Dr Matthew Smith Emergency Specialist Types of pain Special Populations Assessment History Examination Investigations Differential Diagnosis Management overview Cases if time permits ID: 158609
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Slide1
An approach to abdominal pain
Dr. Matthew SmithEmergency SpecialistSlide2
Types of pain
Special PopulationsAssessmentHistoryExaminationInvestigations
Differential Diagnosis
Management - overview
Cases ( if time permits)Slide3
VisceralParietal Pain
Types Of PainSlide4
Visceral Pain
Stretching of nerve fibres of walls or capsules of organsCrampy DullAchyOften unable to lie still
Bilateral innervationSlide5
Parietal Pain
Parietal peritoneum irritatedUsually anterior abdominal wallLocalised to the dermatome superficial to the site of painful stimulusSlide6
CourseSlide7
Referred Pain
Examples of referred pain?Slide8
Special PopulationsSlide9
Elderly
May lack physical findings despite having serious pathologyAs patients age increases diagnostic accuracy declines
Risk of Vascular Catastrophes
Assume surgical cause until proven otherwise
30-40% of geris with
abdo
pain need surgery
Biliary tract Disease is the commonest
cause
Age > 65 need to think of reasons not to CT!
Mortality is 7% in the over 80’s - equivalent to AMI!Slide10
Elderly Patient think Nasties!
AAA Ischaemic Gut Bowel Obstruction
Diverticulitis
Perforated Peptic Ulcer
Cholecystitis
AppendicitisSlide11
Women of Childbearing Age
Must Ascertain whether PREGNANTALL WOMEN OF CHILDBEARING AGE WITH ABDO PAIN NEED BHCGGravid uterus displaces intra-abdominal organs making presentations atypical
Pregnant women still get common surgical abdominal conditionsSlide12
History
What are the key points of the abdominal pain history?Slide13
History
HPCPainProvocativePalliativeQualityRadiation
Symptoms associated with
Timing
Taken for the pain
Consultations/ Presentations
Associated Symptoms –
Gastro – intestinal
Genito-urinary
GynaecologicSlide14
History
PMHDMHTLiver DiseaseRenal Disease
Sexually Transmitted Infections
PSH
Abdominal Surgery
Pregnancies
Deliveries/ Abortions/
Ectopics
TraumaSlide15
History
MedsNSAIDsSteroidsOCP/ Fertility DrugsNarcoticsImmunosuppressants
Chemotherapy agent
ALLS
Contrast
AnalgesicSlide16
High Yield Questions
Which came first – pain or vomiting?How long have you had the pain?Constant or intermittent?History of cancer,
diverticulosis
, gall
stones,Inflammatory
BD?
Vascular
history, HT, heart disease or AF?Slide17
Examination
Lots of information from the end of the bedDistressed vs. non distressedLying still - peritonitis
Writhing
– Renal Colic
Vital
Signs
NEVER ignore abnormal vital signs!
Always document as part of your assessmentSlide18Slide19Slide20Slide21
Investigations
BedsideUABlood?
Leucocyte Esterase and nitrites
Urine HCG
ECG – anyone with upper abdominal pain or elderly
Bloods
ALL
WOMEN OF CHILDBEARING
AGE
NEED
BHCG
What are your differentials?
Avoid machine gun approach!Slide22
Radiology
CXR –?perforation?Extra abdominal pathology?Complications of intra-abdominal diseaseSlide23
Which of the following is
NOT an indication for plain abdominal imaging?Bowel Obstruction
Constipation
Tracking Renal Calculi
Foreign BodySlide24Slide25Slide26Slide27Slide28
Other imaging
USS Biliary DiseaseGood for
gynae
complaints
Rule out Ectopic
pregnancy
Appendicitis in children
No radiationSlide29
CT is accurate for diagnosis of
Renal colicAppendicitisDiverticulitis
AAA
Intraabdominal
Abscesses
Mesenteric Ischaemia
Bowel Obstruction
Avoid repeated CT scans
Limit use in younger patients
Avoid where possible in pregnant femalesSlide30
Imaging
Dose (mSV)
CXR equivalents
Pelvic
XR
0.6
6
Abdominal XR
0.7
7
CT
abdo
-pelvis
14
140
CT
aortogram
24
240Slide31
Management
ResuscitateLarge bore accessN Saline bolus 20ml/kg x 2 if shockedIf bleeding think hypotensive resuscitationAll should be NBM until provisional diagnosis
Ensure
normothermia
Maintenance fluids and fluid balance
Analgesia doesn’t mask signs
Use a the pain scale
Morphine titrated to pain. Normally 0.1mg/Kg
Paracetamol adjunct
NSAIDs for renal colic
Correct Electrolytes
ThromboprophylaxisSlide32
CasesSlide33
Case 1
21 year old female 24 hour history of vague peri
-umbilical abdominal pain.
Moved
down to the
RIF.
Now
constant and sharp.
Associated with 2x vomits and feels flushed
No
appetite
Normal BowelsSlide34
What clinical signs may lead you to a diagnosis of appendicitis?
Lie stillRIF tenderness
Rebound
Rovsig’s
sign
Psoas
SignSlide35
Imaging?
AXR rarely usefulUSS
Not as good as CT
Good for female to exclude
gynae
pathology
If appendix is visualised is useful
CT
Only if there is doubt about diagnosis
Sensitivity up to 98%
High radiation dose
Diagnose other pathology if no
appendicitis
ElderleySlide36Slide37
Management
NBMAnalgesiaAnti-emetic if necessary
Maintenance fluids
IVABs – e.g.
Ceftriaxone, Gentamicin
and Metronidazole
Surgical ReferralSlide38
Case 2
40 yr old obese femaleRUQ painPain is constant
nausea
,
vomiting
fevers
and chills
PMH
Asthma
MEDS
OCP
SH
Drinks 2 std / week
Smokes 20/day
Nil drugsSlide39
On Examination
Looks distressed.Not jaundiced
T
38
C
P
120
BP 100/
60
RR
20
Sats
98% RA
Tender in the RUQ and Murphy’s positive.Slide40
What bloods will you order on this patient?Slide41
HB 138
WCC 16.0Neuts 12.4Lymph 1.6
EUC Normal
Bil
9 (<18)
ALP 450 (30-130)
GGT 320 (<60)
ALT 41 (5-55)
AST 30 (5-55)
Amylase
28 (<120)
Lipase
40 (<60)Slide42Slide43Slide44
Management
NBMIVF
IV abs
–Ampicillin + Gentamicin
Analgesia
+-
anti emetic
Refer
to surgeonsSlide45
Case 3
52 yr old alcoholicConstant
epigastric pain radiating to the back. Worsening over the past 2
days
Improved with sitting up and forwards
Nausea and
vomiting
Bowels
OK
PMH Chronic Airways Limitation
Alcoholic Gastritis
MEDS Thiamine 100 mg daily
SH Boarding house resident
Drinks 4 litres wine/day
Smokes 20/daySlide46
Looks unwell and dehydrated
T38.4C P105
BP 130/70
RR 18
Sats 93%
RASlide47
Reduced AE L base
Tender Epigastrium and RUQNo guarding/ reboundSlide48
What blood tests will you order?Slide49
Blood Results
BiochemNa 129K 4.0Cr 62
Ur 8.0
Amylase 1080 (<120)
Lipase
950 (<60)
Bil
11 ( 18)
GGT 900 (<60)
ALP 200 ( < 140)
AST
300 (5-55)
ALT 250 (5-55)
LDH
800( 105-333)
Glucose 15
Alb 23
Ca (
Corr)
2.0
Haem
HB
114
WCC 17
Coags
NormalSlide50
What imaging will you perform ( if any)?Slide51
CXRSlide52
Imaging
CTConfirms diagnosisIdentifies complications
Help’s grade
severity
Not always necessary in ED
USS
Poor visualisation of pancreas
Good for looking at gall stones/ biliary tree dilatation
CXR
Look for complications
Pleural Effusion,
Atelectasis
, ARDSSlide53
Management
O2NBMIVF
Analgesia
+-Antibiotics (controversial)
Correct
Electrolytes
Thromboprophylaxis
IDC/Art-line/CVC depending on
severity
Surgical Admit +_ ICU reviewSlide54
Causes
G
all stones
E
toh
T
rauma
S
teroids
M
umps
A
utoimmune
S
corpion
Bites
H
yperlidaemia
/hypercalcaemia/hypothermia
E
RCP
D
rugsSlide55
Case 4
27 yr old female6/40LIF constant severe sharp pain
Radiating to the back
Light bright red PV spotting
Feels light headed
PMH
IVF
Previous D+C x
2
Ovarian Cysts
MEDS Nil
SH Lives with partner
Non-smoker
Non-DrinkerSlide56
On Examination
Looks unwell. Pale, diaphoretic, restlessP 150 BP 7
0/40
RR
26 Sats
98
% RA
Tender and guarding in the LIF
PV
Bright
red blood spotting
L
adnexal
tenderness ++Slide57
How do you manage this patient?
Panic! ( don’t!)Call for senior helpLarge bore IV access x 2
(16
G or larger)
Urgent Cross Match
Fluid resuscitation
Call O+G urgently
Needs OT immediatelySlide58
Case 5
88 yr old female. Peri-umbilical, colicky abdominal pain for 2 days
Abdominal distension
Vomits x 10
Reduced flatus and NOB for 2 days.
PMH
Cholecystectomy
appendectomy
TAH BSO
HypertensionSlide59
On examination
Looks distressedLying StillT
37.5
P 110 sinus
BP
150/80
RR
18
Sats
98% RA
Abdomen
Distended
Generally tender
No guarding rebound or rigidity
High pitched bowel soundsSlide60
InvestigationsSlide61
Investigations
EUC/CMP/FBPAXRCXRCT Slide62Slide63Slide64
Management
NBMFluid resuscitationMonitor volume status – may have large volume shifts
Correct Electrolytes
Analgesia
NG
if vomiting
IV Abs –
Amp+Gent+Met
Urgent Surgical consult for OTSlide65
Small Bowel
Adhesions
Hernias
Polyps
Lymphoma
Adenocarcinoma
Gall Stones
Inflammatory BDSlide66
Large Bowel
Almost never adhesions or hernia
CARCINOMA
Diverticulitis
Sigmoid Volvulus
Faecal ImpactionSlide67
Case 6
73 yr old male presents with sudden onset of central abdominal pain radiating to the back. He also reports weakness to both legsPMH HT
Hypercholesterolemia
Current
smoker 30/
day
MEDS
Aspirin 100mg Daily
Perindopril
5 mg Daily
Atorvastatin
10 mg Daily
SH
Lives Alone
Fully independent with ADLS
Occasional alcoholSlide68
Examination
Distressed P 130
BP
80/60
RR
26 Sats
99
% RA
Abdomen
Non-distended
Generally tender
Reduced
power 3/5 to hip flexors
Slide69
Bedside Ultrasound
9cmSlide70
Management of ruptured AAA
Senior helpABCLarge Bore IV Access x 2
Hypotensive resuscitation
Analgesia
Ensure O
neg
available
Ensure
normothermia
Urgent Vascular Consult
To OTSlide71
Last Case!
85 yr old male. Nursing home resident Central Abdominal Pain
Sudden onset. Severe
PMH
Dementia
MI
MEDS
Clopidogrel 75 mg Daily
Metoprolol 25 mg BD
Perindopril
5 mg daily
SH
Mild dementia
Forgetful
Requires some assistance with bathing and toileting
Feeds Self
Walks with frame
Non-smoker
Non-drinkerSlide72
Examination
Looks dry and emaciatedP 120- 140 BP 110/70
RR
30
Sats
96% RA
T 37.4
C
Abdomen
Generally tender
No guarding rigidity or rebound Slide73
ECG
Slide74
Differential?Slide75
ABG
pH 7.10pCO2 15P02 80Bic
8
BE -15
Lactate 10.2Slide76
Management
02NMBIV access
IVF
Analgesia
IV abs
Urgent
Surgical
Consult
Urgent CT mesenteric angiogram
OTSlide77
Take Home Message
Exclude life threatening pathologyBHCG in female of child bearing ageBe mindful of radiation exposure
Beware
o
f
Abdominal pain in the
Elderly
Never ignore abnormal vital signsSlide78
Mesenteric Ischaemia
Surgical EmergencySmall bowel has warm ischaemic time of 2-3 hoursRapidly progresses to gangrene, septic shock and death
Need high index of suspicion to diagnose it
Severe pain but little tenderness on examinationSlide79
Case 7
40 yr old male presents with sudden onset of severe R loin to groin pain. Excruciating pain.Coming in waves. Feels nauseated and has vomited 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% RA
R renal angle tenderSlide80
Differential Diagnosis?
Renal ColicPancreatitisCholecystitisAppendicitisRuptured/leaking AAASlide81
UA
Erythrocytes ++++No leucocytesNo nitritesSlide82Slide83
Investigations
UAEUCFBC(other bloods if diagnosis unclear)
CT KUBSlide84
Management
Analgesia NSAID e.g. PR indomethacin 100
mg 1
st
line
Morphine IV titrated to pain
IV
fluids – maintenance only
ObserveSlide85
Who should we CT
CTOngoing painImpaired renal function
Fever
Diagnosis not clearSlide86
Indications for admission
InfectionImpaired Renal FunctionPain ongoing– needing IV opiatesStone > 5mmObstruction/hydronephrosis on CT
Stag horn Calculus on CTSlide87
ECG
What does the ECG show?Sinus TachycardiaVT
VF
Rapid Atrial Fibrillation
No idea!Slide88
ECG