A 24-year-old male presented with one day of abdominal pain localized to the right lower abdomen. On examination, he had tenderness and guarding in the right lower quadrant. The differential diagnosis includes appendicitis. Laboratory tests and a CT scan may be needed to make a definitive diagnosis.
A 68-year-old female presented with two days of left lower quadrant abdominal pain, diarrhea, fever and nausea. She has a history of hypertension and diverticulosis. On examination, she had tenderness in the left lower quadrant. The differential diagnosis includes diverticulitis.
This document provides an overview of gastroenterology and hepatology. It discusses common GI diseases and symptoms, as well as various tests used to evaluate GI structure, infections, and function. These include imaging studies, endoscopy, biopsies, bacterial cultures, serology tests, breath tests, and radioisotope tests to assess conditions like gastric emptying, HP infection, Meckel's diverticulum, bleeding, and malabsorption. Therapeutic endoscopy is highlighted as a less invasive alternative to surgery for many GI conditions.
1. The goal is to rule out life-threatening causes of abdominal pain such as a ruptured abdominal aortic aneurysm or bowel perforation.
2. A urine pregnancy test should be obtained in all women of childbearing age to exclude ectopic pregnancy.
3. The history and physical exam aim to determine the location and characteristics of the pain to narrow the differential diagnosis and guide testing.
Investigations in the case of abdominal painAbino David
This document discusses investigations for abdominal pain. It outlines various examinations of feces, vomitus, ascitic fluid, and radiological tests that can help diagnose the underlying cause of abdominal pain. Macroscopic and microscopic examination of feces can provide clues to conditions like malabsorption, steatorrhea, dysentery, or bleeding. Chemical tests on feces can detect occult blood or measure fat and nitrogen content. Analysis of vomitus may indicate gastric outlet obstruction or gastrocolic fistula. Ascitic fluid appearance and biochemical tests help differentiate between portal hypertension, tuberculosis peritonitis, and malignancy. Radiological investigations include plain films, barium studies, ultrasound, endoscopy, CT, MRI, and laparoscopy
The document describes various medical tests used to evaluate the gastrointestinal system, including non-invasive imaging tests like X-rays, ultrasounds, CT scans, and MRI scans. It also discusses endoscopy procedures like colonoscopy, sigmoidoscopy, and upper endoscopy where a flexible tube with a camera is inserted into parts of the GI tract to examine the inside. Additionally, it provides details on functional tests like anorectal manometry and pH monitoring that evaluate muscle strength and acid levels in the esophagus and rectum.
This document provides an overview of abdominal, hematologic, gynecologic, genitourinary, and renal emergencies. It begins with introducing the case study of a 67-year-old woman experiencing abdominal pain and discusses the chief complaint and physical exam. It then provides introductions to different types of emergencies and outlines abdominal structures and functions. The majority of the document focuses on acute abdominal pain, describing causes like peritonitis, appendicitis, and pancreatitis. It discusses signs and symptoms of different conditions that can cause acute abdominal pain.
This document provides an overview of the management approach for acute abdomen. It begins with definitions and epidemiology, noting that acute abdomen is undiagnosed abdominal pain lasting less than 7-10 days. It then covers the surgical and medical causes, with etiological classifications including inflammatory/infective, perforation, obstruction, infarction, and spontaneous bleeding. Differential diagnoses are provided for different age groups. The management approach involves clinical evaluation, resuscitation, diagnostic tools like ultrasound and CT scan, and categorizing patients based on urgency of condition.
1. The document discusses the evaluation and management of acute abdominal pain in the emergency department. Acute abdominal pain accounts for 4-10% of emergency department visits, with 50% receiving a clear diagnosis and 15-30% requiring surgery.
2. Key points for assessing abdominal pain include differentiating life-threatening causes, performing a thorough physical exam, using analgesics during the exam which does not affect diagnostic accuracy, and considering observation for uncertain diagnoses.
3. Factors such as fever, leukocytosis, and abdominal tenderness on exam can help determine if a patient requires surgery or other specific treatment. Observation with reassessment is appropriate for unclear cases.
This document provides an overview of gastroenterology and hepatology. It discusses common GI diseases and symptoms, as well as various tests used to evaluate GI structure, infections, and function. These include imaging studies, endoscopy, biopsies, bacterial cultures, serology tests, breath tests, and radioisotope tests to assess conditions like gastric emptying, HP infection, Meckel's diverticulum, bleeding, and malabsorption. Therapeutic endoscopy is highlighted as a less invasive alternative to surgery for many GI conditions.
1. The goal is to rule out life-threatening causes of abdominal pain such as a ruptured abdominal aortic aneurysm or bowel perforation.
2. A urine pregnancy test should be obtained in all women of childbearing age to exclude ectopic pregnancy.
3. The history and physical exam aim to determine the location and characteristics of the pain to narrow the differential diagnosis and guide testing.
Investigations in the case of abdominal painAbino David
This document discusses investigations for abdominal pain. It outlines various examinations of feces, vomitus, ascitic fluid, and radiological tests that can help diagnose the underlying cause of abdominal pain. Macroscopic and microscopic examination of feces can provide clues to conditions like malabsorption, steatorrhea, dysentery, or bleeding. Chemical tests on feces can detect occult blood or measure fat and nitrogen content. Analysis of vomitus may indicate gastric outlet obstruction or gastrocolic fistula. Ascitic fluid appearance and biochemical tests help differentiate between portal hypertension, tuberculosis peritonitis, and malignancy. Radiological investigations include plain films, barium studies, ultrasound, endoscopy, CT, MRI, and laparoscopy
The document describes various medical tests used to evaluate the gastrointestinal system, including non-invasive imaging tests like X-rays, ultrasounds, CT scans, and MRI scans. It also discusses endoscopy procedures like colonoscopy, sigmoidoscopy, and upper endoscopy where a flexible tube with a camera is inserted into parts of the GI tract to examine the inside. Additionally, it provides details on functional tests like anorectal manometry and pH monitoring that evaluate muscle strength and acid levels in the esophagus and rectum.
This document provides an overview of abdominal, hematologic, gynecologic, genitourinary, and renal emergencies. It begins with introducing the case study of a 67-year-old woman experiencing abdominal pain and discusses the chief complaint and physical exam. It then provides introductions to different types of emergencies and outlines abdominal structures and functions. The majority of the document focuses on acute abdominal pain, describing causes like peritonitis, appendicitis, and pancreatitis. It discusses signs and symptoms of different conditions that can cause acute abdominal pain.
This document provides an overview of the management approach for acute abdomen. It begins with definitions and epidemiology, noting that acute abdomen is undiagnosed abdominal pain lasting less than 7-10 days. It then covers the surgical and medical causes, with etiological classifications including inflammatory/infective, perforation, obstruction, infarction, and spontaneous bleeding. Differential diagnoses are provided for different age groups. The management approach involves clinical evaluation, resuscitation, diagnostic tools like ultrasound and CT scan, and categorizing patients based on urgency of condition.
1. The document discusses the evaluation and management of acute abdominal pain in the emergency department. Acute abdominal pain accounts for 4-10% of emergency department visits, with 50% receiving a clear diagnosis and 15-30% requiring surgery.
2. Key points for assessing abdominal pain include differentiating life-threatening causes, performing a thorough physical exam, using analgesics during the exam which does not affect diagnostic accuracy, and considering observation for uncertain diagnoses.
3. Factors such as fever, leukocytosis, and abdominal tenderness on exam can help determine if a patient requires surgery or other specific treatment. Observation with reassessment is appropriate for unclear cases.
The document discusses guidelines for the management of achalasia cardia. It provides definitions and classifications for achalasia. It outlines the appropriate diagnostic evaluation and treatment approaches for achalasia based on the level of facility - whether it is a secondary/non-metro hospital or a tertiary/metro super specialty center. Investigations and treatment options are more limited at secondary centers, while tertiary centers can utilize advanced tests like high resolution manometry and perform endoscopic or surgical therapies.
This document provides information on evaluating and diagnosing dyspepsia. It lists the most common causes of dyspepsia as functional or non-ulcer dyspepsia. Other potential causes discussed include peptic ulcer disease, GERD, biliary tract disease, pancreatitis, cancer, IBS, and various metabolic disorders and medications. It provides questions to ask patients to determine the underlying cause, such as symptoms, medical history, risk factors. Common drugs associated with dyspepsia are also listed. Diagnosis involves considering the differential, patient history, and potentially endoscopy, urea breath testing, and other studies.
This document provides an overview of gastric outlet obstruction (GOO). It discusses that GOO can result from benign or malignant causes that obstruct gastric emptying. The most common benign causes are peptic ulcer disease and gastric polyps, while pancreatic cancer is the most common malignant cause. Patients present with nausea, vomiting, weight loss, and dehydration. Diagnosis involves distinguishing mechanical from functional causes, and benign from malignant etiologies. Treatment depends on the underlying cause, with surgery considered for benign cases unresponsive to medical management or in select malignant cases for palliation.
Acute Abdomen describes sudden, severe abdominal pain of unclear origin lasting less than 24 hours, which may indicate a medical or surgical emergency. A thorough history, physical exam including assessment of the abdomen and vital signs, and diagnostic tests are needed to determine the cause. Relieving pain with analgesics is recommended while diagnosis is pursued. The document provides guidance on evaluating patients with acute abdominal pain.
This document provides an overview of acute pancreatitis, including:
- The definition, classification, and pathophysiology of the disease. It involves inflammation of the pancreas that can range from mild to severe.
- Common causes or etiologies like gallstones, alcohol use, hyperlipidemia.
- Typical clinical presentation including severe abdominal pain, nausea, vomiting. Findings on physical exam can include abdominal tenderness.
- Tests and severity scores used to evaluate patients and monitor for complications. Treatment involves pain control, fluid resuscitation, and treating any underlying causes or complications. Outcomes depend on the severity of the attack.
This document discusses chronic pancreatitis, including its definition, causes, symptoms, diagnostic tests, and surgical treatment options. It notes that chronic pancreatitis is characterized by irreversible morphological changes and permanent loss of pancreatic function. The main indications for surgery are intractable pain and complications. Surgical options include drainage procedures like longitudinal pancreaticojejunostomy or cyst-enterostomies, as well as resections like Whipple procedure or distal pancreatectomy. The goals of surgery are pain relief, control of complications, and improved quality of life. While surgery provides sustained pain relief in over 85% of patients, outcomes may be complicated by associated issues like portal hypertension.
Sarah is a 45-year-old female who presents with abdominal pain localized to her epigastric and right upper quadrant that worsened after eating. She has a history of similar pain episodes and comorbidities of diabetes and hypercholesterolemia. On examination, she has tenderness in her epigastric and right upper quadrants with a positive Murphy's sign. Imaging reveals findings consistent with acute cholecystitis. She is started on antibiotics and supportive care and recommended for a laparoscopic cholecystectomy to treat her acute cholecystitis.
This document provides information on differential diagnosis and evaluation of abdominal pain localized to the epigastric region. It discusses obtaining a thorough history and performing physical exam, lab tests, imaging studies, and endoscopy to diagnose potential causes such as biliary diseases, gastrointestinal issues, cardiac problems, vascular issues, and others. Key details on symptoms, diagnostic criteria, and evaluation of specific conditions like cholecystitis, pancreatitis, peptic ulcer disease, and mesenteric ischemia are also provided.
This document describes gastric outlet obstruction (GOO), including its causes, symptoms, examinations, investigations, differential diagnosis, and treatment options. GOO is caused by any mechanical impediment to gastric emptying. Common symptoms include abdominal pain, nausea, vomiting of undigested food, early satiety, and weight loss. Investigations may include blood tests, imaging like x-rays and endoscopy, and gastric function tests. Treatment depends on the underlying cause but may involve resuscitation, antisecretory drugs, endoscopic procedures, or surgery like vagotomy with pyloroplasty or gastric resection. Post-operative complications can include bleeding, strictures, dumping syndrome, and duodenal blowout.
This document discusses Zollinger-Ellison syndrome, which is characterized by severe peptic ulcers caused by excessive stomach acid production due to a non-beta cell tumor known as a gastrinoma. It describes the pathophysiology, tumor distribution, clinical manifestations, diagnosis, and treatment of the condition. The gastrinoma secretes gastrin which stimulates acid secretion, potentially reaching the small intestine and inactivating pancreatic enzymes. Diagnosis involves biochemical tests and imaging to locate the tumor. Treatment options include proton pump inhibitors, somatostatin analogues, and surgery to cure the condition.
Abdominal pain is one of the common symptoms for 17 more diseases. This ppt will help you to get awareness of Abdominal pain and its causes, signs and symptoms, treatment, natural remedies, and medical advice, diagnosis investigation, abdominal pain faqs etc.
Information about Sigmoid Diverticular Disease by Dr Dhaval Mangukiya.
Details of sigmoid diverticular disease, classification of diverticular disease, pathophysiology, diverticular disease, presenting sumptoms, physical findings, diagnostic tests etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
This document summarizes a seminar on the management of acute abdomen. It defines acute abdomen and outlines the approach to diagnosis, which includes obtaining a history, performing a physical examination, and ordering investigations. Common causes of acute abdomen discussed include acute appendicitis, perforated peptic ulcer disease, acute cholecystitis, acute pancreatitis, and intestinal obstruction from sigmoid volvulus. The document provides details on the clinical presentation, differential diagnosis, and treatment of acute abdomen cases.
This document summarizes the surgical management of complications from peptic ulcer disease. It discusses the trends in hospitalizations for ulcer disease over time, predictors of rebleeding, and the value of endoscopic treatments. For bleeding ulcers, the choice of operation depends on factors like the Forrest classification and ulcer location/type. For gastric outlet obstruction and perforation, the document compares non-operative and operative options and factors like vagotomy type, drainage procedures, and H. pylori status that influence choice of treatment.
1. A 24-year-old male presents with right lower quadrant abdominal pain radiating to the groin. On exam, he has mild guarding and tenderness in the right lower quadrant. His differential diagnosis includes appendicitis.
2. A 68-year-old female presents with left lower quadrant pain, diarrhea, fevers and nausea. On exam, she has tenderness in the left lower quadrant. Her differential diagnosis includes diverticulitis.
3. The document discusses the history, exam, differential diagnosis, diagnostic workup, and treatment of common causes of acute abdominal pain such as appendicitis and diverticulitis.
This document provides an overview of common gastric problems for interns, including approaches to epigastric pain, alarm features in dyspeptic patients, and gastrointestinal evaluation of iron deficiency anemia. It discusses peptic ulcer disease, including causes, complications like bleeding and perforation, and treatment options. Evaluation of epigastric pain involves ruling out life-threatening conditions before considering treatments for conditions like gastritis. Endoscopy is recommended for dyspeptic patients with alarm features or risk factors for malignancy.
This document discusses types of abdominal pain and causes of acute and chronic abdominal pain. It describes four types of abdominal pain: visceral, parietal, referred, and psychogenic. Causes of acute abdominal pain include inflammation, perforation, obstruction, and rare medical conditions. Chronic or recurrent abdominal pain can be caused by retroperitoneal issues, psychological factors, locomotor issues, metabolic/endocrine disorders, drugs/toxins, or hematological disorders.
- Acute pancreatitis has varying levels of severity from mild to severe cases with high mortality. Nonoperative management is the mainstay involving fluid resuscitation, nutritional support, symptomatic treatment, and monitoring for complications.
- In severe cases, aggressive fluid resuscitation is important to prevent shock while enteral nutrition via nasogastric or nasojejunal tubes is preferred over total parenteral nutrition or prolonged nil per os.
- ERCP is indicated for cholangitis or significant biliary obstruction but not for mild biliary pancreatitis without obstruction. Infected necrosis is best drained after 4 weeks to allow development of fibrous walls.
The document discusses a case of acute abdominal pain in a 24-year-old male. It provides details of the patient's history, physical exam findings, and differential diagnosis. The document then reviews approaches to evaluating abdominal pain, including types of pain, history taking, physical exam maneuvers, potential diagnoses, appropriate tests, and disposition planning.
writes I have a good salary, am married, and have two children. My whole life I've been drawn to prescription and have always enjoyed it. However, I have a unattached in English literature, so I've always put it as unattainable to become a doctor. Now, once again, I'm bearing in mind doing one of the post bac premed programs out there and going for it.
The document discusses guidelines for the management of achalasia cardia. It provides definitions and classifications for achalasia. It outlines the appropriate diagnostic evaluation and treatment approaches for achalasia based on the level of facility - whether it is a secondary/non-metro hospital or a tertiary/metro super specialty center. Investigations and treatment options are more limited at secondary centers, while tertiary centers can utilize advanced tests like high resolution manometry and perform endoscopic or surgical therapies.
This document provides information on evaluating and diagnosing dyspepsia. It lists the most common causes of dyspepsia as functional or non-ulcer dyspepsia. Other potential causes discussed include peptic ulcer disease, GERD, biliary tract disease, pancreatitis, cancer, IBS, and various metabolic disorders and medications. It provides questions to ask patients to determine the underlying cause, such as symptoms, medical history, risk factors. Common drugs associated with dyspepsia are also listed. Diagnosis involves considering the differential, patient history, and potentially endoscopy, urea breath testing, and other studies.
This document provides an overview of gastric outlet obstruction (GOO). It discusses that GOO can result from benign or malignant causes that obstruct gastric emptying. The most common benign causes are peptic ulcer disease and gastric polyps, while pancreatic cancer is the most common malignant cause. Patients present with nausea, vomiting, weight loss, and dehydration. Diagnosis involves distinguishing mechanical from functional causes, and benign from malignant etiologies. Treatment depends on the underlying cause, with surgery considered for benign cases unresponsive to medical management or in select malignant cases for palliation.
Acute Abdomen describes sudden, severe abdominal pain of unclear origin lasting less than 24 hours, which may indicate a medical or surgical emergency. A thorough history, physical exam including assessment of the abdomen and vital signs, and diagnostic tests are needed to determine the cause. Relieving pain with analgesics is recommended while diagnosis is pursued. The document provides guidance on evaluating patients with acute abdominal pain.
This document provides an overview of acute pancreatitis, including:
- The definition, classification, and pathophysiology of the disease. It involves inflammation of the pancreas that can range from mild to severe.
- Common causes or etiologies like gallstones, alcohol use, hyperlipidemia.
- Typical clinical presentation including severe abdominal pain, nausea, vomiting. Findings on physical exam can include abdominal tenderness.
- Tests and severity scores used to evaluate patients and monitor for complications. Treatment involves pain control, fluid resuscitation, and treating any underlying causes or complications. Outcomes depend on the severity of the attack.
This document discusses chronic pancreatitis, including its definition, causes, symptoms, diagnostic tests, and surgical treatment options. It notes that chronic pancreatitis is characterized by irreversible morphological changes and permanent loss of pancreatic function. The main indications for surgery are intractable pain and complications. Surgical options include drainage procedures like longitudinal pancreaticojejunostomy or cyst-enterostomies, as well as resections like Whipple procedure or distal pancreatectomy. The goals of surgery are pain relief, control of complications, and improved quality of life. While surgery provides sustained pain relief in over 85% of patients, outcomes may be complicated by associated issues like portal hypertension.
Sarah is a 45-year-old female who presents with abdominal pain localized to her epigastric and right upper quadrant that worsened after eating. She has a history of similar pain episodes and comorbidities of diabetes and hypercholesterolemia. On examination, she has tenderness in her epigastric and right upper quadrants with a positive Murphy's sign. Imaging reveals findings consistent with acute cholecystitis. She is started on antibiotics and supportive care and recommended for a laparoscopic cholecystectomy to treat her acute cholecystitis.
This document provides information on differential diagnosis and evaluation of abdominal pain localized to the epigastric region. It discusses obtaining a thorough history and performing physical exam, lab tests, imaging studies, and endoscopy to diagnose potential causes such as biliary diseases, gastrointestinal issues, cardiac problems, vascular issues, and others. Key details on symptoms, diagnostic criteria, and evaluation of specific conditions like cholecystitis, pancreatitis, peptic ulcer disease, and mesenteric ischemia are also provided.
This document describes gastric outlet obstruction (GOO), including its causes, symptoms, examinations, investigations, differential diagnosis, and treatment options. GOO is caused by any mechanical impediment to gastric emptying. Common symptoms include abdominal pain, nausea, vomiting of undigested food, early satiety, and weight loss. Investigations may include blood tests, imaging like x-rays and endoscopy, and gastric function tests. Treatment depends on the underlying cause but may involve resuscitation, antisecretory drugs, endoscopic procedures, or surgery like vagotomy with pyloroplasty or gastric resection. Post-operative complications can include bleeding, strictures, dumping syndrome, and duodenal blowout.
This document discusses Zollinger-Ellison syndrome, which is characterized by severe peptic ulcers caused by excessive stomach acid production due to a non-beta cell tumor known as a gastrinoma. It describes the pathophysiology, tumor distribution, clinical manifestations, diagnosis, and treatment of the condition. The gastrinoma secretes gastrin which stimulates acid secretion, potentially reaching the small intestine and inactivating pancreatic enzymes. Diagnosis involves biochemical tests and imaging to locate the tumor. Treatment options include proton pump inhibitors, somatostatin analogues, and surgery to cure the condition.
Abdominal pain is one of the common symptoms for 17 more diseases. This ppt will help you to get awareness of Abdominal pain and its causes, signs and symptoms, treatment, natural remedies, and medical advice, diagnosis investigation, abdominal pain faqs etc.
Information about Sigmoid Diverticular Disease by Dr Dhaval Mangukiya.
Details of sigmoid diverticular disease, classification of diverticular disease, pathophysiology, diverticular disease, presenting sumptoms, physical findings, diagnostic tests etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
This document summarizes a seminar on the management of acute abdomen. It defines acute abdomen and outlines the approach to diagnosis, which includes obtaining a history, performing a physical examination, and ordering investigations. Common causes of acute abdomen discussed include acute appendicitis, perforated peptic ulcer disease, acute cholecystitis, acute pancreatitis, and intestinal obstruction from sigmoid volvulus. The document provides details on the clinical presentation, differential diagnosis, and treatment of acute abdomen cases.
This document summarizes the surgical management of complications from peptic ulcer disease. It discusses the trends in hospitalizations for ulcer disease over time, predictors of rebleeding, and the value of endoscopic treatments. For bleeding ulcers, the choice of operation depends on factors like the Forrest classification and ulcer location/type. For gastric outlet obstruction and perforation, the document compares non-operative and operative options and factors like vagotomy type, drainage procedures, and H. pylori status that influence choice of treatment.
1. A 24-year-old male presents with right lower quadrant abdominal pain radiating to the groin. On exam, he has mild guarding and tenderness in the right lower quadrant. His differential diagnosis includes appendicitis.
2. A 68-year-old female presents with left lower quadrant pain, diarrhea, fevers and nausea. On exam, she has tenderness in the left lower quadrant. Her differential diagnosis includes diverticulitis.
3. The document discusses the history, exam, differential diagnosis, diagnostic workup, and treatment of common causes of acute abdominal pain such as appendicitis and diverticulitis.
This document provides an overview of common gastric problems for interns, including approaches to epigastric pain, alarm features in dyspeptic patients, and gastrointestinal evaluation of iron deficiency anemia. It discusses peptic ulcer disease, including causes, complications like bleeding and perforation, and treatment options. Evaluation of epigastric pain involves ruling out life-threatening conditions before considering treatments for conditions like gastritis. Endoscopy is recommended for dyspeptic patients with alarm features or risk factors for malignancy.
This document discusses types of abdominal pain and causes of acute and chronic abdominal pain. It describes four types of abdominal pain: visceral, parietal, referred, and psychogenic. Causes of acute abdominal pain include inflammation, perforation, obstruction, and rare medical conditions. Chronic or recurrent abdominal pain can be caused by retroperitoneal issues, psychological factors, locomotor issues, metabolic/endocrine disorders, drugs/toxins, or hematological disorders.
- Acute pancreatitis has varying levels of severity from mild to severe cases with high mortality. Nonoperative management is the mainstay involving fluid resuscitation, nutritional support, symptomatic treatment, and monitoring for complications.
- In severe cases, aggressive fluid resuscitation is important to prevent shock while enteral nutrition via nasogastric or nasojejunal tubes is preferred over total parenteral nutrition or prolonged nil per os.
- ERCP is indicated for cholangitis or significant biliary obstruction but not for mild biliary pancreatitis without obstruction. Infected necrosis is best drained after 4 weeks to allow development of fibrous walls.
The document discusses a case of acute abdominal pain in a 24-year-old male. It provides details of the patient's history, physical exam findings, and differential diagnosis. The document then reviews approaches to evaluating abdominal pain, including types of pain, history taking, physical exam maneuvers, potential diagnoses, appropriate tests, and disposition planning.
writes I have a good salary, am married, and have two children. My whole life I've been drawn to prescription and have always enjoyed it. However, I have a unattached in English literature, so I've always put it as unattainable to become a doctor. Now, once again, I'm bearing in mind doing one of the post bac premed programs out there and going for it.
1) The document discusses the evaluation and management of acute abdominal pain, focusing on history taking, physical exam, differential diagnosis, and initial testing.
2) Common causes of acute abdominal pain in the emergency department setting include nonspecific abdominal pain, appendicitis, biliary tract disease, small bowel obstruction, gynecologic issues, and pancreatitis.
3) The history should inquire about the characteristics of the pain, associated symptoms, past medical history, surgical history, medications, and social history. The physical exam involves inspection, auscultation, and palpation of the abdomen along with pertinent system reviews.
4) Initial testing may
This document discusses a case of a 20-year-old man presenting with abdominal pain and diarrhea who was found to have elevated inflammatory markers and free fluid on ultrasound. It then provides a general overview of acute abdomen including common causes, diagnostic approach, important physical exam findings and signs, and appropriate imaging studies.
Dr. Guy Nicastri, Associate Professor of Surgery and Family Medicine at the Warren Alpert School of Medicine at Brown University takes us through some of the pearls of the Acute Abdomen Examination in the Adult
This document discusses the approach to recurrent abdominal pain in children. It defines acute, subacute, and chronic abdominal pain and discusses recurrent abdominal pain. The most common causes of abdominal pain seen in emergency departments are also summarized. A full history and physical exam are important for evaluating abdominal pain, and diagnostic testing should be guided by symptoms and exam findings. Home care and lifestyle advice are usually sufficient for recurrent abdominal pain in children without concerning alarm symptoms.
This document outlines a presentation on the pathophysiology and management of acute abdomen. It begins with definitions of acute abdomen and types of abdominal pain. Pathophysiological mechanisms including luminal obstruction, inflammation, peritonitis, ischemia and non-specific pain are described. Common causes like appendicitis, cholecystitis, bowel obstruction and perforated viscus are listed. Immediately life-threatening diagnoses of perforated viscus, bowel ischemia, ruptured abdominal aortic aneurysm and ruptured ectopic pregnancy are highlighted. Clinical assessment techniques and investigations are outlined. Management principles focusing on ABCs, fluid resuscitation and need for surgery in some cases are emphasized in the take-home message.
The 15-year-old boy presented with gradually worsening lower right abdominal pain for 4 days, along with nausea, vomiting, and loss of appetite. On examination, he had tenderness in the right iliac fossa and rebound tenderness. Acute appendicitis should be considered, as the presentation is consistent with the classic progression of abdominal pain from periumbilical to localized right lower quadrant pain, along with common associated symptoms of anorexia, nausea, and vomiting. Laboratory tests such as a CBC can help evaluate for elevated white blood cells, though the diagnosis of appendicitis is primarily based on the history and physical exam findings.
This document provides an introduction to examining the abdomen in clinical skills. It outlines the anatomy and physiology of the abdomen, landmarks, techniques for inspection, auscultation, percussion and palpation. Specific assessment techniques are described for organs like the liver and spleen. Common abdominal disorders and patterns of abdominal pain are also discussed. The goal is to teach medical students how to properly examine the abdomen.
A 22-year-old woman presents with severe lower abdominal pain. The differential diagnosis includes appendicitis, pelvic inflammatory disease, ovarian cyst, and ectopic pregnancy. Given her age, a pregnancy test and pelvic exam are important to evaluate for potential gynecologic causes of her pain.
The document discusses the acute abdomen, which refers to symptoms and signs of acute intra-abdominal disease that are usually best treated with surgery. It defines the different types of abdominal pain and covers the epidemiology, causes, diagnostic evaluation including history, exams, labs, and imaging. High risk patients are identified. The management of acute abdomen in the emergency department is outlined, including when surgery is indicated versus other conservative treatments.
The document discusses the acute abdomen, which refers to symptoms and signs of acute intra-abdominal disease that usually require surgical intervention. It defines the types of abdominal pain and covers the epidemiology, causes, diagnostic evaluation including history, physical exam, labs, and imaging. Evaluation focuses on identifying patients at high risk who may require urgent surgery. The differential diagnosis is broad and includes appendicitis, diverticulitis, cholecystitis, and others. History, exam, and testing can help distinguish surgical from non-surgical causes to guide emergency management and need for operation.
This document presents the case of an 18-year-old female patient with intermittent epigastric pain for 9 days. Physical examination revealed direct tenderness in the epigastric area and Murphy's sign was positive. Blood tests showed leukocytosis. Ultrasound showed gallbladder hydrops and cholecystolithiasis. The patient was diagnosed with acute cholecystitis and underwent an emergency open cholecystectomy. Her postoperative course was uncomplicated and she was discharged in stable condition.
1) Acute abdomen is a common presentation accounting for 4-10% of emergency department visits. 50% have a clear diagnosis while 15-30% require surgical procedures, especially in the elderly.
2) Unique presentations can occur in pediatric and elderly patients, with the elderly having higher rates of misdiagnosis and mortality due to less prominent physical exam findings.
3) A thorough history and physical exam remain important for assessing abdominal pain, though imaging studies can help when the diagnosis is unclear. Close observation is often needed to determine if the condition is surgical or non-surgical.
This document discusses the acute abdomen, including definitions, clinical diagnosis, differential diagnosis, evaluation, and management. An acute abdomen is signs and symptoms of intra-abdominal disease that may require surgery. The clinical diagnosis involves characterizing the pain location, onset, and nature. Broad differential categories include inflammation, obstruction, ischemia, and perforation. Evaluation involves history, physical exam, labs, and imaging like ultrasound or CT scan. Decision for surgery is made for peritonitis, severe unrelenting pain, instability, or suspected intestinal ischemia/strangulation. Common etiologies are perforated ulcer, appendicitis, diverticulitis, bowel obstruction, cholecystitis, ischemic or perforated bowel, and ruptured
This document discusses the relationship between the gastrointestinal (GI) system and other body systems. It outlines how the neurological, endocrine, respiratory, cardiovascular, muscular, integumentary, digestive, urinary, lymphatic, and reproductive systems interact with and can affect the GI system. It also provides details on assessing the GI system through health history, physical examination, diagnostic tests, and various radiologic and endoscopic procedures.
This document discusses various causes of acute abdominal pain, including non-specific abdominal pain (34%), acute appendicitis (28%), acute cholecystitis (10%), small bowel obstruction (4%), perforated peptic ulcer (3%), pancreatitis (3%), and diverticular disease (2%). It describes the pathophysiology of visceral, parietal, and referred pain. It provides details on localized pain patterns from various abdominal organs and conditions. It also outlines the important history, physical exam findings, and initial investigations for evaluating a patient with acute abdominal pain.
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
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Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
2. Case #1
24 yo healthy M with one day hx 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.
Review of Systems (ROS) otherwise negative.
Past Medical History (PMHx): negative
Past Surgical History (PSurgHx): negative
Meds: none
No known drug allergies (NKDA)
Social hx: no alcohol, tobacco or drug use
Family hx: non-contributory
3. Abdominal pain
What else do you want to know?
What is on your differential diagnosis so far?
(healthy male with RLQ abd pain….)
How do you approach the complaint of abdominal
pain in general?
Let’s review in this lecture:
Types of pain
History and physical examination
Labs and imaging
Abdominal pain in special populations (Elderly)
Clinical pearls to help you in the ED
4. “Tell me more about your pain….”
Location
Quality
Severity
Onset
Duration
Modifying factors
Change over time
5. What kind of pain is it?
Visceral
Involves hollow or solid organs; midline pain due to
bilateral innvervation
Steady ache or vague discomfort to excruciating or
colicky pain
Poorly localized
Epigastric region: stomach, duodenum, biliary tract
Periumbilical: small bowel, appendix, cecum
Suprapubic: colon, sigmoid, GU tract
6. What kind of pain is it?
Parietal
Involves parietal peritoneum
Localized pain
Causes tenderness and guarding which progress
to rigidity and rebound as peritonitis develops
7. What kind of pain is it?
Referred
Produces symptoms not signs
Based on developmental embryology
Ureteral obstruction → testicular pain
Subdiaphragmatic irritation → ipsilateral
shoulder or supraclavicular pain
Gynecologic pathology → back or proximal
lower extremity
Biliary disease → right infrascapular pain
MI → epigastric, neck, jaw or upper extremity
pain
9. And don’t forget the history
GI
Past abdominal surgeries, h/o GB disease, ulcers; FamHx IBD
GU
Past surgeries, h/o kidney stones, pyelonephritis, UTI
Gyn
Last menses, sexual activity, contraception, h/o PID or STDs, h/o ovarian
cysts, past gynecological surgeries, pregnancies
Vascular
h/o MI, heart disease, a-fib, anticoagulation, CHF, PVD, Fam Hx of AAA
Other medical history
DM, organ transplant, HIV/AIDS, cancer
Social
Tobacco, drugs – Especially cocaine, alcohol
Medications
NSAIDs, H2 blockers, PPIs, immunosuppression, coumadin
10. Moving on to the Physical Exam
General
Pallor, diaphoresis, level of distress or
discomfort, is the patient lying still or moving
around in the bed
Vital Signs
Orthostatic VS when volume depletion is
suspected
Cardiac
Arrhythmias
Lungs
Pneumonia
11. Moving on to the Physical Exam
Abdomen
Look for distention, scars, masses
Auscultate – hyperactive or obstructive BS
increase likelihood of SBO fivefold – otherwise
not very helpful
Palpate for tenderness, masses, aortic aneurysm,
organomegaly, rebound, guarding, rigidity
Percuss for tympany
Look for hernias!
Rectal exam
12. Moving on to the Physical Exam
Back
CVA tenderness
Pelvic exam
Cervical motion tenderness (CMT)
Vaginal discharge – Culture
Adenexal mass or fullness
13. Abdominal Findings
Guarding
Voluntary
Contraction of abdominal musculature in
anticipation of palpation
Diminish by having patient flex knees
Involuntary
Reflex spasm of abdominal muscles
aka: rigidity
Suggests peritoneal irritation
14. Abdominal Findings
Rebound
Present in 1 of 4 patients without peritonitis
Pain referred to the point of maximum tenderness
when palpating an adjacent quadrant is suggestive
of peritonitis
Rovsing’s sign in appendicitis
Rectal exam
Little evidence that tenderness adds any useful
information beyond abdominal examination
Gross blood or melena indicates a GIB
15. Differential Diagnosis
It’s Huge!
Use history and physical exam to narrow it down
Rule out life-threatening pathology
Half the time you will send the patient home with a
diagnosis of nonspecific abdominal pain (NSAP or
Abdominal Pain – NOS)
90% will be better or asymptomatic at 2-3 weeks
17. Most Common Causes in the ED
Non-specific abd pain 34%
Appendicitis 28%
Biliary tract dz 10%
SBO 4%
Gyn disease 4%
Pancreatitis 3%
Renal colic 3%
Perforated ulcer 3%
Cancer 2%
Diverticular dz 2%
Other 6%
18. What kind of tests should you
order?
Depends what you are looking for!
Abdominal series
3 views: upright chest, flat view of abdomen,
upright view of abdomen
Limited utility: restrict use to patients with
suspected obstruction or free air
Ultrasound
Good for diagnosing AAA but not ruptured AAA
Good for pelvic pathology
19. What kind of tests should you
order?
CT abdomen/pelvis
Noncontrast for free air, renal colic, ruptured AAA, (bowel obstruction)
Contrast study for abscess, infection, inflammation, unknown cause
MRI
Most often used when unable to obtain CT due to contrast issue
Labs
CBC: “What’s the white count?”
Chemistries
Liver function tests, Lipase
Coagulation studies
Urinalysis, urine culture
GC/Chlamydia swabs
Lactate
20. Disposition
Depends on the source
Non-specific abdominal pain
No source is identified
Vital signs are normal
Non specific abdominal exam, no evidence of
peritonitis or severe pain
Patient improves during ED visit
Patient able to take fluids
Have patient return to ED in 12-24 hours for re-
examination if not better or if they develop new
symptoms
21. Back to Case #1….24 yo with RLQ pain
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
What is your differential diagnosis and what do
you do next?
22. Appendicitis
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
Findings
Depends on duration of
symptoms
Rebound, voluntary guarding,
rigidity, tenderness on rectal
exam
Psoas sign
Obturator sign
Fever (a late finding)
Urinalysis abnormal in 19-40%
CBC is not sensitive or specific
Abdominal xrays
Appendiceal fecalith or gas,
localized ileus, blurred right
psoas muscle, free air
CT scan
Pericecal inflammation, abscess,
periappendiceal phlegmon,
fluid collection, localized fat
stranding
27. Appendicitis
Diagnosis
WBC
Clinical appendicitis – call
your surgeon
Maybe appendicitis - CT
scan
Not likely appendicitis –
observe for 6-12 hours or re-
examination in 12 hours
Treatment
NPO
IVFs
Preoperative antibiotics –
decrease the incidence of
postoperative wound
infections
Cover anaerobes, gram-
negative and enterococci
Zosyn 3.375 grams IV or
Unasyn 3 grams IV
Analgesia
28. Case #2
68 yo F with 2 days of LLQ abd pain, diarrhea,
fevers/chills, nausea; vomited once at home.
PMHx: HTN, diverticulosis
PSurgHx: negative
Meds: HCTZ
NKDA
Social hx: no alcohol, tobacco or drug use
Family hx: non-contributory
29. Case #2 Exam
T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99%
room air
Gen: uncomfortable appearing, slightly pale
CV/Pulmonary: normal heart and lung exam, no
LE edema, normal pulses
Abd: soft, moderately TTP LLQ
Rectal: normal tone, guiac neg brown stool
What is your differential diagnosis & what
next?
30. Diverticulitis
Risk factors
Diverticula
Increasing age
Clinical features
Steady, deep discomfort
in LLQ
Change in bowel habits
Urinary symptoms
Tenesmus
Paralytic ileus
SBO
Physical Exam
Low-grade fever
Localized tenderness
Rebound and guarding
Left-sided pain on rectal
exam
Occult blood
Peritoneal signs
Suggest perforation or
abscess rupture
31. Diverticulitis
Diagnosis
CT scan (IV and oral
contrast)
Pericolic fat stranding
Diverticula
Thickened bowel wall
Peridiverticular abscess
Leukocytosis present in
only 36% of patients
Treatment
Fluids
Correct electrolyte
abnormalities
NPO
Abx: gentamicin AND
metronidazole OR
clindamycin OR
levaquin/flagyl
For outpatients (non-toxic)
liquid diet x 48 hours
cipro and flagyl
32. Case #3
46 yo M with hx of alcohol abuse with 3 days of
severe upper abd pain, vomiting, subjective fevers.
Med Hx: negative
Surg Hx: negative
Meds: none; Allergies: No known drug allergies
(NKDA)
Social hx: homeless, heavy alcohol use, smokes
2ppd, no drug use
33. Case #3 Exam
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 tenderness to
palpation (TTP) epigastric, +voluntary guarding
Rectal: heme neg stool
What is your differential diagnosis & what next?
34. Pancreatitis
Risk Factors
Alcohol
Gallstones
Drugs
Amiodarone, antivirals,
diuretics, NSAIDs, antibiotics,
more…..
Severe hyperlipidemia
Idiopathic
Clinical Features
Epigastric pain
Constant, boring pain
Radiates to back
Severe
N/V
bloating
Physical Findings
Low-grade fevers
Tachycardia, hypotension
Respiratory symptoms
Atelectasis
Pleural effusion
Peritonitis – a late finding
Ileus
Cullen sign*
Bluish discoloration around the
umbilicus
Grey Turner sign*
Bluish discoloration of the
flanks
*Signs of hemorrhagic pancreatitis
35. Pancreatitis
Diagnosis
Lipase
Elevated more than 2 times
normal
Sensitivity and specificity
>90%
Amylase
Nonspecific
Don’t bother…
RUQ US if etiology unknown
CT scan
Insensitive in early or mild
disease
NOT necessary to diagnose
pancreatitis
Useful to evaluate for
complications
Treatment
NPO
IV fluid resuscitation
Maintain urine output of 100
mL/hr
NGT if severe, persistent nausea
No antibiotics unless severe
disease
E coli, Klebsiella, enterococci,
staphylococci, pseudomonas
Imipenem or cipro with
metronidazole
Mild disease, tolerating oral
fluids
Discharge on liquid diet
Follow up in 24-48 hours
All others, admit
36. Case #4
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, denies alcohol or drug use, lives
alone
37. Case #4 Exam
T: 99.1, HR: 70, BP: 90/45, R: 22, O2sat: 96% room
air
General: elderly, thin male, ill-appearing
CV: normal
Lungs: clear
Abd: mildly distended and diffusely tender to
palpation, +rebound and guarding
Rectal: blood-streaked heme + brown stool
What is your differential diagnosis & what
next?
38. Peptic Ulcer Disease
Risk Factors
H. pylori
NSAIDs
Smoking
Hereditary
Clinical Features
Burning epigastric pain
Sharp, dull, achy, or “empty” or
“hungry” feeling
Relieved by milk, food, or antacids
Awakens the patient at night
Nausea, retrosternal pain and
belching are NOT related to PUD
Atypical presentations in the elderly
Physical Findings
Epigastric tenderness
Severe, generalized pain
may indicate perforation
with peritonitis
Occult or gross blood per
rectum or NGT if bleeding
39. Peptic Ulcer Disease
Diagnosis
Rectal exam for occult blood
CBC
Anemia from chronic blood
loss
LFTs
Evaluate for GB, liver and
pancreatic disease
Definitive diagnosis is by EGD
or upper GI barium study
Treatment
Empiric treatment
Avoid tobacco, NSAIDs, aspirin
PPI or H2 blocker
Immediate referral to GI if:
>45 years
Weight loss
Long h/o symptoms
Anemia
Persistent anorexia or vomiting
Early satiety
GIB
41. Perforated Peptic Ulcer
Abrupt onset of severe epigastric pain followed by
peritonitis
IV, oxygen, monitor
CBC, T&C, Lipase
Acute abdominal x-ray series
Lack of free air does NOT rule out perforation
Broad-spectrum antibiotics
Surgical consultation
42. Case #5
35 yo healthy F to ED c/o nausea and vomiting
since yesterday along with generalized abdominal
pain. No fevers/chills, +anorexia. Last stool 2 days
ago.
Med Hx: negative
Surg Hx: s/p hysterectomy (for fibroids)
Meds: none, Allergies: NKDA
Social Hx: denies alcohol, tobacco or drug use
Family Hx: non-contributory
43. Case #5 Exam
T: 36.9, HR: 100, BP: 130/85, R: 22, O2 sat: 97%
room air
General: mildly obese female, vomiting
CV: normal
Lungs: clear
Abd: moderately distended, mild TTP diffusely,
hypoactive bowel sounds, no rebound or guarding
What is your differential and what next?
45. Bowel Obstruction
Mechanical or nonmechanical
causes
#1 - Adhesions from previous
surgery
#2 - Groin hernia incarceration
Clinical Features
Crampy, intermittent pain
Periumbilical or diffuse
Inability to have BM or flatus
N/V
Abdominal bloating
Sensation of fullness, anorexia
Physical Findings
Distention
Tympany
Absent, high pitched or
tinkling bowel sound or
“rushes”
Abdominal tenderness:
diffuse, localized, or minimal
46. Bowel Obstruction
Diagnosis
CBC and electrolytes
electrolyte abnormalities
WBC >20,000 suggests bowel
necrosis, abscess or peritonitis
Abdominal x-ray series
Flat, upright, and chest x-ray
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
Treatment
Fluid resuscitation
NGT
Analgesia
Surgical consult
Hospital observation for ileus
OR for complete obstruction
Peri-operative antibiotics
Zosyn or unasyn
47. Case #6
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
48. Case #6 Exam
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 TTP RUQ, +Murphy’s sign, non-
distended, normal bowel sounds
What is your differential and what next?
49. Cholecystitis
Clinical Features
RUQ or epigastric pain
Radiation to the back or
shoulders
Dull and achy → sharp
and localized
Pain lasting longer than
6 hours
N/V/anorexia
Fever, chills
Physical Findings
Epigastric or RUQ pain
Murphy’s sign
Patient appears ill
Peritoneal signs suggest
perforation
50. Cholecystitis
Diagnosis
CBC, LFTs, Lipase
Elevated alkaline phosphatase
Elevated lipase suggests
gallstone pancreatitis
RUQ US
Thicken gallbladder wall
Pericholecystic fluid
Gallstones or sludge
Sonographic murphy sign
HIDA scan
more sensitive & specific than
US
H&P and laboratory findings
have a poor predictive value – if
you suspect it, get the US
Treatment
Surgical consult
IV fluids
Correct electrolyte
abnormalities
Analgesia
Antibiotics
Ceftriaxone 1 gram IV
If septic, broaden coverage to
zosyn, unasyn, imipenem or
add anaerobic coverage to
ceftriaxone
NGT if intractable vomiting
51. Case #7
34 yo healthy M with 4 hour hx of sudden onset
left flank pain, +nausea/vomiting; no prior hx of
similar symptoms; no fevers/chills. +difficulty
urinating, no hematuria. Feels like has to urinate
but cannot.
PMHx: neg
Surg Hx: neg
Meds: none,
Allergies: NKDA
Social hx: occasional alcohol, denies tobacco or
drug use
Family hx: non-contributory
52. Case #7 Exam
T: 98.9, HR: 110, BP: 150/90, R: 20, O2 sat: 99% room air
General: writhing around on stretcher in pain,
+diaphoretic
CV: tachycardic, heart sounds normal
Lungs: clear
Abd: soft; non-tender
Back: mild left CVA tenderness
Genital exam: normal
Neuro exam: normal
What is your differential diagnosis and what next?
53. Renal Colic
Clinical Features
Acute onset of severe,
dull, achy visceral pain
Flank pain
Radiates to abdomen or
groin including testicles
N/V and sometimes
diaphoresis
Fever is unusual
Waxing and waning
symptoms
Physical Findings
non tender or mild
tenderness to palpation
Anxious, pacing,
writhing in bed – unable
to sit still
54. Renal Colic
Diagnosis
Urinalysis
RBCs
WBCs suggest infection or
other etiology for pain (ie
appendicitis)
CBC
If infection suspected
BUN/Creatinine
In older patients
If patient has single kidney
If severe obstruction is
suspected
CT scan
In older patients or patients
with comorbidities (DM,
SCD)
Not necessary in young
patients or patients with h/o
stones that pass
spontaneously
Treatment
IV fluid boluses
Analgesia
Narcotics
NSAIDS
If no renal insufficiency
Strain all urine
Follow up with urology in 1-2
weeks
If stone > 5mm, consider
admission and urology consult
If toxic appearing or infection
found
IV antibiotics
Urologic consult
55. Just a few more to go….hang in
there
Ovarian torsion
Testicular torsion
Abd pain in the Elderly
56. Ovarian Torsion
Acute onset severe pelvic pain
May wax and wane
Possible hx of ovarian cysts
Menstrual cycle: midcycle also
possibly in pregnancy
Can have variable exam:
acute, rigid abdomen,
peritonitis
Fever
Tachycardia
Decreased bowel sounds
May look just like Appendicitis
Ultrasound
Labs
CBC, beta-hCG,
electrolytes, T&S
IV fluids
NPO
Pain medications
GYN consult
57. Testicular Torsion
Sudden onset of severe testicular
pain
If torsion is repaired within 6
hours of the initial insult,
salvage rates of 80-100% are
typical. These rates decline to
nearly 0% at 24 hours.
Approximately 5-10% of torsed
testes spontaneously detorse,
but the risk of retorsion at a later
date remains high.
Most occur in males less than
20yrs old but 10% of affected
patients are older than 30 years.
Detorsion
Emergent urology consult
Ultrasound with Doppler
58. Abdominal Pain in the Elderly
Mortality rate for abdominal
pain in the elderly is 11-14%
Perception of pain is altered
Altered reporting of pain:
stoicism, fear,
communication problems
Most common causes:
Cholecystitis
Appendicitis
Bowel obstruction
Diverticulitis
Perforated peptic ulcer
Don’t miss these:
AAA, ruptured AAA
Mesenteric ischemia
Myocardial ischemia
Aortic dissection
59. Abdominal Pain in the Elderly
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
60. Mesenteric Ischemia
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
Nausea, vomiting and anorexia are common
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
61. Abdominal Aortic Aneurysm
Risk increases with age, women >70, men >55
Abdominal pain in 70-80% (not back pain!)
Back pain in 50%
Sudden onset of significant pain
Atypical locations of pain: hips, inguinal area, external genitalia
Syncope can occur
Hypotension may be present
Palpation of a tender, enlarged aorta on exam is an important finding
May present with hematuria
Suspect it in any older patient with back, flank or abdominal pain especially
with a renal colic presentation
Ultrasound can reveal the presence of a AAA but is not helpful for rupture. CT
abd/pelvis without contrast for stable patients. High suspicion in an unstable
patient requires surgical consult and emergent surgery.
62. Abdominal Pain Clinical Pearls
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
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