Acute abdomen

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นพ.ประสิทธิ์ วุฒิเมธาวี

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Acute abdomen

  1. 1. Acute abdomen for EP Prasit Wuthisuthimethawee Department of Emergency Medicine Prince of Songkla University
  2. 2. Male 34 years old No underlying dis. Check up at GP During took blood examination  abd pain & syncope
  3. 3. Objectives Abdominal pain pathway Critical points for assessing abdominal pain
  4. 4. Epidemiology 4-10 % of all emergency department visit 50 % have clearly diagnosis 15-30% require surgical procedure esp. elderly Acute appendicitis is the most common
  5. 5. Epidemiology Unique in Pediatric and Elderly
  6. 6. Acute abdominal pain among elderly patients 3 years, 831 cases Non-specific 22-24% Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%) less peritoneal signs Laurell H, Hansson LE, Gunnarsson U. Gerontology. 2006;52(6): 339-44
  7. 7. Emergency department diagnosis of acute abdominal pain in elderly patients 1 year retrospective review, 378 cases Non-specific (35.2%), acute gastritis/gastroenteritis (10.6%), and biliary tract dis. (8.2%) Othong R, Wuthisuthimethawee P, Vasinanukorn P Songkla Med J vol. 28 No 1 Jan-Feb 2010 Non-specific; 90% dissolved, 5.4% Sx.
  8. 8. Predictor for an intensive care or specific treatment in the elderly patients with acute abdominal pain 1 year retrospective review, 386 cases Dyspepsia (21.8%), non-specific (17.6%) and acute gastroenteritis (8.8%) Worapraatya P, Wuthisuthimethawee P, Vasinanukorn P Male, BT < 38, PR >90, abnormal abd contour, and Localize tenderness or guarding
  9. 9. Pain pathway
  10. 10. Abdominal pain pathway 3 type; visceral, somatic, and referred pain
  11. 11. Abdominal pain pathway Visceral pain Wall or capsule of solid organs/bowel Midline, dull, archy and cramping pain Autonomic; pallor, diaphoresis, nausea, and vomiting
  12. 12. Abdominal pain pathway Somatic pain Parietal peritoneum Sharp, discrete, and localized Tenderness, guarding, and rebound
  13. 13. Abdominal pain pathway Somatic pain
  14. 14. Abdominal pain pathway Referred pain Cutaneous site distant from the diseased organ Diaphragm  C3-5: neck and shoulder pain
  15. 15. Abdominal pain pathway Referred pain
  16. 16. Critical points for assessing abdominal pain
  17. 17. Life threatening conditions Vascular disease Acute myocardial infarction Ruptured ectopic pregnancy Perforated visceral organs
  18. 18. Life threatening conditions Intestinal obstruction Acute hemorrhagic pancreatitis Esophageal rupture
  19. 19. Aim Surgical or Non-surgical
  20. 20. Physical examination Accuracy 55-65% with final diagnosis Reexamination and observation Technique !
  21. 21. Physical examination Bowel sound Little diagnostic value
  22. 22. Physical examination Do not forget PR
  23. 23. Physical examination Analgesic ?
  24. 24. Analgesia on abdominal examination Analgesia is safe in abdominal pain Br J Surg. 2003 Jan;90(1):5-9 Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain
  25. 25. Analgesia on abdominal examination Reexam in 60 minutes Prospective, double-blind clinical trial No differences with respect to changes in physical examination or diagnostic accuracy J Am Coll Surg. 2003 Jan;196(1):18-31 Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial
  26. 26. Analgesia on abdominal examination Opioid improve patients comfort and does not retard decision to treat Cochrane Database Syst Rev. 2007 Jul 18;(3): CD005660 Analgesia in patients with acute abdominal pain
  27. 27. Analgesia on abdominal examination 8-18 years old, 90 patients Randomized double-blind placebo-controlled trial Morphine did not delay surgical decision, not more effective than placebo to diminishing pain Ann Emerg Med. 2007 Oct;50(4):371-8. Epub 2007 Jun 27 Efficacy and impact of intravenous morphine before surgical consultation in children with right lower quadrant pain suggestive of appendicitis: a randomized controlled trial
  28. 28. Buscopan ? Medication on abdominal examination
  29. 29. Clinical assessment Reassessment
  30. 30. Clinical assessment Patient’s quantification of pain is unreliable
  31. 31. Clinical assessment Corticosteroids and immunosuppressants
  32. 32. Clinical assessment Chronic dis.: CRF
  33. 33. Clinical assessment Fever ?
  34. 34. Clinical assessment Prior abdominal surgery
  35. 35. Clinical assessment Hernia Genitalia
  36. 36. Clinical assessment Peripheral pulse
  37. 37. Clinical assessment Menstrual history Urine pregnancy test
  38. 38. Clinical assessment WBC 30% in abdominal pain of unknown etiology
  39. 39. Clinical assessment 20% of pancreatitis have normal amylase
  40. 40. Clinical assessment 20% of pancreatitis have normal amylase
  41. 41. Clinical assessment Lactase and mesenteric ischemia 100% sensitive and 42% specific
  42. 42. Clinical assessment Film acute abdomen 10-38% confirm diagnosis
  43. 43. Gallstone Ileus
  44. 44. Portal vein gas
  45. 45. Clinical assessment USG and CT scan Angiogram Tech99m RBC scan
  46. 46. Clinical assessment Myocardial infarction, pneumonia, or pulmonary embolus can present as abdominal pain
  47. 47. Clinical assessment Psychiatric disorder The last diagnosis
  48. 48. Mamagement Bowel rest +/- decompression IV resuscitation with correct electrolyte Antiemesis ? Analgesia ? Antibiotic ? Pre-op in surgical case
  49. 49. Uncertain Diagnosis Observation Review the cause Consultation
  50. 50. Uncertain Diagnosis When in doubt, don’t send them out! Cope’s Early Diagnosis of the Acute Abdomen, 20th ed.. New York, Oxford University Press, 2000.
  51. 51. Case 1 Male 34 years old No underlying dis. Check up at GP During took blood examination  abd pain & syncope
  52. 52. Case 1 At ER Sweating, looked pale V/S BP 95/60 P 112 RR 26 Abd: tenderness at RLQ, guarding ?
  53. 53. What is diagnosis ?
  54. 54. Case 2 Female 53 years old LLQ abdominal pain for 1 day V/S BP 140/80 P 90 RR 24 Underlying HT
  55. 55. Case 2 Abd: LLQ pain, guarding ? CVA: tenderness Lt. Diclofenac  improved Recurrent 2 times in 3 days UA: microscopic hematuria
  56. 56. What is diagnosis ?
  57. 57. Hematuria may be seen in abdominal aortic aneurysm (30%)
  58. 58. Case 3 Female 47 years old RLQ abdominal pain for 1 day V/S BP 130/80 P 82 RR 22 No known underlying dis.
  59. 59. Case 3 Abd: RLQ pain, guarding ?, CVA: not tender CBC: leukocytosis UA: WNL
  60. 60. What is diagnosis ?
  61. 61. ?
  62. 62. Clinical assessment
  63. 63. ขอบคุณครับ
  64. 64. Special sign Iliopsoas and Obturator < 10% in appendicitis
  65. 65. Special sign Fist Percussion
  66. 66. Special sign Rovsing’s Sign Only 5% of patients
  67. 67. High-Yield historical questions How old are you ? Which came first-pain or vomiting ? How long have you had the pain ? Have you ever had abdominal surgery ?
  68. 68. High-Yield historical questions Is the pain constant or intermittent ? Have you ever had this before ? Do you have a history of cancer diverticulosis ? Do you have HIV ?
  69. 69. High-Yield historical questions How much alcohol do you drink per day ? Are you pregnant ? Are you taking antibiotic or steroid ? Did the pain start centrally and migrate ? Do you have a history of CAD, HT, AF ?
  70. 70. Etiology and clinical course of abdominal pain In senior patients; a prospective, multicenter study 3 years, 831 cases Non-specific 22-24% Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%) less peritoneal signs Lewis LM, Banet GA, Blenda M, et al. J Gerontol A Biol Sci Med Sci. 2005

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