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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.

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Dr matthew smith emergency specialist

Dr. Matthew Smith

Emergency Specialist

An approach to abdominal pain


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

Types Of Pain

Visceral

Parietal Pain


Visceral 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 Pain

  • Parietal peritoneum irritated

  • Usually anterior abdominal wall

  • Localised to the dermatome superficial to the site of painful stimulus


Course

Course


Referred pain

Referred Pain

  • Examples of referred pain?


Special populations

Special Populations


Elderly

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

Elderly Patient think Nasties!

  • AAA

  • Ischaemic Gut

  • Bowel Obstruction

  • Diverticulitis

  • Perforated Peptic Ulcer

  • Cholecystitis

  • Appendicitis


Women of childbearing age

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

History

  • What are the key points of the abdominal pain history?


History1

History

  • HPC

  • Pain

    • Provocative

    • Palliative

    • Quality

    • Radiation

    • Symptoms associated with

    • Timing

    • Taken for the pain

  • Consultations/ Presentations

Associated Symptoms –

  • Gastro – intestinal

  • Genito-urinary

  • Gynaecologic


History2

History

  • PMH

    • DM

    • HT

    • Liver Disease

    • Renal Disease

    • Sexually Transmitted Infections

  • PSH

    • Abdominal Surgery

    • Pregnancies

      • Deliveries/ Abortions/ Ectopics

    • Trauma


History3

History

  • Meds

    • NSAIDs

    • Steroids

    • OCP/ Fertility Drugs

    • Narcotics

    • Immunosuppressants

    • Chemotherapy agent

  • ALLS

    • Contrast

    • Analgesic


High yield questions

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

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

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

Radiology

  • CXR –?perforation

    • ?Extra abdominal pathology

    • ?Complications of intra-abdominal disease


An approach to abdominal pain

Which of the following is NOT an indication for plain abdominal imaging?

  • Bowel Obstruction

  • Constipation

  • Tracking Renal Calculi

  • Foreign Body


Other imaging

Other imaging

  • USS

    • Biliary Disease

    • Good for gynae complaints

    • Rule out Ectopic pregnancy

    • Appendicitis in children

    • No radiation


An approach to abdominal pain

  • 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


Management

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

Cases


Case 1

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

What clinical signs may lead you to a diagnosis of appendicitis?

Lie still

RIF tenderness

Rebound

Rovsig’s sign

Psoas Sign


Imaging

Imaging?

  • AXR rarely useful

  • USS

    • Not as good as CT

    • Good for female to exclude gynaepathology

    • 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


Management1

Management

  • NBM

  • Analgesia

  • Anti-emetic if necessary

  • Maintenance fluids

  • IVABs – e.g. Ceftriaxone, Gentamicin and Metronidazole

  • Surgical Referral


Case 2

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

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

What bloods will you order on this patient?


An approach to abdominal pain

  • 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)


Management2

Management

  • NBM

  • IVF

  • IV abs –Ampicillin + Gentamicin

  • Analgesia +- anti emetic

  • Refer to surgeons


Case 3

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 Limitation

    Alcoholic Gastritis

    MEDS Thiamine 100 mg daily

    SH Boarding house resident

    Drinks 4 litres wine/day

    Smokes 20/day


An approach to abdominal pain

  • Looks unwell and dehydrated

  • T38.4C

  • P105

  • BP 130/70

  • RR 18

  • Sats 93% RA


An approach to abdominal pain

  • Reduced AE L base

  • Tender Epigastrium and RUQ

  • No guarding/ rebound


What blood tests will you order

What blood tests will you order?


Blood results

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

What imaging will you perform ( if any)?


An approach to abdominal pain

CXR


Imaging1

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


Management3

Management

  • O2

  • NBM

  • IVF

  • Analgesia

  • +-Antibiotics (controversial)

  • Correct Electrolytes

  • Thromboprophylaxis

  • IDC/Art-line/CVC depending on severity

  • Surgical Admit +_ ICU review


Causes

Causes

Gall stones

Etoh

Trauma

Steroids

Mumps

A utoimmune

Scorpion Bites

Hyperlidaemia/hypercalcaemia/hypothermia

E RCP

D rugs


Case 4

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 examination1

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

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

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 examination2

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


Investigations1

Investigations


Investigations2

Investigations

  • EUC/CMP/FBP

  • AXR

  • CXR

  • CT


Management4

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

Small Bowel

  • Adhesions

  • Hernias

  • Polyps

  • Lymphoma

  • Adenocarcinoma

  • Gall Stones

  • Inflammatory BD


Large bowel

Large Bowel

  • Almost never adhesions or hernia

  • CARCINOMA

  • Diverticulitis

  • Sigmoid Volvulus

  • Faecal Impaction


Case 6

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


Examination1

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

Bedside Ultrasound

9cm


Management of ruptured aaa

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

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


Examination2

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


An approach to abdominal pain

ECG


Differential

Differential?


An approach to abdominal pain

ABG

  • pH 7.10

  • pCO2 15

  • P02 80

  • Bic 8

  • BE -15

  • Lactate 10.2


Management5

Management

  • 02

  • NMB

  • IV access

  • IVF

  • Analgesia

  • IV abs

  • Urgent Surgical Consult

  • Urgent CT mesenteric angiogram

  • OT


Take home message

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

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

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

Differential Diagnosis?

  • Renal Colic

  • Pancreatitis

  • Cholecystitis

  • Appendicitis

  • Ruptured/leaking AAA


An approach to abdominal pain

  • UA

    • Erythrocytes ++++

    • No leucocytes

    • No nitrites


Investigations3

Investigations

  • UA

  • EUC

  • FBC

  • (other bloods if diagnosis unclear)

  • CT KUB


Management6

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

Who should we CT

  • CT

    • Ongoing pain

    • Impaired renal function

    • Fever

    • Diagnosis not clear


Indications for admission

Indications for admission

  • Infection

  • Impaired Renal Function

  • Pain ongoing– needing IV opiates

  • Stone > 5mm

  • Obstruction/hydronephrosis on CT

  • Stag horn Calculus on CT


An approach to abdominal pain

ECG

  • What does the ECG show?

  • Sinus Tachycardia

  • VT

  • VF

  • Rapid Atrial Fibrillation

  • No idea!


An approach to abdominal pain

ECG


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