Prasit acute abdomen
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  • 1. Acute abdomen for EP Prasit Wuthisuthimethawee Department of Emergency Medicine Prince of Songkla University
  • 2. Male 34 years oldNo underlying dis.Check up at GPDuring took blood examination abd pain & syncope
  • 3. ObjectivesAbdominal pain pathwayCritical points for assessing abdominal pain
  • 4. Epidemiology4-10 % of all emergency department visit50 % have clearly diagnosis15-30% require surgical procedure esp. elderlyAcute appendicitis is the most common
  • 5. EpidemiologyUnique in Pediatric and Elderly
  • 6. Acute abdominal pain among elderly patients3 years, 831 casesNon-specific 22-24%Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%)less peritoneal signs Laurell H, Hansson LE, Gunnarsson U. Gerontology. 2006;52(6): 339-44
  • 7. Emergency department diagnosis of acute abdominalpain in elderly patients 1 year retrospective review, 378 cases Non-specific (35.2%), acute gastritis/gastroenteritis (10.6%), and biliary tract dis. (8.2%) Non-specific; 90% dissolved, 5.4% Sx. Othong R, Wuthisuthimethawee P, Vasinanukorn P Songkla Med J vol. 28 No 1 Jan-Feb 2010
  • 8. Predictor for an intensive care or specific treatment inthe elderly patients with acute abdominal pain 1 year retrospective review, 386 cases Dyspepsia (21.8%), non-specific (17.6%) and acute gastroenteritis (8.8%) Male, BT < 38, PR >90, abnormal abd contour, and Localize tenderness or guarding Worapraatya P, Wuthisuthimethawee P, Vasinanukorn P
  • 9. Pain pathway
  • 10. Abdominal pain pathway3 type; visceral, somatic, and referred pain
  • 11. Abdominal pain pathwayVisceral pain Wall or capsule of solid organs/bowel Midline, dull, archy and cramping pain Autonomic; pallor, diaphoresis, nausea, and vomiting
  • 12. Abdominal pain pathwaySomatic pain Parietal peritoneum Sharp, discrete, and localized Tenderness, guarding, and rebound
  • 13. Abdominal pain pathwaySomatic pain
  • 14. Abdominal pain pathwayReferred pain Cutaneous site distant from the diseased organ Diaphragm  C3-5: neck and shoulder pain
  • 15. Abdominal pain pathwayReferred pain
  • 16. Critical points for assessing abdominal pain
  • 17. Life threatening conditionsVascular diseaseAcute myocardial infarctionRuptured ectopic pregnancyPerforated visceral organs
  • 18. Life threatening conditionsIntestinal obstructionAcute hemorrhagic pancreatitisEsophageal rupture
  • 19. AimSurgical or Non-surgical
  • 20. Physical examinationAccuracy 55-65% with final diagnosisReexamination and observationTechnique !
  • 21. Physical examination Bowel soundLittle diagnostic value
  • 22. Physical examination Do not forget PR
  • 23. Physical examination Analgesic ?
  • 24. Analgesia on abdominal examination Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain Analgesia is safe in abdominal pain Br J Surg. 2003 Jan;90(1):5-9
  • 25. Analgesia on abdominal examinationEffects of morphine analgesia on diagnostic accuracy inEmergency Department patients with abdominal pain:a prospective, randomized trial Prospective, double-blind clinical trial Reexam in 60 minutes No differences with respect to changes in physical examination or diagnostic accuracy J Am Coll Surg. 2003 Jan;196(1):18-31
  • 26. Analgesia on abdominal examination Analgesia in patients with acute abdominal pain Opioid improve patients comfort and does not retard decision to treat Cochrane Database Syst Rev. 2007 Jul 18;(3): CD005660
  • 27. Analgesia on abdominal examinationEfficacy and impact of intravenous morphine before surgicalconsultation in children with right lower quadrant painsuggestive of appendicitis: a randomized controlled trial Randomized double-blind placebo-controlled trial 8-18 years old, 90 patients Morphine did not delay surgical decision, not more effective than placebo to diminishing pain Ann Emerg Med. 2007 Oct;50(4):371-8. Epub 2007 Jun 27
  • 28. Medication on abdominal examination Buscopan ?
  • 29. Clinical assessment Reassessment
  • 30. Clinical assessmentPatient’s quantification of painis unreliable
  • 31. Clinical assessmentCorticosteroids andimmunosuppressants
  • 32. Clinical assessmentChronic dis.: CRF
  • 33. Clinical assessment Fever ?
  • 34. Clinical assessmentPrior abdominal surgery
  • 35. Clinical assessment Hernia Genitalia
  • 36. Clinical assessmentPeripheral pulse
  • 37. Clinical assessmentMenstrual historyUrine pregnancy test
  • 38. Clinical assessmentWBC 30% in abdominalpain of unknown etiology
  • 39. Clinical assessment20% of pancreatitishave normal amylase
  • 40. Clinical assessment20% of pancreatitishave normal amylase
  • 41. Clinical assessmentLactase and mesenteric ischemia100% sensitive and 42% specific
  • 42. Clinical assessmentFilm acute abdomen10-38% confirm diagnosis
  • 43. Gallstone Ileus
  • 44. Portal vein gas
  • 45. Clinical assessmentUSG and CT scanAngiogramTech99m RBC scan
  • 46. Clinical assessmentMyocardial infarction, pneumonia,or pulmonary embolus can presentas abdominal pain
  • 47. Clinical assessmentPsychiatric disorderThe last diagnosis
  • 48. MamagementBowel rest +/- decompressionIV resuscitation with correct electrolyteAntiemesis ? Analgesia ? Antibiotic ?Pre-op in surgical case
  • 49. Uncertain DiagnosisObservationReview the causeConsultation
  • 50. Uncertain DiagnosisWhen in doubt, don’t send them out! Cope’s Early Diagnosis of the Acute Abdomen, 20th ed.. New York, Oxford University Press, 2000.
  • 51. Case 1Male 34 years oldNo underlying dis.Check up at GPDuring took blood examination abd pain & syncope
  • 52. Case 1At ERSweating, looked paleV/S BP 95/60 P 112 RR 26Abd: tenderness at RLQ, guarding ?
  • 53. What is diagnosis ?
  • 54. Case 2Female 53 years oldUnderlying HTLLQ abdominal pain for 1 dayV/S BP 140/80 P 90 RR 24
  • 55. Case 2Abd: LLQ pain, guarding ?CVA: tenderness Lt.UA: microscopic hematuriaDiclofenac  improvedRecurrent 2 times in 3 days
  • 56. What is diagnosis ?
  • 57. Hematuria may be seen inabdominal aortic aneurysm (30%)
  • 58. Case 3Female 47 years oldNo known underlying dis.RLQ abdominal pain for 1 dayV/S BP 130/80 P 82 RR 22
  • 59. Case 3Abd: RLQ pain, guarding ?,CVA: not tenderCBC: leukocytosisUA: WNL
  • 60. What is diagnosis ?
  • 61. ?
  • 62. Clinical assessment
  • 63. ขอบคุณครับ
  • 64. Special signIliopsoas and Obturator< 10% in appendicitis
  • 65. Special signFist Percussion
  • 66. Special signRovsing’s SignOnly 5% of patients
  • 67. High-Yield historical questions How old are you ? Which came first-pain or vomiting ? How long have you had the pain ? Have you ever had abdominal surgery ?
  • 68. High-Yield historical questions Is the pain constant or intermittent ? Have you ever had this before ? Do you have a history of cancer diverticulosis ? Do you have HIV ?
  • 69. High-Yield historical questions How much alcohol do you drink per day ? Are you pregnant ? Are you taking antibiotic or steroid ? Did the pain start centrally and migrate ? Do you have a history of CAD, HT, AF ?
  • 70. Etiology and clinical course of abdominal painIn senior patients; a prospective, multicenter study3 years, 831 casesNon-specific 22-24%Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%)less peritoneal signs Lewis LM, Banet GA, Blenda M, et al. J Gerontol A Biol Sci Med Sci. 2005