Recommended
More Related Content
What's hot
What's hot (20)
Similar to Approach to Acute Abdominal Pain (in emergency ward)
Similar to Approach to Acute Abdominal Pain (in emergency ward) (20)
More from niraj phoju
Recently uploaded
Recently uploaded (20)
Approach to Acute Abdominal Pain (in emergency ward)
- 1. Department of Emergency Medicine H o w t o a p p r o a c h a c a s e o f i n e m e r g e n c y ? Niraj Phoju (94)Dhruba Chhetri (93)
- 2. Objectives: To assess a patient complaining of acute abdomen. To formulate the differential diagnosis for acute abdomen. To initiate basic initial therapy for a patient in acute abdomen. To consult the patient to medicine or surgical ward.
- 3. 26 yrs male presented to the ED of KISTMCTH at 11 am with the complain of left lower abdomen pain for 1 hr. The vitals was stable at the time of presentation and later on USG bilateral nephrolithiasis with mild hydronephrosis on left kidney was found. The pain subsided after IV analgesic and the patient left on LAMA. 43yrs male presented to ED of KISTMCTH at 9 am with the complain of Pain in right lower region for 1 day. The vitals was stable at the time of presentation and later on USG the diagnosis of Acute appendicitis was made. Later after surgical consultation, emergency open appendectomy was planned.
- 4. Definition Acute abdomen is a term used to include a spectrum of surgical, medical and gynecological conditions, ranging from trivial to life threatening, which require hospital admission, investigation and treatment.
- 5. •Nature and quality of pain is difficult for patient to explain •Location and severity of pain may change over time •Atypical and variable presentations common •Abdominal pain in women •Extra-abdominal cause of abdominal pain •Referred pain Challenges
- 6. A n a t o m y Regions of abdomen Development Nerve supply
- 7. A n a t o m y Regions of abdomen Development Nerve supply
- 9. A n a t o m y Regions of abdomen Development Nerve supply
- 10. A n a t o m y Regions of abdomen Development Nerve supply Abdominal wall and Parietal peritonium Somatic nerves Abdominal organs and visceral peritonium Autonomic nerves
- 11. C a u s e s o f A c u t e A b d o m e n
- 12. Based on site of pathology : • Intra-peritoneal • Retro-peritoneal • Pelvic Abdomino-pelvic causes: • Eg. Pneumonia, MI, Diabetic ketoacidosis Non-abdomino-pelvic causes:
- 13. Peptic ulcer perforation Acute pancrestitis Intestinal ischemia Diabetic ketoacidosis Henoch-Schonlein Purpura Acute adrenal insufficiency Lead poisoning Acute intermittent porphyria Acute appendicitis Acute cholecystitis Renal colic Acute diverticulitis Acute salpingitis Acute intestinal obstruction
- 17. Severe pain= Triage 2 Abdominal pain with stable vitals= Triage 3 Triage
- 18. History : SOCRATES Site Onset Character Radiation Associated symptoms Time Exacerbating factors Severity
- 19. History : SOCRATES Site: where do you fell the pain most? Onset: can you remember how it started? Did it come over a few mins, hrs or days? Character: how would you describe the pain? Is it always there or does it come and go? Radiation: does it always stay there or does it move? Associated symptoms: do you have any other symptoms? Time: how long have you had the pain? Exacerbating factors: do you think is it getting better or worse? Does anything makes it better or worse? Severity: (Subjective) Score pain from 1-10
- 20. History: Site of pain • Where do you fell the pain most?
- 21. History : SOCRATES Site: where do you fell the pain most? Onset: can you remember how it started? Did it come over a few mins, hrs or days? Character: how would you describe the pain? Is it always there or does it come and go? Radiation: does it always stay there or does it move? Associated symptoms: do you have any other symptoms? Time: how long have you had the pain? Exacerbating factors: do you think is it getting better or worse? Does anything makes it better or worse? Severity: (Subjective) Score pain from 1-10
- 22. History : SOCRATES Site: where do you fell the pain most? Onset: can you remember how it started? Did it come over a few mins, hrs or days? Character: how would you describe the pain? Is it always there or does it come and go? Radiation: does it always stay there or does it move? Associated symptoms: do you have any other symptoms? Time: how long have you had the pain? Exacerbating factors: do you think is it getting better or worse? Does anything makes it better or worse? Severity: (Subjective) Score pain from 1-10
- 23. History: Onset and Character • How would you describe the pain? Is it always there or does it come and go? • Dull/ Sharp/ Burning/ Steady/ Intermittent/ Throbbing
- 24. History : SOCRATES Site: where do you fell the pain most? Onset: can you remember how it started? Did it come over a few mins, hrs or days? Character: how would you describe the pain? Is it always there or does it come and go? Radiation: does it always stay there or does it move? Associated symptoms: do you have any other symptoms? Time: how long have you had the pain? Exacerbating factors: do you think is it getting better or worse? Does anything makes it better or worse? Severity: (Subjective) Score pain from 1-10
- 25. History : SOCRATES Site: where do you fell the pain most? Onset: can you remember how it started? Did it come over a few mins, hrs or days? Character: how would you describe the pain? Is it always there or does it come and go? Radiation: does it always stay there or does it move? Associated symptoms: do you have any other symptoms? Time: how long have you had the pain? Exacerbating factors: do you think is it getting better or worse? Does anything makes it better or worse? Severity: (Subjective) Score pain from 1-10
- 26. Associated symptoms • Diarrhea, constipation, bleeding, distension GI: • Jaundice Hepatobiliary: • Dysuria, oliguria Urological: • LMP, timing of symptoms with menstrual cycle Gynecological: Pyrexia , Malaise, Nausea, Vomiting Malignancy: weight loss, fatigue and loss of appetite
- 27. History : SOCRATES Site: where do you fell the pain most? Onset: can you remember how it started? Did it come over a few mins, hrs or days? Character: how would you describe the pain? Is it always there or does it come and go? Radiation: does it always stay there or does it move? Associated symptoms: do you have any other symptoms? Time: how long have you had the pain? Exacerbating factors: do you think is it getting better or worse? Does anything makes it better or worse? Severity: (Subjective) Score pain from 1-10
- 28. History : SOCRATES Site: where do you fell the pain most? Onset: can you remember how it started? Did it come over a few mins, hrs or days? Character: how would you describe the pain? Is it always there or does it come and go? Radiation: does it always stay there or does it move? Associated symptoms: do you have any other symptoms? Time: how long have you had the pain? Exacerbating/Relieving factors: do you think is it getting better or worse? Does anything makes it better or worse? Severity: (Subjective) Score pain from 1-10
- 29. History: Exacerbating/Relieving factors • do you think is it getting better or worse? Does anything makes it better or worse?
- 30. History : SOCRATES Site: where do you fell the pain most? Onset: can you remember how it started? Did it come over a few mins, hrs or days? Character: how would you describe the pain? Is it always there or does it come and go? Radiation: does it always stay there or does it move? Associated symptoms: do you have any other symptoms? Time: how long have you had the pain? Exacerbating factors: do you think is it getting better or worse? Does anything makes it better or worse? Severity: (Subjective) Score pain from 1-10
- 31. Other History Past medical and surgical history Drug use Social history: alcohol, smoking, blood transfusion, tattoos, IV drug abuse, foreign travel Family history: IBD, Peptic ulcers, Colorectal carcinoma Last meal
- 32. Abdominal examination Inspection Palpation Percussion Auscultation General examination Appearance Position Vitals
- 37. Signs of peritonitis Murphy’s sign Grey Turner’s sign Cullen’s sign • Rovsing’s sign • Pointing sign • Psoas sign • Obturator sign Signs for appendicitis
- 39. Clinical featuresConditions History Examination Acute appendicitis Nausea, vomiting, central abdominal pain which later shifts to the right iliac fossa Fever, tenderness,palpable mass in the right iliac fossa. Acute pancreatitis Anorexia, nausea, vomiting, constant severe epigastric pain, previous alcohol abuse/cholelithiasis Fever, periumbilical or loin bruising, epigastric tenderness, variable guarding, reduced or absent bowel sounds Acute diverticulitis Lower abdominal pain,nausea dairrhoea or constipation and may be blood in stool. Fever, tenderness. Acute cholecystitis Pain in right hypochondrium that may radiate to shoulder or scapula,nausea & vomiting Fever, tenderness, murphy’s sign
- 40. Pelvic inflammatory disease Sexually active young female,STD history,recent gynaecological procedure,pregnancy or use of intruterine contraceptive device,lower abdominal pain,irregular mensturation. Fever, vaginal discharge, pelvic peritonitis causing tenderness on rectal examination, right upper quadrant tenderness, pain/tenderness on vaginal examination (cervical excitation), swelling/ fullness in the fornix on vaginal examination
- 41. Peptic ulcer vomiting at onset associated with severe acute onset abdominal pain, previous history of dyspepsia, ulcer disease, NSAIDs or corticosteroid therapy Shallow breathing with minimal abdominal wall movement, abdominal tenderness and guarding, board-like rigidity, abdominal distention and absent bowel sound. Ruptured ectopic pregnancy premenopausal; delayed or missed menstrual period, hypotension, unilateral iliac fossa pain, pleuritic shoulder tip pain, ‘prune juice’-like vaginal discharge Suprapubic,tenderness,periumbilical bruising, pain and tenderness on vaginal examination (cervical excitation), swelling/ fullness in the fornix on vaginal examination Ruptured aortic aneurysm Sudden onset of severe, tearing back/loin/abdominal pain, hypotension and past history of vascular disease and/or high blood pressure Shock and hypotension, pulsatile, tender, abdominal mass, asymmetrical femoral pulses
- 42. Intestinal obstruction Colicky central abdominal pain, nausea, vomiting and constipation Surgical scars, hernias, mass, distension, visible peristalsis, increased bowel sounds Ureteric colic Flank pain(colicky) that may radiate to hypochondrium. Tenderness,
- 43. Diabetic ketoacidosis Nausea and vomiting,abdominal pain,excessive thrist and urine production,diabetis history usually. Tenderness,dry mouth,ketotic odor is present Acute intermittent porphyria Severe and poorly localized abdominal pain.urinary symptoms(painful urination, urinary retention). High blood pressure,↑heart rate ,proximal muscle weakness.
- 44. Blood • CBC • C-reactive protein • Urea and Electrolytes • Serum amylase, lipase • LFT, RFT • ABG • Blood glucose • Ca++ Urinalysis • Microscopy • Dip stick test • UPT Radiology • Plain X-Ray • USG • Contrast studies • CT Endoscopy Peritoneal • Lavage • Laparoscopy Investigations
- 46. Management: •The main therapeutic goals in managing acute abdominal pain are physiologic stabilization, mitigation of symptoms (e.g, nausea and pain), and expeditious diagnosis, with consultation if required. Immediate Management
- 48. Disposition from ED: • Clinical findings : Subsided • Vitals : Normal or near normal • Abdominal examinations : No abnormal findings • Able to take fluids by mouth Consider followings before discharge: Clear instruction for Follow-up.
- 50. Peptic ulcer perforation Acute pancrestitis Intestinal ischemia Diabetic ketoacidosis Henoch-Schonlein Purpura Acute adrenal insufficiency Lead poisoning Acute intermittent porphyria Acute appendicitis Acute cholecystitis Renal colic Acute diverticulitis Acute salpingitis Acute intestinal obstruction
- 51. Investigations
- 52. References: Rosen’s Emergency Medicine Concepts and Clinical Practice, 9th Tintinallis Emergency Medicine A Comprehensive Study Guide, 8th Davidson's Principles and practice of medicine, 22nd Edition Principles and Practice of Surgery 7th Edition 2017 Bailey and Love’s Short Practice of Surgery, 26th Edition
Editor's Notes
- Severe abdominal pain Sudden onset or gradual Less than 24 hr duration Unclear etiology Symptom of many diseases
- Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like; 1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia 2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis 3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
- Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like; 1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia 2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis 3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
- Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like; 1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia 2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis 3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
- Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like; 1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia 2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis 3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
- Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like; 1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia 2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis 3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
- Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like; 1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia 2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis 3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
- Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like; 1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia 2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis 3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
- Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like; 1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia 2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis 3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
- Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like; 1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia 2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis 3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
- h/o immunosuppersive therapy may indicate infection. h/o NSAID/ anti-coagulants may indicate GI bleeding. h/o chronic opoid therapy may indicate constipation or even bowel obstruction. h/o previous surgery may indicate adhesion thus intestinal obstruction.
- Significant tachycardia and hypotension are indicators that hypovolemia or sepsis may be present. Elevated temperature is associated with intra-abdominal infections. Vital signs may be misleading and should be interpreted in the context of the entire presentation. Abdominal examination requires properly positioning the patient supine and exposing the abdomen. For female patients, abdominal evaluation should include a pelvic examination when there is pain or tenderness below the umbilicus.
- Examine each quadrant. Culprit quadrant at last.
- Rectal examination usually has limited use in case of acute abdomen except when there is suspicion of GI hemorrhage, prostatitis or peri-rectal diseases. Main use of digital rectal examination is in the detection of 1. melena or heme-positive stool, 2. anal fissure or fistulae, 3. stool impaction, or 4. the empty vault associated with bowel obstruction. Urogenital examination is important. Testicular torsion Inguinal hernia (risk of srtangulation) In view of the evolving nature of abdominal pain, repetitive examinations are useful.(esp. in case of suspected Appendicitis)