Abdo Pain in the EDClinical Cases
Miss A
7 F
Unwell for 3 days with abdominal pain
Generalised
Afebrile
Normal bowel habits
1x vomit
Miss A
Further history
Nil medical problems
Immunised
Nil unwell contacts/travel
Generally unwell for past 3 weeks- easily fatigued, decreased school performance
Miss A
Examination
Weight 22kg
Looks unwell
HR 150
RR 50
Afebrile
BP 90/-
Clutching abdomen- Not distended- Nil peritonism- BS present
What next?
RCH Age Corrected Observations
Miss A
Investigations
- Urine dip
Leuks 0
Nitrites 0
SG 1.005
Urobilinogen 3.2
Ketone 16
Bilirubin 0
Protein trace
Glucose >1000
What is the next test?
Miss A
BSL
‘hi’
Ketones
7.4
Diagnosis?
Miss A
Diabetic Ketoacidosis
Diagnostic criteria
- Glucose >11mmol/K
- Venous pH <7.3 OR bicarbonate <15mmol/L
- Presence of ketonaemia OR ketonuria
Treatment of DKA differs in children
Involve the paeds unit early with first presentation DKA but DO NOT delay management
Fluid resuscitation is the first priority, HOWEVER
Children are prone to cerebral oedema with rapid or over- volume resus
- Symptoms include new/increasing headache, confusion, drowsiness, seizures
Miss A
Management Steps
� Obtain the child’s weight
� ABC
� Assess extent of
dehydration
� 2x IV access
� Venous gas, bloods
� Consider septic workup
� First presentation DKA� Insulin antibodies� GAD antibodies� ZnT8 antibodies� Coeliac screen� TSH, T4
Degree of dehydration Clinical signs
Assessment Percentage
Mild <4% No clinical signs
Moderate 4-7% Easily detectable dehydration –decreased tissue turgor, poor central capillary return
Severe >7% Shock - Poor perfusion, rapid pulse, hypotension
Miss A
Management Steps
� Hourly blood glucose, ketones
� 2-4 hourly VBG, UEC, CMP
Goals of Therapy
- Correct dehydration
- Reverse ketosis, correct acidosis
and glucose
- Monitor for complications- Hypokalaemia- Hypoglycaemia- Cerebral oedema
- Identify and treat cause (if present)
Blood Gas ValuespH 7.01pCO2 15pO2 45HCO3- 9BE -10
Na 136K 3.4
Glu 37Lac 3.2
Miss A
Management Steps
� 10-20ml/kg nsaline bolus
� Keep child nil by mouth
� Follow the RCH DKA guideline and check fluid orders carefully with nursing staff
� Admit to paeds
� Consider tf if� <2 yrs old� Coma/cardiovascular compromise� Suggestion of cerebral oedema� Severe acidosis ph <7.1 or HCO3 <5
Medical Causes of Abdominal Pain
1. DKA
2. Porphyria
3. Addisons disease
Miss B
18 F
3/7 increasing RIF pain
Very severe this AMà presented to ED
Nil vomiting, diarrhoea, LUTS
Nil travel or unwell contacts
Phx endometriosis, nil reg meds
Miss B
Further History
Insidious onset
Non migratory
Associated lower back pain
Eating and drinking as normal
Miss B
Examination
HR 92
BP 120/80
Afebrile
Abdo: tender RIF to palpation, nil rebound, not cross tender, psoas sign –ve
What next?
- Bloods?
- USS?
- Analgesia, home?
Miss B
Bloods
- FBE 99/12.1/379
- CRP 40
USS
Booked for 3pm
Send her home?
Miss B
Urine dip
- N.. Aside from
- +ve HCG
So what next?
• Approximate gestational age• Quantitative HCG• G&H + Ab• Bedside USS
Miss B
� Bedside USS
� Which is which?� Normal pelvic USS� Positive fast� Yolk sac� Positive fast
Miss B
Progress
- LMP 6 weeks ago
- Bedside fast –ve, nil intrauterine contents seen
- Quan HCG 3000
- Formal USS 3pm: Code blue!
- What’s the diagnosis?
Miss B
Diagnosis
- Ruptured ectopic pregnancy
Miss B
Management of ruptured ectopic pregnancy
- ABC
- Large bore dual IV access
- Call O&G urgently
- Cross match 4 units
- Permissive hypotension
- Get to theatre
Mr C
87 M
7 days of constipation
Seen in ED 5 days ago
AXR demonstrating constipation
Sent home with PO aperients, + microlax enema
Passed 1x small stool since, now vomiting
Further History
Not usually constipated, nil phx of same
Phx IHD, dyslipidaemia, GORD
Associated abdominal discomfort and LoA
Nil LoW, nil night sweats
Tolerating fluids, though intermittently vomiting for 24/24
Mr C
Examination
Obs WNL
Abdomen distended
Nil bowel sounds
Tympanic percussion note
Generally tender without peritonism
Mr C
Investigations
What is relevant?
What is the provisional diagnosis?
Mr C
Investigations in Abdominal Pain
A good history will guide you best
“Abdominal Bloods”
Consider VBG
Urine dip
CTAP
Mr C
Interpretations of CT Abdomen
Have a process
Do a scroll through first and look for obvious abnormalities
Always look at the scan you have ordered
A CT KUB can be a good tool for patients with poor renal function, non-bowel pathology, or other contraindications to contrast
Mr C
Constipation in the Elderly
- A red flag diagnosis
- Its not constipation until the CT says it is
- Consider the aetiology- Why a change in bowel habits?- Does the patient need an IP or OP scope?- Which patients are appropriate for SSOU vs expectant mx at home?
Mr C
Conclusion
- Hemicolectomy
- Complicated be anastamotic leak, return to theatre, breakdown of lapatotomy woundà stoma formation
- Nil mets or local invasion
Mr C
Mrs O
77 F
From home
Presenting with high fever and RUQ pain, increasing over past 48/24
Differentials?
Mrs O
Further History
Intermittent RUQ pain for months
Usually spont resolves after a few hours
Nil previous investigation
Onset of constant RUQ pain 48/24 ago
Last 24/24 fevers, rigors, 2x vomits
Phx
TIA, pancreatitis, peripheral vascular disease, recurrent UTI
Mrs O
Examination
GCS 14- mildly confused
HR 105
T 38. 6
BP 75/50
RR 28
Scleral icterus
Jaundiced
RUQ peritonism
Mrs O
What is the diagnosis?
What is the next step?
How should this patient be
managed?
Mrs O
Differentials in RUQ Pain
- Which is which?- Cholelithiasis- Cholecystitis- Choledocholithiasis- Cholangitis
Mrs O
Relevant Investigations for Mrs O
WCC 24, Neuts 18
CRP 260
ALP 230
GGT 211
Bili 84
AST 74
ALT 99
What is the Diagnosis?
Mrs O
Ascending Cholangitis
Charcot’s Triad
1. Jaundice
2. Fever
3. RUQ pain
Reynolds Pentad
1. Jaundice
2. Fever
3. RUQ pain
4. Shock
5. Confusion
Mrs O
Management of Ascending Cholangitis
- ABC
- Blood cultures
- Tazocin 4.5g IV OR 2g IV ceftriaxone + 500mg IV metronidazole
- Haemodynamic support if required
- Early AGSU referral
- CTAP +/- MRCP, then ERCP
- ICU/HDU if unstable
Resources
RCH DKA guideline
https://www.rch.org.au/clinicalguide/guideline_index/Diabetic_Ketoacidosis/
Radiopaedia
LIFTL
eTG