Abdominal Pain II – Lower abdominal and pelvic pain - PowerPoint Presentation

Slide1

Abdominal Pain II – Lower abdominal and pelvic pain

EMC SDMH 2015

Slide2

Objectives

Briefly revise patterns of pain

radiation

Differentials of lower abdominal

pain

Review assessment of

appendicitis

Review assessment of

diverticulitis

Review assessment of types of bowel

obstruction

Discuss mesenteric

ischaemia

Briefly review ovarian cyst accidents

Slide3

Pain modalities in the abdomen

Visceral

‘aching, cramping, dull’

Poorly localised – typically midline

 ‘Colicky’

ParietalSomatic, sharp, well localised ‘Peritonitic’ReferredUreteric  teste/vulvaCardiac  epigastrium, arm, backDiaphragmatic  shoulder tip

Slide4

Differentials for lower abdominal pain

Slide5

Appendicitis

Commonest surgical emergency

Typically younger adult

Peak in children 6-9

yrs

old10 % pts > 60yrs age1:1500 pregnanciesInitial diagnostic accuracy of ~ 85%Often delayed diagnosis in children, elderly, pregnancy

Slide6

Clinical features

HISTORY

sens

(spec)

EXAM

Nausea 60-90% (30%)Anorexia 75% (35%)RLQ pain 80% (50%)Migration 80% (80%)Fever 50% (50%)Pain generally precedes nauseaElderly, paediatric more prone to atypical presentationsRLQ tenderness 96%Guarding 25%

Fever 50%

Rectal exam

not

helpful

Rovsings

,

Posas

and

Obturator

signs may be specific, but insensitive

Slide7

Assessment

WCC & CRP?

Slide8

Decision rules

Alvarado Score

Stratifies to high, intermediate and low risk appendicitis

When compared to CT evidence

Score 1-4 4%

Score 5-6 32% Score 7-10 - 78%Prospective use of Alavarado <4 to exclude appendicitis ; 28% appendicitis! (Andrew et al 2013)~ Gestalt assessment 80-85%

Slide9

Imaging

Ultrasound

CT Scan

Operator dependent

Sensitivity 75-90%

Specificity 86-100%PPV and NPV 90-95%Performs better in childrenGenerally accessibleSensitivity & specificity 98%Needs contrastRadiation dose 8-10mSV

Slide10

Management

Early surgical referral

May not require imaging to take to OT

IV Analgesia

IV Fluids

IV antibiotics – reduces peri-operative complication rate

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Diverticulitis

Increasing prevalence

5% of <40

yrs

30% age 60

70% age 8520% chance of diverticulitis10-15% diverticular bleeding70% asymptomatic lifelong diverticulosis5% right sided diverticulosis

Slide12

Clinical features

History

EXAM/LABS

Left lower

abdo

pain (90%)GI disturbance diarrhoea 30%, constipation 50%Anorexia (~40%)Nausea (~40%)Dysuria/Frequency (10%)Fever (30%)Abdominal tenderness (90%)Fever (30%)

Leucocytosis (60%)

Clinical triad of LLQ pain, fever and

leucocytosis

~25%

Slide13

Imaging

CT scan unequivocal test of choice

Diagnosis and severity grading

Diverticulosis

Uncomplicated Diverticulitis

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Management

Uncomplicated (75%)

Inflammation simply confined to diverticulum/lumen wall

Depending upon institutional guidelines -



ImmunocompetentWell appearingPain controlledSelf caringClear fluid dietOral antibiotics(Augmentin Duo) 5-7 days(?)AnalgesiaOutpatient colonoscopy 4-6 weeks

Complicated (25%)Inflammation and free fluid,

abcess

, collection, obstruction ,perforation

NBM

IV Fluids +/- resuscitation fluid

IV antibiotics – triple therapy

Targeted surgical treatment depending upon complication

Slide15

Bowel obstructions

Small bowel

Large bowel

Volvulus

Slide16

Bowel obstruction

History

Exam / LABs

Abdominal pain – cramping/colicky

Distension/bloating

‘Constipation’/nil flatusVomiting – only if proximalAbdominal distensionVariable degree & nature of abdominal tendernessBowel sounds variably present/absentNil specific lab results – consistent with dehydrationAcid base deficit/lactate elevation may suggest ischemia/sepsis – generally normal

Slide17

Imaging

Small

bowel obstruction

Centrally located dilated loops of bowel

apparent

Air-fluid interfaceDilatation >3 cm in 3 loopsValvulae conniventes visible

String of beads sign in otherwise gasless abdomen

AXR Sensitivity 50-66%

Slide18

Imaging

Large

Bowel obstruction

Colonic distension >6 cm (9 cm for cecum

)

Collapsed distal colonPeripherally distributedHaustra visible

Slide19

Imaging

Volvulus –

Sigmoid/

Caecal

Subtype large bowel obstruction

.Characteristic ‘coffee bean’ appearance to dilated bowel for sigmoidCaecal volvulus less distinctive, but looped away from RIF

Slide20

Management

Small bowel (80%)

Large bowel (20%)

Analgesia

NBM.

NGT optionalIV fluids to replace lossesCT scan to establish cause and exclude closed loop obstructionAdhesions/Herniae (internal/external)commonest causesSurgical consultation and admission

AnalgesiaNBM

.

NGT

not

required

IV fluids to replace

losses

CT scan to establish

cause

Carcinoma/Diverticular stricture commonest reasons

Sigmoid volvulus and

caecal

volvulus require urgent decompression to prevent bowel ischemia

Slide21

Acute mesenteric ischaemia

Mesenteric arterial embolus

Mesenteric arterial thrombosis

Mesenteric vein thrombosis

Ischaemic

colitisTypically sudden onset colicky, severe pain; older patient with cardiovascular diseaseLittle to find on exam – pain out of proportion to findingsAssociated forceful offensive diarrhoea; maroon/bloody stool.

Slide22

Management

No

reliable

pathology

Supportive –

Metabolic acidosis +/- lactate (LATE!)WCC >15AmylasaemiaCKImagingAXR – often normalCT – SBO; pneumatosis coli; portal vein gasCT mesenteric angiography gold standard

Treatment – Laparotomy

if appropriate

to treat cause

Broad spectrum IV a/b

Mortality 75-90% if infarction fully established

Survival 50% 5

yrs

if aggressively managed early

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Ovarian cyst accidents

Ovarian cyst torsion

Typically premenopausal

woman

Commoner with PCOS,

OHSSCyst >4 cm, R>L incidenceSevere colicky abdominal pain, becoming constantPain out of proportion to signs50% nausea and vomitingAdnexal mass on USS raises suspicion. Normal flow doesn’t exclude diagnosis

Management = laparoscopic detorsion

(90% success rate if @16

hrs

)

Slide24

Ovarian cyst accidents

Ovarian cyst

rupture

Corpus

luteal cysts responsible, D20-26 of

mensesMittelschmerz = physiological ruptureSudden onset of pain, maximal at onsetSecondarily generalised pelvic pain, aching in natureVariable amount of pain - mild to very severeNot constitutionally unwell, mild peritonism

only.

USS – mild free fluid 40%.

Treatment conservative with analgesia

HAEMORRHAGE

– 3% of ruptures – bleeding from corpus luteal cyst; worsening pain with free fluid. Require laparoscopic OT for

haemostasis

Slide25

Pelvic Inflammatory Disease

Spectrum of illness from acute bilateral pelvic pain



Tubo

-ovarian

abscess and sepsisBilateral crampy dull pain <7 days duration. Exacerbated by coitus75% associated with new PV dischargeAdnexal, uterine or cervical tenderness (95% sensitive). Cervicitis should be present No pathology reliably rules in or out – inflammatory markers expected to be elevated however.

Swabs for chlamydia, gonococcus

USS demonstrates

tubo

-ovarian pathology in more unwell individuals (febrile), but

often normal

Management

Mild infection – Ceftriaxone 500mg + Azithromycin stat dose, metronidazole 14/7 Repeat dose azithromycin 7/7

Major infection – Ceftriaxone 2 g daily +azithromycin +metronidazole

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Questions?

Slide27

Summary

History remains best predictor in appendicitis.

CRP, WCC may be more useful as rule-out tests

Outpatient treatment feasible for diverticulitis

Be mindful of possibility of closed loop obstruction in SBO and need for surgical intervention early

Acute mesenteric ischaemia – suspect early with pain out of proportion to signsOvarian cyst torsion – good prognosis with early OTOvarian cyst haemorrhage can complicate of cyst rupture, but requires OT

Don’t forget PID – although can be difficult to diagnose