Download Symptoms and Signs in Acute Abdominal Pain - Emed

Symptoms and Signs in Acute
Abdominal Pain
Aims & Objectives
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Describe types of pain
Evaluate features of abdominal pain
Outline a plan for investigation
List some special circumstances
Explore differentials
Debunk a few myths
Highlight pitfalls
Pain
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Type
Site
Duration
Aggravating / Relieving factors
Character
Radiation
Associated Phenomena
Types of Pain
• Visceral pain:
– dull, poorly localized pain in midline epigastrium,
periumbilical region or lower midabdomen
– crampy, burning and gnawing
• Referred Pain:
– pain felt in areas remote to the disease organ (subphrenic
abscess felt as shoulder pain)
Chronology
• Sudden onset, well localized = intra-abdominal
catastrophe
– perforated viscus,
– mesentaric infarction
– ruptured aneurysm
• Progression
– appendicitis increases,
– gastroenteritis decreases,
– colic crescendo/decrescendo
• Duration hours to days more severe than pain lasting
weeks
Site
• May not be specific
• Pain of diaphragmatic irritation may
present as shoulder pain
• Changes in location may be marker of
progression
• Appendicitis - McBurney’s point
• Perforated ulcer - vague pain to
peritonitis
Aggravating and Relieving factors
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Peritonitis  lie motionless
Renal colic  writhe, unable to find comfortable position
Fatty foods  biliary colic
Pain improves with eating  DU
Worse with eating  GU, mesenteric ischemia
Intensity and character
• Perception of intensity is dependent on point of
reference of patient
• Not very useful
• Treat
• ‘Patient is always right’
Obtaining a history
• PMH
– bowel obstruction, renal colic, PID tend to recur
• ROS
– fever, chills  infectious
– nausea, vomiting with no flatus  bowel obstruction
– dysuria, pregnancy, menstrual history
Physical Examination
Physical Examination
• Still patient  peritonitis
• Writhing patient  colic, bowel obstruction
• Look for medical causes
- lower lobe pneumonia
- myocardial Infarction
• Remember the old and the young may present very
atypically
– elderly, diabetics, immunocompromised may present with
minimal symptoms
Physical Examination
• Severe tenderness with rigidity  peritonitis 
surgical colleagues
• Mild tenderness  gastroenteritis
• Palpate from areas of least pain to areas with most pain
• Peritonitis (shake bed, deep breath)
• Pelvic, Genital and Rectal exam on every patient with
severe abdominal pain
Investigations
Investigations
• FBC
• U&E
• Pregnancy test in all women of reproductive age
with abdominal pain
• LFTs, amylase on patients with upper abdominal
pain
Diagnostic Imaging
• Plain Film
– Consider erect chest x-ray
– Consider abdomen (will it really make a difference? )
• Ultrasound for patients with biliary or pelvic symptoms
• CT Abdomen and Pelvis
– evaluates vasculature, inflammation and solid organs
The differential..
• Acute Cholecystitis
– cystic duct obstructed, RUQ pain  R scapula
– Murphy’s sign,
– LFTS, amylase
• Acute Appendicitis
– anorexia, N/V and vague periumbilical pain
– 6-8 hrs pain migrates to RLQ, fever
– Progresses to localized peritoneal irritation
The differential (cntd)
• Pancreatitis
• Inflammatory bowel disease
• Acute Diverticulitis
– most commonly in sigmoid colon
– symptoms related to inflammation or obstruction
– Consider CT useful early to r/o abscess
The differential (cntd)
• Bowel Obstruction
– 70% of cases in adults are post-op
– adhesions, incarcerated hernias
– bilious vomiting, feculent vomiting  distal
obstruction
– X-rays  dilated bowel with fluid levels
• Perforated DU
– usually in the anterior duodenal bulb
– usually sudden acute pain with peritonitis
– Chest x-ray may show free air under diaphragm
The differential (cntd)
• Acute mesenteric ischemia
– intestinal angina (pain with eating)
– “vasculopath” (cad, pvd, abdo bruits etc)
– acute onset of periumbilical abdominal pain out of proportion
to physical findings
– Consider if atrial fibrillation
– acidosis may herald intestinal infarction
– surgery if acute vascular occlusion noted
The differential (cntd)
• AAA
– acute onset of tearing abdominal pain
– tender abdominal mass in 90%
– triad of hypotension, pulsatile mass and abdominal pain
noted in 75%
– Alert surgeons/anaesthetist/theater
• Others:
– endometriosis, salpingitis, tubo-ovarian absess, ovarian
cysts or torsion, ectopic pregnancy
Special Circumstances
• Pregnancy
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appendicitis, cholecystitis, pyelonephritis,
adnexal problems (ovarian torsion, ovarian cyst rupture)
appendicitis 7/1000 pregnancies
3% fetal loss with surgery, but 20% with perforated
appendix
Special Circumstances
• Very Young
– appendicitis and abdominal trauma secondary to NAI
– PID, Meckel’s diverticulum, cystitis, enteritis, IBD
• Very Old
– symptoms may be subtle
– compulsive evaluation
Special Circumstances
• Immuno-compromised
– chemotherapy, organ transplants, immunosupression for
autoimmune disease, AIDS
– symptoms are subtle
– unique to immunocompromised host (neutropenic enterocolitis,
GVH, CMV infections, KS, lymphoma/leukemia obstruction)
Chronic Abdominal Pain
• 15% of population complain of recurrent chronic
abdominal pain
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Abdominal pain lasting > 6 months
IBS
Women 70% of all IBS patients
obtain history of abuse (physical/sexual)
exhaustive work-up usually negative
Any Questions
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Summary
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Obtain detailed history
Careful examination and re-examination
Consider patient co-morbidity
Prompt, appropriate investigations
Ask for help if confused!!
Upper G.I. Haemorrhage
Causes
• Oesophageal
Mallory Weiss
Tumour
Oesophagitis
Varices
• Peptic Ulcer Disease
• NSAIDs
• Aorto-eneteric fistula
Clinical Presentation
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Melaena
Haematemesis
Hypovolaemia
Anaemia
History of recent abdo pain
History of NSAIDs
Primary Assessment
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Primary Assessment
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Protect airway against aspiration
Pulse
Blood pressure
Respiratory Rate
Look for indicators of cause
Resuscitation
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Oxygen
Cardiac Monitor
Widebore Cannulation
Restore intravascular volume
Warmed saline
Blood
• Insert CVP
• Insert urinary catheter
Resuscitation
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Consider FFP
Consider platelets
Endoscopy
Early surgical referral
+/- Surgery
Secondary Assessment
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Good History
Drug History
Jaundice
Other medical problems
PR
Secondary Assessment
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FBC
Gp and X-match
Coag Screen
U&E
LFTs
CXR
ECG
Definitive Care
• Early endoscopy
• +/- surgery
Severe continuous bleeding
60 years with > 4 units transfusion
< 60 years with > 8 units transfusion
Adverse prognostic factors
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Age > 60
Signs of hypovolaemia
Hb <10gm
Severe co-existent disease
Continued bleeding or re-bleeding
Varices
Any Questions
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Summary
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Is the airway at risk ?
Is oxygenation adequate ?
Are there signs of circulatory failure ?
Early attention to electrolytes
Attention to fluid balance
Early referral