The Pitfalls in Acute Abdomen in Emergency Department by pyw18970

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									Acute Abdominal Pain in ED

       侯重光, 顏鴻章

    台北榮民總醫院 急診部

                        How CK
Acute Abdominal Pain, Cause ?
    A Dilemma for Doctors

 • It’s not so important to identify a
   cause of abdominal pain as to
   recognize a surgical abdomen.

                                    How CK
   The Epidemiology of Acute
        Abdominal Pain
• 5-10% of all ED visits.
• Among them, 14-40% patients need surgical
• Challenge for emergency physician (EP):
  – About 1/3 have an atypical presentation.
  – If misdiagnosis, mortality rate 2.5 times higher than
    correct diagnosis in the elderly.

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Three Subgroups of Patients with
 Abdominal Pain Who deserve
       Particular Focus
• The elderly.
• The immunocompromised. (e.g. HIV)
• Women of childbearing age.

                               How CK
 The Most Important Concept for EP in
     Approaching Abdominal Pain
• To Differentiate
  – Who is the patient of acute abdomen?
  – What are the probable diagnoses you have in mind?
  – Why do you consider such diagnosis?
  – How do you prove it?
  – When will you consult surgeon for operation?
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Causes of Acute Abdominal Pain in the ED
  Cause                                   Percentage of Cases
  Nonspecific abdominal pain                        41-46
  Appendicitis                                        4-24
  Cholecystitis                                     2.5-9
  Gastroenteritis                                      7
  Salpingitis                                         2-7
  UTI                                                 3-5
  Small-bowel obstruction                           2.5-4
  Renal colic                                       1.5-4
  Constipation                                         2
  Pancreatitis                                        1-2
  Diverticulitis                                      1-2
  Abdominal aneurysm, ectopic pregnancy               <1
             (Brewer et al., 1979; Scand J Gastroenterol)
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Acute Abdominal Pain in Patients Under
and Over Age 50
Under 50 (6317 cases), %              Over 50 (2406 cases), %
Nonspecific abd. pain        39.5     Cholecystitis           20.5
Appendicitis                 32.5     Nonspecific abd. Pain   15.7
Cholecystitis                 6.3     Appendicitis            15.2
Obstruction                   2.5     Obstruction             12.5
Pancreatitis                  1.6     Pancreatitis            7.3
Diverticular disease         <0.1     Diverticular disease    5.5
Cancer                       <0.1     Cancer                  4.1
Hernia                       <0.1     Hernia                  3.1
Vascular                     <0.1     Vascular                2.3
               (Telfer et al., 1988; Scand J Gastroenterol)
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Important Extra-abdominal Causes of Abdominal Pain
    • Systemic                           – Pneumonia
       –   DKA                           – Pulmonary embolism
       –   Alcoholic ketoacidosis        – Herniated thoracic disc
       –   Uremia                          (neuralgia)
       –   Sickle cell disease        • Genitourinary
       –   Porphyria                     – Testicular torison
       –   SLE                           – Renal colic
       –   Vasculitis                 • Infectious
       –   Glaucoma                      – Strep pharyngitis (more often
       –   Hyperthyroidism                 in children)
    • Toxic                              – Rocky Mountain Spotted
       –   Methanol poisoning              Fever
       –   Heavy metal toxicity          – Monocucleosis
       –   Scorpion bite              • Abdominal wall
       –   Black widow spider bite       – Muscle spasm
    • Thoracic                           – Muscle hematoma
       – Myocardial infarction/          – Herpes zoster
         Unstable angina
                Emerg Med Clin North Am 1989; 7: 721-740        How CK
Three Types of Abdominal Pain

     • Visceral Pain
     • Somatic (Parietal) Pain
     • Referred Pain

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   The Physiology and Mechanisms
         of Abdominal Pain
• Visceral Pain
  – Within the muscular walls of hollow organs and the capsules
    of solid organs.
  – Stimulated primarily by stretching, distension, and excessive
  – Characteristically deep, dull, aching or cramping, and
    poorly localized.
  – Usually felt in the midline, unaccompanied by

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 The Physiology and Mechanisms
       of Abdominal Pain
• Somatic (Parietal) Pain
  – Afferent fibers: from T6 to L1, more localized.
  – Characteristically sharper, aggravated by
    stimulation of the parietal peritoneum with
    movement, coughing, or walking.
  – True parietal pain      surgical cause of
    abdominal pain.

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 The Physiology and Mechanisms
       of Abdominal Pain
• Referred Pain
  – Pain felt a site other than that of the primary noxious
  – Occurs in an area supplied by the same neurosegment as
    the involved organ.
  – Most visceral pain is of this type.
  – Usually intense and most often secondary to an
    inflammatory lesion.
  – Subdiaphragm disorder~shoulder pain
  – Biliary tract disorder~right shoulder pain
  – Small bowel disorder~back pain
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    High-Yield Historical Questions
1. How old are you? (Advanced age mean increased risk)
2. Describe the position, character,and migration of the pain
  sudden coupled with weakness or fainting, less acute but still
  abrupt onset ,or begin gradually and maximize slowly
  Is the pain constant or intermittent? (Constant pain is worse)
  Have you ever had this before? (No prior episodes is worse)
  Did the pain start centrally and migrate to the right lower quadrant?
  (High specificity for appendicitis)
3. Have you noticed specific aggravating or relieving factors? (Eating,
   defecation or fleatus)
4. Have you ever had abdominal surgery? (Consider obstruction in
   patients who report previous abdominal surgery)
                                                            How CK
      High-Yield Historical Questions
5. Do you have nausea, vomiting, diarrhea or bowel habit change?
   (D/D true diarrhea, overflow incontinence or tenesmus)
6. Do you have HIV? (Consider occult and unusual infection, 30%
   mortality of surgical treatment)
7. How much alcohol do you drink per day? (Consider pancreatitis,
   hepatitis, or cirrhosis)
8. Are you pregnant? (Test for pregnancy-consider ectopic pregnancy,
   menstrual history, sexual exposure history)
9. Are you taking antibiotics or steroids? (These may mask infection)
10. Do you have a history of vascular or heart disease, hypertension, or
   atrial fibrillation? (Consider mesenteric ischemia and abdominal

                                                             How CK
The Important Physical Examination
        of Acute Abdomen
• General
  – Facial expression, diaphoresis, pallor, and
    degree of agitation
• Vital signs
  – BT > 40 °C or < 35° C  consider abdominal
  – Tachypnea, bradypnea or tachycardia

                                                  How CK
The Important Physical Examination
        of Acute Abdomen
• Inspection
• Auscultation
   – Hyperactive BS, hypoactive BS or silent BS
   – Pulsatile bruit
• Palpation – the most critical step
  – Goal: To define an anatomic area of maximal tenderness.
  – Where is the tender point?
  – Is there muscle guarding or rigidity?
      • Only 21% > 70 y patients with PPU present with epigastric rigidity.
   – Is there rebounding pain?
• Rectal digital examination
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        Laboratory Examination
• Serum electrolyte
• Urinalysis
• ß-HCG – woman of childbearing age
• Bilirubin, Alk-p, ALT, AST, G-GT – RUQ pain, jaundice
• Amylase, lipase – epigastralgia
• EKG, CK – epigastralgia with aged patient

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Indications for Abdominal Plain Films
 Suspected Diagnosis Clinical Findings
 Perforated viscus*          Sudden-onset pain
                             Rigid abdomen
                             Decreased bowel sounds
 Bowel obstruction*          Prior abdominal surgery
                             Abdominal distension
                             Abnormal bowel sounds
                             High risk for obstruction or volvulus
 Foreign body                Mental retardation
                             Suspicion of rectal foreign body
         Ann intern Med 1982; 97: 257-261
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Important Imaging Studies for
      Acute Abdomen
• Standing CXR and left decubitus KUB
  (repeated if necessary)-----HOP
• Ultrasound: for solid organs.
• CT of abdomen for abscess, free air, vessel,
  tumor and ischmial bowel.
• Angiography: Especially in non-diagnostic
  ischemial bowel.

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    The Roles and Diagnosis of
        Ultrasound for EP
• Perforated ulcer (X)           • Diverticulitis (?)
• Cholecystitis (O)              • Appendicitis (O)
• Pancreatitis (O)               • Salpingitis (O)
• Pyelonephritis (O)             • Ovarian cyst (O)
• Abdominal aneurysm (O) • Ectopic pregnancy (O)
• Renal colic (O)                • Fecal impaction (X)
               Kang et al., 1989 (Appendicitis)
               Chern et al., 1997 (Psoas muscle abscess)
               Yen et al., 1999 (Renal abscess)            How CK
              Dangerous Mimics
True Diagnosis         Initial Misdiagnosis
Appendicitis           Gastroenteritis, PID, UTI
Ruptured abdominal     Renal colic, diverticulitis, lumbar strain
aortic aneurysm
Ectopic pregnancy      PID, UTI, corpus luteum cyst
Diverticulitis         Constipation, gastroenteritis, pyelonephritis
Perforated viscus      PUD, pancreatitis, nonspecific abdominal pain
Bowel obstruction      Constipation, gastroenteritis, nonspecific
                                abdominal pain
Mesenteric ischemia    Gastroenteritis, constipation, ileus small bowel
Incarcerated or        Ileus or small bowel obstruction
strangulated hernia
Shock or sepsis from   Urosepsis or pneumonia (in elderly)
perforation, bleed,
abdominal infection
                                                             How CK
Five Major Categories of Acute
      Abdomen (BIOPI)
 • Bleeding or rupture of vessels or
 • Ischemia or Infarction
 • Obstruction
 • Perforation
 • Inflammation
                                  How CK
The Demography of 271 Pitfalls in Acute Abdomen
in VGH-Taipei from Sep. 1992 to Jan. 1996
100                                                                      98
 90                                                                                                       Age
 50                                                                                                       No.
 40                                                                           36.1
 30                                                               30.9

 20                         18                    20                                 18
                 12                    12
 10    7                         6.8                   7.5                                6.8
           2.4        4.4                   4.4                                                 2 0.7
  0                                                                                                     Year
      < 20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 > 90
                  Male : Female 212 (78%) : 59 (22%)
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The Percentage of Pitfalls in Five Categories
of Acute Abdomen in VGH-Taipei from Sep.
1992 to Jan. 1996
                                            No (%)
• Inflammation                              142 (52%)
• Perforation                                46 (17%)
• Bleeding or rupture of vessels or tumor    33 (13%)
• Obstruction                                27 (10%)
• Ischemia or Infarction                     17 (6%)
• Miscellaneous                               6 (2%)

                                               How CK
The Common Pitfalls Generated by
• Can’t detect abnormalities by history taking & physical
    – Inadequate history and physical examination are the most
      common sources of error in diagnosing a surgical cause of
      abdominal pain.
    – Up to 1/3 of presentations are atypical
    – Pain perception and the muscular response to peritoneal
      irritation may be altered in the elder patients.
•   Misinterpretation of laboratory data.
•   Inadequate information supply from image studies.
•   Insufficient consultation and team work.
•   Misjudgement of timing for operation.
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Common Pitfalls in Acute Appendicitis
• Abdominal pain and tenderness are present in
  nearly 100% of patients with appendicitis; other clinical
  features are less reliable.
• Fever occurs in only 16% of patients with acute
  appendicitis; its presence is more suggestive of
  appendiceal perforation.
• DD: True diarrhea or tenesmus.
• Rovsing sign, Iliopsoas sign, Obturator sign
• Murphy sequence appears in only 22% elderly.
  – Perforation rate about 60% (age > 60 Y/O)
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Delayed Appendectomy for Appendicitis:
      Causes and Consequences
• More than 72 h from initial symptoms to operation.
• Delay in diagnosis:
  – 15/40 (37.5%) was attributed to factors controlled by
  – 25/40 (62.5%) by physician.

• Perforation (90%), postoperative
  complications (60%) and length of stay were
  related to the delay in diagnosis.
        (Von Titte et al., Am. J. Emerg. Med. 1996; 14: 620-2)
                                                                 How CK
Common Pitfalls in Acute Appendicitis
 • Rupture Appendicitis may present as diffused
   peritonitis or intestinal obstruction.
 • Caution is advised in evaluating the young, the
   elderly, pregnant women, and women of
   childbearing age. The diagnosis is often elusive,
   and many patients proceed to perforation.
 • When in doubt, admit the patient for observation and
   sequential physical examination.

                                                  How CK
Common Pitfalls in Acute Cholecystitis
  • Not considering symptomatic gallstones in patients
    with mild or atypical presentations of nausea,
    dyspepsia, chest pain, mild fever of
    unknown origins, AMS, no significant
    abdominal tenderness.
  • Silent abdominal pain in DM, elderly, debilitated,
    or NSAID or narcotics for pain relieve patients.
  • Failure to recognize acute gallbladder disease in

                                                   How CK
Common Pitfalls in Acute Cholecystitis

 • Diffuse tenderness and positive rebounding
   pain without free air in CXR or decubitus KUB
   may indicate acute cholecystitis with
 • Failure to obtain timely surgical consultation.

                                              How CK
 Common Pitfalls in Abdominal
     Aortic Aneurysm
• AAAs are frequently misdiagnosed, especially in the
  obese, any palpable abdominal pulsation-----
  suspected of being an AAA, even if a mass cannot be
  clearly discerned.
• Back pain or flank pain is common symptom.
• Peritoneal signs may not be present unless free
  rupture into the abdominal cavity.
• EPs May misdiagnoses of AAA, such as renal colic
  or lumbosacral disk disease.
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   Common Pitfalls in Abdominal
       Aortic Aneurysm
• Sound practice to perform a PE specifically aimed at
  ruling out an aneurysm in all patients > 50 who present
  with abdominal or back pain.
• Not incidental finding, Any back or abdominal pain
  in the presence of a pulsatile abdominal mass should be
  considered to be due to an expanding or leaking
  aneurysm unless there is overwhelming evidence to
  the contrary.

                                                  How CK
    Common Pitfalls in Abdominal
        Aortic Aneurysm
• S/S of Shock                     AAA rupture (80%
    without S/S before rupture)
•   KUB: enlarged & unusually calcified mass (65% of
    patients with symptomatic AAA)
•   Rapid bedside ultrasonography: unstable Pts, 100%
    sensitivity, obesity or bowel gas may make the study
    difficulty to perform, rupture cannot be reliably seen
•   CT: stable Pts
•   Early surgical consultation
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Common Pitfalls in Bowel Obstruction
 • Delays in diagnosing intestinal obstruction and
   obtaining surgical consultation result in poor patient
   outcome. Patient procrastination in seeking medical
   attention compounds the problem. Thus, the goal of
   intervention before strangulation may not be
   achieved in time to avoid catastrophic consequence.
 • Another common pitfall is the failure to replenish
   lost fluid and electrolytes. Uncorrected losses result
   in a poor surgical candidate and contribute to
   increased morbidity and mortality.

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Common Pitfalls in Mesenteric
  Ischemia and Infarction
• The most common pitfall in mesenteric ischemia is,
  ironically, failure to make the diagnosis while the
  patient is still living or salvageable.
• Underlying diseases: Af, Severe CHF, RHD,
• CT-Angiography: 82% sensitivity for mesenteric
  infarction vs 87.5% in angiography.(Radiology 197: 79-82, 1995)

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Common Pitfalls in Mesenteric
  Ischemia and Infarction
• Perhaps the greatest pitfall is reluctance to
  obtain angiography.
• Early radiographic consultation and refusal
  to “wait until morning” are essential to a
  good outcome.

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  Emergency Department Evaluation
        of Acute Abdomen
• History and PE repeatedly.
• Menstruation history (LMP, ovulation, sexual
  exposure), Rapid pregnancy test: women of
  childbearing age.
• Lab: CBC, liver panel, EKG for elderly.
• Plain KUB: helpful in obstruction; 40% patients invisible
  free air.
• Ultrasound and CT scan: aneurysm, cholelithiasis,
  ectopic pregnancy, and ureterolithiasis.
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Emergency Department Management
       of Acute Abdomen
• IV volume replacement and NG decompression
• Antibiotics: indicated if infection is suspected.
• Narcotic analgesia (?) Timing (?)
  – Pro: Humane; permit a more accurate history and
    PE. Morphine (2-5 mg IV)
  – Con: Surgeon is hostile to this approach,
    consultation immediately.

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 Special Consideration in Evaluation
    of Acute Abdomen in Elderly
• History
  – Hard to take due to hearing loss, dementia, old CVA.
  – More patience and diligence.
  – Consulting primary care physician, families, and
    reviewing medical records.
  – The elderly patient with abdominal pain may have a
    potentially lethal process despite a nonspecific or
    even relatively benign examination and normal
    laboratory studies
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Special Consideration in Evaluation
   of Acute Abdomen in Elderly
• Physical Examination
  – To examine the entire patient.
  – Tachycardia or tachypnea
     • pain, early sepsis, hypoxia, volume depletion, acidosis
       and hemorrhage.
  – Auscultation: bruits and bowel sound.
  – Palpation: pulsatile mass
  – Check for hernia.
  – All have digital examination.
                                                        How CK
Special Consideration in Evaluation
   of Acute Abdomen in Elderly
• Laboratory Studies
  – EKG for upper abdominal pain, nausea, or
    vomiting elderly.
  – WBC: commonly normal, should not be
    used as a criterion of infection.
  – Arterial blood gas.

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Special Consideration in Management
    of Acute Abdomen in Elderly
 • Disposition
   – Surgical consultation and admission: Persistent
     abdominal pain > 6 h.
   – ED observation: Several hours for unclear
   – Discharge patients: A follow-up appointment
     within 12 to 24 h must be arrange.
   – Family members instruction: Revisit immediately
     for any worsening of pain or change in status.
                                                   How CK
   The Identification of High Risk
   Patients with Acute Abdomen
• Elderly > 65 y         • Elevation of Band
• S/S of Shock             WBC
• Peritoneal sign (+)    • Fever cause ? Or BTI
  – silent bowel sound   • Hypothermia
• Pulsatile mass         • Acute renal failure
• Refractory pain post   • Not post-surgical
  Tx                       obstruction

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Sample Discharge Instructions for the
   Patient with Abdominal Pain
• Pain that gets worse or moves to just one spot.
• Pain that gets worse if you cough or sneeze.
• Pain that does not get better in 24 hours.
• Inability to keep down liquids--especially if you
  are making less urine.
• Fainting.

                                               How CK
Sample Discharge Instructions for the
   Patient with Abdominal Pain
• Blood in the vomit or stool.
• High fever or shaking chills.
• Swelling of the abdomen.
• Any new or worsening problem.
• Remember that the ED is open 24 hours a day,
  every day, and we are always glad to see you.

                                         How CK
  感   謝

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