Acute pain abdomen

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Acute pain abdomen

  1. 1. DR VARUN K PG GASTROENTEROLOGY
  2. 2.         Definition Pain pathway Types of pain Natural history Causes of pain abdomen Clinical case scenarios Management Conclusion
  3. 3.   Pain less than one week duration. Abdominal pain is the presenting complaint in 1.5 percent of office-based visits and in 5 percent of emergency department visits.  Annual incidence approx. 63/1000 ED visits.  Admission rate varies (high as 63% in pts > 65 yrs old.)  1.Woodwell DA, Cherry DK. National Ambulatory Medical Care Survey: 2002 summar. Adv Data. . 2004;(346):1–44.  2. Kamin RA, Nowicki TA, Courtney DS, Powers RD. Pearls and pitfalls in the emergency department evaluation of abdominal pain. Emerg Med Clin North Am. 2003;21(1):61–72
  4. 4.  Three types of pain exist: 1. Visceral 2. Parietal 3. Referred
  5. 5.      Visceral pain is transmitted by C fibers. Involves hollow or solid organs; midline pain due to bilateral innvervation Steady ache or vague discomfort to excruciating or colicky pain Poorly localized Secondary autonomic symptoms present.
  6. 6.    Abdominal visceral nocioceptors respond to mechanical and chemical stimuli. The principal mechanical signal to which visceral nocioceptors are sensitive is stretch. Chemical nocioceptors are activated by substances released in response to inflammation and injury.
  7. 7.    Somatic-parietal pain is mediated by A-δ fibers that are distributed principally to skin and muscle. Signals from this neural pathway are perceived as sharp, sudden, well localized pain, such as that which follows an acute injury. These fibers convey pain sensations through spinal nerves.
  8. 8.   Stimulation of these fibers activates local regulatory reflexes mediated by the enteric nervous system and long spinal reflexes mediated by the autonomic nervous system, in addition to transmitting pain sensation to the central nervous system. Reflexive responses, such as involuntary guarding and abdominal rigidity, are mediated by spinal reflex arcs involving somatic-parietal pain pathways.
  9. 9.    Somatic A-d fibers mediate touch, vibration, and proprioception in a dermatomal distribution that matches the visceral innervation of the injured viscera and synapse with inhibitory interneurons of the substantia gelatinosa in the spinal cord. In addition, inhibitory neurons that originate in the mesencephalon, periventricular gray matter, and caudate nucleus descend within the spinal cord to modulate afferent pain pathways. These inhibitory mechanisms allow cerebral influences to modify afferent pain impulses.
  10. 10.  Referred pain is felt in areas remote from the diseased organs and results when visceral afferent neurons and somatic afferent neurons from a different anatomic region converge on second-order neurons in the spinal cord at the same spinal segment.
  11. 11.    Subdiaphragmatic irritation → ipsilateral shoulder or supraclavicular pain(kehr’s sign). Biliary disease → right infrascapular pain MI → epigastric, neck, jaw or upper extremity pain
  12. 12.              Gastritis Acute Gastroenteritis Hepatic abscess Rectal sheath hematoma Herpes Zoster UTI Tabes dorsalis Sickle cell disease Diabetes Mellitus Thyrotoxicosis Addisonians disease Poryphyria Hereditary Spherocytosis
  13. 13. Acute appendicitis Acute diverticulitis Acute pancreatitis Acute cholecystitis Intestinal obstruction Billiary colic Ureteric colic Acute retention of urine Perforation of peptic ulcer Perforation of appendix Ruptured AAA Perforated oesophgagus
  14. 14.         Ectopic pregnancy PID Salpingitis Mittelschmerz Endometriosis Dysmenorrhoea Fibroid degeneration Ovarian cyst – rupture, torsion , hemorrhage
  15. 15.  LOCATION OF PAIN Right upper quadrant Left upper quadrant Right lower quadrant  Left lower quadrant  Suprapubic    IMAGING Ultrasonography CT CT with iv contrast media CT with oral and IV contrast media Ultrasonography
  16. 16.          24 year healthy male with one day history of abdominal pain. Pain was generalized at first, now worse in right lower abd & radiates to his right groin. He has vomited twice today. Denies any diarrhea, fevers, dysuria or other complaints. No appetite today. ROS otherwise negative. PMHx: negative PSurgHx: negative Meds: none Social hx: no alcohol, tobacco or drug use Family hx: non-contributory
  17. 17.      Physical exam: T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat: 100% room air Uncomfortable appearing, slightly pale Abdomen: soft, non-distended, tender to palpation in RLQ with mild guarding; hypoactive bowel sounds Genital exam: normal
  18. 18.      Classic presentation Periumbilical pain Anorexia, nausea, vomiting Pain localizes to RLQ Occurs only in ½ to 2/3 of patients 26% of appendices are retrocecal and cause pain in the flank; 4% are in the RUQ A pelvic appendix can cause suprapubic pain, dysuria Males may have pain in the testicles Addiss DG, Shaffer N, Fowler B, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990; 132:910-25. (Ref 21.)
  19. 19.       Depends on duration of symptoms Rebound, voluntary guarding, rigidity, tenderness on rectal exam Fever (a late finding) Urinalysis abnormal in 19-40% CBC is not sensitive or specific Addiss DG, Shaffer N, Fowler B, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990; 132:910-25. (Ref 21.)
  20. 20. Abdominal xrays Appendiceal fecolith or gas, localized ileus, blurred right psoas muscle, free air  CT scan Pericecal inflammation, abscess, periappendiceal phlegmon, fluid collection, localized fat stranding 
  21. 21.     NPO IVFs Preoperative antibiotics – decrease the incidence of postoperative wound infections Analgesia
  22. 22.    Alvarado Score is numerical, it has been evaluated for ruling in and ruling out appendicitis. Studies ruling out appendicitis (using Alvarado < 3-4) have a sensitivity of 96%; studies ruling in appendicitis (using Alvarado > 6-7) have a sensitivity of 58-88%, depending on the study and score cutoffs used. The 2007 McKay study recommends CT scan for Alvarado 4-6, surgical consultation for Alvarado ≥ 7, and for Alvarado ≤ 3, no CT for diagnosing appendicitis, as appendicitis is unlikely
  23. 23.  68 yo F with 2 days of LLQ abd pain, constipation, fevers/chills, nausea; vomited once at home.  PMHx: HTN, diverticulosis  PSurgHx: negative  Meds: HCTZ  Social hx: no alcohol, tobacco or drug use
  24. 24.     T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99% room air Gen: uncomfortable appearing, slightly pale Abd: soft, moderately tender LLQ Rectal: normal tone, guiac neg brown stool
  25. 25.       FINDINGS: Steady, deep discomfort in LLQ Change in bowel habits Urinary symptoms Tenesmus Paralytic ileus
  26. 26.       Low-grade fever Localized tenderness Rebound and guarding Left-sided pain on rectal exam Occult blood Peritoneal signs-Suggest perforation or abscess rupture
  27. 27.   CT scan (IV and oral contrast) Pericolic fat stranding Diverticula Thickened bowel wall Peridiverticular abscess Leukocytosis present in only 36% of patients
  28. 28.     Hinchey grade I diverticulitis :localized pericolic abscess or inflammation frequently Hinchey grade II diverticulitis: pelvic, intraabdominal, or retroperitoneal abscess. Hinchey III :generalized purulent peritonitis Hinchey IV generalized fecal peritonitis.
  29. 29.    Fluids Correct electrolyte abnormalities Antibiotics.
  30. 30.      46 yo M with hx of alcohol abuse with 3 days of severe boring upper abd pain radiating to back relieved on leaning forward , vomiting, subjective fevers. Med Hx: negative Surg Hx: negative Meds: none; Social hx: heavy alcohol use, smokes 2ppd, no drug use
  31. 31.       Vital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat: 95% room air General: ill-appearing, appears in pain CV: tachycardic, normal heart sounds, pulses normal Lungs: clear Abdomen: mildly distended, moderately TTP epigastric, +voluntary guarding Rectal: heme neg stool
  32. 32.     CLINICAL FEATURES Epigastric pain -Constant, boring pain,Radiates to back. Vomiting. Fever.
  33. 33.     Patients are usually tachycardic and tachypneic. Abdominal examination reveals hypoactive bowel sounds and marked tenderness to percussion and palpation in the epigastrium. Abdominal rigidity is a variable finding. In rare patients, flank or periumbilical ecchymoses (Grey-Turner’s or Cullen’s sign, respectively) develop in the setting of pancreatic necrosis with hemorrhage.
  34. 34.     Lipase -Elevated more than 3 times normal ;Sensitivity and specificity >90% Amylase-Nonspecific USG abdomen if etiology unknown CT scan-Useful to evaluate for complications
  35. 35.      NPO IV fluid resuscitation Maintain urine output of 100 mL/hr NGT if severe, persistent nausea No antibiotics unless severe disease
  36. 36.      72 yo M with hx of CAD on aspirin and Plavix with several days of dull upper abd pain and now with worsening pain “in entire abdomen” today. Some relief with food until today, now worse after eating lunch. Med Hx: CAD, HTN, CHF Surg Hx: appendectomy Meds: Aspirin, Plavix, Metoprolol, Lasix Social hx: smokes 1ppd, denies alcohol or drug use, lives alone
  37. 37. CLINICAL FEATURES  Burning epigastric pain leading to sudden onset severe diffuse abdominal pain  Epigastric tenderness  Severe, generalized pain may indicate perforation with peritonitis  Occult or gross blood per rectum or NGT if bleeding.
  38. 38.    Acute abdominal x-ray series -Lack of free air does not rule out perforation Broad-spectrum antibiotics Surgical consultation
  39. 39.       35 yo healthy F to ED c/o nausea and vomiting since yesterday along with generalized abdominal pain ,cramping in nature more in the periumbilical area not radiating No fevers/chills, +anorexia. Last stool 2 days ago. Med Hx: negative Surg Hx: s/p hysterectomy (for fibroids) Social Hx: denies alcohol, tobacco or drug use Family Hx: non-contributory
  40. 40.       Crampy, intermittent pain Periumbilical or diffuse Inability to have BM or flatus Nausea and vomiting Abdominal bloating Sensation of fullness, anorexia
  41. 41.     Distention Tympany Absent, high pitched or tinkling bowel sound or “rushes” Abdominal tenderness: diffuse, localized, or minimal
  42. 42.      CBC and electrolytes electrolyte abnormalities WBC >20,000 suggests bowel necrosis, abscess or peritonitis Abdominal x-ray series-Air-fluid levels, dilated loops of bowel,Lack of gas in distal bowel and rectum CT scan-Identify cause of obstruction, Delineate partial from complete obstruction
  43. 43.     Fluid resuscitation NGT Analgesia Hospital observation for ileus or for complete obstruction
  44. 44.      48 yo obese F with one day hx of upper abd pain after eating, does not radiate, is intermittent cramping pain, +N/V, no diarrhea, subjective fevers. No prior similar symptoms. Med hx: denies Surg hx: denies No meds or allergies Social hx: no alcohol, tobacco or drug use
  45. 45.      T: 100.4, HR: 96, BP: 135/76, R: 18, O2 sat: 100% room air General: moderately obese, no acute distress CV: normal Lungs: clear Abd: moderately tender RUQ, +Murphy’s sign, non-distended, normal bowel sounds
  46. 46.       RUQ or epigastric pain Radiation to the back or shoulders Dull and achy Pain lasting longer than 6 hours Nausea,Vomiting,anorexia Fever, chills.
  47. 47.    Epigastric or RUQ pain Murphy’s sign Peritoneal signs suggest perforation
  48. 48.   RUQ US Thicken gallbladder wall Pericholecystic fluid Gallstones or sludge Sonographic murphy sign HIDA scan-more sensitive & specific than US
  49. 49.       Surgical consult IV fluids Correct electrolyte abnormalities Analgesia Antibiotics NGT if intractable vomiting
  50. 50.     Sudden onset of acute, severe abdominal pain localized to the midabdomen or paravertebral or flank areas. The pain is tearing in nature and associated with prostration,lightheadedness, and diaphoresis. Physical examination reveals a pulsatile, tender abdominal mass in about 90% of cases. The classic triad of hypotension, a pulsatile mass, and abdominal pain is present in 75% of cases and mandates immediate surgical intervention.
  51. 51.      Consider this diagnosis in all elderly patients with risk factors Atrial fibrillation, recent MI,Atherosclerosis, CHF, digoxin therapy Hypercoagulability, prior DVT, liver disease. Severe pain, often refractory to analgesics Relatively normal abdominal exam Embolic source: sudden onset (more gradual if thrombosis) Nausea, vomiting and anorexia are common
  52. 52.     50% will have diarrhea Eventually stools will be guiaic-positive Metabolic acidosis and extreme leukocytosis when advanced disease is present (bowel necrosis) Diagnosis requires mesenteric angiography or CT angiography
  53. 53.   It is defined as pathologic elevation of intraabdominal pressure. An elevated intra-abdominal pressure may develop in a patient who survives massive volume resuscitation with resulting visceral edema or who has a disease such as severe pancreatitis that can cause visceral or retroperitoneal edema.
  54. 54.        The World Society for Abdominal Compartment Syndrome has established a consensus grading scheme for ACS based on the measured bladder pressure. A normal value for bladder pressure is less than 7 mm Hg. Grade I ACS is defined as a pressure of 12 to 15 mm Hg. Grade II as 16 to 20 mm Hg, Grade III as 21 to 25 mm Hg and Grade IV as greater than 25 mm Hg. An G, West M. Abdominal compartment syndrome: A concise clinical review. Crit Care Med 2008; 36:1304-10
  55. 55.   Nonsurgical options for treating low-grade ACS include gastric decompression, sedation, neuromuscular blockade, placing the patient in a reverse Trendelenburg position while allowing the hips to remain in a neutral position, and diuretics. In a patient with high grade ACS, particularly when renal and respiratory function is compromised, laparotomy and creation of an open abdomen is most effective.
  56. 56.    Mortality rate for abdominal pain in the elderly is 11-14% Perception of pain is altered Altered reporting of pain: stoicism, fear, communication problems
  57. 57.            Most common causes: Cholecystitis Appendicitis Bowel obstruction Diverticulitis Perforated peptic ulcer Don’t miss these: AAA, ruptured AAA Mesenteric ischemia Myocardial ischemia Aortic dissection
  58. 58.       Appendicitis – do not exclude it because of prolonged symptoms. Only 20% will have fever, N/V, RLQ pain and ↑WBC Acute cholecystitis – most common surgical emergency in the elderly. Perforated peptic ulcer – only 50% report a sudden onset of pain. In one series, missed diagnosis of PPU was leading cause of death. Mesenteric ischemia – we make the diagnosis only 25% of the time. Early diagnosis improves chances of survival. Overall survival is 30%. Increased frequency of abdominal aortic aneurysms AAA may look like renal colic in elderly patients
  59. 59.   Pregnant women develop acute appendicitis and cholecystitis at the same rate as their nonpregnant counterparts. A number of additional diagnoses, such as placental abruption and pain related to tension on the broad ligament, must be distinguished from nonobstetric diagnoses.
  60. 60.    Appendicitis occurs in approximately 1 in 2000 pregnancies and is equally distributed among the three trimesters. Biliary tract disease is also common during pregnancy. Open or laparoscopic management of these diseases is safe but is associated with a rate of preterm delivery of approximately 12% for appendectomy and 11% for cholecystectomy.
  61. 61.  Immunocompromised hosts may manifest with acute abdominal pain, including neutropenic enterocolitis, drug-induced pancreatitis, graft-versus-host disease, pneumatosis intestinalis, and cytomegalovirus (CMV) and fungal infections.
  62. 62.  In general, immunocompromised patients may lack the definitive signs of an acute abdominal crisis usually seen in immunocompetent persons; an elevated temperature, peritoneal signs, and leukocytosis may be absent in these cases.
  63. 63.     Acetaminophen Non-steroidal anti-inflammatory drugs (NSAIDs) Opioids Treatment of cause.
  64. 64.    In order to obtain the best therapeutic effect while minimising side effects, many analgesic drugs require careful titration and individualisation of dose regimens. Multimodal analgesia (that is, the concurrent use of different classes of analgesics) improves the effectiveness of acute pain management. Drug administration can be by oral, subcutaneous, intramuscular, intravenous, epidural, intrathecal, inhalational, rectal, transdermal or transmucosal routes
  65. 65.  Some specialised analgesia delivery techniques require greater medical and nursing knowledge and expertise like Patient-controlled analgesia, Epidural and intrathecal analgesia ,Other regional analgesic procedures, Continuous infusions of opioids, local anaesthetics, ketamine and other drugs.
  66. 66.    NON-PHARMACOLOGICAL THERAPIES Non-pharmacological therapies must be considered as complementary to pharmacological therapies. Psychological interventions, acupuncture, transcutaneous electrical nerve stimulation and physical therapy may be effective in some acute pain settings.
  67. 67.   Sir Zachary Cope stated that “Morphine does little or nothing to stop serious intraabdominal disease, but it puts an efficient screen in front of the symptoms. Six studies in which the early administration of analgesia was compared with administration of placebo in patients with acute abdominal pain have shown that the patients who receive analgesics are more comfortable and do not experience a delay in diagnosis.
  68. 68.       Significant abdominal tenderness should never be attributed to gastroenteritis Incidence of gastroenteritis in the elderly is very low Always perform genital examinations when lower abdominal pain is present – in males and females, in young and old In older patients with renal colic symptoms, exclude AAA Severe pain should be taken as an indicator of serious disease Pain awakening the patient from sleep should always be considered signficant
  69. 69.       Sudden severe pain suggests serious disease Pain almost always precedes vomiting in surgical causes; converse is true for most gastroenteritis and NSAP Acute cholecystitis is the most common surgical emergency in the elderly A lack of free air on a chest xray does NOT rule out perforation Signs and symptoms of PUD, gastritis, reflux and nonspecific dyspepsia have significant overlap If the pain of biliary colic lasts more than 6 hours, suspect early cholecystitis
  70. 70. THANK YOU

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