abdominal pain in adults

7/31/2019 Abdominal Pain in Adults

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ABDOMINAL PAIN IN

ADULTS


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often difficult for the patient to convey.

findings are variable and can be misleading.

The location and severity of the pain may be dynamic.

Benign-appearing symptoms and presentations may evolveinto life-threatening conditions.

accounting for up to 10% of all ED visits.

DIAGNOSTICALLY CHALLENGING


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Distention of hollow organs by fluid or gas and capsularstretching of solid organs from edema, blood, cysts, orabscesses are the most common stimuli. This discomfort ispoorly characterized and difficult to localize.

If the involved organ is affected by peristalsis, the pain often isdescribed as intermittent, crampy, or colicky.

Foregut structures (stomach, duodenum, liver, and pancreas)are associated with upper abdominal pain.

Midgut derivatives (small bowel, proximal colon, and

appendix) are associated with periumbilical pain. Hindgut structures (distal colon and genitourinary tract) are

associated with lower abdominal pain.


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Visceral pain can be perceived in a location remote from theactual disease process.

The early periumbilical pain of appendicitis . When the parietal

peritoneum becomes involved, the pain localizes to the rightlower quadrant of the abdomen, the usual location of theappendix.


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e.g.-epigastric pain associated with an inferior myocardialinfarction and

the shoulder pain associated with blood in the peritonealcavity irritating the diaphragm.

REFERRED PAIN


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REFERRED PAIN


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early stabilization,

history,

physical examination, and

any ancillary tests collectively facilitating appropriatemanagement and disposition plans.

DIAGNOSTIC APPROACH


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Classically, potential diagnoses are divided into

intra-abdominopelvic (intraperitoneal, retroperitoneal, andpelvic) causes (e.g., appendicitis, cholecystitis, pancreatitis)

andextra-abdominopelvic processes (e.g., pneumonia,

myocardial infarction, ketoacidosis).

DIFFERENTIAL CONSIDERATIONS


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Ruptured ectopic pregnancy

Ruptured or leaking abdominal aneurysm

Mesenteric ischemia

Intestinal obstruction

Perforated viscus

Acute pancreatitis

LIFE-THREATENING CAUSES


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Physiologically compromised patients A B C

Extreme conditions such as ruptured abdominal aorticaneurysm, massive gastrointestinal hemorrhage, ruptured

spleen, and hemorrhagic pancreatitis may require blood orblood product replacement.

Bedside ultrasonography

early surgical consultation when indicated.

RAPID ASSESSMENT AND STABILIZATION


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A careful and focused history is central

HIGH-YIELD HISTORICAL QUESTIONS--

PIVOTAL FINDINGS


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The diffuse, severe, colicky pain =bowel obstruction

pain out of proportion to examination = mesentericischemia

The radiation of pain from the epigastrium straight through to

the midback = pancreatitisThe radiation of pain to the left shoulder = splenic pathology,

diaphragmatic irritation, or free intraperitoneal fluid

associated with syncope = perforation of gastric or duodenalulcer, ruptured aortic aneurysm, or ruptured ectopic

pregnancy

NATURE OF THE PAIN


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Vitals HR BP Temp

Inspection

Palpation

PR , PV

PHYSICAL EXAMINATION


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Physiologic stabilization, mitigation of symptoms and expeditious diagnosis, withconsultation, if required.

In the acute setting, analgesia usually is accomplished with intravenously titratedopioids.

Intravenous ketorolac is useful for both ureteral and biliary colic as well as some

gynecologic conditions, but is notindicated for general treatment ofundifferentiated abdominal pain.Among patients with gastrointestinal hemorrhageand potential surgical candidates, ketorolac has been shown to increase bleeding timesin healthy volunteers.

The burning pain caused by gastric acid may be relieved by antacids. Intestinal cramping may be diminished with oral anticholinergics although evidence

for this is scant and highly variable.

Gastric emptying by nasogastric tube with suction is appropriate for suspected smallbowel obstruction and intractable pain or vomiting.

If intra-abdominal infection is suspected, broad-spectrum antibiotic therapy should beinitiated promptly.

EMPIRICAL MANAGEMENT


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surgical versus nonsurgical consultation

40% of patients has nonspecific abdominal pain, thedisposition can be as difficult

nonspecific abdominal pain that is considered potentially

worrisome ,have the patient reevaluated after 8 to 12 hours

DISPOSITION


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In undiagnosed cause of nonspecific abdominal pain ,theconditions that should be met :

examination findings should be benign overall, with normalvital signs.

Pain and nausea should be controlled, andthe patient should be able to eat and drink.

BEFORE YOU DISCHARGE THEPATIENT


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If a patient is to be discharged home without a specific diagnosis,clear instructions to the patient must include the followinginformation:What the patient has to do for relief of symptoms or to maximizechances of resolution of the condition (e.g., avoiding exacerbatingfood or activities, taking medications as prescribed)

Under what circumstances, with whom, and in what time frame toseek follow-up evaluation, if all goes as desired on the basis of whatis known when the patient is in the ED

Under what conditions the patient should seek more urgent carebecause of unexpected changes in his or her condition (such as withnatural progression of the process before improvement, incorrectdiagnosis made in the ED, or untoward reactions to medications)

BEFORE YOU DISCHARGE THEPATIENT


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THANK YOU

abdominal pain in adults

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