1. Abdominal Pain AMY LITTLE, MD ALBANY MEDICAL CENTER

2. GOALS • Review the anatomy of the abdomen • Quadrants • Peritoneal vs. Retroperitoneal • Solid vs. Hollow organ • Vascular structures • Assessment (History and Physical Exam) • Management • Abdominal trauma • Special situations

3. The Abdomen • Everything between diaphragm and pelvis • Injury and illness can be very difficult to assess because of large variety of structures

4. Abdominal Anatomy • Abdomen divided into four quadrants by body mid-line, horizontal plane through umbilicus • Organs can be located by quadrant

5. Abdominal Anatomy • Right Upper Quadrant • Liver • Gall Bladder • Right Kidney • Ascending Colon • Transverse Colon

6. Abdominal Anatomy • Left Upper Quadrant • Spleen • Stomach • Pancreas • Left Kidney • Transverse Colon • Descending Colon

7. Abdominal Anatomy • Right Lower Quadrant • Ascending Colon • Appendix • Right Ovary (female) • Right Fallopian Tube (female)

8. Abdominal Anatomy • Left Lower Quadrant • Descending Colon • Sigmoid colon • Left Ovary (female) • Left Fallopian Tube (female)

9. Abdominal Anatomy • Periumbilical area • Located around (peri) the navel (umbilicus) • Small bowel lies in all quadrants in periumbilical area • Suprapubic area • Located just above pubic bone • Urinary bladder, uterus lie in this area

10. Abdominal Cavity • Peritoneum = abdominal cavity lining • Divides abdomen into two spaces • Peritoneal cavity • Retroperitoneal space (retro=behind)

11. Retroperitoneal Pancreas Kidney Ureter Inferior vena cava Abdominal aorta Urinary bladder Reproductive organs Peritoneal Spleen Liver Stomach Gall bladder Bowel Abdominal Anatomy NOTE: Disease or injury of retroperitoneal organs often causes back pain.

12. Abdominal Anatomy • REVIEW: Organs are classified by • Quadrant, periumbilical, or suprapubic • Peritoneal or retroperitoneal • Organs can also be classified as: • Solid • Hollow • Majorvascular

13. Solid Organs • Liver • Spleen • Kidney • Pancreas NOTE: When solid organs are injured, they bleed heavily and cause shock.

14. Solid Organs • Liver • Largest abdominal organ • Most frequently injured • Fractures of ribs 8-12 on right side • Bleeding can be either: • Slow, contained under capsule • Free into peritoneal cavity

15. Solid Organs • Spleen • Frequently injured with trauma ribs 9-11 on left side • Bleeds easily • Capsule around spleen tends to slow development of shock • Rapid shock onset when capsule ruptures

16. Solid Organs • Pancreas • Lies across lumbar spine • Sudden deceleration produces straddle injury • Very little hemorrhage • Leakage of enzymes digests structures in retroperitoneal space, causes volume loss, shock

17. Solid Organs • Kidney • Retroperitoneal • Vulnerable to trauma (blunt & penetrating), infection, obstruction, chronic disease • Tenderness: Lower ribs, upper L-spine, flank • Pain: groin, shoulder, back, flank

18. Hollow Organs • Stomach • Gall bladder • Large, small intestines • Ureters, urinary bladder, urethra Rupturecauses content spillage&inflammationof peritoneum.

19. Hollow Organs • Stomach • Acid, enzymes • Immediate peritonitis • Pain, tenderness, guarding, rigidity

20. Hollow Organs • Colon • Spillage of bacteria • May take 6 hrs to develop peritonitis • Small Bowel • Fewer bacteria • May take 24-48 hours to develop peritonitis

21. Hollow Organs: Urinary System • Ureters • Penetrating injury • Bladder • Blunt injury (seatbelts, pelvic fracture) • Urethra • Straddle injury Signs and Symptoms • Abnormal urination (Urgency, Inability, Dysuria, Hematuria) • Blood at external meatus • Perineal bruising (butterfly bruise) • Scrotal hematoma • Shock • Abdominal distension

22. Major Vascular Structures • Aorta • Inferior vena cava • Major branches Injury can cause severe blood loss;exsanguination (bleeding out).

23. QUESTIONS about Abdominal Anatomy?

24. ASSESSMENT of Abdominal Pain History LOCATION • Where do you hurt? • Know locations of major organs • But realize abdominal pain locations do not always correlate well with source

25. ASSESSMENT of Abdominal Pain QUALITY • What does pain feel like? • Steady pain - inflammatory process • Crampy pain - obstructive process

26. ASSESSMENT of Abdominal Pain ONSET • Was onset of pain gradual or sudden? • Sudden = perforation, hemorrhage, infarct • Gradual = peritoneal irritation, hollow organ distension

27. ASSESSMENT of Abdominal Pain RADIATION • Does pain radiate (travel) anywhere? • Right shoulder, angle of right scapula = gall bladder • Left shoulder = spleen, stomach • Around flank to groin = kidney, ureter

28. ASSESSMENT of Abdominal Pain • DURATION • > 6 hour duration = ? surgical significance • ASSOCIATED SYMPTOM: • Nausea &/or vomiting? Bloody? “Coffee Grounds”? Any blood in GI tract = Emergency until proven otherwise

29. ASSESSMENT of Abdominal Pain • Change in urinary habits? Urine appearance? • Change in bowel habits? Diarrhea? Appearance of bowel movements? Melena? Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss.

30. ASSESSMENT of Abdominal Pain • Females • Last menstrual period? • Abnormal vaginal bleeding? In females, abdominal pain = Gynecological problem until proven otherwise.

31. PHYSICAL EXAM • General Appearance • Lies perfectly still inflammation = peritonitis • Restless, writhing obstruction • Abdominal distension? • Ecchymosis around umbilicus, flanks?

32. PHYSICAL EXAM • Vital signs • Tachycardia = Early shock &/or pain (more important than BP) • Rapid shallow breathing = peritonitis

33. PHYSICAL EXAM • Palpate each quadrant • Work toward area of pain • Warmhands • Patient on back, knee bent (if possible) • Note tenderness, rigidity, involuntary guarding, voluntary guarding, masses • Bowel sounds (?)

34. Management • Airway • High concentration O2 • Anticipate vomiting • Anticipate hypovolemia • Need PIV, IVF • Nothing by mouth except medications

35. Management • Consider referred cardiac pain: • Adults > 30 • Diabetics • History of cardiac problems • In females, consider gynecological problems, especially ruptured ectopic pregnancy (surgical emergency)

36. QUESTIONS about general assessment or management?

37. REVIEW: GOALS • Review the anatomy of the abdomen • Quadrants • Peritoneal vs. Retroperitoneal • Solid vs. Hollow organ • Vascular structures • Assessment (History and Physical Exam) • Management NEXT: • Abdominal trauma • Special situations

38. Abdominal Trauma • Most survive to reach hospital • Most common factors leading to death • Failure to adequately evaluate • Delayed resuscitation • Inadequate volume replacement • Inadequate/missed diagnosis • Delayed surgery

39. High Index of Suspicion in Trauma • Mechanism • Unexplained hypovolemic shock • Signs of injured abdomen • Management

40. Mechanism • Look for signs of injury • Bruises • Tire marks • Obvious open injuries • Trauma to lower chest, back, flank, buttocks, and perineum • Injury above umbilicus also involves chest until proven otherwise

41. Unexplained Shock • Assess vital signs; skin color, temperature; capillary refill • Tachycardia; restlessness; cool, moist skin • In trauma, signs of shock suggest abdominal injury if no other obvious causes present • Assume any abdominal injury is serious until proven otherwise!

42. Signs of Injured Abdomen • Diffuse tenderness • Pain • Pain referred to shoulder = Organ under diaphragm involved (?spleen) • Pain referred to back = Retroperitoneal organ involved (?kidney)

43. Abdominal Trauma Management • Less important to diagnose exact injury • Treat clinical findings (open wounds, hypotension/tachycardia) • Management same regardless of specific organ(s) injured

44. Abdominal Trauma Management • Airway • C-Spine if mechanism indicates • High flow O2 • Assist ventilations if needed • Give nothing by mouth • (?) MAST may be helpful in slowing intraabdominal bleeding with shock

45. Special situations in Abdominal Pain • Impaled objects • Evisceration • Trauma to the reproductive system • Sexual assault

47. Impaled Object • Leave in place • Shorten if necessary for transport • Leave part of object exposed

48. Evisceration • With large laceration abdominal contents may spill out • Do NOTtry to replace

49. Evisceration • Cover exposed organs with saline moistened multi-trauma dressing • Do NOT use 4 x 4s • Cover first dressing with second DRY dressing or aluminum foil

50. Reproductive System Trauma • Can occur to both external and internal reproductive systems • External • More common • Pain, extensive bleeding • Internal • Less frequently injured • Treat like blunt or penetrating soft tissue injuries elsewhere on body