E-learning program in emergency medicine 2018

1. Evaluation of Acute
Abdominal Pain in
Emergency department
Dr.Venugopalan P P
Lead Consultant in Emergency Medicine
Aster DM healthcare

2. Scope of Problem
● Evaluation is most challenging
● 7 percentage of ED presentation
● Diagnostic possibilities :
From Life threatening to Self limiting
From Common to Unusual
● Benign-presentations may progress
to life-threatening conditions.
● Etiology remain undiagnosed in 40
percent cases

3. What is important ?
Recognition of surgical or life-threatening
causes is more important than establishing a
firm diagnosis.

4. Anatomical
basics
Abdominal pain typically derived from one or more
of three distinct pain pathways:
1. Visceral
2. Parietal (somatic)
3. Referred

5. Visceral abdominal pain
1. Caused by distention, contraction or stretching of hollow and solid organs
2. Often the earliest manifestation of a particular disease process.
3. Vary from a steady ache or vague discomfort to excruciating or colicky
pain.
4. Organs affected by peristalsis, the pain is intermittent, crampy, or colicky in
nature.

6. Visceral abdominal pain
● Visceral pain fibers : Bilateral, Unmyelinated ,
Enter the spinal cord at multiple levels,
● Usually dull, midline and poorly localized
● Epigastric, periumbilical, or infraumbilical
depending on the involved organ's embryonic
origin.

7. Visceral
abdominal
pain
● Foregut structures(stomach, duodenum,
liver, biliary tract and pancreas)produce
upper (epigastric) abdominal pain.
● Midgut structures(small bowel, appendix
and proximal colon) cause periumbilical
pain.
● Hindgut structures(distal colon and
genitourinary system) cause
lower(infraumbilical) abdominal pain.

8. Visceral Abdominal pain

9. Parietal(Somatic)Abdominal pain
● Ischemia, inflammation or
stretching of the parietal
peritoneum
● Myelinated afferent fibers
transmit the painful stimulus to
specific dorsal root ganglia on
the same side
● Dermatomal level as the origin of
the pain
● Localized to the region of the
painful stimulus

10. Parietal(Somatic)Abdominal pain
● Sharp, knife-like and constant
● Coughing and moving are likely to aggravate it
● Account for physical examination findings of tenderness to
palpation, guarding, rebound and rigidity.

12. Parietal(Somatic)
Abdominal pain
● Begin with visceral pain and
progress to somatic pain.
● The pain of early appendicitis is
often periumbilical (visceral) but
localizes to the right lower quadrant
(parietal) as the inflammation
extends to the peritoneum.
● Cholecystitis may begin as
epigastric (visceral) pain and
progress to right upper quadrant
(somatic) pain and/or right shoulder
(referred) pain.

13. Referred pain
➔ Pain felt at a distance from the diseased organ.
➔ Shared central pathways for afferent neurons
from different locations
● Pneumonia may present with abdominal pain
because the T9 distribution of neurons is shared
by the lung and abdomen
● Epigastric pain associated with myocardial
infarction (MI)
● Shoulder pain associated with diaphragmatic
irritation (e.g., ruptured spleen)
● Right infra scapular pain associated with biliary
disease
● Testicular pain associated with acute ureteral
obstruction.

14. Snapshot: three different types of pain

15. History : Need
to get answer
on the following
questions
1.Where is your pain?
2.Has it migrated?
3.Does the pain radiate
anywhere?
4.How did the pain begin
(sudden vs. gradual onset)? How
long have you had the pain?
5.What were you doing when the
pain began?

16. History :Need to
get answer on the
following
questions
6.What does the pain feel
like?
7.On a scale of 0–10, how
severe is the pain?
8.Does anything make the
pain better or worse?
9.Have you had the pain
before?

17. PQRST - A
Approach
● Presentation,Progression,
Precipitating factors, Palliative
● Quality
● Radiation,Relieving factors
● Site,Severity
● Temporal ,Treatment taken
● Associated symptoms

18. Associated
Symptoms
Gastro Intestinal
● Nausea
● Vomiting
● Anorexia
● Constipation
● Diarrhea
● Bleeding.

19. Associated
Symptoms
Genitourinary
● Dysuria
● Frequency
● Urgency
● Hematuria.

20. Associated
Symptoms
Gynecologic
● Pregnancy
● Menses
● Contraception
● Fertility, sexual activity, sexually
transmitted infections (STIs)

21. Associated
Symptoms
Gynecologic
● Vaginal discharge or bleeding,
Dyspareunia
● Previous gynecologic history
including surgeries
● Previous pregnancies
● Infections

22. Associated
Symptoms
Cardiopulmonary
● Cough
● Dyspnea
● Chest pain.

23. Pain
character
and
Diagnostic
clues

24. Colicky pain : Diagnostic clues

25. Past Medical
/Surgical
History
● Abdominal surgery :bowel obstruction due to
adhesions.
● Cardiovascular disease, hypertension or atrial
fibrillation:Mesenteric ischemia and AAA.
● Cirrhosis and ascites :Spontaneous bacterial
peritonitis
● Diabetes, heart disease, or chronic obstructive
pulmonary disease (COPD): complicate the
evaluation and stabilization

26. Past Medical
/Surgical History
● Medications
● (Nonsteroidal antiinflammatory drugs
[NSAIDs], corticosteroids,
antibiotics,immunosuppressants) :
1.Lead to abdominal pain
2.Make evaluation more challenging
● Alcohol consumption : GI bleeding,
pancreatitis, hepatitis or cirrhosis.

27. Red flags
Emergency physician
Recognizing “red flags” (warning signs
and symptoms) from the history and
physical examination that raise concern
for life-threatening or dangerous

28. Ominous signs in acute
abdominal pain
Red flags
1. Sudden onset , maximal intensity pain
2. Pain that disrupt sleep
3. Pain followed by vomiting
4. Migration/Localization of pain

29. Ominous signs in acute
abdominal pain
Red Flags
5. Pain with movements
6. Inability to maintain oral intake
7. Fever
8. Pain out of proportion to Examination

30. History : Evaluation and
clues to Red flag and
Diagnosis

31. History :Red flag
clues
Sudden onset
1. AAA
2. Aortic dissection
3. Ectopic pregnancy
4. Mesenteric ischaemia
5. Visceral perforation

32. History of Abdominal Pain : Red flag clues
Out of proportion to exam Mesenteric ischemia
Pregnant Ectopic pregnancy
Trauma Intra abdominal Injury
( Liver,Spleen)
Syncope Ectopic pregnancy , AAA

33. History :Red flag
clues
Elderly
1. AAA
2. Mesenteric ischemia
3. MI
4. Perforated ulcer
5. Bowel obstruction
6. Appendicitis
7. Cholecystitis

34. History : Reg flag clues
Tearing pain / History of
Vascular diseases
AAA, Aortic dissection
Risk factors of coronary
artery diseases
MI, Mesenteric ischemia
Abdominal surgery Bowel obstruction

35. Physical Examination
● General Exam
● Vitals
● Abdomen
● Other body areas

36. Physical
Examination
1.Localize the organ system responsible for
disease
2.Examine other body areas may provide clues to
the etiology of the pain
● Pelvic (women)
● Genitourinary (men)
● Back
● Rectal areas

37. General appearance
● Patients with pallor or distress are generally more acutely ill
● Peritonitis tend to lie still to avoid exacerbating their pain
● Ureteral colic or mesenteric ischemia may writhe in pain
● Nonspecific abdominal pain, gastroenteritis and ureteral colic are
usually less aggravated by movement.

38. Vital signs :
Leading and
misleading fever
● Appendicitis and cholecystitis may present with
temperatures <100.2°F (37.8°C)
● Elderly or immunocompromised patients may not
mount a fever or may present with hypothermia
despite a serious underlying illness.
● The majority of elderly patients with acute
appendicitis or cholecystitis are afebrile in spite of
higher rates of perforation and sepsis.

39. Vital signs :
Leading and
misleading fever
● Presence of fever should alert the
physician to the possibility of infection
as the cause of pain
● Acute onset of a high fever and chills
make appendicitis less likely than
pneumonia or pyelonephritis in the
appropriate clinical setting.

40. OtherVital
signs
● Hypotension: dehydration, sepsis or internal hemorrhage,
and is a worrisome finding in an elderly patient
● Tachycardia: occult blood loss, sepsis, volume contraction
or pain .Medications such as beta-blockers may blunt such
a response.
● Increased respiratory rate : severe pain, metabolic
acidosis or an extra-abdominal cause such as PE,
pneumonia or MI.

41. Abdominal
Examination
Look,Listen and Feel
● Inspection
● Auscultation
● Percussion
● Palpation

42. Abdomen:
What should
you look ?
● Distention
● Masses
● Bruising
● Scars from prior surgeries
● Cutaneous signs of portal
hypertension.
Cullen's sign (a bluish umbilicus) &
Grey Turner's sign (discoloration of
the flank) are signs of
retroperitoneal hemorrhage.

44. Abdomen:
What should
you listen ?
1.Absent or diminished bowel sounds provide little
useful clinical information.
2.High-pitched or tinkling sounds can be
associated with SBO, especially in the presence of
abdominal distention.
3.Low-pitched and less frequent bowel sounds are
classically associated with large bowel obstruction.

45. Abdomen: What
should you
listen?
4.Bruits :indicate the
presence of an AAA in an
elderly patient.
5.Pregnant patient, assess
for fetal heart tones, which
can be heard in 90% of
patients by 12 weeks
gestation.

46. Abdomen : Percussion
● Size of organs
● Distinguishing between distention
caused by air or fluid
● Tympany : excessive gas in the
bowel or peritoneal cavity
● Shifting dullness or a fluid wave
suggests ascites.

47. Abdomen :
Palpation -
How to start
with ?
● First calm the patient and gain his or her
cooperation.
● Flex the legs at the knee and hip may relax
abdominal musculature
● Be gentle
● A rough or painful examination is not only
distressing to the patient but may mislead the
examining physician.

48. Abdomen :
Palpation -
How to start
with ?
● By localizing tenderness to a specific
abdominal region, the clinician often can
narrow the diagnostic possibilities to the
organs within that anatomic region.
● Assess for signs of peritoneal irritation

49. Abdomen :
Palpation - How
to start with ?
● Ask the patient to point with one
finger to the location of greatest
discomfort.
● Palpation should be performed
systematically
● Observe the patient's facial
expressions for signs of pain during
palpation
● Pulsatile mass suggestive of AAA.

50. Guarding ● Involuntary: Reflex spasm of the abdominal
wall musculature in response to palpation or
underlying peritoneal irritation ()
● Voluntary:In response to the physician's cold
hands, fear, anxiety, or being ticklish.
● Involuntary guarding, which has greater clinical
significance, is more likely to occur with
surgical illness and is not relieved by physician
encouragement.

51. Guarding Rebound
Tenderness

52. Rebound
Tenderness
● Elicited by slow, gentle, deep palpation of an
area of tenderness followed by abrupt
withdrawal of the examiner's hand
● Hallmark of surgical disease
● Several recent studies have questioned its
sensitivity, specificity and prospective utility for
surgical conditions.
● Usefulness get questioned

53. 1
2
3
Rebound
Tenderness :
Alternatives?
Cough test: Ask patient cough and looks for evidence of
post-tussive abdominal pain, such as grimacing, flinching or
grabbing the belly
Heel drop sign:The patient experiences pain on dropping the
heels to the ground after standing on his or her toes
Children, this may be tested by having them jump up and
down.

54. Special signs or
Techniques
1. Murphy's sign : Elicited when a patient abruptly ends deep inspiration
during palpation of the RUQ.
Murphy's sign is very sensitive for acute cholecystitis and biliary colic.
2. Psoas sign: The patient flex the thigh against resistance.
3. Obturator sign:Patient internally and externally rotate their flexed hip

55. Psoas & Obturator signs
Pain elicited by either the psoas or obturator maneuvers
suggests irritation of the respective muscles by an
inflammatory process such as acute appendicitis, a
ruptured appendix or pelvic inflammatory disease (PID).

56. Special signs
or
Techniques
4. Rovsing sign: Pain in the RLQ precipitated by
palpation of the left lower quadrant (LLQ).
Suggestive of appendicitis
5. Carnett's sign: Increased tenderness to palpation
when the abdominal muscles are contracted, as
when the patient lifts his or her head or legs off the
bed.To distinguish abdominal wall from visceral
pain.

57. Carnett's and Rovsing signs

58. Pelvic Exams
● Any woman of childbearing age with
abdominal pain
● Differentiate a gynecologic cause from
other causes of pain
1. Cervical appearance
2. Cervical motion tenderness (CMT)
3. Adnexal tenderness or masses
4. Uterine size
5. Presence or absence of discharge,
pus or blood

59. Two possibilities
1. Although women with appendicitis or
PID may have CMT or adnexal
tenderness, the presence of pus at
the cervical os suggests PID
2. A woman with severe PID may also
experience RUQ tenderness due to
perihepatic inflammation
(Fitz–Hugh–Curtis syndrome)

60. Genital
● Every male with abdominal pain
should have a genital examination.
● The groin should be inspected and
palpated for hernias, which may be the
cause of an acute bowel obstruction.
● The external genitalia and scrotum
should also carefully be evaluated for
any tenderness, masses, or
abnormalities.

61. Rectal
Necessary component of the
evaluation of patients with
abdominal pain.
● Prostate and Perirectal disease
● Stool impactions
● Rectal foreign bodies
● Gastrointestinal (GI) bleeding
● Occult blood in the right clinical
setting should raise suspicion for
intestinal ischemia.

62. Back
Gently percussing the
costovertebral angles (CVA)
of the back to elicit pain
● Pyelonephritis
● Obstructive uropathy.

63. Skin
● Thorough skin
examination can provide
important diagnostic
clues.
● Pale, cool & moist skin
shock or dehydration.
● Jaundice: biliary or
hepatic disease
● Petechiae and spider
hemangiomas : liver
disease.

64. Head to Foot
● Abdominal pain may be
elicited by
extra-abdominal causes,
such as pharyngitis,
pneumonia and MI.
● These conditions can be
missed without a
comprehensive physical
examination.

65. Examination findings :
Red flag clues

66. Examination findings : Red flag clues
1 Hypotension ● AAA,
● Ectopic
pregnancy
2 Peritoneal signs/Rigidity ● Acute surgical
emergency
3 Abdominal distension or
Bilious emesis
● Bowel
obstruction
● Volvulus
● Malrotation

67. Examination findings : Red flag clues
4 Pulsatile mass AAA
5 Fever,RUQ Pain,Jaundice Cholangitis
6 Ascitis SBP

68. Examination findings : Red flag clues
7 Blood in stool ● Colitis,
● Intussusception
● Inflammatory bowel
diseases
● Cancer
8 Benign abdominal
exam but severe
pain
● Mesenteric
ischaemia
● MI

69. Differential Diagnosis :
Anatomical Region Approach

70. Acute
abdominal
pain :
Differential
Diagnosis

71. Extra
Abdominal
Causes

72. Acute
Abdominal
pain
Differential
Diagnosis

73. Acute
Abdominal
pain
Differential
Diagnosis

74. Diagnosis of
Acute Abdomen
Algorithmic
approach
Rosen; 9th edn

75. Risky patients
Acute abdominal pain

76. Diagnostic
Tests
Blood
1. WBC
2. Pregnancy test /HCG
3. Lipase/Amylase
4. Liver function tests
5. Serum Electrolytes
6. Blood sugar
7. S.Phosphate and lactate

77. Diagnostic
Tests
Blood tests: Facts
1. The WBC should never be used to
make the sole diagnosis of
abdominal pathology, nor should it
be used in isolation to exclude
reasonable diagnostic possibilities
2. Decision making in cases of
abdominal pain rests primarily on a
careful history and thorough physical
examination, not the WBC count.

78. Diagnostic
Tests
Blood tests: Facts
The serum amylase may also be
elevated in
1. Peptic ulcer
2. Liver disease
3. SBO
4. Common Bile duct stones
5. Bowel infarction
6. Ectopic pregnancy
7. Ethanol intoxication
8. Diabetic ketoacidosis (DKA)

79. Diagnostic
tests
Blood tests: Facts
Serum lipase has a higher
sensitivity and specificity
for pancreatitis than total
amylase, and is therefore
the most useful test in a
patient with suspected
pancreatitis.

80. Diagnostic
Tests
Blood test : Facts
● Serum phosphate and
serum lactate may be
elevated in cases of
bowel ischemia.

81. Diagnostic
Tests
Pregnancy tests : Facts
1. All female patients of childbearing
age with abdominal pain should
have a pregnancy test
2. A positive pregnancy test expands
the differential diagnosis (e.g.,
ectopic pregnancy)
3. Influences the choice of medications
or adjunctive studies, and may
impact disposition.
4. Do not omit pregnancy testing in
patients who report sexual
abstinence, tubal ligation, or
contraceptive use.

82. Diagnostic
Tests
Urine analysis
1. Leukocyte esterase
2. Nitrites
3. Microscopy/RBC/Pus cells
4. Sugar
5. Ketone

83. Diagnostic Tests
ECG
● All patients with unexplained epigastric or abdominal pain.
● Elderly patients with vague, poorly localized abdominal
complaints

84. Diagnostic
Tests
ECG- Facts
1. An acute coronary
syndrome (ACS) or inferior
MI can present with
epigastric pain, diaphoresis
and vomiting.
2. Though a normal ECG in
the setting of abdominal
pain does not exclude MI, it
makes it less likely.

85. Diagnostic
Tests
Radiologic studies
1. Plain films
2. Ultrasound
3. Computed Tomography
4. CECT

86. Diagnostic
Tests
Plain films : Facts
● Overutilized, difficult to
interpret (even in
experienced hands)
● Rarely provide useful
clinical information.

87. Diagnostic
tests
Plain films : Facts
● Plain films are unlikely to
be helpful in patients with
nonspecific abdominal
pain, suspected
appendicitis and UTIs
● Cloud the diagnosis,
leading to delays in
management

88. Diagnostic
Tests
Plain films : Facts
Plain films of the abdomen should be
restricted to patients with
1. Suspected bowel
obstruction
2. Perforated viscus
3. Foreign bodies.

89. Diagnostic
Tests
Plain films :
What should you look for ?
1. Dilated loops of large or small bowel
2. Air-fluid levels
3. Abnormal calcifications ( abdominal
aorta, urinary tract, gallbladder
[gallstones], or appendix
[appendicolith])
4. Air in abnormal locations (free air
under the diaphragm, in the portal
vein, bowel wall, or between loops of
bowel)

90. Plain films : abdomen

91. Plain film Abdomen: Dilated Bowel loops , Air fluid levels

92. Diagnostic
Tests
Ultrasound : Facts
● Extremely useful diagnostic
modality in patients with
abdominal pain.
● Advantages of ultrasound
lack of ionizing radiation
low cost
widespread availability.
● Preferred imaging
approach for evaluating
patients with RUQ pain

93. Diagnostic
Tests
Ultrasound : Facts
● Acute cholecystitis, ultrasound may
detect
1. Gallstones
2. Gallbladder wall thickening
3. Pericholecystic fluid
4. Sonographic Murphy's sign.
● Imaging the pelvic organs
“Transvaginal approach is preferred and
superior to the transabdominal approach
for the diagnosis of ectopic pregnancy”

94. USG- Gallbladder
Diagnostic Tests

95. Diagnostic
Tests
Ultrasound : Facts
● When radiation is a concern,
ultrasound is the procedure of choice
for identifying acute appendicitis,
especially in children, women of
reproductive age and pregnant
patients
● Swollen, non compressible appendix
>7 mm in diameter with a target
configuration mm, consistent with
acute appendicitis.

96. Diagnostic
Tests
Ultrasound : Appendicitis

97. Diagnostic
Tests
Goal-directed bedside
ultrasonography in ED
1. Confirm an intrauterine pregnancy,
dramatically lowering the risk of ectopic
pregnancy
2. Screen for the presence of an AAA
3. Screen for the presence of free
intraperitoneal fluid in patients with
suspected ectopic pregnancy or
abdominal trauma

98. Ectopic gestation
Diagnostic tests
Goal-directed bedside ultrasonography in ED

99. Diagnostic
Tests
Ultrasound : Ruptured Abdominal
Aortic Aneurysm

100. USG Abdomen : Free fluid Diagnostic tests

101. Diagnostic
Tests
Ultrasound :Facts
A negative ultrasound does not
exclude the diagnosis of either
appendicitis or ectopic
pregnancy

102. Diagnostic
Tests
CT Abdomen : Facts
1. Modality of choice undifferentiated
abdominal pain who require imaging
2. It allows visualization of the
structures of the peritoneal and
retroperitoneal space, uninhibited by
the presence of bowel gas or fat
3. Due to its exceptional accuracy, CT
is often the primary imaging modality
in patients with suspected
appendicitis.

103. Diagnostic
Tests
CT is useful for determining
the diagnosis (and in many
cases, the clinical severity)
● Renal colic
● Bowel obstruction
● Bowel perforation
● Bowel ischemia
RBBB

104. Diagnostic
Tests
CT is useful for determining
the diagnosis (and in many
cases, the clinical severity)
● Solid organ injury
● AAA
● Pancreatitis
● Intra-abdominal abscess
● Diverticulitis
RBBB
SAPID

105. Diagnostic Tests
CT Abdomen

106. Diagnostic
Tests
CECT : Facts
1. IV contrast is useful for
identifying mesenteric
ischemia
2. Oral contrast may assist
with the visualization of
intra-abdominal abscesses.

107. Diagnostic
Tests
CECT :Major drawbacks
CECT
1. Cost
2. Contrast
3. Complication- nephrotoxicity
4. Concern on radiation
5. Considerations of availability.
5 C,s

108. General Principle of
Treatments
1. Begins with the ABCs (airway, breathing, circulation)
2. The main goals of treatment
● Physiologic stabilization
● Symptom relief
● Preparation for surgical intervention when warranted
3. ED Disposition

109. 1 2 3 4 5
General Principle of Treatments
Volume repletion Pain relief Antibiotics Control of Emesis NPO

110. General
Treatment
Volume repletion: Facts
1. Crystalloids are the initial fluids of
choice in both children and adults.
2. Rate of repletion is determined by
the patient's degree of hypovolemia,
cardiovascular status, and response
to initial therapy
3. Life-threatening hemodynamic
collapse, blood products may be the
initial resuscitation fluid.

111. General
Treatment
Pain Relief : facts
● No clear evidence supporting the
notion that Narcotics mask
symptoms and signs
● Administration of moderate doses of
analgesia and the ensuing pain relief
do not cloud diagnostic findings;
instead, this approach actually may
aid in the diagnosis of surgical
disease.

112. General
Treatment
Pain Relief : facts
1. In the acute setting, pain relief is
typically achieved with IV titration of
opioid analgesics such as morphine
sulfate or fentanyl
2. Ketorolac is not recommended for
treatment of undifferentiated
abdominal pain as it may mask
abdominal findings and increase
bleeding times.

113. General
Treatment
Antibiotic : Facts
1. Abdominal infections are often
polymicrobial and necessitate
coverage for enteric Gram-negatives,
Gram-positives and anaerobic
bacteria.
2. The specific regimen must take into
account the patient's presentation,
comorbid conditions, and local
bacterial drug sensitivities and
drug-resistance patterns.

114. General
Treatment
Antibiotics

115. Acute Abdominal pain
Treatment algorithm
Rosen 9t Edn

116. 1 2 3 4
Special group of patients
Elderly Pediatric Pregnant Immunocompromised

117. Special group of
patients
Elderly : Facts
● Diagnosis and management of
abdominal pain in elderly patients
challenging
● Surgical causes of abdominal pain
increase in incidence with advancing
age
● Surgical illness in elderly is more
rapidly life-threatening than in
younger patients.

118. Special group of
patients
Elderly : Facts
● Greater risk for vascular
catastrophes such as ruptured AAA,
mesenteric ischemia and MI
● Elderly patients are more likely to
present without the classic or
expected historical or physical
examination findings associated
with a common disease
● Patient mortality and rates of
misdiagnosis increase exponentially
each decade after age 50.

119. Special group of
patients
Pediatric : Facts
● Illnesses relatively unique
to children include
intussusception, volvulus,
pyloric stenosis and
Hirschsprung's disease
● Any child presenting with
bilious vomiting should be
presumed to have a bowel
obstruction.

120. Acute Abdomen in Children : DD

121. Acute
Abdominal
pain in
Children

122. Special group of
patients
Pregnant : Facts
By 12 weeks gestation: Enlarging uterus
extends into the abdomen
1. Impeding physical examination
2. Altering the location of pelvic and
abdominal organs
3. Masking peritoneal signs

123. Special group of
patients
Pregnancy : Differential
diagnosis of abdominal pain
1. Pregnancy-specific
conditions (Placental
abruption, Uterine rupture)
2. Gynecologic causes
(Ovarian torsion, Fibroid
degeneration)
3. Abdominal conditions
(Appendicitis, Biliary
disease, Bowel
obstruction).

124. Special group of
patients
Pregnant : Facts
● Delays in diagnosis and
treatment can increase
maternal and fetal/newborn
morbidity and mortality
● Rapid evaluation and early
obstetric and surgical
consultation are paramount

125. Special group of
patients
Immunocompromised with HIV
infection : Additional considerations
1. Enterocolitis with profuse diarrhea and
dehydration
2. Large bowel perforation associated
with cytomegalovirus (CMV)

126. Special group
of patients
Immunocompromised with HIV
infection : Additional considerations
3.Bowel obstruction from Kaposi's
sarcoma, lymphoma or atypical
mycobacteria
4. Biliary tract disease from
cryptosporidium or CMV
5. Drug-induced pancreatitis.

127. Special group of
patients
Immunocompromised : Facts
● Antibiotics, steroids or other
immunosuppressants may mask
abdominal examination findings
● Steroid use can lead to
demargination of leukocytes, making
interpretation of the WBC count
more difficult
● Steroids promote peptic ulcer
disease, leading to an increased
incidence of perforated viscus.

128. 1 2 3
Disposition
Surgical consultation Serial evaluation Discharge

129. Disposition
Surgical consultation
Emergent consultation
● Life-threatening diagnoses such as
Ruptured AAA or Ectopic pregnancy
Urgent consultation
● Appendicitis
● Intestinal obstruction
● Perforated ulcer
● Acute cholecystitis.

130. Disposition
Serial Evaluation
1. Extended evaluation of a patient with
an early or atypical presentation of
appendicitis or another acute
abdominal process
2. Kept in the ED or admitted to the
hospital for serial abdominal
examinations
3. Serial evaluation, preferably by the
same physician, allows a patient's
clinical picture to evolve or resolve
over a period of time.

131. Disposition
Discharge rules
● After a thorough work-up in the ED or
serial observation, patients without
evidence of concerning medical or
surgical illness may be discharged
Undiagnosed abdominal pain
1. Arrange for a repeat evaluation
within 12–24 hours (either in the ED
or with an outpatient clinic)
2. Emphasize the need to return to the
ED if symptoms worsen

132. Disposition
Discharge rules
1. Advise a clear liquid diet
2. Avoid narcotic analgesics
3. Patients returning to the ED with
worsening symptoms, the additional
opportunity to establish the
diagnosis should be welcomed
4. Patients in whom reliable follow-up
cannot be arranged or assured may
require admission.

133. Pearls and Pitfalls
Acute Abdominal pain
evaluation

134. Pearls
● Do not restrict the diagnosis solely by the location of the
pain.
● Do not use the presence or absence of fever to distinguish
between surgical and medical causes of abdominal pain.
● The WBC count is of little clinical value in the patient with
possible appendicitis.
● Any woman with childbearing potential and abdominal
pain has an ectopic pregnancy until her pregnancy test
comes back negative.

135. Pearls
● Pain medications reduce pain and suffering without
compromising diagnostic accuracy
● An elderly patient with abdominal pain has a high
likelihood of surgical disease.
● Obtain an ECG in all older patients and those with cardiac
risk factors presenting with abdominal pain
● The use of abdominal ultrasound or CT may help evaluate
patients over the age of 50 with unexplained abdominal or
flank pain for the presence of AAA.

136. Concepts and facts taken from ...

137. drvenugopalpp@gmail.com
91 9847054747
www.drvenu.blogspot.com