Your SlideShare is downloading. ×

Abdominal Emergencies Cdem

4,030

Published on

Published in: Health & Medicine, Education
0 Comments
8 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
4,030
On Slideshare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
0
Comments
0
Likes
8
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Abdominal Emergencies SAEM Undergraduate Medical Education Committee Emergency Medicine Clerkship Lecture Series Primary Author: John Sarko, MD Reviewer: David Wald, DO
  • 2. Learning Objectives • Review the presentation, work up and management of serious causes of abdominal pain and other abdominal emergencies that can present to the ED
  • 3. Case #1 • Paramedics arrive with a 65 year old man complaining of sudden severe left flank and epigastric pain • PMH: None • No medications, NKDA • SH: Smokes 1ppd x 30 years
  • 4. Case #1 Physical exam: • VS: BP 82/40 P 110 RR 16 T 37.2°F • HEENT: Normal • Heart: Regular rhythm, tachycardic • Lungs: Clear all fields • Abdomen: Non-distended, + bowel sounds, soft, slightly tender in epigastrium • Guaiac negative brown stool
  • 5. Case #1 Physical exam: • Extremities: Diminished dorsalis pedis pulses, capillary refill time 3 sec • Skin: Clammy, cool • Neurologic: A+O x 3, anxious, moves all extremities, GCS 15
  • 6. Differential Diagnosis Always consider life-threatening conditions first! • Abdominal aortic aneurysm • Perforated peptic ulcer • Acute pancreatitis • Incarcerated hernia • Nephrolithiasis • Gastritis
  • 7. Key Point Abdominal pain associated with hypotension = “Vascular Emergency”
  • 8. Case #1 • Describe your initial management? • What needs to be done with this patient in the first 5 minutes? ED safety net 2 large bore IV lines (14 or 16 gauge) Resuscitation with NS Cardiac monitoring Supplemental O2
  • 9. Case #1 • Based on your clinical suspicion, what laboratory studies are indicated? CBC, BMP, coags Type and Cross x 6u
  • 10. Case #1 • Based on your clinical suspicion, what radiographic study should be obtained? Abdominal US (Performed at the bedside) Abdominal CT (Stable patient, US unavailable)
  • 11. CT Scan
  • 12. Abdominal Aortic Aneurysm • True aneurysm: Dilation of all 3 layers of the arterial wall • Normal abdominal aorta diameter is ≤ 2 cm • 3 cm or greater defines an aneurysm • Most AAA’s involve the infrarenal aorta • Can be associated with trauma, infection, connective tissue disease, and arteritis
  • 13. Abdominal Aortic Aneurysm Epidemiology and Risk Factors • Occurs in 2-5% of patients over 50 • Mean age at diagnosis is 65-70 years • Major risk factors • Atherosclerosis • Peripheral vascular disease (PVD) • First degree relative with AAA • 10x higher risk
  • 14. Abdominal Aortic Aneurysm Clinical presentation • Unruptured: Can be asymptomatic or may have gradual onset of vague, dull, constant abdominal pain • Some are diagnosed incidentally • Do not rely on palpating an abdominal mass or a pulsatile aorta
  • 15. Abdominal Aortic Aneurysm Clinical presentation • No risk of rupturing an aneurysm by palpating the abdomen! • Abdominal bruit is present in only 10-30% of cases • Peripheral pulses are often maintained in the absence of PVD
  • 16. Abdominal Aortic Aneurysm Clinical presentation • Ruptured AAA: Classic triad is abdominal pain, hypotension, and syncope • Rupture may be the first presentation of the aneurysm • Patients may have abdominal pain, back pain, and / or flank pain
  • 17. Abdominal Aortic Aneurysm Clinical presentation • Rupture is more likely if AAA > 5.5 cm • When rupture occurs, the AAA often leaks into the retroperitoneum • Can be associated with severe back or flank pain • If the rupture is intraperitoneal, death is imminent
  • 18. Abdominal Aortic Aneurysm Diagnostic adjuncts • Plain films (supine and lateral abdomen) • Usually non-specific • May be able to identify calcifications of the abdominal wall • Retroperitoneal hemorrhage may obscure the psoas muscle shadow or kidney
  • 19. CT vs Ultrasound CT Scan Ultrasound • Patient leaves the • Patient stays in the ED (stable patient) ED (unstable) • Takes time • Quicker • Provides more • Often can answer anatomic the ? (AAA yes or no) information • Can’t visualize • Requires IV dye retroperitoneum
  • 20. Abdominal Aortic Aneurysm Diagnostic adjuncts • Angiography: No place in emergency evaluation • MRI: No place in emergency evaluation
  • 21. Differential Diagnosis • Pyelonephritis • Cholelithiasis • Nephrolithiasis • Myocardial infarction • Acute pancreatitis • Bowel obstruction • Diverticulitis • Incarcerated hernia • Acute appendicitis • Ruptured ectopic pregnancy • Intestinal ischemia • Psoas abscess • Perforated viscus • Rectus sheath • Cholecystitis hematoma
  • 22. Abdominal Aortic Aneurysm Outcome • Without surgery, mortality is 100% when rupture occurs • Surgical mortality is 50% in ruptured AAA • Mortality is 5% when the repair is elective
  • 23. Abdominal Aortic Aneurysm Management • No one with a ruptured or suspected ruptured AAA is stable! • When the clinical suspicion is high enough, or when the diagnosis is made, the hemodynamically unstable patient must undergo surgery
  • 24. Abdominal Aortic Aneurysm Treatment • Early vascular surgery consultation is warranted in all cases • Do not keep the patient in the ED in to normalize the vital signs when the patient has a ruptured AAA
  • 25. Abdominal Aortic Aneurysm Treatment • Traditional repair: Laparotomy • Open the aneurysm, place the graft, close the aneurysm over the graft • Endovascular repair: Via femoral artery • Stent is placed inside aneurysm
  • 26. Abdominal Aorta Normal AAA – 4 cm
  • 27. Case #2 • A 75 year old female presents with sudden onset of diffuse abdominal pain that woke her from sleep • She is in obvious pain, tearful • PMH: atrial fibrillation • Meds: coumadin (ran out a week ago) • NKDA
  • 28. Case #2 Physical exam • VS: BP 146/90 HR 118 RR 24 T 37.0°F SaO2 98% • Heart: irregularly irregular, tachycardic • Lungs: CTA • Abdomen: non-distended, soft, non- tender, no palpable masses
  • 29. Case #2 Physical exam • Guaiac positive, brown stool • Extremities: no edema, moves all extremities, dorsalis pedis pulses intact
  • 30. Case #2 Diagnostic Adjuncts • Abdominal plain film: Non-specific bowel gas pattern, no free air • CT Abdomen/pelvis: Ischemia of small bowel, filling defect in proximal superior mesenteric artery
  • 31. Acute Mesenteric Ischemia • Life threatening vascular emergency • Rare cause of abdominal pain, but overall mortality is 60-80% • Time is of the essence
  • 32. Acute Mesenteric Ischemia • Intestinal blood supply is from: • Celiac plexus • Superior mesenteric artery (SMA) • Inferior mesenteric artery (IMA) • Internal iliac artery • Most cases are due to occlusion of SMA or IMA
  • 33. Acute Mesenteric Ischemia • This patient’s history of atrial fibrillation makes her most likely to have mesenteric ischemia due to arterial embolism • The embolic event leads to acute arterial occlusion
  • 34. Acute Mesenteric Ischemia Etiology • Embolic: 40-50% • Most often just distal to origin of middle colic artery of SMA. • Thrombotic: 25-30% • Can be an arterial or venous occlusion • Arterial: Most often at origin of SMA • Venous: Starts in venous arcades and progresses to SMV
  • 35. Acute Mesenteric Ischemia Etiology • Non-occlusive: 20% • Due to low flow state and mesenteric vasoconstriction
  • 36. Acute Mesenteric Ischemia Risk factors • History of embolic events • Dysrhythmias • Valve disease • Endocarditis • Ventricular aneurysms • Myocardial infarction • Cardiomyopathy
  • 37. Acute Mesenteric Ischemia Risk factors • Recent angiography • Atherosclerosis • Hypovolemia • Vasopressors • Hypotension • Decreased cardiac output • Digoxin
  • 38. Acute Mesenteric Ischemia Presentation • Severe abdominal pain • Pain is out of proportion to findings on physical exam • Peritoneal findings occur late • Mimics many other causes of abdominal pain, therefore, a very • Difficult diagnosis to make
  • 39. Acute Mesenteric Ischemia Presentation • Pain from embolic or thrombotic (arterial) etiology • Acute and severe, usually periumbilical early on • Pain from occlusive disease • Patients may report “intestinal angina,” pain that occurs after eating • May cause them to eat frequent, small meals, and lose weight
  • 40. Acute Mesenteric Ischemia Presentation • Pain from mesenteric venous thrombosis • Diffuse, nonspecific, may be in the lower abdomen • Patients typically present 1-2 weeks after the onset of pain • Anorexia and diarrhea
  • 41. Acute Mesenteric Ischemia Presentation • Non-occlusive ischemia • Usually elderly, debilitated, critically ill patients
  • 42. Acute Mesenteric Ischemia Diagnosis • Must be suspected • Consider in elderly patient with abdominal pain • Specifically, the patient with pain out of proportion to their physical examination • Lab values are nonspecific • Elevated lactic acid is suggestive • Early on may lack sensitivity • Lactic acidosis is a late finding
  • 43. Acute Mesenteric Ischemia Diagnosis • KUB rarely shows thumb printing (thickened bowel wall) • Duplex ultrasound operator dependent • CT may occasionally show ischemic bowel or filling defect in artery • Special protocols may increase its sensitivity
  • 44. Acute Mesenteric Ischemia Diagnosis • Angiography is the gold standard • Localizes the clot, and diagnoses nonocclusive ischemia • One of the few times we need to obtain urgent angiography in the ED • MRI is limited to diagnosing chronic ischemia
  • 45. Acute Mesenteric Ischemia Treatment of occlusive ischemia • Heparin • Glucagon: 1ug/kg/min, titrated to 10ug/kg/ min (if angiography not done) • Intraarterial papaverine • Laparotomy usually necessary to remove embolus, bypass the occlusion, remove dead bowel
  • 46. Acute Mesenteric Ischemia Treatment of non-occlusive ischemia • Fewer good options because this is usually due to underlying conditions • Remove offending stimulus • Correct underlying conditions • Vasodilation, anticoagulants, mesenteric regional blockade, and intraarterial papaverine
  • 47. Acute Mesenteric Ischemia Treatment of non-occlusive ischemia • Vasodilation, anticoagulants, mesenteric regional blockade, and intraarterial papaverine • Laparotomy only necessary if dead bowel is suspected
  • 48. Acute Mesenteric Ischemia Treatment of mesenteric venous thrombosis • Heparin • IV thrombolytics and thrombectomy occasionally used
  • 49. Acute Mesenteric Ischemia Mortality • Arterial: 70-100% • Acute venous thrombosis: 30-40% • Chronic venous thrombosis: 20% • Nonocclusive ischemia: 70-80%
  • 50. Case #3 • A 56 year old male presents with 3 days of epigastric abdominal pain and vomiting dark blood approximately 1 hour PTA • PMH: Arthritis • Medications: Naproxen • NKDA
  • 51. Case #3 • Social: Smokes 1 ppd x 20 years, occasional alcohol use Physical exam: • VS: BP 100/55 HR 122 R 18 T 37.5°F • General: Middle aged male appears uncomfortable • Heart: Regular, tachycardic
  • 52. Case #3 • Lungs: CTA • Abdomen: Non-distended, soft, + BS, epigastric tenderness, no rebound or guarding, guaiac negative stool • Extremities: Cool and clammy
  • 53. Case #3 Initial management • 2 large bore IV’s • Crystalloid resuscitation with normal saline solution • Type and cross x 4-6 units • NG lavage • Secondary measure • Only after obtaining secure vascular access and stabilizing the patient
  • 54. GI Bleed • Upper GI bleed is defined as bleeding proximal to the ligament of Treitz • Incidence is 50 –150 per 100,000 adults annually • Lower GI bleed is defined as bleeding distal to the ligament of Treitz
  • 55. GI Bleed UGIB Etiology • Peptic ulcer disease (PUD) #1 • Gastric erosions • Variceal bleeding • Mallory-Weiss tear • Esophagitis • Duodenitis • Rare: Aortoenteric fistula, renal disease
  • 56. UGIB Terminology • Hematemesis: Vomiting blood • Melenemesis: Coffee grounds emesis, partially digested blood • Melena: Black, tarry stool, often foul smelling • *Most common presentation of PUD • Hematochezia: Maroon or dark red stool • Up to 10% of cases are caused by UGIB
  • 57. UGIB: Essentials • Vital signs are vital! • Remember that a stable BP does not insure that the patient is stable • Hypotension can be a late finding (class 3 shock) • Obtaining a detailed history is important • Abdominal tenderness may or may not be present • Heme testing stool can provide valuable information, but may be negative early on
  • 58. NG Lavage • When performing a NG lavage, the preferred solution is? • Sterile water • Sterile saline • Tap water • Iced or cold tap water
  • 59. NG Lavage • When performing a NG lavage, the preferred solution is? • Most people use tap water at room temperature • No one solution is best • Cold water has not been shown to be advantageous
  • 60. NG Lavage • Which of the following conditions represent a relative contraindication to placing an NG tube? • Suspected or known esophageal varices • Active peptic ulcer disease • Mallory-Weiss tears • Gastric bypass surgery
  • 61. NG Lavage • Which of the following conditions represent a relative contraindication to placing an NG tube? • Traditionally, NG tube placement should be avoided in patients with prior gastric bypass surgery • It is recommended to discuss the case with the surgeon prior to placement
  • 62. GI Bleed • Laboratory studies • CBC • Coagulation studies • Type and screen or cross • Electrolytes and renal function • Elevated BUN can be due to an UGIB
  • 63. Subspecialty Consultation Subspecialty consultation can be institution dependant • GI consultants • Usually assist in the management of UGIB • Emergent endoscopy may need to be performed in the ED or ICU • Surgical consultants • Usually assist in the management of LGIB
  • 64. Disposition • Traditionally, all patients with upper and lower GIB (known or highly suspected) are admitted • Exceptions • Hemorrhoids or fissures • Stable patients with a negative work up • Normal hemoglobin, (-) NG lavage, no active rectal bleeding
  • 65. Disposition • ICU admission • Hemodynamically unstable, active bleeding, severe anemia, coagulopathy, need for urgent endoscopy or blood transfusion • Stepdown or floor bed • Hematemesis that quickly clears in stable patient, stable vital signs
  • 66. UGIB: Treatment • Octreotide or somatostatin to reduce splanchnic blood flow • Proton pump inhibitors • Decrease acid secretion which contributes to ulcer formation • Sengstaken-Blakemore tube for intractable hemorrhage (very rare)
  • 67. UGIB: Treatment • Endoscopy: Mainstay of treatment • Allows identification of bleeding site • Emergent for suspected variceal bleeding, rebleeding, or intractable hemorrhage • Can be performed in 12-24 hours if bleeding stops • Has not reduced mortality
  • 68. UGIB: Risk Stratification Rebleeding and mortality increase with: • Hemoglobin of < 11 g/dl • Shock or hypotension on presentation • Tachycardia of > 110-120 per minute • Age > 60 • Coagulopathy • Co-morbidities such as cancer
  • 69. LGIB • Usually presents with hematochezia • Melena can be seen from right side colonic bleeds • 10% due to upper GI source; NG lavage may help identify source • Causes include: Upper GI bleeding, diverticulosis (most common), angiodysplasia, cancer, rectal disease, ischemic colitis, and IBD
  • 70. LGIB • Resuscitation first! • Diagnostic maneuvers • Anoscopy – localizes lesion to rectum • Colonoscopy – procedure of choice (difficult to perform without bowel prep or if active bleeding) • Nuclear red blood cell scan (rarely performed in the ED setting) • Angiography (may provide information to help localize the source of the acute LGIB)
  • 71. LGIB Treatment • Embolization • Intraarterial vasopressin • Surgery
  • 72. Abdominal Pain Summary • One of the most common complaints prompting a visit to the ED • Definitive diagnosis can be ubiquitous • Attempts are often made to rule out certain conditions • The need for hospital admission increases dramatically with advancing age (> 65 years)
  • 73. Abdominal Pain Summary • Obtaining an accurate history is paramount to developing a sound differential • Remember some patients present with atypical features • Non-specific abdominal pain is a diagnosis of exclusion • Beware of prematurely labeling a patient with a diagnosis of “gastroenteritis”
  • 74. Abdominal Pain Remember • It is never appropriate to diagnose pregnancy by CT scan

×