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Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
Abdominal Emergencies Cdem
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Abdominal Emergencies Cdem

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  • 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

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