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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