Evaluation and Management of Acute Abdominal Pain

MEDICAL STUDENT SERIES Evaluation and Management of Acute Abdominal Pain W.F. Holdefer, M.D. Department of Emergency Medicine Risk Stratification Potentially Life-Threatening Immediate Cardiac Splenic rupture, hemorrhagic pancreatitis Ruptured ectopic pregnancy AAA, leaking or ruptured MEDICAL STUDENT SERIES Potentially Life Threatening Within hours Inflammatory Disease (surgical Rx) Appendicitis, cholycystitis,perforated viscus, infarcted bowel, torsion/rupture ovarian cyst, incarcerated hernia Inflammatory Disease (non-surgical Rx) Pancreatitis, PID, diverticulitis (uncompl.) MEDICAL STUDENT SERIES Types of Abdominal Pain Visceral Distention of viscus ( crampy, gaseous pain) Poorly localized Ex.: appendicitis, biliary colic, obstruction Somatic Parietal peritoneal inflammation Sharper, better localized MEDICAL STUDENT SERIES Types of Abdominal Pain Referred Visceral dz.may produce distant pain Ex.: neck/shoulder pain from diaphragmatic irritation MEDICAL STUDENT SERIES Abdominal Pain Intra-abdominal Origin Peritoneal Inflammation (peritonitis) Peritoneal surface area = 50% BSA Significant fluid loss, metabolic disorder, hypotension. Visceral peritoneal inflammation produces ileus, bowel distention, intraluminal fluid loss MEDICAL STUDENT SERIES MEDICAL STUDENT SERIES Intra-abdominal Origin Peritonitis Primary Uncommon (pneumo, strep, e. coli, tb.) Secondary Disease or injury of abdominal or pelvic viscera (polymicrobial) Perforation of appendix, diverticulum, peptic ulcer, Intra-Abdominal Origin Peritonitis (cont’d.) gallbladder, mesenteric ischemia; mechanical obstruction, volvulus; pancreatitis; PID(TOA) Increased morbidity / mortality children (omentum not fully developed) and elderly (omental atrophy) MEDICAL STUDENT SERIES MEDICAL STUDENT SERIES Peritonitis Symptoms Abdominal pain, fever, nausea, vomiting Quality of pain related to irritant: gastric acid - acute, intense urine (non-infected) - minimal Intra-abdominal Origin Obstruction/Inflammation/Perforation Intestines (appendix, PUD, diverticulitis) Biliary Subsystem ( cholycystitis,pancreatitis, hepatitis) Renal Subsystem (renal/ureteral calculi) Vascular Subsystem ( AAA, mesenteric ischemia) MEDICAL STUDENT SERIES Extra-abdominal Origin Abdominal Wall Pain (myositis, contusion) Pelvic Disease (torsion/rupture ovarian cyst, TO abscess, salpingitis, ruptured ectopic pregnancy) esophageal rupture Porphyria, blk. widow/brn. recluse/ scorpion bites, sickle cell crisis MEDICAL STUDENT SERIES MEDICAL STUDENT SERIES Referred Pain Location Upper abdominal Etiology MI, pneumothorax esophageal rupture Biliary disease Pancreatitis,perforated PUD Mid-back/ scapula Midline Common Etiologies of Acute Intra-abdominal Pain Intra-Abdominal Acute Surgical Rx: peritonitis, perforated viscus, AAA rupture/leak, appendicitis, ruptured ectopic, bowel obstruction/ infarction, ureteral stone, cholecystitis Possible Surgical Rx: diverticulitis, pancreatitis, salpingitis (TOA) MEDICAL STUDENT SERIES Common Chronic Etiologies of Acute Abdominal Pain Reflux esophagitis PUD Ulcerative colitis Regional enteritis Irritable bowel syndrome MEDICAL STUDENT SERIES Extra-abdominal Etiologies of Acute Abdominal Pain AMI Pneumonia Acute spontaneous pneumothorax (PTX) Acute hepatitis Rheumatic fever Acute intermittent porphyria MEDICAL STUDENT SERIES Locations of Acute Abdominal Pain RUQ Intra-abdominal: acute cholycystitis, Perforated duodenal ulcer,retrocaecal appendicitis, hepatitis, hepatic abcess, acute pancreatitis Extra-abdominal: angina, AMI, pyelonephritis, pericarditis, pneumonia MEDICAL STUDENT SERIES Locations of Acute Abdominal Pain LUQ Intra-abdominal: acute pancreatitis, splenic dz. (-megaly, rupture, infarct, aneurysm), AAA leak/rupture, perforation gastric ulcer/colon Extra-abdominal: AMI, angina, pneumonia, pyelonephritis MEDICAL STUDENT SERIES Locations of Acute Abdominal Pain RLQ Intra-abdominal: appendicitis, regional enteritis, cholycystitis, intestinal obstruction, perforated ulcer/cecum, leaking AAA, ruptured ectopic, ovarian cyst, TOA, ureteral stone, incarcerated inguinal hernia Extra-abdominal: psoas abcess, vesiculitis MEDICAL STUDENT SERIES LLQ Intra-abdominal: diverticulitis, obstruction, appendicitis, leaking AAA, ruptured ectopic, ovarian cyst, TOA, incarcerated inguinal hernia, ureteral stone, perforated desc. colon, regional enteritis Extra-abdominal: psoas abcess, vesiculitis Locations of Acute Abdominal Pain MEDICAL STUDENT SERIES Locations of Acute Abdominal Pain Diffuse Pain Intra-abdominal: peritonitis, pancreatitis, sickle cell crisis, early appendicitis, expanding or leaking AAA, mesenteric thrombosis, gastroenteritis, obstruction, strangulated inguinal hernia, diverticulitis, colitis Extra-abdominal: uremia, diabetes, leukemia MEDICAL STUDENT SERIES Abdominal Pain Clinical Evaluation HISTORY Pain Onset Time, activity, severity, location of pain Referred Pain (MI, PTX, PTE, pneumonia) Change in location, radiation or referred pain MEDICAL STUDENT SERIES Clinical Evaluation (cont’d.) Pain Character/Severity Explosive, excruciating - AMI, perforated viscus, biliary/renal colic, ruptured AAA Rapid, severe, constant - pancreatitis, MEDICAL STUDENT SERIES MEDICAL STUDENT SERIES Clinical Evaluation (cont’d.) mesenteric thrombosis, ischemic bowel Gradual steady pain - cholycystitis, appendicitis, diverticulitis Intermittent colicky pain mechanical obstruction MEDICAL STUDENT SERIES Clinical Evaluation (cont’d) Associated Symptoms Nausea/Vomiting Prominent - gastroenteritis, gastritis, pancreatitis, high intestinal obstruction Explosive - Mallory-Weiss, Boerhaave Hematemesis - PUD, gastritis; may require emergent intervention MEDICAL STUDENT SERIES Clinical evaluation (cont’d.) Alterations in Bowel Habits Diarrhea Constipation/Obstipation Melena Stool caliber/color MEDICAL STUDENT SERIES Clinical Evaluation (cont’d.) Fever/Chills Often with biliary, renal disease With appendicitis, suggest perforation With jaundice, suggest suppurative cholycystitis Gynecologic history +UCG, abd. pain = R/O ectopic pregnancy Clinical Evaluation (cont’d.) C-V Symptons Palpitations associated with A fib., embolic disease Angina, claudication, ischemic/infarcted bowel PMH Prior episodes, hospitalization, operation MEDICAL STUDENT SERIES MEDICAL STUDENT SERIES Clinical Evaluation (cont’d.) Fatty food intolerance, gall bladder disease; antacid use, PUD ETOH abuse, pancreatitis Prior abdominal surgery - most common cause of mechanical bowel obstruction Abdominal Exam Patient position pancreatitis- lat. decub., knees/hips flexed retrocaecal appendicitis- rt. hip flexed peritonitis- motionless bilat. hip flexion Reflex spasm of abdominal musculature Distention/visible peristalsis- intestinal obstruction MEDICAL STUDENT SERIES Abdominal Exam Tenderness, guarding, rebound Localized (area overlying involved viscus; abscess, appendicitis) Psoas, obturator signs (abscess, retrocaecal appendix Diffuse tenderness (involvement entire parietal peritoneum; perforated viscus) MEDICAL STUDENT SERIES MEDICAL STUDENT SERIES Abdominal Exam (cont’d.) Bowel sounds High pitched during pain: obstruction Continous hyperactive: gastroenteritis Absent: ileus Pelvic exam Salpingitis (TOA) vs appendicitis MEDICAL STUDENT SERIES Abdominal Exam (cont’d.) Rectal exam Prostate, masses, strictures Tenderness pelvic peritoneum - pelvic abscess, appendicitis MEDICAL STUDENT SERIES Diagnostic Adjuncts Lab Studies Valuable, but rarely establish diagnosis CBC, lytes, chems, urinalysis, amylase (serum/urine), amylase/creatine clearance ratio, lipase, liver function profile MEDICAL STUDENT SERIES Diagnostic Adjuncts (cont’d.) ECG Radiologic Findings Pneumonia Sub-diaphragmatic free air - perforated viscus Mediastinal air - esophageal disruption MEDICAL STUDENT SERIES Diagnostic Adjuncts (cont’d.) Air fluid levels - obstruction, ileus Abnormal densities - renal/ureteral calculi, gallstones, pancreatic calcifications Displacement gastric bubble/splenic flexure - splenomegaly (etiology?)