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An approach to abdominal pain

Dr. Matthew Smith Emergency Specialist. An approach to abdominal pain. Types of pain Special Populations Assessment History Examination Investigations Differential Diagnosis Management - overview Cases ( if time permits). Types Of Pain. Visceral Parietal Pain. Visceral Pain.

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An approach to abdominal pain

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  1. Dr. Matthew Smith Emergency Specialist An approach to abdominal pain

  2. Types of pain • Special Populations • Assessment • History • Examination • Investigations • Differential Diagnosis • Management - overview • Cases ( if time permits)

  3. Types Of Pain Visceral Parietal Pain

  4. Visceral Pain • Stretching of nerve fibres of walls or capsules of organs • Crampy • Dull • Achy • Often unable to lie still • Bilateral innervation

  5. Parietal Pain • Parietal peritoneum irritated • Usually anterior abdominal wall • Localised to the dermatome superficial to the site of painful stimulus

  6. Course

  7. Referred Pain • Examples of referred pain?

  8. Special Populations

  9. Elderly • May lack physical findings despite having serious pathology • As patients age increases diagnostic accuracy declines • Risk of Vascular Catastrophes • Assume surgical cause until proven otherwise • 30-40% of geris with abdo pain need surgery • Biliary tract Disease is the commonest cause • Age > 65 need to think of reasons not to CT! • Mortality is 7% in the over 80’s - equivalent to AMI!

  10. Elderly Patient think Nasties! • AAA • Ischaemic Gut • Bowel Obstruction • Diverticulitis • Perforated Peptic Ulcer • Cholecystitis • Appendicitis

  11. Women of Childbearing Age • Must Ascertain whether PREGNANT • ALL WOMEN OF CHILDBEARING AGE WITH ABDO PAIN NEED BHCG • Gravid uterus displaces intra-abdominal organs making presentations atypical • Pregnant women still get common surgical abdominal conditions

  12. History • What are the key points of the abdominal pain history?

  13. History • HPC • Pain • Provocative • Palliative • Quality • Radiation • Symptoms associated with • Timing • Taken for the pain • Consultations/ Presentations Associated Symptoms – • Gastro – intestinal • Genito-urinary • Gynaecologic

  14. History • PMH • DM • HT • Liver Disease • Renal Disease • Sexually Transmitted Infections • PSH • Abdominal Surgery • Pregnancies • Deliveries/ Abortions/ Ectopics • Trauma

  15. History • Meds • NSAIDs • Steroids • OCP/ Fertility Drugs • Narcotics • Immunosuppressants • Chemotherapy agent • ALLS • Contrast • Analgesic

  16. High Yield Questions • Which came first – pain or vomiting? • How long have you had the pain? • Constant or intermittent? • History of cancer, diverticulosis, gall stones,Inflammatory BD? • Vascular history, HT, heart disease or AF?

  17. Examination • Lots of information from the end of the bed • Distressed vs. non distressed • Lying still - peritonitis • Writhing – Renal Colic • Vital Signs • NEVER ignore abnormal vital signs! • Always document as part of your assessment

  18. Investigations • Bedside • UA • Blood? • Leucocyte Esterase and nitrites • Urine HCG • ECG – anyone with upper abdominal pain or elderly • Bloods • ALL WOMEN OF CHILDBEARING AGE NEED BHCG • What are your differentials? • Avoid machine gun approach!

  19. Radiology • CXR –?perforation • ?Extra abdominal pathology • ?Complications of intra-abdominal disease

  20. Which of the following is NOT an indication for plain abdominal imaging? • Bowel Obstruction • Constipation • Tracking Renal Calculi • Foreign Body

  21. Other imaging • USS • Biliary Disease • Good for gynae complaints • Rule out Ectopic pregnancy • Appendicitis in children • No radiation

  22. CT is accurate for diagnosis of • Renal colic • Appendicitis • Diverticulitis • AAA • Intraabdominal Abscesses • Mesenteric Ischaemia • Bowel Obstruction • Avoid repeated CT scans • Limit use in younger patients • Avoid where possible in pregnant females

  23. Management • Resuscitate • Large bore access • N Saline bolus 20ml/kg x 2 if shocked • If bleeding think hypotensive resuscitation • All should be NBM until provisional diagnosis • Ensure normothermia • Maintenance fluids and fluid balance • Analgesia doesn’t mask signs • Use a the pain scale • Morphine titrated to pain. Normally 0.1mg/Kg • Paracetamol adjunct • NSAIDs for renal colic • Correct Electrolytes • Thromboprophylaxis

  24. Cases

  25. Case 1 21 year old female • 24 hour history of vague peri-umbilical abdominal pain. • Moved down to the RIF. • Now constant and sharp. • Associated with 2x vomits and feels flushed • No appetite • Normal Bowels

  26. What clinical signs may lead you to a diagnosis of appendicitis? Lie still RIF tenderness Rebound Rovsig’s sign Psoas Sign

  27. Imaging? • AXR rarely useful • USS • Not as good as CT • Good for female to exclude gynaepathology • If appendix is visualised is useful • CT • Only if there is doubt about diagnosis • Sensitivity up to 98% • High radiation dose • Diagnose other pathology if no appendicitis • Elderley

  28. Management • NBM • Analgesia • Anti-emetic if necessary • Maintenance fluids • IVABs – e.g. Ceftriaxone, Gentamicin and Metronidazole • Surgical Referral

  29. Case 2 • 40 yr old obese female • RUQ pain • Pain is constant • nausea, vomiting • fevers and chills • PMH Asthma • MEDS OCP • SH • Drinks 2 std / week • Smokes 20/day • Nil drugs

  30. On Examination • Looks distressed. • Not jaundiced • T 38 C • P 120 • BP 100/60 • RR 20 • Sats 98% RA • Tender in the RUQ and Murphy’s positive.

  31. What bloods will you order on this patient?

  32. HB 138 • WCC 16.0 • Neuts 12.4 • Lymph 1.6 • EUC Normal • Bil 9 (<18) • ALP 450 (30-130) • GGT 320 (<60) • ALT 41 (5-55) • AST 30 (5-55) • Amylase 28 (<120) • Lipase 40 (<60)

  33. Management • NBM • IVF • IV abs –Ampicillin + Gentamicin • Analgesia +- anti emetic • Refer to surgeons

  34. Case 3 • 52 yr old alcoholic • Constant epigastric pain radiating to the back. Worsening over the past 2 days • Improved with sitting up and forwards • Nausea and vomiting • Bowels OK PMH Chronic Airways Limitation Alcoholic Gastritis MEDS Thiamine 100 mg daily SH Boarding house resident Drinks 4 litres wine/day Smokes 20/day

  35. Looks unwell and dehydrated • T38.4C • P105 • BP 130/70 • RR 18 • Sats 93% RA

  36. Reduced AE L base • Tender Epigastrium and RUQ • No guarding/ rebound

  37. What blood tests will you order?

  38. Blood Results Biochem • Na 129 • K 4.0 • Cr 62 • Ur 8.0 • Amylase 1080 (<120) • Lipase 950 (<60) • Bil 11 ( 18) • GGT 900 (<60) • ALP 200 ( < 140) • AST 300 (5-55) • ALT 250 (5-55) • LDH 800( 105-333) • Glucose 15 • Alb 23 • Ca (Corr) 2.0 Haem • HB 114 • WCC 17 • Coags Normal

  39. What imaging will you perform ( if any)?

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