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AN APPROACH TO ABDOMINAL

PAIN

Dr. Matthew SmithEmergency Specialis t

http://www.3dscience.com/3D_Models/Human_Anatomy/Female_Systems/3D_Models/Human_Anatomy/Female_Systems/Female_Digestive_3.phphttp://www.3dscience.com/3D_Models/Human_Anatomy/Female_Systems/3D_Models/Human_Anatomy/Female_Systems/Female_Digestive_3.phphttp://www.3dscience.com/3D_Models/Human_Anatomy/Female_Systems/3D_Models/Human_Anatomy/Female_Systems/Female_Digestive_3.php

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Types of painSpecial Populations

AssessmentHistoryExaminationInvestigations

Differential DiagnosisManagement - overviewCases ( if time permits)

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VisceralParietal Pain

Types Of Pain

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Visceral Pain

Stretching of nervefibres of walls orcapsules of organs

CrampyDullAchy

Often unable to lie stillBilateral innervation

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Parietal Pain

Parietal peritoneum irritatedUsually anterior abdominal wall

Localised to the dermatome superficial to thesite of painful stimulus

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Course

Visceral

Non specific

Parietal

Localised tenderness Guarding Rigidity Rebound

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Referred Pain

Examples of referred pain?

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Special Populations

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Elderly

May lack physical findings despite having seriouspathology As patients age increases diagnostic accuracy

declinesRisk of Vascular Catastrophes Assume surgical cause until proven otherwise30-40% of geris with abdo pain need surgeryBiliary tract Disease is the commonest causeAge > 65 need to think of reasons not to CT!Mortality is 7% in the over 80s - equivalent to AMI!

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Elderly Patient think

Nasties!AAAIschaemic Gut

Bowel ObstructionDiverticulitisPerforated Peptic

UlcerCholecystitisAppendicitis

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Women of Childbearing Age

Must Ascertain whether PREGNANTALL WOMEN OF CHILDBEARING AGE WITH

ABDO PAIN NEED BHCGGravid uterus displaces intra-abdominalorgans making presentations atypicalPregnant women still get common surgicalabdominal conditions

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History

What are the key points of the abdominalpain history?

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History

HPCPain

Provocative

PalliativeQualityRadiationSymptoms associated withTimingTaken for the pain

Consultations/Presentations

Associated Symptoms Gastro intestinalGenito-urinaryGynaecologic

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History

PMHDMHT

Liver DiseaseRenal DiseaseSexually Transmitted Infections

PSHAbdominal SurgeryPregnancies

Deliveries/ Abortions/ EctopicsTrauma

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History

MedsNSAIDsSteroidsOCP/ Fertility DrugsNarcoticsImmunosuppressants

Chemotherapy agentALLSContrastAnalgesic

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High Yield Questions

Which came first pain or vomiting?How long have you had the pain?

Constant or intermittent?History of cancer, diverticulosis, gallstones,Inflammatory BD?

Vascular history, HT, heart disease or AF?

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Examination

Lots of information from the end of the bedDistressed vs. non distressed

Lying still - peritonitisWrithing Renal Colic

Vital Signs

NEVER ignore abnormal vital signs!Always document as part of your assessment

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Investigations

BedsideUA

Blood?

Leucocyte Esterase and nitritesUrine HCG

ECG anyone with upper abdominal pain or elderlyBloods

ALL WOMEN OF CHILDBEARING AGE NEED BHCGWhat are your differentials?Avoid machine gun approach!

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Radiology

CXR?perforation?Extra abdominal pathology?Complications of intra-abdominal disease

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Which of the following is NOT an indication forplain abdominal imaging?

1. Bowel Obstruction2. Constipation3. Tracking Renal Calculi4. Foreign Body

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Other imaging

USSBiliary DiseaseGood for gynae complaints

Rule out Ectopic pregnancyAppendicitis in childrenNo radiation

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CT is accurate fordiagnosis of

Renal colic

AppendicitisDiverticulitisAAAIntraabdominal

AbscessesMesenteric IschaemiaBowel Obstruction

Avoid repeated CTscansLimit use in youngerpatientsAvoid where possible inpregnant females

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Imaging Dose (mSV) CXR equivalents

Pelvic XR 0.6 6

Abdominal XR 0.7 7

CT abdo-pelvis 14 140

CT aortogram 24 240

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Management

ResuscitateLarge bore accessN Saline bolus 20ml/kg x 2 if shockedIf bleeding think hypotensive resuscitationAll should be NBM until provisional diagnosisEnsure normothermia

Maintenance fluids and fluid balanceAnalgesia doesnt mask signs

Use a the pain scaleMorphine titrated to pain. Normally 0.1mg/Kg

Paracetamol adjunctNSAIDs for renal colic

Correct ElectrolytesThromboprophylaxis

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Cases

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Case 1

21 year old female24 hour history of vague peri-umbilicalabdominal pain.Moved down to the RIF.Now constant and sharp.Associated with 2x vomits and feels flushed

No appetiteNormal Bowels

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What clinical signs may lead you to adiagnosis of appendicitis?

Lie still

RIF tendernessReboundRovsigs sign

Psoas Sign

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Imaging?

AXR rarely useful

USSNot as good as CTGood for female to exclude gynae pathology

If appendix is visualised is useful

CTOnly if there is doubt about diagnosisSensitivity up to 98%High radiation doseDiagnose other pathology if no appendicitisElderley

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Management

NBMAnalgesiaAnti-emetic if necessaryMaintenance fluidsIVABs e.g. Ceftriaxone, Gentamicin andMetronidazoleSurgical Referral

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Case 2

40 yr old obese femaleRUQ painPain is constantnausea, vomitingfevers and chills

PMH AsthmaMEDS OCP

SHDrinks 2 std / weekSmokes 20/dayNil drugs

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On Examination

Looks distressed.Not jaundicedT 38 CP 120BP 100/60RR 20

Sats 98% RATender in the RUQ andMurphys positive.

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What bloods will you order

on this patient?

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HB 138WCC 16.0Neuts 12.4Lymph 1.6

EUC NormalBil 9 (

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Management

NBMIVFIV abs Ampicillin + GentamicinAnalgesia +- anti emeticRefer to surgeons

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Case 3

52 yr old alcoholicConstant epigastric pain radiating to theback. Worsening over the past 2 daysImproved with sitting up and forwardsNausea and vomitingBowels OK

PMH Chronic Airways LimitationAlcoholic Gastritis

MEDS Thiamine 100 mg daily

SH Boarding house residentDrinks 4 litres wine/daySmokes 20/day

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Looks unwell anddehydrated

T38.4CP105BP 130/70

RR 18Sats 93% RA

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Reduced AE L baseTenderEpigastrium andRUQNo guarding/

rebound

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What blood tests will youorder?

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Blood Results

BiochemNa 129K 4.0Cr 62Ur 8.0

Amylase 1080 (

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What imaging will you perform

( if any)?

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CXR

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Imaging

CTConfirms diagnosisIdentifies complicationsHelps grade severityNot always necessary in ED

USSPoor visualisation ofpancreasGood for looking at gallstones/ biliary treedilatation

CXRLook for complicationsPleural Effusion,

Atelectasis, ARDS

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Management

O2NBMIVFAnalgesia+-Antibiotics (controversial)Correct Electrolytes

ThromboprophylaxisIDC/Art-line/CVC depending on severitySurgical Admit +_ ICU review

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Causes

G all stonesE tohT raumaS teroidsM umpsA utoimmuneS corpion Bites

H yperlidaemia/hypercalcaemia/hypothermiaE RCPD rugs

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Case 4

27 yr old female6/40LIF constant severe sharp painRadiating to the backLight bright red PV spotting

Feels light headed

PMHIVFPrevious D+C x 2Ovarian Cysts

MEDS Nil

SH Lives with partnerNon-smokerNon-Drinker

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How do you manage this

patient?Panic! ( dont!) Call for senior helpLarge bore IV access x 2 (16 G or larger)Urgent Cross MatchFluid resuscitationCall O+G urgentlyNeeds OT immediately

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Case 5

88 yr old female.Peri-umbilical, colicky abdominal pain for 2 daysAbdominal distensionVomits x 10Reduced flatus and NOB for 2 days.PMH

Cholecystectomyappendectomy TAH BSOHypertension

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On examination

Looks distressedLying StillT 37.5 P 110 sinusBP 150/80RR 18Sats 98% RAAbdomen

DistendedGenerally tenderNo guarding rebound or rigidityHigh pitched bowel sounds

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Investigations

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Investigations

EUC/CMP/FBPAXR

CXRCT

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Management

NBMFluid resuscitationMonitor volume status may have large volumeshiftsCorrect ElectrolytesAnalgesia

NG if vomitingIV Abs Amp+Gent+MetUrgent Surgical consult for OT

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Large Bowel

Almost neveradhesions or hernia

CARCINOMADiverticulitisSigmoid VolvulusFaecal Impaction

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Case 6

73 yr old male presents with sudden onset of central abdominalpain radiating to the back. He also reports weakness to both legsPMH

HTHypercholesterolemiaCurrent smoker 30/day

MEDSAspirin 100mg DailyPerindopril 5 mg DailyAtorvastatin 10 mg Daily

SHLives AloneFully independent with ADLSOccasional alcohol

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Examination

DistressedP 130BP 80/60

RR 26 Sats99% RAAbdomen

Non-distendedGenerally tenderReduced power 3/5 tohip flexors

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Bedside Ultrasound

9cm

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Management of ruptured AAA

Senior helpABCLarge Bore IV Access x 2Hypotensive resuscitationAnalgesiaEnsure O neg available

Ensure normothermiaUrgent Vascular ConsultTo OT

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Last Case!

85 yr old male. Nursing home residentCentral Abdominal PainSudden onset. SeverePMH

DementiaMI

MEDSClopidogrel 75 mg DailyMetoprolol 25 mg BDPerindopril 5 mg daily

SHMild dementiaForgetfulRequires some assistance with bathingand toiletingFeeds SelfWalks with frameNon-smokerNon-drinker

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Examination

Looks dry and emaciatedP 120- 140 BP 110/70 RR 30Sats 96% RAT 37.4 CAbdomen

Generally tender No guarding rigidity or rebound

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ECG

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Differential?

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ABG

pH 7.10pCO2 15

P02 80Bic 8BE -15

Lactate 10.2

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Management

02NMBIV accessIVFAnalgesiaIV abs

Urgent Surgical ConsultUrgent CT mesenteric angiogramOT

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Take Home Message

Exclude life threatening pathologyBHCG in female of child bearing age

Be mindful of radiation exposureBeware of Abdominal pain in the ElderlyNever ignore abnormal vital signs

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Mesenteric Ischaemia

Surgical EmergencySmall bowel has warm ischaemic time of 2-3hoursRapidly progresses to gangrene, septic shockand deathNeed high index of suspicion to diagnose it

Severe pain but little tenderness on examination

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Case 7

40 yr old male presents with sudden onset ofsevere R loin to groin pain. Excruciatingpain.Coming in waves. Feels nauseated and hasvomited 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% RAR renal angle tender

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Differential Diagnosis?

Renal ColicPancreatitis

CholecystitisAppendicitisRuptured/leaking AAA

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UAErythrocytes ++++No leucocytesNo nitrites

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Investigations

UAEUCFBC(other bloods if diagnosis unclear)CT KUB

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Management

AnalgesiaNSAID e.g. PR indomethacin 100 mg 1 st lineMorphine IV titrated to painIV fluids maintenance onlyObserve

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Who should we CT

CTOngoing painImpaired renal functionFeverDiagnosis not clear

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Indications for admission

InfectionImpaired Renal FunctionPain ongoing needing IV opiatesStone > 5mmObstruction/hydronephrosis on CT

Stag horn Calculus on CT

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ECG

What does the ECG show?1. Sinus Tachycardia2. VT3. VF4. Rapid Atrial Fibrillation

5. No idea!

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ECG