Abrupt Abdominal Pain PowerPoint Presentation, PPT - DocSlides

Abrupt Abdominal Pain

HPI:

C.B, a former heavy smoking 69 yo M with a h/o hypertension and COPD presents to the ED with sudden onset abdominal, lower back and R flank pain that started 45 min ago while at home watching TV. He also c/o feeling ‘dizzy’ and some nausea at the time. He denies LOC, chest pain, dyspnea, vomiting, difficulty urinating or blood in his stool. He has not ever had a pain like this before. The pain was a 9/10 initially, but is about a 6/10 after taking some Tylenol at home. His dizziness and nausea are improved at this time.

ROS:

HEENT

: denies headache, visual changes

CV: no chest pain

Resp

: denies dyspnea, chronic cough

GI: Midline,

peri

-umbilical abdominal pain, nausea w/ pain initially, denies vomiting, diarrhea and blood in stool

GU: no dysuria, hematuria

Ext: denies leg pain, Some R flank and lower back pain

Neuro

: no LOC

or weakness

PMHx

:

COPD, Hypertension, Hyperlipidemia

PSHx

:

appendectomy at age 20, ‘had a normal colonoscopy’ 3 years ago

Medications:

Spiriva,

Metoprolol

and hydralazine, simvastatin, Fish oil and daily multivitamin

SocHx

:

Former 50 year 2 pack/day smoking history, has been smoke free for 6 months

Moderate alcohol use

Denies recreational drugs

Married, retired truck driver

FamHx

:

Mother – had hypertension

Father – depression

Brother – hypertension and ‘some surgery for an aneurysm’

Physical Exam

Gen: mild distress

HEENT: NCAT, PERRL, EOMI

CV: RRR, no r/m/g, 2+ radial and dorsal

pedis

pulses

Pulm

: CTA, regular respirations

Abd

: mild

peri

-umbilical tenderness to palpation, pulsatile mass

Ext: normal strength, no CVA tenderness

Skin: no rashes or lesions

Neuro

: A&Ox3, no focal

neuro

deficits

Differential Diagnosis?

Perforated viscusPancreatitisAbdominal Aortic Aneurysm (AAA)Urinary CalculiBowel obstructionMusculoskeletal pain

DDx

:

What would you order next?

Labs

Vitals

Urine

Hemoccult

CBC

Coagulation

studies

CMP

Lipase and amylase

Imaging

Plain radiography

Abdominal Ultrasound

Abdominal CT w/ and w/o

contrast if stable

Results

LabsVitals – 100/60 115 37.5 97% on RAUrine – normalHemoccult - negativeCBC 14 8.0 200PT/INR and PTT all normalCMP - 140/ 4.0/ 100/ 24/ 15/ 1.0 / 95Lipase 25, Amylase 50, ALT 25, AST 35

Bedside Abdominal Ultrasound

Imaging: Bedside US

Imaging: Bedside US

http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htm

Abdominal CT

http://www.medscape.com/content/2004/00/47/08/470838/470838_fig.html

Diagnosis?

Abdominal Aortic Aneurysm (AAA)

Bedside Abdominal US shows AAA 6.0 cm in diameter

Confirmed with Abdominal CT with contrast

Treatment

C.B. is started on IVFs, given 02 by nasal cannula and vascular surgery is consulted

Because of the sudden onset of pain, size of aneurysm, hypotension and feeling ‘dizzy’, there is concern C.B.’s AAA may be rupturing.

He is admitted to vascular surgery for stabilization and urgent AAA repair.

Abdominal Aortic Aneurysm

Presentation

Flank, back or abdominal pain

severe and abrupt onset, 50% describe pain as a ripping or tearing

GI bleeding

Syncope (10%)

Extremity ischemia from embolization of a thrombus

Shock: hemorrhagic

Sudden death

Atypical presentations may complicate the diagnosis:

Flank, groin or isolated quadrants of abdominal pain

Nausea, vomiting

Bladder pain

Hip pain

Tenesmus

Diagnosis

Physical Exam:

Palpable abdominal mass (only present in 2%)

Tender abdomen

Hypotension

Decreased femoral pulses

Look for

peri

-umbilical

ecchymosis (Cullen sign) or flank ecchymosis (Grey Turner sign

), which indicate acute rupture

Labs:

H&H may not be affected

Treatment/Management

Symptomatic AAAs require an emergency vascular surgical consult for repair

Concurrent stabilization with IVFs, O2 and bedside diagnosis with US (>90% sensitive for demonstrating presence and measuring diameter

Classic triad of symptom: abdominal and/or back pain, a pulsatile abdominal mass, and hypotension only occur in ~1/3 of patients with ruptured AAAs.

Non-symptomatic AAAs

Prompt outpatient referral to vascular surgeon and BP control

.

AAAs between 4-5cm in diameter are associated with a 1% per year risk of rupture, monitoring every 6 months with US or CT scans.

Any Aneurysm >5.5cm in diameter should be repaired.

Gross Pathology - AAA

Gross Pathology – Ruptured AAA

Microscopic Images - AAA

A microscopic image of the abdominal aortic aneurysm shows intense inflammatory change and fibrosis in the adventitia (H and E, original magnification ×40).

I

nflammation

Fibrosis

Inflammatory cells are mainly lymphocytes, plasma cells, and

eosinophils (H and E, original magnification ×400).

Microscopic Images - AAA

Obliterative

phlebitis is observed (EvG, original magnification ×200)

Microscopic Images - AAA

Immunostaining

of IgG4 reveals numerous IgG4-positive plasma cells within the lesion (immunostaining of IgG4, original magnification ×400).

Microscopic Images - AAA

Bedside US

Bedside US

Imaging: Plain radiography

http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htm

CT without IV contrast Ruptured Abdominal Aortic Aneurysman abdominal aortic aneurysm (A) with high density blood (arrows) indicating rupture.

http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htm

References:

Prince

LA, Johnson GA. Chapter 63. Aneurysms of the Aorta and Major Arteries. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide

. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6359748. Accessed November 6, 2012

.

Elefteriades

JA, Olin JW,

Halperin

JL. Chapter 106. Diseases of the Aorta. In:

Fuster

V, Walsh RA, Harrington RA, eds.

Hurst's The Heart

. 13th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=7836581. Accessed November 7, 2012

.

Images from

http://

www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/aneurysm2.htm

Yasushi Matsumoto, Satomi

Kasashima

,

Atsuhiro

Kawashima,

Hisao

Sasaki,

Masamitsu

Endo,

Kengo

Kawakami,

Yoh

Zen,

Yasuni

Nakanuma

, A case of multiple immunoglobulin G4–related

periarteritis

: a tumorous lesion of the coronary artery and abdominal aortic aneurysm, Human Pathology, Volume 39, Issue 6, June 2008, Pages 975-980, ISSN 0046-8177, 10.1016/j.humpath.2007.10.023. (http://www.sciencedirect.com/science/article/pii/S004681770700576X) Keywords: IgG4; Autoimmune pancreatitis; Retroperitoneal fibrosis; Aneurysm; Arteritis