Acute abdominal pain dr bachar raad
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Acute abdominal pain dr bachar raad Acute abdominal pain dr bachar raad Presentation Transcript

  • Dr Bachar RAAD MD ER Club October 2011
  • Why is this important? Abdominal pain is one of the most common reasons for outpatient and ER visits A lot can happen in the abdomen and you need an organized approach
  • Just a few diagnoses to ponder… Esophagitis  Endometriosis GERD  Vitamin D deficiency Gastric ulcer  Adrenal insufficiency Gastritis  Pancreatitis Duodenal ulcer  Cholangitis Duodenitis  Cholecystitis Gastric outlet obstruction  Choledocholithiasis Bowel obstruction  Incarcerated hernia Intussusception  UTI Bowel perforation  Nephrolithiasis Cancer  Abdominal migraine Hepatitis  Celiac artery compression syndrome Splenic infarct  Uterine pathology Splenic abscess  HIV Mesenteric ischemia  Hemophilia Somatization  Sickle cell disease IBS  Trauma Crohn’s disease  Pneumonia Ulcerative colitis  Subdiaphragmatic abscess Gastroenteritis  Myocardial infarction Familial Mediterranean fever  Pericarditis Acute intermittent porphyria  Prostatitis Appendicitis  Idiopathic inflammatory disorders AAA rupture  Epiploic appendagitis Esophageal spasm  Hereditary angioedema Diverticulitis  Painful rib syndrome Ectopic pregnancy  Wandering spleen syndrome Pelvic inflammatory disease  Abdominal wall pain Fitz-Hugh-Curtis  Leukemia Abdominal epilepsy  Lead poisoning
  • So how do we organize this? Definition Location Type of pain Approach to the patient Surgical abdomen Special Circumstances
  • Acute abdominal pain Generally present for less than a couple weeks  Usually days to hours old  Don’t forget about the chronic pain that has acutely worsened More immediate attention is required Surgical v. nonsurgical
  • Chronic abdominal pain Generally present for months to years Generally not immediately life threatening Outpatient work-up is prudent
  • Localizing pain -- RUQ  Hepatitis  Cholecystitis  Cholangitis  RLL pneumonia  Subdiaphragmatic abscess
  • Localizing pain -- LUQ  Splenic infarct  Splenic abscess  Gastritis/PUD
  • Localizing pain -- RLQ  Appendicitis  Inguinal hernia  Nephrolithiasis  IBD  Salpingitis  Ectopic pregnancy  Ovarian pathology
  • Localizing pain -- LLQ  Diverticulitis  Inguinal hernia  Nephrolithiasis  IBD  Salpingitis  Ectopic pregnancy  Ovarian pathology
  • Localizing pain -- epigastric  PUD  Gastritis  Pancreatitis  GERD  Cardiac (MI, pericarditis, etc)
  • Localizing pain -- periumbilical  Pancreatitis  Obstruction  Early appendicitis  Small bowel pathology  Gastroenteritis
  • Localizing pain -- pelvic  UTI  Prostatitis  Bladder outlet obstruction  PID  Uterine pathology
  • Understanding the Types of Abdominal Pain • Visceral – Crampy, achy, diffuse, – Poorly localized • Somatic – Sharp, cutting, stabbing – Well localized • Referred – Distant from site of generation – Symptoms, but no signs
  • Approach to the patient History is THE MOST IMPORTANT part of the diagnostic process  Location, quality, severity, radiation, exacerbating or alleviating factors, associated symptoms ○ Visceral v. peritoneal  A good thorough medical history  A good thorough social history, including alcohol, drugs, domestic abuse, stressors, etc.  Family history is important (IBD, cancers, etc)  MEDICATION INVENTORY
  • Approach to the patient Physical exam  Vitals, general appearance  A good thorough medical exam ○ Jaundice, signs of chronic liver disease  Abdominal exam ○ Look, listen, feel ○ Know a few tricks  Pelvic exam
  • Approach to the patient Labs  CBC, electrolytes, BUN, Cr, coagulation.  Amylase and lipase, LFTs  UA  betaHCG  Lactate
  • Approach to the patient Imaging  Plain films (KUB, CHEST)  Ultrasound  CT  Angiography
  • Surgical abdomen This is the first thing to be considered in acute abdominal pain  Early identification is a must as prognosis worsens rapidly with delay in treatment Important to get surgeons involved early if this is even mildly suspected This is a clinical diagnosis
  • Surgical abdomen Presentation is usually bad  Fevers, tachycardia, hypotension  VERY tender abdomen, possibly rigid Presentation can vary with other demographic and medical factors  Advanced age  Immunosuppression
  • Surgical abdomen Peritonitis  Often signals an intraabdominal catastrophe ○ Perforation, big abscess, severe bleeding  Patient usually appears ill  Exam findings ○ Rebound, rigidity, tender to percussion or light palpation, pain with shaking bed
  • Surgical abdomen Work-up  Start with stat labs  Surgical abdominal series (plain films)  Consider stat CT if readily available Sometimes patients go straight to surgery as initial step Again, get surgeons involved early for guidance and early intervention
  • Special Circumstances Pregnancy  appendicitis, cholecystitis, pyelonephritis,  adnexal problems (ovarian torsion, ovarian cyst rupture)  appendicitis 7/1000 pregnancies  3% fetal loss with surgery, but 20% with perforated appendix
  • Special Circumstances Very Young  Appendicitis and abdominal trauma  Meckel’s diverticulum, cystitis, enteritis Very Old  Symptoms may be subtle
  • Special Circumstances Immuno-compromised  chemotherapy, organ transplants, immunosupression for autoimmune disease, AIDS  symptoms are subtle
  • Thank You