emergencies in patient with abdominal pain to be ruled out first that might save the patients life , with ther clinical minute diagnosis and management in the ER then and there.

1. ACUTE ABDOMINAL PAIN
by-Dr.Paila Naveen.
Mentor-Dr.Hasmitha
Head-Dr.Bharath mugada.

2. "Everything should be made as simple as
possible, but not simpler."
-Albert Einstein

3. PATHOPHYSIOLOGY
• VISCERAL PAIN
Stretching of ummylenated fibre's
Crampy ,dull/aching type .
It can be steady or intermittant.
Segmental distribution of visceral pain

4. PARIETAL PAIN
• Irritation of the myelinated fibers which
innervate the parietal peritoneum.
• In due evolvement of the disease this pain
gives way for Guarding and Rigidity signs.
• Patients have rebound tenderness and pain
increases with mobility.

5. REFERRED PAIN
• This pain id based on development embriology.
• Pain is felt at a location distant fron diseased
organ.
Convergence –projection
theory.
the basis for referred pain is
due to the convergence of
somatic and visceral fibers on
the second order in dorsal horn
that project to the thalamus
and then to somatosensory
fibers.

6. CLINICAL RISK.
• Patient acuity and risk factors
Markers of patient Acuity:
1. Severe pain of rapid onset
2. Abnormal vital signs (Tachycardia, Tachyopnea, low BP)
3. Signs of shock
4. Dehydration
5. Visceral involvement
(eg.pallor,diaphoresis,vomiting)

7. PAIN DISTRIBUTION OVER THE
ABDOMEN.
• DIFFUSE
• RIGHT UPPER QUADRANT PAIN (RUQ)
• LEFT UPPER QUADRANT PAIN (LUQ)
• RIGHT LOWER QUADRANT PAIN (RUQ)
• LEFT LOWER QUADRANT PAIN (LUQ)

9. Features of high risk abdominal pain.

11. DIVISION
• GENERAL.
• UPPER.
• LOWER.
• PELVIC.

12. CASE HISTORY
• A 66 years old Caucasian male presented with a 3 days history of nausea,
vomiting, right lower abdominal pain and lower back pain. He had been
complaining from upper abdominal discomfort for few months before his
admission, this was treated as gastritis by his General Practitioner
• The patient was known to have chronic obstructive air way disease (on
inhalers). He was a smoker for years, who smoked about 25 cigarettes a
day.
• On clinical examination he was fully orientated, alert and not pale. His
vital signs chart showed a temperature of 36.6°C, pulse of 85 and blood
pressure of 153/61. Abdominal examination revealed a tender expansile
mass in the upper abdomen with peritonism in the right iliac fossa.
• His blood tests showed elevated WCC of 13000 and CRP of 64 with normal
Hb and other parameters. Due to his abdominal signs, an immediate
abdominal Computerized Tomography (CT) scan was arranged
DIFFERENTIAL DIAGNOSIS?

13. DIAGNOSIS?

14. Ruptured/leaking abdominal aortic
aneurysm (AAA)
Clinical
M/C
• Usually asymptomatic until rupture.
• Acute epigastric & back pain .
• Wide pulsatile abdominal mass .
• Shock.
The only physical exam maneuver of demonstrated value is abdominal palpation to
detect abnormal widening of aortic pulsation →Sensitivity 76% for AAAs greater
than 5cm .

15. U/C
• Syncope (5% of ruptured AAA)
• Renal colic mimic (back pain, hematuria)
• Diverticulitis mimic (LLQ pain, guaiac pos stools)
• Neuropathy
• Unexplained ecchymosis
• Fistula (Aorto-caval or aorto-enteric fistulas)
✓ Retroperitoneal rupture → compressive
neuropathy to femoral/obturator nerve → ant
thigh pain/numbness & weak knee flex/hip
extension)
✓ Blue toe syndrome (embolism from AAA)
✓ GI bleed in patient with AAA or AAA repair is Aorto-Enteric Fistula
(until proven otherwise)

16. Pain characteristics
• LOCATION-Mid-abdomen or flank.
• RADIATION -Back, groin, or thigh.
• ONSET-Severe, sudden, constant.

17. Transverse image of an abdominal
aortic aneurysm

19. Risk factors
• Age
• male
• HTN
• smoking
• CAD/PVD,
• Fam hx
Work-up
• ED U/S
 ED physicians can accurately determine the presence of AAA
as well as the maximal aortic diameter
 Use for an unstable patient that can’t go to CT
 Use to look for alternate diagnosis
• CT scan
 Best study for stable AAA →measure size and extent
Disposition options
• Risk of rupture increases as size increases.
• Incidental AAA < 5.5cm
 Observation vs home, close follow-up (discuss with surgery dept)
 No improved survival seen with repair of small aneurysms < 5.5cm
• Incidental AAA>5cm
 Admit Surgical eval → OR (unless high risk)
• AAA + unexplained symptoms
 Surgery consult + monitored bed or the OR Blood pressure control
(β-blocker + Nipride vs Labetalol)

20. • Ruptured AAA
 OR (fatal if not treated surgically) Resuscitation
✓ Large bore IVs, IVF, T&C 6 Units PRBCs
Poor prognostic factors: hypotension, ↓hematocrit,
advanced age.
O
R
Indications for OR
• Ruptured AAA
• symptomatic,
• rapid expansion
• asymptomatic > 5.5cm

21. • A 48-year-old woman presented to the ED with significant periumbilical
abdominal pain and left lower extremity pain, She stated that the pain
worsened with movement and change in position. The claudication in the
patient’s left lower extremity began a few weeks prior to presentation, at
which time she had received medical attention, The patient noted that
when the abdominal pain began, the pain in her leg became more
frequent and of higher intensity, with intermittent numbness. She
reported some nausea, paresthesia, and sensory changes to the left lower
extremity; however, she denied diarrhea, headache, fever, back pain,
urinary symptoms, chest pain, and shortness of breath.
• Smoker+ ocassional alcoholic+ H/O colon cancer 4 yrs back under gone
resection.
• During the physical examination, the patient was diaphoretic,
uncomfortable, and in severe distress. BP:146/77 mm Hg; RR: 18 /Min HR:
129 bPM; TEMP:Normal
• Spo2:94%
• distention+ tenderness+ guarding+ rigidity+ rebound tenderness+.
• Absent palpable dorsalis pedis pulse to the left lower extremity, The right
lower extremity had palpable dorsalis pedis and posterior tibial pulses.
DIFFERENTIAL DIAGNOSIS?

22. ACUTE MESENTERIC ISCHEMIA
• Embolism from
dislodged thrombus
in LV, LA, A-fib, or
heart valves →
impacted 3- 10cm
from SMA origin.
M/C
Atrial fibrillation

25. CLINICAL FEATURES
Classic Triad
• Pain out of proportion to exam
• Gut emptying (vomiting/diarrhea)
• Underlying cardiac disease
1/3 of patients have had a previous embolic
event.
ACS OF THE GUT

26. Work-up
• Labs: Non-specific and occur late, once bowel necrosis
has occurred ↑Lactate: late sign, not diagnostic but
predictive of mortality.
• Xray Plain films: used to exclude other causes of
abdominal pain.
• CT A/P Findings
✓ Focal/segmental bowel wall thickening, thumb printing,
mesenteric v. thrombus
✓ Non-enhancement of arteries
✓ Pneumatosis, portal venous gas
• Angiography: definitive study, diagnostic and
therapeutic

27. Erect abdomen X-RAY.

28. COMPLICATIONS
TO AVOID THIS WE TREAT ASAP

29. TREATMENT
• Mortality 70-90% overall →diagnosis prior to infarction is strongest
predictor of survival
• Resuscitation→ IVF, management of arrhythmias/CHF,
correction of acidosis
• Antibiotics (treat bacterial translocation)
• Anticoagulation (Heparin)→arterial & venous
thrombosis/embolism
• Thrombolysis→arterial embolism
• Vasodilation (Papaverine) (An infusion of 30-60 mg/hr may be started
after angiography) →NOMI
• IR: Vasodilator/stent therapy,
thrombectomy/embolectomy
• Surgery: Arterial bypass, resection of necrotic bowel

30. • A 75-year-old lady presents with a 6-hour
history of severe, gripping abdominal pain
that peaks in waves. She has had eight
episodes of bilious vomiting. She denies any
urinary or bowel symptoms. Her co-
morbiditiesHTN, osteoporosis and
Hypercholesterolaemia.Non smoker non
alcoholic
• EXAMINATION
Vital signs: temperature of 36.7°C, heart rate of 108, blood pressure of 154/78,
respiratory rate of 22, 97% saturation on room air.Her abdomen is tender in the peri-
umbilical region and distended. She has hyper-resonant Bowel sounds but no
organomegaly or peritonism. There is a mass extending into the inner thigh area that
is irreducible and tender. The contents are tense and feel like bowel. The overlyingskin
is normal..
DIFFERENTIAL DIAGNOSIS?

31. BOWEL OBSTRUCTION

32. Causes

33. CLINICAL FEATURES
• There are four cardinal signs of IO:
1. Colicky pain
2. Distension
3. Vomiting
4. Absolute constipation.
These clinical features are also influenced by site of
obstruction wether
• Small bowel
• Large bowel
And on the onset of obstruction.
• Acute
• Chronic
• Acute on chronic.

36. COMPLICATIONS
Hypovolemia
intestinal ischemia
infarction
peritonitis and sepsis

37. INVESTIGATIONS
Lab Investigations:
• FBC
• Clooting profile
• ABG
• Optional (ESR,CRP,LFT,TUMOR
MARKERS)
-High Hb and hematocrit
-leukocytosis
-anemia
+electrolyte depletion
Radiological:
• X-Rays -gas pattern(dilated loops)
Small bowel-valvulae coniventes
Large bowel-haustrations.
-Fluid levels
-Masses shadow
-Fecal pattern

38. U/S -FREE FLUID
-MASSES
-MUCOSAL FOLDS
-PATTERN OF PERISTALYSIS
CT,MRI,CONTRAST STUDIES -LEVEL OF OBSTRUCTION
-PARTIALOR COMPLETE
--CAUSE OF THE OBSTRUCTION.
OPTIONAL
(COLONOSCOPY,ENDOSCOPY,LAPROS
COPY)

40. TREATMENT OF ACUTE INTESTINAL OBSTRUCTION
Measures to treat intestinal obstruction
• Gastrointrestinal drainage
• Fluid and electrolyte replacement
• Relief of obstruction
• Surgical treatment
Non-operative trial Up to 75% with partial SBO and
35-50% complete SBO resolve with IVF and bowel
decompression alone.

41. When to go ?
Early surgery
• Signs of strangulation (fever, peritonitis)
• De novo obstruction (no h/o abdominal
surg/adhesions)→unlikely to respond to
conservative treatment .

43. FINDINGS AND CAUSES?

44. BOWEL PERFORATION

45. HISTORY
Age
Abdominal Pain(All questions of pain>>SOCRATES
Vomiting
 Hiccups
 Endoscopic procedures
 Chronic history (As in UC)
 History of Trauma (Penetrating)
 History of NSAID use

46. EXAMINATION
• Assess the patient's general appearance
• Examine the abdomen for any external signs of injury,
abrasion or ecchymosis.
• Observe patients' breathing patterns and abdominal
movements with breathing, and note any abdominal
distention or discoloration. (INSPECTION)
• Tenderness on percussion may suggest peritoneal
inflammation. (PALPATION)
• Bowel sounds are usually absent in generalized peritonitis.
(ASCULTATION)
• Rectal and bimanual vaginal and pelvic examinations may
help in assessing conditions such as acute appendicitis,
ruptured tubo-ovarian abscess, and perforated acute
diverticulitis.(P/V, P/R)

47. Signs and symptoms

48. INVESTIGATIONS
Baseline Investigations
• Complete blood count
• Serum Electrolytes
• RBS
• Virology
• LFTs and RFTs

49. Specific Investigations
• Ultrasound Abdomen
• X-ray ABDOMEN erect and supine
• CT Scan abdomen
• Laparoscopy
• Peritoneal Diagnostic Tap

50. TREATMENT
• TREATMENT FOR INTESTINAL PERFORATION IS
ALWAYS SURGICAL !!!
• PRE SURGICAL WORKUP
• Keep Patient NPO
• Establish intravenous access, and initiate
crystalloid therapy in patients with clinical signs
of dehydration or septicemia
• Start intravenous administration of antibiotics to
patients with signs of septicemia

51. USE OF ANTIBIOTICS.

52. INITIAL
RESUSCITATION1  ABCs
 IV/O2/Monitor
 Resuscitation:IVF/PRBCs?
 Surgery consult?
2 CRITICAL
CONDITION
AAA
 Usually asymptomatic till rupture
 Acute enigastric and back pain
 Wide pulasatile abdominal mass
 Syncope,shock
 Renal mimic (back pain,hematuria)
 Diverticulitis mimic (LLQ pain,guaiac +stools)
 Risk
factors(age,male,HTN,smoking,CAD/pvd,Female)
STABLE
• CT Scan
UNSTABLE
• Bedside USG
• OR
MESENTERIC
ISCHEMIA
 Risk factors:elderly,etiology specific.
 Sudden abdominal pain,poorly localized
out of proportion to exam (visceral pain)
 Gi bleeding(SMA supplies R colon)
 Late:Peritoneral signs
 Subacute:gradual development vague
abdominal S/Sx
LABS
Met acidosis
Raised:lactate,wbc,
amylase,hb,LDH,guaiac
stools
CT vsAngiography
• IVF/Abx/Anticoag
• Papaverine?
• surgery

53. BOWEL
PERFORATION.
 Sudden onset sharp ,severe abdominal pain
 Peritoneal signs,rigidity,rebound guarding.
 Motionless,distress.
• Upright CXR:
free air
• CT?
• Antibiotics?
• NG suction
• Surgery C/S
BOWEL
OBSTRUCTION
 Colicky Abdominal pain.
 Abdominal distension
 Vomiting (bilious,feeculent)
 Obstipation/constipation.
• AAs:Obstructive
pattern,air/fluid
levels.
• IVF/Decompres
ssion (NG)
• CT?Antibiotics?
• Surgery
Consult.
REFFERED PAIN
 MYOCARDIAL INFRACTION
 AORTIC DISSECTION
 PNEUMONIA-LOWER LOBE
 PULMONARY EMBOLISM.
• ECG
• CXR
• Further testing
as needed.

54. CONCLUSION
• A lesson frequently relearned by everyone is that
if one listens carefully, the patient will tell the
physician the diagnosis. The history and physical
should yield the diagnosis some 90-95% of the
time. Additional testing should be used to confirm
the presumptive diagnosis. It is rare that “fishing”
with laboratory tests will yield a diagnosis when
the H&P does not and this practice should be
condemned. This cannot be stressed enough. It
will keep the physician from “shotgunning”
unnecessary laboratory and X-ray tests, wasting
time and patient’s money. When in doubt, go back
and talk with and re-examine the patient

55. “Think mechanical and work
mechanical, if U are lazy
enough better not take an Acute
Abdomen Case.”
• THANK YOU

56. REFRENCES.
• Tintinallis guide of emergency medicine.
• Rosens textbook of emergency medicine.(Rosen’s Emergency Medicine:
Chapter 90, Disorders of the Small Intestine)
• Emergency medicine, clinical essentials, ed 2, Philadelphia, 2013, Elsevier.)
• (Soto JA, Lucey BC: Emergency radiology: the requisites, ed 2,
Philadelphia, 2017, Elsevier.)
• (CMEDownload:UCSF High Risk 2009-Snoey
• (Essentials 2012-"AAA The Great Masquerader")
• (Arch Intern Med. 2004;164:1054-1062, Gastroenterology 2000;118:951-
968)
• (Essentials 2012: "There is a Clot in the Gut")
• FERRI’S CLINICAL ADVISOR 2019
• A,B,C Differential Diagnosis of Emergency medicine.
• UPTODATE.
• The Chief Complaint Emergency Medical Handbook 2014.

57. Vote of thanks
• Dr Bharath.
• Dr Hashmitha.