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ACUTE
ABDOMINAL PAIN
PGI Karen Cas
Acute abdominal pain
O Pain of less than 1
week’s duration
3 categories
O VISCERAL PAIN
O PARIETAL PAIN
O REFERRED PAIN
Visceral Pain
O Usually caused by stretching of fibers
innervating the walls or capsules of hollow
or solid organs, respec...
Parietal Pain
O Caused by irritation of fibers that innervate
the parietal peritoneum, usually the
portion covering the an...
Referred pain
O Felt at a location distant from the diseased
organ
O Usually ipsilateral to the involved organ
Abdominal Topography:
“Four-quadrant approach”
Pain Attributes
O P – precipitating (aggravating) / palliating
(alleviating) factors
O Q – quality
O R – radiation
O S – s...
Physical Exam
O INSPECTION – distention, scars, masses
O AUSCULTATION – normal / increased
bowel sounds, hyperactive / obs...
CLASSIFICATION
O INTRA-ABDOMINAL
O Gastrointestinal
O Genitourinary
O Gynecologic
O Vascular
O EXTRA-ABDOMINAL
O Cardiopul...
Treatment
O HYPOTENSION
O Isotonic crystalloid
O Vasoconstrictors (dopamine,
norepinephrine)
O Pump failure : Dobutamine
O...
Disposition
O Indication for admission:
O Appear ill
O Elderly or immunocompromised
O With unclear diagnosis
O With reason...
THANK YOU!
Gastrointestinal
O APPENDICITIS
O BILIARY TRACT DISEASE
O SMALL BOWEL OBSTRUCTION
O ACUTE PANCREATITIS
O DIVERTICULITIS
Appendicitis
O Clinical features
with predictive
value
O RLQ pain
O Pain migration
from the
periumbilical
area to RLQ
O Ri...
Appendicitis
O CT scan – generally preferred
O ULTRASOUND
O Color flow Doppler
Biliary Tract Disease
O Most ommon
diagnosis in ED
patients ≥50 years
old
O Steady post-
prandial upper
abdominal pain tha...
Biliary Tract Disease
O ULTRASOUND is better in the
identification of Cholecystitis than in the
detection of Common duct o...
Small Bowel Obstruction
O Central issues:
O Diagnosis of the
primary disorder, and
O Early detection of
secondary
strangul...
Small Bowel Obstruction
O Ischemic bowel sec to
strangulation
O Extremely difficult to
detect clinically or
with plain
rad...
Acute Pancreatitis
O 80% caused by alcohol
or gallstones
O Steady and severe pain
that extends well
beyond the upper
abdom...
Acute Pancreatitis
O Serum lipase – begun to replace amylase
as the preferred ED screening test for
suspected acute pancre...
Acute Pancreatitis
O Double contrast
helical CT
O MR
cholangiopancreato
graphy (MRCP)
O ALT >150 U/L
(including
alcoholics...
Diverticulitis
O Pain confined to LLQ (<1/4 of cases)
O Pain in lower half of abdomen (1/3 of
cases)
O Generalized tendern...
Diverticulitis
O CT with colonic
contrast
O Sonography
Genitourinary
O RENAL COLIC
O ACUTE URINARY RETENTION
Renal Colic
O Pain: unilateral
flank, abrupt
onset, colicky, radiates
to groin/testicle/labia
O Non-contrast helical CT
O ...
Renal Colic
O Older patients: exclusion of an abdominal
aortic aneurysm (AAA)
O (+) Anterior abd tenderness – impacted
sto...
Acute Urinary Retention
O ACUTE URETHRAL OBSTRUCTION
O Another most common GU cause of abd
pain
O Distended bladder
O Inse...
Gynecologic
O ACUTE PID
O ECTOPIC PREGNANCY
Acute Pelvic Inflammatory
Disease
O Abnormal vaginal discharge
O Only PE finding assoc with laparoscopic
PID
O Transvagina...
Ectopic Pregnancy
O Pain may be absent at earlier stage with a
sentinel complaint of only vaginal bleeding
O ANY WOMAN OF ...
Ectopic Pregnancy
O Transvaginal sonography
O Culdocentesis – compares poorly to TVS
Vascular
O ABDOMINAL AORTIC ANEURYSM
O MESENTERIC ISCHEMIA
O ISCHEMIC COLITIS
Abdominal Aortic Aneurysm
O Tend to enlarge, become aneurysmal over
years
O Triad:
HYPOTENTION, ABDOMINAL/BACK
PAIN, PULSA...
AAA
O Aortic sonogram
O Non-contrast helical
CT
O Helical unenhanced
abdominopelvic CT
Mesenteric Ischemia
O Arterial disease
O Occlusive (thrombotic/embolic)
O Non-occlusive (NOMI)
Mesenteric Ischemia
O Distinctions made among 4 major forms
1. Embolic is abrupt; MVT is most indolent
2. NOMI accompanied...
Ischemic colitis
O A disease of older patients
O Diffuse or lower abdominal visceral pain
O Accompanied by diarrhea, often...
Ischemic colitis
O Colonoscopy
O Color doppler sonography
Cardiopulmonary
O Pain of the upper half of the abdomen
(with or without tenderness)
O Chest film
O Epigastric pain + age ...
Abdominal wall
O Pain originating from the abdominal wall
may be confused with visceral pain
because superficial innervati...
Hernias
O Defect through which intraabdominal
contents protrude, often
intermittently, during transient increases in
intra...
Hernias
O Inguinal – most common
O Femoral hernias – women
O Sonography of the abdominal wall
Toxic
O Infectious agents
irritate GI tract –
crampy
O Concomitant vomiting
or diarrhea
O Poisoning
O Overdose
O Opioid wi...
Metabolic
O Anion-gap metabolic acidoses (DKA,
AKA)
O Gastric distention
O Paralytic ileus
O If acidosis is resistant to s...
Metabolic
O ENDOCRINOPATHIES
O Adrenal crisis
O Thyroid storm
O Hypo- and hypercalcemia
O Shock
O Diffusely peritoneal
Neurogenic
O Dysesthetic sensation
O “hover” sign
O Radicular problems
O Zosteriform radiculopathy
O Dysesthesia outlining...
NSAP
O Diagnosis of exclusion
O Nausea – most common symptom after
abdominal pain
O Mid-epigastric and lower half of the
a...
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Acute Abdominal Pain

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Differentials of acute abdominal pain in Emergency Room (ER) cases.
Source: Tintinalli

Published in: Health & Medicine
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  • Transcript of "Acute Abdominal Pain"

    1. 1. ACUTE ABDOMINAL PAIN PGI Karen Cas
    2. 2. Acute abdominal pain O Pain of less than 1 week’s duration
    3. 3. 3 categories O VISCERAL PAIN O PARIETAL PAIN O REFERRED PAIN
    4. 4. Visceral Pain O Usually caused by stretching of fibers innervating the walls or capsules of hollow or solid organs, respectively.
    5. 5. Parietal Pain O Caused by irritation of fibers that innervate the parietal peritoneum, usually the portion covering the anterior abdominal wall. O Can be localized to the dermatome superficial to the site of the painful stimulus
    6. 6. Referred pain O Felt at a location distant from the diseased organ O Usually ipsilateral to the involved organ
    7. 7. Abdominal Topography: “Four-quadrant approach”
    8. 8. Pain Attributes O P – precipitating (aggravating) / palliating (alleviating) factors O Q – quality O R – radiation O S – severity O T – timing / duration / onset
    9. 9. Physical Exam O INSPECTION – distention, scars, masses O AUSCULTATION – normal / increased bowel sounds, hyperactive / obstructive bowel sounds O PALPATION – tenderness, voluntary guarding O PELVIC EXAM – women of reproductive age O RECTAL EXAM – stool color, +/- blood, tenderness
    10. 10. CLASSIFICATION O INTRA-ABDOMINAL O Gastrointestinal O Genitourinary O Gynecologic O Vascular O EXTRA-ABDOMINAL O Cardiopulmonary O Abdominal wall O Toxic O Metabolic O Neurogenic O NON-SPECIFIC ABDOMINAL PAIN
    11. 11. Treatment O HYPOTENSION O Isotonic crystalloid O Vasoconstrictors (dopamine, norepinephrine) O Pump failure : Dobutamine O ANALGESIC O Opioids, NSAIDs O ANTI-EMETIC O Metoclopramide O ANTIBIOTICS
    12. 12. Disposition O Indication for admission: O Appear ill O Elderly or immunocompromised O With unclear diagnosis O With reasonably unexcluded potential causes of abdominal pain O Intractable pain or vomiting O Acute or chronically altered mental status O Inability to follow discharge or follow-up instructions O Lacking social supports O Alcohol or other drug use
    13. 13. THANK YOU!
    14. 14. Gastrointestinal O APPENDICITIS O BILIARY TRACT DISEASE O SMALL BOWEL OBSTRUCTION O ACUTE PANCREATITIS O DIVERTICULITIS
    15. 15. Appendicitis O Clinical features with predictive value O RLQ pain O Pain migration from the periumbilical area to RLQ O Rigidity O Pain before vomiting O Positive psoas sign
    16. 16. Appendicitis O CT scan – generally preferred O ULTRASOUND O Color flow Doppler
    17. 17. Biliary Tract Disease O Most ommon diagnosis in ED patients ≥50 years old O Steady post- prandial upper abdominal pain that radiates to the upper back
    18. 18. Biliary Tract Disease O ULTRASOUND is better in the identification of Cholecystitis than in the detection of Common duct obstruction O Cholescintigraphy (radionuclide scanning) O MR Cholangiography
    19. 19. Small Bowel Obstruction O Central issues: O Diagnosis of the primary disorder, and O Early detection of secondary strangulation or ischemia O Historical features 1. Previous abdominal surgery 2. Intermittent/colick y pain O PE findings 1. Abdominal distention 2. Abnormal BS
    20. 20. Small Bowel Obstruction O Ischemic bowel sec to strangulation O Extremely difficult to detect clinically or with plain radiography O CT O Useful in altering the likelihood of ischemia
    21. 21. Acute Pancreatitis O 80% caused by alcohol or gallstones O Steady and severe pain that extends well beyond the upper abdomen to cause generalized tenderness O Resides deep in the belly and extends into the retroperitoneum
    22. 22. Acute Pancreatitis O Serum lipase – begun to replace amylase as the preferred ED screening test for suspected acute pancreatitis O Accuracy of serum lipase in the diagnosis of acute pancreatitis is inversely related to the time elapsed between symptom onset and presentation
    23. 23. Acute Pancreatitis O Double contrast helical CT O MR cholangiopancreato graphy (MRCP) O ALT >150 U/L (including alcoholics) O Increased risk of biliary pancreatitis
    24. 24. Diverticulitis O Pain confined to LLQ (<1/4 of cases) O Pain in lower half of abdomen (1/3 of cases) O Generalized tenderness O Elderly
    25. 25. Diverticulitis O CT with colonic contrast O Sonography
    26. 26. Genitourinary O RENAL COLIC O ACUTE URINARY RETENTION
    27. 27. Renal Colic O Pain: unilateral flank, abrupt onset, colicky, radiates to groin/testicle/labia O Non-contrast helical CT O Doppler UTZ + elevation of “renal resistive index” in one kidney relative to the other may identify stone in ipsilateral ureter
    28. 28. Renal Colic O Older patients: exclusion of an abdominal aortic aneurysm (AAA) O (+) Anterior abd tenderness – impacted stone at the ureterovesical junction
    29. 29. Acute Urinary Retention O ACUTE URETHRAL OBSTRUCTION O Another most common GU cause of abd pain O Distended bladder O Insertion of urethral catheter – dx & tx
    30. 30. Gynecologic O ACUTE PID O ECTOPIC PREGNANCY
    31. 31. Acute Pelvic Inflammatory Disease O Abnormal vaginal discharge O Only PE finding assoc with laparoscopic PID O Transvaginal sonography O Positive: thickened tubal wall O Transvaginal power doppler O Positive: hyperemia + tubal inflammation
    32. 32. Ectopic Pregnancy O Pain may be absent at earlier stage with a sentinel complaint of only vaginal bleeding O ANY WOMAN OF CHILDBEARING AGE WHO PRESENTS TO ED W/ ABD PAIN OR ABNORMAL VAGINAL BLEEDING SHOULD RECEIVE A QUALITATIVE PREGNANCY TEST AS A SCREENING MEASURE.
    33. 33. Ectopic Pregnancy O Transvaginal sonography O Culdocentesis – compares poorly to TVS
    34. 34. Vascular O ABDOMINAL AORTIC ANEURYSM O MESENTERIC ISCHEMIA O ISCHEMIC COLITIS
    35. 35. Abdominal Aortic Aneurysm O Tend to enlarge, become aneurysmal over years O Triad: HYPOTENTION, ABDOMINAL/BACK PAIN, PULSATILE ABDOMINAL MASS O Absence of abd pain – compatible with a contained leak extending to retroperitoneum
    36. 36. AAA O Aortic sonogram O Non-contrast helical CT O Helical unenhanced abdominopelvic CT
    37. 37. Mesenteric Ischemia O Arterial disease O Occlusive (thrombotic/embolic) O Non-occlusive (NOMI)
    38. 38. Mesenteric Ischemia O Distinctions made among 4 major forms 1. Embolic is abrupt; MVT is most indolent 2. NOMI accompanied by low-flow state, typically due to cardiac disease 3. MVT may be more amenable to non- invasive diagnosis with CT; in younger px; lower mortality; tx w/ immediate anticoag 4. Arteriography w/ papaverine infusion – impt in px w/ splanchnic vasoconstriction
    39. 39. Ischemic colitis O A disease of older patients O Diffuse or lower abdominal visceral pain O Accompanied by diarrhea, often mixed with blood O Rectal sparring O Segmental portions of the mucosa and submucosa slough
    40. 40. Ischemic colitis O Colonoscopy O Color doppler sonography
    41. 41. Cardiopulmonary O Pain of the upper half of the abdomen (with or without tenderness) O Chest film O Epigastric pain + age grp CAD is prevalent O Cardiac history O ECG
    42. 42. Abdominal wall O Pain originating from the abdominal wall may be confused with visceral pain because superficial innervation from the lower thoracic roots enter the spinal cord via the same dorsal horn as the deeper visceral afferents O Carnett’s sign / sit-up test O (+) abdominal wall syndrome
    43. 43. Hernias O Defect through which intraabdominal contents protrude, often intermittently, during transient increases in intraabdominal pressure O Uncomplicated O Asymptomatic or at worst, aching & uncomfortable O Significant pain: incarcerated or strangulated
    44. 44. Hernias O Inguinal – most common O Femoral hernias – women O Sonography of the abdominal wall
    45. 45. Toxic O Infectious agents irritate GI tract – crampy O Concomitant vomiting or diarrhea O Poisoning O Overdose O Opioid withdrawal O Peritoneal tenderness O Infarction O Penetration O Perforation
    46. 46. Metabolic O Anion-gap metabolic acidoses (DKA, AKA) O Gastric distention O Paralytic ileus O If acidosis is resistant to standard treatment, or pain persists after normalization of pH, intraabdominal disease should be suspected
    47. 47. Metabolic O ENDOCRINOPATHIES O Adrenal crisis O Thyroid storm O Hypo- and hypercalcemia O Shock O Diffusely peritoneal
    48. 48. Neurogenic O Dysesthetic sensation O “hover” sign O Radicular problems O Zosteriform radiculopathy O Dysesthesia outlining a dermatome on either side of the involved root O Lancinating, ticlike bouts of shooting pain or continuous burning O Vesicles
    49. 49. NSAP O Diagnosis of exclusion O Nausea – most common symptom after abdominal pain O Mid-epigastric and lower half of the abdomen O Lab test usually normal / mild leukocytosis
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