1 din 850 sarciniFrecvent diagnosticul este pus cu intarziereSe poate prezenta ca o durere de hipocondru drept Colecistiteincidenta crescuta la gravideSarcini ectopiceIntotdeauna trebuie cautat si infirmat un astfel de dg.la orice gravidaMcInturff - Abdominal Pain

Dureri iradiateDe la AbdomenSpre lombe: pancreatite, anevrism aortic abdominal

Spre umar: boli biliare,splenice Spre scrot /labii: urolitiaza/colica renalaMcInturff - Abdominal Pain

Dureri iradiateSpre AbdomenInfarct miocardic Pneumonii,pleureziiDureri testiculareAfectiuni medulareEclampsieInsuficienta corticosuprarenala ac.Coma ceto-acidozicaPorfiria acutaDrepanocitozaMcInturff - Abdominal Pain

Concluzii50% din pacienti parasesc departamentul de urgenta fara un diagnostic precis Examinarile repetate sunt un important instrument diagnosticMcInturff - Abdominal Pain

1122334455667788991010111112121313Pain:Character: burningRadiation: occasionally straight backOnset: often worse between meals or at night, often waking the patient.Course: typically prior pain and recurrent in nature.- often patients will report symptomatic relief with variousantacids or over-the-counter drugs.1414Pain: Onset - typically sudden but occasionally gradualSeverity - excruciating but milder in lesser attacks (chronic pancreatitis)Radiation - occasionally to the back, typically epigastric

Also Seen: fever (even without abscess), vomiting, shock, epigastrictenderness, epigastric rigidity.

A history of ETOH abuse or biliary colic can give clues to possible etiology. Drug history is also of importance.

Ransons Criteria - while of no benefit diagnostically, these criteria are beneficial prognostically. When strongly considering pancreatitis in ones differential, consider ordering the lab criteria.

15151616171718181919202021211) The pain is typically deep and constant until inflammation produces the localized tenderness. Usually seen in LLQ but may occur anywhere along the colons course to include the RLQ.2) A rectal exam is important as it may show rectal bleeding and tenderness. Patients often complain of tenesmus.3) Patients may complain of diarrhea or constipation. Urinary frequency and dysuria may be seen. Fistula formation may produce pneumaturia.4) Fever, nausea and vomiting are occasionally seen though temperature is typically low grade. 5) WBC is mildly or moderately elevated.22222323242425252626Appendicitis:Same frequency as in general population. Diagnosis is more difficult, frequently delayed and the disease is fraught with more complications and a worse prognosis during pregnancy.Pain is less well localized and nausea/anorexia/vomiting/fever are less reliable. Appendix rises toward the right subcostal margin. Often mistaken for pyelonephritis.Recall normal leukocytosis of pregnancy and how that may not increase with appendicitis.

Cholecystitis:Pregnant females are predisposed toward stone formation during pregnancy because of incomplete gallbladder emptying following meals. 272728282929