Acute abdomen for EP

Prasit WuthisuthimethaweeDepartment of Emergency MedicinePrince of Songkla University

Male 34 years old

No underlying dis.

Check up at GP

During took blood examination abd pain & syncope

Objectives

Abdominal pain pathway

Critical points for assessing abdominal pain

Epidemiology

4-10 % of all emergency department visit

50 % have clearly diagnosis

15-30% require surgical procedure esp. elderly

Acute appendicitis is the most common

Epidemiology

Unique in Pediatric and Elderly

Acute abdominal pain among elderly patients

3 years, 831 cases

Non-specific 22-24%

Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%)less peritoneal signs

Laurell H, Hansson LE, Gunnarsson U.Gerontology. 2006;52(6): 339-44

Emergency department diagnosis of acute abdominal pain in elderly patients

1 year retrospective review, 378 cases

Non-specific (35.2%), acute gastritis/gastroenteritis (10.6%), and biliary tract dis. (8.2%)

Othong R, Wuthisuthimethawee P, Vasinanukorn PSongkla Med J vol. 28 No 1 Jan-Feb 2010

Non-specific; 90% dissolved, 5.4% Sx.

Predictor for an intensive care or specific treatment inthe elderly patients with acute abdominal pain

1 year retrospective review, 386 cases

Dyspepsia (21.8%), non-specific (17.6%) and acute gastroenteritis (8.8%)

Worapraatya P, Wuthisuthimethawee P, Vasinanukorn P

Male, BT < 38, PR >90, abnormal abd contour, andLocalize tenderness or guarding

Pain pathway

Abdominal pain pathway

3 type; visceral, somatic, and referred pain

Abdominal pain pathway

Visceral pain

Wall or capsule of solid organs/bowel

Midline, dull, archy and cramping pain

Autonomic; pallor, diaphoresis, nausea, and vomiting

Abdominal pain pathway

Somatic pain

Parietal peritoneum

Sharp, discrete, and localized

Tenderness, guarding, and rebound

Abdominal pain pathway

Somatic pain

Abdominal pain pathway

Referred pain

Cutaneous site distant from the diseased organ

Diaphragm C3-5: neck and shoulder pain

Abdominal pain pathway

Referred pain

Critical points for assessing abdominal pain

Life threatening conditions

Vascular disease

Acute myocardial infarction

Ruptured ectopic pregnancy

Perforated visceral organs

Life threatening conditions

Intestinal obstruction

Acute hemorrhagic pancreatitis

Esophageal rupture

Aim

Surgical or Non-surgical

Physical examination

Accuracy 55-65% with final diagnosis

Reexamination and observation

Technique !

Physical examination

Bowel sound

Little diagnostic value

Physical examination

Do not forget PR

Physical examination

Analgesic ?

Analgesia on abdominal examination

Analgesia is safe in abdominal pain

Br J Surg. 2003 Jan;90(1):5-9

Effect on diagnostic efficiency of analgesia for

undifferentiated abdominal pain

Analgesia on abdominal examination

Reexam in 60 minutes

Prospective, double-blind clinical trial

No differences with respect to changes in physical

examination or diagnostic accuracy

J Am Coll Surg. 2003 Jan;196(1):18-31

Effects of morphine analgesia on diagnostic accuracy in

Emergency Department patients with abdominal pain:

a prospective, randomized trial

Analgesia on abdominal examination

Opioid improve patients comfort and does not retard decision to treat

Cochrane Database Syst Rev. 2007 Jul 18;(3): CD005660

Analgesia in patients with acute abdominal pain

Analgesia on abdominal examination

8-18 years old, 90 patients

Randomized double-blind placebo-controlled trial

Morphine did not delay surgical decision,

not more effective than placebo to diminishing pain

Ann Emerg Med. 2007 Oct;50(4):371-8.

Epub 2007 Jun 27

Efficacy and impact of intravenous morphine before surgical

consultation in children with right lower quadrant pain

suggestive of appendicitis: a randomized controlled trial

Buscopan ?

Medication on abdominal examination

Clinical assessment

Reassessment

Clinical assessment

Patient’s quantification of pain is unreliable

Clinical assessment

Corticosteroids and immunosuppressants

Clinical assessment

Chronic dis.: CRF

Clinical assessment

Fever ?

Clinical assessment

Prior abdominal surgery

Clinical assessment

Hernia

Genitalia

Clinical assessment

Peripheral pulse

Clinical assessment

Menstrual history

Urine pregnancy test

Clinical assessment

WBC 30% in abdominal pain of unknown etiology

Clinical assessment

20% of pancreatitis

have normal amylase

Clinical assessment

20% of pancreatitis

have normal amylase

Clinical assessment

Lactase and mesenteric ischemia

100% sensitive and 42% specific

Clinical assessment

Film acute abdomen

10-38% confirm diagnosis

Gallstone Ileus

Portal vein gas

Clinical assessment

USG and CT scan

Angiogram

Tech99m RBC scan

Clinical assessment

Myocardial infarction, pneumonia, or pulmonary embolus can present as abdominal pain

Clinical assessment

Psychiatric disorder

The last diagnosis

Mamagement

Bowel rest +/- decompression

IV resuscitation with correct electrolyte

Antiemesis ? Analgesia ? Antibiotic ?

Pre-op in surgical case

Uncertain Diagnosis

Observation

Review the cause

Consultation

Uncertain Diagnosis

When in doubt, don’t send them out!

Cope’s Early Diagnosis of the Acute

Abdomen, 20th ed.. New York, Oxford

University Press, 2000.

Case 1

Male 34 years old

No underlying dis.

Check up at GP

During took blood examination abd pain & syncope

Case 1

At ER

Sweating, looked pale

V/S BP 95/60 P 112 RR 26

Abd: tenderness at RLQ, guarding ?

What is diagnosis ?

Case 2

Female 53 years old

LLQ abdominal pain for 1 day

V/S BP 140/80 P 90 RR 24

Underlying HT

Case 2

Abd: LLQ pain, guarding ?CVA: tenderness Lt.

Diclofenac improved

Recurrent 2 times in 3 days

UA: microscopic hematuria

What is diagnosis ?

Hematuria may be seen in

abdominal aortic aneurysm (30%)

Case 3

Female 47 years old

RLQ abdominal pain for 1 day

V/S BP 130/80 P 82 RR 22

No known underlying dis.

Case 3

Abd: RLQ pain, guarding ?,CVA: not tender

CBC: leukocytosisUA: WNL

What is diagnosis ?

?

Clinical assessment

ขอบคุณครับ

Special sign

Iliopsoas and Obturator

< 10% in appendicitis

Special sign

Fist Percussion

Special sign

Rovsing’s Sign

Only 5% of patients

High-Yield historical questions

How old are you ?

Which came first-pain or vomiting ?

How long have you had the pain ?

Have you ever had abdominal surgery ?

High-Yield historical questions

Is the pain constant or intermittent ?

Have you ever had this before ?

Do you have a history of cancer diverticulosis ?

Do you have HIV ?

High-Yield historical questions

How much alcohol do you drink per day ?

Are you pregnant ?

Are you taking antibiotic or steroid ?

Did the pain start centrally and migrate ?

Do you have a history of CAD, HT, AF ?

Etiology and clinical course of abdominal painIn senior patients; a prospective, multicenter study

3 years, 831 cases

Non-specific 22-24%

Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%)less peritoneal signs

Lewis LM, Banet GA, Blenda M, et al.J Gerontol A Biol Sci Med Sci. 2005