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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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slide2

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
referred pain
Referred Pain
  • Examples of referred pain?
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
slide23

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
slide29

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
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.
slide41

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

slide46
Looks unwell and dehydrated
  • T38.4C
  • P105
  • BP 130/70
  • RR 18
  • Sats 93% RA
slide47
Reduced AE L base
  • Tender Epigastrium and RUQ
  • No guarding/ rebound
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
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
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
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
slide75
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
slide81

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
slide87
ECG
  • What does the ECG show?
  • Sinus Tachycardia
  • VT
  • VF
  • Rapid Atrial Fibrillation
  • No idea!
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