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Differentials of acute abdominal pain in Emergency Room (ER) cases. Source: Tintinalli
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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