Acute abdomen for EP Prasit Wuthisuthimethawee Department of Emergency Medicine Prince of Songkla University
Male 34 years oldNo underlying dis.Check up at GPDuring took blood examination abd pain & syncope
ObjectivesAbdominal pain pathwayCritical points for assessing abdominal pain
Epidemiology4-10 % of all emergency department visit50 % have clearly diagnosis15-30% require surgical procedure esp. elderlyAcute appendicitis is the most common
EpidemiologyUnique in Pediatric and Elderly
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
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
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
Abdominal pain pathway3 type; visceral, somatic, and referred pain
Abdominal pain pathwayVisceral pain Wall or capsule of solid organs/bowel Midline, dull, archy and cramping pain Autonomic; pallor, diaphoresis, nausea, and vomiting
Abdominal pain pathwaySomatic pain Parietal peritoneum Sharp, discrete, and localized Tenderness, guarding, and rebound
Abdominal pain pathwaySomatic pain
Abdominal pain pathwayReferred pain Cutaneous site distant from the diseased organ Diaphragm C3-5: neck and shoulder pain
Abdominal pain pathwayReferred pain
Critical points for assessing abdominal pain
Life threatening conditionsVascular diseaseAcute myocardial infarctionRuptured ectopic pregnancyPerforated visceral organs
Life threatening conditionsIntestinal obstructionAcute hemorrhagic pancreatitisEsophageal rupture
AimSurgical or Non-surgical
Physical examinationAccuracy 55-65% with final diagnosisReexamination and observationTechnique !
Physical examination Bowel soundLittle diagnostic value
Physical examination Do not forget PR
Physical examination Analgesic ?
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
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
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
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
Medication on abdominal examination Buscopan ?
Clinical assessment Reassessment
Clinical assessmentPatient’s quantification of painis unreliable
Clinical assessmentUSG and CT scanAngiogramTech99m RBC scan
Clinical assessmentMyocardial infarction, pneumonia,or pulmonary embolus can presentas abdominal pain
Clinical assessmentPsychiatric disorderThe last diagnosis
MamagementBowel rest +/- decompressionIV resuscitation with correct electrolyteAntiemesis ? Analgesia ? Antibiotic ?Pre-op in surgical case
Uncertain DiagnosisObservationReview the causeConsultation
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.
Case 1Male 34 years oldNo underlying dis.Check up at GPDuring took blood examination abd pain & syncope
Case 1At ERSweating, looked paleV/S BP 95/60 P 112 RR 26Abd: tenderness at RLQ, guarding ?
What is diagnosis ?
Case 2Female 53 years oldUnderlying HTLLQ abdominal pain for 1 dayV/S BP 140/80 P 90 RR 24
Case 2Abd: LLQ pain, guarding ?CVA: tenderness Lt.UA: microscopic hematuriaDiclofenac improvedRecurrent 2 times in 3 days
What is diagnosis ?
Hematuria may be seen inabdominal aortic aneurysm (30%)
Case 3Female 47 years oldNo known underlying dis.RLQ abdominal pain for 1 dayV/S BP 130/80 P 82 RR 22
Case 3Abd: RLQ pain, guarding ?,CVA: not tenderCBC: leukocytosisUA: WNL
What is diagnosis ?
Special signIliopsoas and Obturator< 10% in appendicitis
Special signFist Percussion
Special signRovsing’s SignOnly 5% of patients
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 ?
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 ?
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 ?
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