Diagnosis And Management Of Acute Abdominal Pain


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Diagnosis And Management Of Acute Abdominal Pain

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  • Diagnosis And Management Of Acute Abdominal Pain

    1. 1. Diagnosis and Management of Acute Abdominal Pain Dimitri Raptis and Alec Engledow
    2. 3. Definition 1 <ul><li>Acute abdominal pain (AAP): </li></ul><ul><ul><li>Presentation of previously undiagnosed abdominal pain </li></ul></ul><ul><ul><li>Lasting 1/52 or < </li></ul></ul><ul><ul><li>Prior to a clinical encounter in 1 0 or 2 0 care </li></ul></ul>1 De Dombal FT. Diagnosis of acute abdominal pain . New York: Churchill Livingstone; 1991.
    3. 4. Introduction <ul><li>> 1000 causes exist 2 </li></ul><ul><ul><li>NSAP (34%) </li></ul></ul><ul><ul><li>Acute appendicitis (28%) </li></ul></ul><ul><ul><li>Acute chlecystitis (10%) </li></ul></ul><ul><ul><li>SBO (4%) </li></ul></ul><ul><ul><li>Perforated PU (3%) </li></ul></ul><ul><ul><li>Pancreatitis (3%) </li></ul></ul><ul><ul><li>Diverticular disease (2%) </li></ul></ul><ul><ul><li>Others (13%) </li></ul></ul><ul><li>20-40% admission rates </li></ul><ul><li>50-65% inaccurate initial diagnosis </li></ul>2 De Dombal FT, Margulies M. Acute abdominal pain. Surgery 1996;
    4. 5. Pathophysiology <ul><li>Visceral pain </li></ul><ul><ul><li>Distention, inflammation or ischaemia in hollow viscous & solid organs </li></ul></ul><ul><ul><li>Localisation depends on the embryologic origin of the organ: </li></ul></ul><ul><ul><ul><li>Forgut to epigastrium </li></ul></ul></ul><ul><ul><ul><li>Midgut to umbilicus </li></ul></ul></ul><ul><ul><ul><li>Hindgut to the hypogastric region </li></ul></ul></ul><ul><li>Parietal pain </li></ul><ul><ul><li>is localised to the dermatome above the site of the stimulus. </li></ul></ul><ul><li>Referred pain </li></ul><ul><ul><li>produces symptoms, not signs e.g. tenderness </li></ul></ul>
    5. 6. Generalized AP <ul><li>Perforation </li></ul><ul><li>AAA </li></ul><ul><li>Acute pancreatitis </li></ul><ul><li>DM </li></ul><ul><li>Bilateral pleurisy </li></ul>
    6. 7. Central AP <ul><li>Early appendicitis </li></ul><ul><li>SBO </li></ul><ul><li>Acute gastritis </li></ul><ul><li>Acute pancreatitis </li></ul><ul><li>Ruptured AAA </li></ul><ul><li>Mesenteric thrombosis </li></ul>
    7. 8. Epigastric pain <ul><li>DU / GU </li></ul><ul><li>Oesophagitis </li></ul><ul><li>Acute pancreatitis </li></ul><ul><li>AAA </li></ul>
    8. 9. RUQ pain <ul><li>Gallbladder disease </li></ul><ul><li>DU </li></ul><ul><li>Acute pancreatitis </li></ul><ul><li>Pneumonia </li></ul><ul><li>Subphrenic abscess </li></ul>
    9. 10. LUQ pain <ul><li>GU </li></ul><ul><li>Pneumonia </li></ul><ul><li>Acute pancreatitis </li></ul><ul><li>Spontaneous splenic rupture </li></ul><ul><li>Acute perinephritis </li></ul><ul><li>Subphrenic abscess </li></ul>
    10. 11. Suprapubic pain <ul><li>Acute urinary retention </li></ul><ul><li>UTIs </li></ul><ul><li>Cystitis </li></ul><ul><li>PID </li></ul><ul><li>Ectopic pregnancy </li></ul><ul><li>Diverticulitis </li></ul>
    11. 12. RIF pain <ul><li>Acute appendicitis </li></ul><ul><li>Mesenteric adenitis (young) </li></ul><ul><li>Perf DU </li></ul><ul><li>Diverticulitis </li></ul><ul><li>PID </li></ul><ul><li>Salpingitis </li></ul><ul><li>Ureteric colic </li></ul><ul><li>Meckel’s diverticulum </li></ul><ul><li>Ectopic pregnancy </li></ul><ul><li>Crohn’s disease </li></ul><ul><li>Biliary colic (low-lying gall bladder) </li></ul>
    12. 13. Loin pain <ul><li>Muscle strain </li></ul><ul><li>UTIs </li></ul><ul><li>Renal stones </li></ul><ul><li>Pyelonephritis </li></ul>
    13. 14. LIF pain <ul><li>Diverticulitis </li></ul><ul><li>Constipation </li></ul><ul><li>IBS </li></ul><ul><li>PID </li></ul><ul><li>Rectal Ca </li></ul><ul><li>UC </li></ul><ul><li>Ectopic pregnancy </li></ul>
    14. 15. Limitations <ul><li>Limitations based on the relationship between </li></ul><ul><ul><li>Overlying tenderness </li></ul></ul><ul><ul><li>Underlying surgical disease </li></ul></ul><ul><li>35% of intra-operative diagnoses are considered to have had atypical presentations 3 </li></ul>3 Staniland, JR, Br Med J 3:393, 1972
    15. 16. Key points on history <ul><li>Site </li></ul><ul><li>Nature & character </li></ul><ul><li>Duration </li></ul><ul><li>Intensity </li></ul><ul><li>Precipitating & relieving factors </li></ul><ul><li>Associated symptoms </li></ul>
    16. 17. Classification by nature <ul><li>Colicky pain </li></ul><ul><ul><li>Baseline of no pain in true colic </li></ul></ul><ul><ul><li>IBS </li></ul></ul><ul><ul><li>Bowel obstruction </li></ul></ul>
    17. 18. Nagging & Grumbling <ul><li>Biliary colic </li></ul><ul><li>Cholecystitis </li></ul><ul><li>PID </li></ul><ul><li>UTI </li></ul>
    18. 19. Stabbing <ul><li>AAA </li></ul>
    19. 20. Burning or boring <ul><li>PUD </li></ul><ul><li>Oesophagitis </li></ul>
    20. 21. Gnawing <ul><li>Pancreatitis </li></ul><ul><li>Pancreatic Ca </li></ul>
    21. 22. Associated symptoms <ul><li>Fever </li></ul><ul><li>Genitourinary </li></ul><ul><li>Gynaecological </li></ul><ul><li>Vascular </li></ul>
    22. 23. PMSH <ul><li>Previous episodes of AP </li></ul><ul><li>Investigations </li></ul><ul><li>Operations </li></ul><ul><li>Chronic disease </li></ul><ul><li>Immunosuppression </li></ul><ul><li>Medications (NSAIDs) </li></ul>
    23. 24. Physical examination <ul><li>OBS are important </li></ul><ul><li>Observation </li></ul><ul><ul><li>Bending Forward: Chronic Pancreatitis </li></ul></ul><ul><ul><li>Jaundiced: CBD obstruction </li></ul></ul><ul><ul><li>Dehydrated: Peritonitis, Small Bowel obstruction </li></ul></ul>
    24. 25. Systemic Examination <ul><li>Abdomen: </li></ul><ul><li>Inspection </li></ul><ul><ul><li>- Scaphoid or flat in peptic ulcer </li></ul></ul><ul><ul><li>- Distended in ascites or intestinal obstruction </li></ul></ul><ul><ul><li>- Visible peristalsis in a thin or malnourished patient (with obstruction) </li></ul></ul>
    25. 26. Systemic Examination <ul><li>Palpation </li></ul><ul><li>Check for Hernia sites </li></ul><ul><li>Tenderness </li></ul><ul><li>Rebound tenderness </li></ul><ul><li>Guarding- involuntary spasm of muscles during palpation </li></ul><ul><li>Rigidity- when abdominal muscles are tense & board-like. Indicates peritonitis. </li></ul>
    26. 27. Systemic Examination <ul><li>Local Right Iliac Fossa tenderness: </li></ul><ul><ul><li>Acute appendicitis </li></ul></ul><ul><ul><li>Acute Salpingitis in females </li></ul></ul><ul><li>Low grade, poorly localized tenderness: </li></ul><ul><ul><li>Intestinal Obstruction </li></ul></ul><ul><li>Tenderness out of proportion to examination: </li></ul><ul><ul><li>Mesenteric Ischemia </li></ul></ul><ul><ul><li>Acute Pancreatitis </li></ul></ul><ul><li>Flank Tenderness: </li></ul><ul><ul><li>Perinephric Abscess </li></ul></ul><ul><ul><li>Retrocaecal Appendicitis </li></ul></ul>
    27. 28. Appendicitis Right lower quadrant pain with palpation of the left lower quadrant Rovsing's sign Pelvic inflammatory disease Manipulation of cervix causes patient to lift buttocks off table Chandelier sign Retroperitoneal haemorrhage Discoloration of the flank Grey-Turner's sign Appendicitis Internal rotation of flexed right hip causing abdominal pain Obturator's sign Appendicitis Hyperextension of right hip causing abdominal pain Iliopsoas sign Acute cholecystitis Abrupt interruption of inspiration on palpation of right upper quadrant Murphy's sign Appendicitis Tenderness located 2/3 distance from anterior iliac spine to umbilicus on right side McBurney's sign Splenic rupture Ectopic pregnancy rupture Severe left shoulder pain Kehr's sign Retroperitoneal haemorrhage Bluish periumbilical discoloration Cullen's sign Association Finding Sign Important Signs in Patients with Abdominal Pain
    28. 29. Physical examination <ul><li>Auscultation </li></ul><ul><ul><li>BS </li></ul></ul><ul><ul><li>> 2min to confirm absent </li></ul></ul><ul><ul><li>High pitched, hyperactive or tinkling </li></ul></ul><ul><ul><li>Bruit in epigastrium </li></ul></ul>
    29. 30. Systemic Examination <ul><li>PR Examination: </li></ul><ul><li>- tenderness </li></ul><ul><li>- induration </li></ul><ul><li>- mass </li></ul><ul><li>- frank blood </li></ul>
    30. 31. Systemic Examination <ul><li>PV Examination </li></ul><ul><li>- Bleeding </li></ul><ul><li>- Discharge </li></ul><ul><li>- Cervical motion tenderness </li></ul><ul><li>- Adnexal masses or tenderness </li></ul><ul><li>- Uterine Size or Contour </li></ul>
    31. 32. Surgical Myths <ul><li>Rebound tenderness, considered the clinical indicator of peritonitis, has a high (25%) false -ve rate 4 </li></ul><ul><li>Rigidity, referred tenderness & cough pain are sufficient evidence for peritonitis 5 </li></ul><ul><li>Except for detection of blood, routine PR exams add little to clinical assessment 6 </li></ul><ul><li>Administration of analgesics prior to surgical consultation does not obscure the diagnosis, but improves accuracy 7 </li></ul>4 Liddington, MI and Thomson, WH, Br J :795, 1991 5 Bennett, DH Br Med J 308:1336, 1994 6 Manimaran, N et al. Ann Roy Col Surg Engl 86:292 2004 7 Brewster, GS et al. 2000 West J Med 172:209
    32. 33. Initial management <ul><li>1st 20 sec there are only 3 diagnoses: </li></ul><ul><ul><li>Very ill: </li></ul></ul><ul><ul><ul><li>Going to die? </li></ul></ul></ul><ul><ul><ul><li>ask for help & resus </li></ul></ul></ul><ul><ul><li>ill: </li></ul></ul><ul><ul><ul><li>stable for couple h? </li></ul></ul></ul><ul><ul><ul><li>Urgent investigations, initial diagnosis & management </li></ul></ul></ul><ul><ul><li>Reasonably well: </li></ul></ul><ul><ul><ul><li>Investigate as appropriate </li></ul></ul></ul><ul><ul><ul><li>formulate diagnosis. </li></ul></ul></ul>
    33. 34. Initial management <ul><li>ABCDE </li></ul><ul><li>Resuscitation & analgesia (opioid IV) </li></ul><ul><li>Full monitoring (including UO) </li></ul><ul><li>Low threshold in seeking senior help </li></ul>
    34. 35. Investigations <ul><li>FBC (Hb & WCC) </li></ul><ul><li>Amylase (Pancreatitis) </li></ul><ul><li>U&Es, LFTs </li></ul><ul><li>Clotting (acute pancreatitis, sepsis, DIC, liver disease) </li></ul><ul><li>Glucose (BM) </li></ul><ul><li>G&S (X-match if necessary) </li></ul><ul><li>ABG </li></ul><ul><li>ECG </li></ul><ul><li>Cardiac enzymes (if appropriate) </li></ul>
    35. 36. Investigations <ul><li>Attention to the WCC as a screening test only if substantially elevated. </li></ul><ul><ul><li>25% of patients with elevated WCC do not have different outcomes from those with a normal WCC 8 </li></ul></ul><ul><li>FBC has a limited clinical utility </li></ul>
    36. 37. Investigations <ul><li>Urinalysis </li></ul><ul><ul><li>Cheap </li></ul></ul><ul><ul><li>Simple & readily available test </li></ul></ul><ul><ul><li>High yield when results fit with the clinical scenario </li></ul></ul><ul><ul><li>MSU </li></ul></ul><ul><li>Pregnancy test </li></ul>
    37. 38. Investigations <ul><li>Radiology </li></ul><ul><ul><li>Erect CXR </li></ul></ul><ul><ul><li>Supine AXR </li></ul></ul><ul><ul><li>USS (?gynae pathology) </li></ul></ul><ul><ul><li>IVU (renal/ureteric colic) </li></ul></ul>
    38. 39. Investigations <ul><li>Plain X-rays have limited utility in the evaluation of AAP </li></ul><ul><ul><li>Low diagnostic yield </li></ul></ul><ul><ul><li>High incidence of misleading incidental findings </li></ul></ul><ul><ul><li>Lack of impact on management </li></ul></ul><ul><ul><li>Exception: Bowel obstruction or perforation </li></ul></ul>
    39. 40. CT scanning <ul><li>No significant advantage in DD of AAP </li></ul><ul><li>Delay of necessary treatment </li></ul><ul><li>Routine use not justified </li></ul><ul><li>Hx taking & physical examination are the basis of correct diagnosis 8 </li></ul><ul><li>Hx, physical examination & lab investigations are often non-specific </li></ul><ul><li>CT is now 1st-line imaging modality in pts with APP. </li></ul><ul><li>MDCT is now faster with thinner slices </li></ul><ul><li>High diagnostic accuracy 9 </li></ul>8 Keeman JN, New diagnostic imaging technology offten offers no advantage in the differential diagnosis of acute abdomen. Ned Tijdschr Geneeskd. 1999. Nov. 6:143(45):2225-9 9 Leschka et al,Multi-detector computer tomography of acute abdomen. Eur Radiol. Dec;15(12):2435-47. 2005
    40. 41. Laparoscopy 10,11 <ul><li>Early diagnostic laparoscopy may result in: </li></ul><ul><ul><li>accurate, </li></ul></ul><ul><ul><li>prompt, </li></ul></ul><ul><ul><li>efficient management of AAP </li></ul></ul><ul><li>Reduces the rate of unnecessary laparotomy </li></ul><ul><li>Increases the diagnostic accuracy </li></ul><ul><li>May be a key to solving the diagnostic dilemma of NSAP. </li></ul>10 Golash and Willson. Early laparoscopy as a routine procedure in the management of acute abdominal pain: a review of 1320 patients. Surg Endosc. 2005 Jul;19(7):882-5 11 Keller et al. Diagnostic laparoscopy in acute abdomen. Chirurg. 2006 Nov;77(11):981-5
    41. 42. Suggestions <ul><li>Audit of all patients referred with AAP to assess: </li></ul><ul><ul><li>Initial diagnosis </li></ul></ul><ul><ul><li>Choice & diagnostic efficacy of investigations </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><li>Timing (length of stay) </li></ul></ul><ul><ul><li>Cost effectiveness </li></ul></ul>
    42. 43. Thank you