1 / 72

Abdominal Pain

Abdominal Pain. William Beaumont Hospital Department of Emergency Medicine. Abdominal Pain. One of the most common CC Confounders making dx difficult Age Corticosteroids Diabetics Recent antibiotics. Abdominal Pain: Pitfalls. Consider non-GI causes

haley-terrell
Télécharger la présentation

Abdominal Pain

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Abdominal Pain William Beaumont Hospital Department of Emergency Medicine

  2. Abdominal Pain • One of the most common CC • Confounders making dx difficult • Age • Corticosteroids • Diabetics • Recent antibiotics

  3. Abdominal Pain: Pitfalls • Consider non-GI causes • Acute MI (inferior), ectopic pregnancy, DKA, sickle cell anemia, porphyria, HSP, acute adrenal insufficiency • History • Location, quality, severity, onset, duration, aggravating and alleviating factors, prior symptoms

  4. Abdominal Pain: History • Sudden onset – perforated viscus • Crushing – esophageal or cardiac dz • Burning – peptic ulcer dz • Colicky – biliary or renal dz • Cramping – intestinal • Ripping – aneurysmal rupture

  5. Abdominal Pain: Physical Exam • Abdomen • Inspection • Bowel sounds • Tenderness (rebound, guarding) • Extra-abdomen exam • Lung, cardiac, pelvic, GU and rectal

  6. Work up: Labs • Beta-hCG • WBC – poor sensitivity and specificity • LFTs – hepatobiliary • Lipase – pancreatic • Electrolytes – CO2 • Lactic acid • Urinalysis – BEWARE

  7. Work up: Imaging • Acute Abdominal Series • Free air and bowel gas • KUB • Poor screening test • Ultrasound – • Biliary dz, AAA, free fluid or air, pelvic pathology • CT – appendicitis, diverticulitis

  8. Case: Upper Abdominal Pain • 79 yo female presents with aching sharp pain in the epigastrium and right upper quadrant ½ hour after eating. Pain radiates to the back. +N, –V • Differential diagnosis? • Testing?

  9. RUQ/midepigastric pain • Biliary disease • PUD/gastritis • Pancreatitis • AAA • Pneumonia (RLL) • Pyelonephritis • Acute MI • Hepatitis • Appendicitis • Fitz-Hugh Curtis syndrome

  10. Gallstones: Risk Factors • Female 4:1 • Fertile • Forty • Fat • Family history • Crohns, UC, SCA, thalassemia • Rapid weight loss, starvation, TPN • Elevated TGs, cholesterol

  11. Cholelithiasis • History: • RUQ/epigastric pain • Nausea/vomiting with fatty meals • Similar episodes in past • PE: RUQ tenderness • Labs: may be normal • ECG: consider in older patients • Imaging: test of choice = US

  12. Cholelithiasis: Treatment • Symptomatic gallstones • Pain control • Anti-emetics • Consult general surgery • 90% with recurrent symptoms • 50% develop acute cholecystitis

  13. Cholelithiasis: Treatment • Asymptomatic gallstones • Incidental finding • 15-20% become symptomatic • Outpatient elective surgery if • Frequent, severe attacks • Diabetic • Large calculi

  14. Acute Cholecystitis • Sudden GB inflammation • Bacterial infection in 50-80% • E. coli, Klebsiella, Enterococci • History/PE: • Fever, tachycardia, RUQ tenderness • Murphy’s sign – low sensitivity • Labs: • Elevated WBC with left shift • LFTs – large elevation  CBD stone

  15. Acute Cholecystitis: Imaging • KUB – stones only seen @ 10% • Air in biliary tree  gangrenous • Ultrasound – sensitivity 90-95% • Gallstones (absent in biliary stasis) • Thickened GB wall • Pericholecystic fluid • CT scan – sensitivity 50% • HIDA scan – negative scan rules out dx • Positive = no visualization of the GB

  16. Acute Cholecystitis

  17. Acute Cholecystits: Treatment • Admit • NPO, IVF • Pain control • Anti-emetics • Antibiotics • Surgical consult

  18. Pancreatitis • Autodigestion of pancreatic tissue • B – Biliary • A – Alcohol • D – Drugs • S – Scorpion bite • H – HyperTG, HyperCa • I – Idiopathic, Infection • T – Trauma

  19. Pancreatitis: History and Physical • History: • Boring pain in LUQ or epigastrium • Constant • Radiates to midback • Nausea, vomiting • PE: • Epigastric or LUQ tenderness • Grey-Turner or Cullen sign

  20. Gray-Turner sign • Flank ecchymosis • Intraperitoneal bleeding • Hemorrhagic pancreatitis, ruptured abdominal aorta, or ruptured ectopic pregnancy

  21. Cullen's Sign • Periumbilical hemorrhage

  22. Pancreatitis: Diagnosis • Lipase – most specific • Ranson’s criteria – predicts outcome • Acutely: >55 yo, glucose > 200, WBC >16k, SGOT (ALT) > 250, LDH > 350 • 48 hrs: HCT decreases > 10%, BUN rises > 5, Ca < 8, pO2 < 60, base deficit >4, fluid sequestration > 6L • 3-4 criteria – 15% mortality • 5-6 criteria – 40% mortality • 7-8 criteria – 100% mortality

  23. Pancreatitis: Imaging • Plain films – sentinel loop (local ileus) • Ultrasound – poor (biliary tree) • *CT scan with contrast*

  24. Pancreatitis: Treatment • NPO, IVF, pain control, antiemetics • Antibiotics if gallstones or septic • Surgical consult • If gallstones, abscess, hemorrhage or pseudocyst • ERCP if CBD stone

  25. Gastritis/PUD • Duodenal 80%; gastric 20% • Etiology: H pylori, NSAIDS, zollinger-ellison syndrome, smoking, ETOH, FHx, male, stress • H pylori – 95% duodenal; 85% gastric • History: • Epigastric constant, gnawing pain • Food lessens – duodenal • Food worsens - gastric

  26. PUD: Workup/Treatment • Workup: • Hemoglobin • PT/PTT – if bleeding • Lipase – rule out pancreatitis • Hemoccult stool – rule out GI bleed • Treatment: • Antacids (GI cocktail), PPI, outpatient endoscopy and H. pylori testing

  27. Perforated Viscus • Rare in small bowel and mid-gut • History: abrupt onset pain • Diagnosis: upright CXR • Tx: IVF, IV abx, NGT, OR

  28. Questions on Upper Abdominal Pain? Let’s Move On Down

  29. Case: Lower Abdominal Pain • History: 35 y/o female c/o 1 day of periumbilical aching pain. +N,+V, +D, +F, +C, +anorexia. Today, she has crampy lower abdominal pain. No urinary sx. • Exam: afebrile, bilateral lower quadrant tenderness (R > L), no rebound or guarding. • Other questions? • Differential diagnosis? Testing?

  30. Appendicitis • Incidence – 6% • Mortality – 0.1% • Perforation 2-6% (9% elderly) • All ages – peak 10 – 30 yo • Difficult dx: young, old, pregnant (RUQ), immunocompromised

  31. Appendicitis • Abdominal pain (98%) • Periumbilical migrating to RLQ < 48 hrs • Anorexia 70% • Nausea, vomiting 67% • Common misdiagnosis – gastroenteritis, UTI

  32. Appendicitis • PE: RLQ tenderness 95% • Rovsing: RLQ pain palpating LLQ • Psoas: R hip elevation,extension • Obturator: flexion, internal rotation

  33. Appendicitis: Diagnosis • Labs: • WBC > 10k – 75% • UA – sterile pyuria • Imaging: • Ultrasound • CT scan

  34. Appendicitis: Treatment • IV fluids, NPO, analgesia • Antibiotics • Surgery consult

  35. Diverticulitis • Inflammation of a diverticulum (herniation of mucosa through defects in bowel wall); sigmoid colon is the most common site • History: • L > R • 3% under 40 • LLQ pain with BMs • N/V/constipation • PE: LLQ tenderness • Diagnosis: clinical, CT

  36. Diverticulitis: Treatment • Admit if fever, abscess • NPO, IV fluids, IV antibiotics • Surgical consultation

  37. Case: Generalized Abdomen Pain • History: 80 y/o male c/o nausea and crampy abdominal pain x 1 day. Emesis which was bilious and is now malodorous and brown. • PE: Diffusely tender, distended, with hyperactive bowel sounds. • Differential Diagnosis? • Workup?

  38. SBO • Etiology • Adhesions (>50%) • Incarcerated hernia • Neoplasms • Adynamic ileus – non mechanical • Abd trauma (post op), infection, hypokalemia, opiates, MI, scleroderma, hypothyroidism • Rare: intusseception, bezoar, Crohn’s ds, abscess, radiation enteritis

  39. LBO • Etiology • Tumor  left = obstruct; right = bleeding • Diverticulitis • Volvulus • Fecal impaction • Foreign body

  40. Bowel Obstruction • Pathophysiology: 3rd spacing  bowel wall ischemia  perforates, peritonitis  sepsis  shock • History: crampy, colicky diffuse abd pain, vomiting (feculent), no flatus or BMs • PE: abdominal distension, high pitched BS, diffuse tenderness • Diagnosis: AAS shows A/F levels with dilated bowel (SB > 3cm; LB > 10cm)

  41. SBO: Imaging

  42. SBO: Treatment • IV fluids! • Correct electrolyte abnormalities • NPO/NGT • Broad spectrum abx if peritonitis • Surgery consult

  43. Sigmoid Volvulus • History: • Elderly, bedridden, psychiatric pts • Crampy lower abd pain, vomiting, dehydration, obstipation • Prior h/o constipation • PE: • Diffuse abd tenderness • Distension

  44. Sigmoid Volvulus

  45. Sigmoid Volvulus: Imaging and Treatment • AAS: dilated loop of colon on left • Barium enema: “bird’s beak” • WBC > 20k: suggests strangulation • CT scan • Treatment: IVF, surgical consult, abx if suspect perforation

  46. Cecal volvulus • Most common in 25-35 year olds • No underlying chronic constipation • History: Severe, colicky abd pain, vomiting • PE: Diffusely tender abdomen, distension

  47. Cecal Volvulus • KUB: coffee bean – large dilated loop colon in midabdomen, empty distal bowel • Tx: surgery • Mortality: 10-15% if bowel viable; 30-40% if gangrene

  48. Hernias • Inguinal (most common) 75% • Indirect 50% vs direct 25% men > women, high risk incarceration in kids • Femoral 5% - women > men • Incisional 10% • Umbilical – newborns, women > men • Incarcerated – unable to reduce • Strangulated – incarcerated with vascular compromise

  49. Hernias • Clinical presentation: • Most are asymptomatic • Leads to SBO sxs • Peritonitis and shock – if strangulation • Treatment: • Reduce if non-tender – trendelenberg, sedation, warm compresses • Do not reduce if possible dead bowel • Admit via OR if strangulation

  50. Mesenteric Ischemia • Etiology • 50% arterial emboli • 20% non-occlusive dz (CHF, sepsis, shock) • 15% arterial thrombi • 5% venous occlusion • Mortality rates 70-90% - delayed dx

More Related