An approach to abdominal pain - Emergency Medicine Education

Report
AN APPROACH TO ABDOMINAL
PAIN
Dr. Matthew Smith
Emergency Specialist
 Types of pain
 Special Populations
 Assessment
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History
Examination
Investigations
Differential Diagnosis
 Management - overview
 Cases ( if time permits)
Types Of Pain
Visceral
Parietal Pain
Visceral Pain
 Stretching of nerve
fibres of walls or
capsules of organs
 Crampy
 Dull
 Achy
 Often unable to lie still
 Bilateral innervation
Parietal Pain
 Parietal peritoneum irritated
 Usually anterior abdominal wall
 Localised to the dermatome superficial to the
site of painful stimulus
Course
• Non specific
Visceral
Parietal
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Localised tenderness
Guarding
Rigidity
Rebound
Referred Pain
 Examples of referred pain?
Special Populations
Elderly
 May lack physical findings despite having serious
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pathology
As 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!
Elderly Patient think
Nasties!
 AAA
 Ischaemic Gut
 Bowel Obstruction
 Diverticulitis
 Perforated Peptic
Ulcer
 Cholecystitis
 Appendicitis
Women of Childbearing Age
 Must Ascertain whether PREGNANT
 ALL WOMEN OF CHILDBEARING AGE WITH
ABDO PAIN NEED BHCG
 Gravid uterus displaces intra-abdominal
organs making presentations atypical
 Pregnant women still get common surgical
abdominal conditions
History
 What are the key points of the abdominal
pain history?
History
 HPC
 Pain
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Provocative
Palliative
Quality
Radiation
Symptoms associated with
Timing
Taken for the pain
 Consultations/
Presentations
Associated Symptoms –
 Gastro – intestinal
 Genito-urinary
 Gynaecologic
History
 PMH
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DM
HT
Liver Disease
Renal Disease
Sexually Transmitted Infections
 PSH
 Abdominal Surgery
 Pregnancies
 Deliveries/ Abortions/ Ectopics
 Trauma
History
 Meds
 NSAIDs
 Steroids
 OCP/ Fertility Drugs
 Narcotics
 Immunosuppressants
 Chemotherapy agent
 ALLS
 Contrast
 Analgesic
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?
Examination
 Lots of information from the end of the bed
 Distressed vs. non distressed
 Lying still - peritonitis
 Writhing – Renal Colic
 Vital Signs
 NEVER ignore abnormal vital signs!
 Always document as part of your assessment
Investigations
 Bedside
 UA
 Blood?
 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!
Radiology
 CXR –?perforation
 ?Extra abdominal pathology
 ?Complications of intra-abdominal disease
Which of the following is NOT an indication for
plain abdominal imaging?
1. Bowel Obstruction
2. Constipation
3. Tracking Renal Calculi
4. Foreign Body
Other imaging
 USS
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Biliary Disease
Good for gynae complaints
Rule out Ectopic pregnancy
Appendicitis in children
No radiation
 CT is accurate for
diagnosis of
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Renal colic
Appendicitis
Diverticulitis
AAA
Intraabdominal
Abscesses
 Mesenteric Ischaemia
 Bowel Obstruction
 Avoid repeated CT
scans
 Limit use in younger
patients
 Avoid where possible in
pregnant females
Imaging
Dose (mSV)
CXR equivalents
Pelvic XR
0.6
6
Abdominal XR
0.7
7
CT abdo-pelvis
14
140
CT aortogram
24
240
Management
 Resuscitate
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Large bore access
N Saline bolus 20ml/kg x 2 if shocked
If bleeding think hypotensive resuscitation
All should be NBM until provisional diagnosis
Ensure normothermia
 Maintenance fluids and fluid balance
 Analgesia doesn’t mask signs
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Use a the pain scale
Morphine titrated to pain. Normally 0.1mg/Kg
Paracetamol adjunct
NSAIDs for renal colic
 Correct Electrolytes
 Thromboprophylaxis
Cases
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 Bowels
What clinical signs may lead you to a
diagnosis of appendicitis?
Lie still
RIF tenderness
Rebound
Rovsig’s sign
Psoas Sign
Imaging?
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AXR rarely useful
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USS
 Not as good as CT
 Good for female to exclude gynae pathology
 If appendix is visualised is useful
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CT
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Only if there is doubt about diagnosis
Sensitivity up to 98%
High radiation dose
Diagnose other pathology if no appendicitis
Elderley
Management
 NBM
 Analgesia
 Anti-emetic if necessary
 Maintenance fluids
 IVABs – e.g. Ceftriaxone, Gentamicin and
Metronidazole
 Surgical Referral
Case 2
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40 yr old obese female
RUQ pain
Pain is constant
nausea, vomiting
fevers and chills
 PMH Asthma
 MEDS OCP
 SH
 Drinks 2 std / week
 Smokes 20/day
 Nil drugs
On Examination
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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.
What bloods will you order
on this patient?
 HB 138
 EUC Normal
 WCC 16.0
 Bil 9
 Neuts 12.4
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 Lymph 1.6
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(<18)
ALP 450 (30-130)
GGT 320 (<60)
ALT 41 (5-55)
AST 30 (5-55)
Amylase 28 (<120)
Lipase 40 (<60)
Management
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NBM
IVF
IV abs –Ampicillin + Gentamicin
Analgesia +- anti emetic
Refer to surgeons
Case 3
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52 yr old alcoholic
Constant 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/day
 Looks unwell and
dehydrated
 T38.4C
 P105
 BP 130/70
 RR 18
 Sats 93% RA
 Reduced AE L base
 Tender
Epigastrium and
RUQ
 No guarding/
rebound
What blood tests will you
order?
Blood Results
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Biochem
Na 129
K 4.0
Cr 62
Ur 8.0
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Amylase 1080 (<120)
Lipase 950 (<60)
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Bil 11 ( 18)
GGT 900 (<60)
ALP 200 ( < 140)
AST 300 (5-55)
ALT 250 (5-55)
LDH 800( 105-333)
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Glucose 15
Alb 23
Ca (Corr) 2.0
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Haem
HB 114
WCC 17
Coags Normal
What imaging will you perform
( if any)?
CXR
Imaging
 CT
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Confirms diagnosis
Identifies 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, ARDS
Management
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O2
NBM
IVF
Analgesia
+-Antibiotics (controversial)
Correct Electrolytes
Thromboprophylaxis
IDC/Art-line/CVC depending on severity
Surgical Admit +_ ICU review
Causes
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G all stones
E toh
T rauma
S teroids
M umps
A utoimmune
S corpion Bites
H yperlidaemia/hypercalcaemia/hypothermia
E RCP
D rugs
Case 4
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27 yr old female
6/40
LIF constant severe sharp pain
Radiating to the back
Light bright red PV spotting
Feels light headed
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PMH
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IVF
Previous D+C x 2
Ovarian Cysts
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MEDS Nil
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SH Lives with partner
Non-smoker
Non-Drinker
On Examination
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Looks unwell. Pale, diaphoretic, restless
P 150
BP 70/40
RR 26 Sats
98% RA
Tender and guarding in the LIF
PV
 Bright red blood spotting
 L adnexal tenderness ++
How do you manage this
patient?
 Panic! ( don’t!)
 Call for senior help
 Large bore IV access x 2 (16 G or larger)
 Urgent Cross Match
 Fluid resuscitation
 Call O+G urgently
 Needs OT immediately
Case 5
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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
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Cholecystectomy
appendectomy
TAH BSO
Hypertension
On examination
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Looks distressed
Lying Still
T 37.5
P 110 sinus
BP 150/80
RR 18
Sats 98% RA
Abdomen
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Distended
Generally tender
No guarding rebound or rigidity
High pitched bowel sounds
Investigations
Investigations
 EUC/CMP/FBP
 AXR
 CXR
 CT
Management
 NBM
 Fluid resuscitation
 Monitor volume status – may have large volume
shifts
 Correct Electrolytes
 Analgesia
 NG if vomiting
 IV Abs – Amp+Gent+Met
 Urgent Surgical consult for OT
Small Bowel
 Adhesions
 Hernias
 Polyps
 Lymphoma
 Adenocarcinoma
 Gall Stones
 Inflammatory BD
Large Bowel
 Almost never
adhesions or hernia
 CARCINOMA
 Diverticulitis
 Sigmoid Volvulus
 Faecal Impaction
Case 6
 73 yr old male presents with sudden onset of central abdominal
pain radiating to the back. He also reports weakness to both legs
 PMH
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HT
Hypercholesterolemia
Current smoker 30/day
 MEDS
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Aspirin 100mg Daily
Perindopril 5 mg Daily
Atorvastatin 10 mg Daily
 SH
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Lives Alone
Fully independent with ADLS
Occasional alcohol
Examination
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Distressed
P 130
BP 80/60
RR 26 Sats
99% RA
Abdomen
 Non-distended
 Generally tender
 Reduced power 3/5 to
hip flexors
Bedside Ultrasound
9cm
Management of ruptured AAA
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Senior help
ABC
Large Bore IV Access x 2
Hypotensive resuscitation
Analgesia
Ensure O neg available
Ensure normothermia
Urgent Vascular Consult
To OT
Last Case!
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85 yr old male. Nursing home resident
Central Abdominal Pain
Sudden onset. Severe
PMH
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MEDS
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Dementia
MI
Clopidogrel 75 mg Daily
Metoprolol 25 mg BD
Perindopril 5 mg daily
SH
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Mild dementia
Forgetful
Requires some assistance with bathing
and toileting
Feeds Self
Walks with frame
Non-smoker
Non-drinker
Examination
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Looks dry and emaciated
P 120- 140
BP 110/70
RR 30
Sats 96% RA
T 37.4 C
Abdomen
 Generally tender
 No guarding rigidity or rebound
ECG
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Differential?
ABG
 pH 7.10
 pCO2 15
 P02 80
 Bic 8
 BE -15
 Lactate 10.2
Management
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02
NMB
IV access
IVF
Analgesia
IV abs
Urgent Surgical Consult
Urgent CT mesenteric angiogram
OT
Take Home Message
 Exclude life threatening pathology
 BHCG in female of child bearing age
 Be mindful of radiation exposure
 Beware of Abdominal pain in the Elderly
 Never ignore abnormal vital signs
Mesenteric Ischaemia
 Surgical Emergency
 Small bowel has warm ischaemic time of 2-3
hours
 Rapidly progresses to gangrene, septic shock
and death
 Need high index of suspicion to diagnose it
 Severe pain but little tenderness on examination
Case 7
 40 yr old male presents with sudden onset of
severe R loin to groin pain. Excruciating
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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 tender
Differential Diagnosis?
 Renal Colic
 Pancreatitis
 Cholecystitis
 Appendicitis
 Ruptured/leaking AAA
 UA
 Erythrocytes ++++
 No leucocytes
 No nitrites
Investigations
 UA
 EUC
 FBC
 (other bloods if diagnosis unclear)
 CT KUB
Management
 Analgesia
 NSAID e.g. PR indomethacin 100 mg 1st line
 Morphine IV titrated to pain
 IV fluids – maintenance only
 Observe
Who should we CT
 CT
 Ongoing pain
 Impaired renal function
 Fever
 Diagnosis not clear
Indications for admission
 Infection
 Impaired Renal Function
 Pain ongoing– needing IV opiates
 Stone > 5mm
 Obstruction/hydronephrosis on CT
 Stag horn Calculus on CT
ECG
 What does the ECG show?
1. Sinus Tachycardia
2. VT
3. VF
4. Rapid Atrial Fibrillation
5. No idea!
ECG
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