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Abdominal Pain

Abdominal Pain. Bart Besinger, MD. Abdominal Pain:. You will see it on every shift. Case #1. 46 year-old woman Sudden onset severe abdominal pain x 30 minutes Epigastric burning on/off x 2 wks PMHx: rotator cuff tendonitis Meds: Ibuprofen Soc: smoker, occasional EtOH. Case #1. Exam

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Abdominal Pain

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  1. Abdominal Pain Bart Besinger, MD

  2. Abdominal Pain: You will see it on every shift.

  3. Case #1 • 46 year-old woman • Sudden onset severe abdominal pain x 30 minutes • Epigastric burning on/off x 2 wks • PMHx: rotator cuff tendonitis • Meds: Ibuprofen • Soc: smoker, occasional EtOH

  4. Case #1 • Exam • 112 132/78 22 374C • Sweaty, obvious discomfort • Abdomen rigid, diffusely tender • Remainder of exam unremarkable

  5. Case #1 What test will confirm your suspected diagnosis?

  6. Case #1

  7. History and Physical • Thorough, but focused • Sometimes diagnostic • Guides work-up, management, disposition

  8. History and Physical Location

  9. History and Physical • Time Course – Sudden Onset • Ruptured viscus • Vascular catastrophes • Renal colic • Ruptured ectopic pregnancy • Ruptured ovarian cyst • Ovarian torsion

  10. History and Physical • Radiation • Pancreatitis to back • Renal colic to groin/testicles • Migration • Appendicitis: periumbilical to RLQ

  11. History and Physical • Associated symptoms • Anorexia: be careful • anorexia is absent in 10-30% of patients with appendicitis

  12. History and Physical • Abdominal examination • Localize area of tenderness • Degree of tenderness • Peritoneal signs

  13. History and Physical • Abdominal examination • Inspect:

  14. History and Physical • Abdominal examination • Inspect:

  15. History and Physical • Bowel sounds • Occasionally helpful • Palpation • Distract the patient! • Tenderness, masses, hernias • Peritoneal signs • Specific examination techniques

  16. Case #1 What are some indications for abdominal plain films?

  17. Case #2 • 15 year-old female • Holding abdomen, moaning in pain • Seen in ED yesterday • Lower abd pain x 2 days, mild dysuria • LMP 1 week ago • Mild suprapubic tenderness • + Leukocyte esterase • Discharged with TMP/SMX

  18. Case #2 • Today, reports increased pain and vaginal spotting • Vitals: 134 78/46 24 366C • Abdomen distended, markedly tender

  19. Case #2 What should have been done on the first visit? Pregnancy Test

  20. UPT • The best test in all of medicine • Cheap • Non-invasive • Incredibly accurate • Yes-No answer

  21. UPT • Required for every reproductive age female with abdominal pain • Sexual hx unreliable • Undiagnosed ectopic can be fatal

  22. Diagnostic Tests • WBC count • Debatable utility • Lacks specificity • Lacks sensitivity • 80-85% for appendicitis

  23. Diagnostic Tests • CT has revolutionized the evaluation of acute abdominal pain • AAA • Appendicitis • Ureterolithiasis • Diverticulitis • SBO • Many others

  24. Diagnostic Tests • CT: the downside • Good, but not perfect • Cost • Contrast • Radiation

  25. Diagnostic Tests • Ultrasound • Bedside vs. formal • RUQ • OB/gyn

  26. Case #3 • 43 yo male • LUQ and epigastric pain “all day” • N/Vx2, no diarrhea • Improved slightly with antacids • PMHx: none • Meds: none • Soc: 1 ppd smoker, drinks 6 pk. per day

  27. Case #3 • VS: 98.9F 92 116/84 18 • Awake, alert, uncomfortable • HEENT, Chest, CV normal • Abd: minimal LUQ tenderness, no peritoneal signs • Rectal: trace heme + • Diagnostic tests?

  28. Case #3

  29. Always consider extra-abdominal causes of abdominal pain.

  30. Extra-abdominal causes • CV: MI • Pulm: PE, pneumonia • ENT: Streptococcal pharyngitis • Abdominal wall: muscular, herpes zoster • GU: testicular torsion • Tox: lead, iron, Black Widow spider • Metabolic: DKA, porphyria, uremia, Ca++ • Psych

  31. Case #4 • 77 yo F • 1 day of N/V/D, several hours of severe, intermittent, diffuse abdominal pain. • PMHx: CAD, DM, HTN • VS: 108 128/92 22 99.5F • Abdomen: diffuse mild tenderness

  32. Case #4 • CBC, BMP, UA, lipase, CT unremarkable • Improved with morphine, ondansetron, fluids • Diagnosis: “acute gastroenteritis” • Discharged to follow up with PMD

  33. Case #4 • Returns 6 hours later • Increased pain, less responsive • VS: 120 90/60 28 99.8F • Abdomen: diffuse tenderness with guarding and rebound • Differential? • Next step?

  34. Case #4 • Surgery Consulted • To OR • Necrotic bowel resected

  35. Be very wary of: • Acute Gastroenteritis • Abdominal pain in the elderly

  36. Acute Gastroenteritis • Common initial diagnosis for patients who return with more significant abdominal pathology • Vomiting (gastritis) AND Diarrhea (enteritis) should be present • V/D seen in many other processes • Abdominal pain should not be prominent

  37. Abdominal pain in the elderly • Significant pathology more likely • Diverticulitis, ischemic bowel, AAA, biliary tract disease, etc. • Co-morbidities common • More difficult to assess • poor historians • exam less reliable • increased pain threshold • atypical presentations common

  38. Abdominal pain in the elderly • Consider a more aggressive work-up • Low threshold for admission

  39. What is the classic presentation of mesenteric ischemia? Pain out of proportion to the physical examination

  40. Case #5 • 21 yo M presents with classic appendicitis • Surgeon is in OR – will be delayed 2 hours • How do you want to manage the patient in the meantime?

  41. ED management • NPO • IV fluids • GI losses, third spacing, poor po intake • Isotonic crystalloid (NS or LR) • Antiemetics • Side effects of older agents • Use 5-HT antagonists (ondansetron)

  42. ED management • Analgesia • Historically controversial • Historic concern: masking of peritoneal signs • Multiple studies demonstrate no alteration of diagnostic accuracy • May improve exam

  43. ED management • Analgesia • Ketorolac • Excellent for biliary or renal colic • Not studied in setting of undifferentiated abdominal pain

  44. ED management • Antibiotics • indications: peritonitis, suspected perforation • many acceptable regimens • cover gram - and anaerobes

  45. Take Home Points • Take a careful, focused H&P • UPT for every reproductive age woman • Avoid labeling abdominal pain “gastroenteritis” • Abdominal pain in the elderly: take it very seriously • Provide analgesia when needed

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