Acute Abdominal Pain
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Acute Abdominal Pain

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

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

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Acute Abdominal Pain Presentation Transcript

  • 1. ACUTE ABDOMINAL PAIN PGI Karen Cas
  • 2. Acute abdominal pain O Pain of less than 1 week’s duration
  • 3. 3 categories O VISCERAL PAIN O PARIETAL PAIN O REFERRED PAIN
  • 4. Visceral Pain O Usually caused by stretching of fibers innervating the walls or capsules of hollow or solid organs, respectively.
  • 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. Referred pain O Felt at a location distant from the diseased organ O Usually ipsilateral to the involved organ
  • 7. Abdominal Topography: “Four-quadrant approach”
  • 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. 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. 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. 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. 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. THANK YOU!
  • 14. Gastrointestinal O APPENDICITIS O BILIARY TRACT DISEASE O SMALL BOWEL OBSTRUCTION O ACUTE PANCREATITIS O DIVERTICULITIS
  • 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. Appendicitis O CT scan – generally preferred O ULTRASOUND O Color flow Doppler
  • 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. 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. 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. 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. 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. 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. 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. 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. Diverticulitis O CT with colonic contrast O Sonography
  • 26. Genitourinary O RENAL COLIC O ACUTE URINARY RETENTION
  • 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. Renal Colic O Older patients: exclusion of an abdominal aortic aneurysm (AAA) O (+) Anterior abd tenderness – impacted stone at the ureterovesical junction
  • 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. Gynecologic O ACUTE PID O ECTOPIC PREGNANCY
  • 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. 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. Ectopic Pregnancy O Transvaginal sonography O Culdocentesis – compares poorly to TVS
  • 34. Vascular O ABDOMINAL AORTIC ANEURYSM O MESENTERIC ISCHEMIA O ISCHEMIC COLITIS
  • 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. AAA O Aortic sonogram O Non-contrast helical CT O Helical unenhanced abdominopelvic CT
  • 37. Mesenteric Ischemia O Arterial disease O Occlusive (thrombotic/embolic) O Non-occlusive (NOMI)
  • 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. 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. Ischemic colitis O Colonoscopy O Color doppler sonography
  • 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. 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. 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. Hernias O Inguinal – most common O Femoral hernias – women O Sonography of the abdominal wall
  • 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. 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. Metabolic O ENDOCRINOPATHIES O Adrenal crisis O Thyroid storm O Hypo- and hypercalcemia O Shock O Diffusely peritoneal
  • 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. 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