assessment of abdominal pain - emergency care

7/29/2019 Assessment of Abdominal Pain - Emergency Care

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GROUP WORK ONASSESSMENT OF

ABDOMINAL PAIN

A.FELICIA CHITRA M.Sc(N);Ph.D

PROFESSOR

MTPG&RIHS

08 .10.2012


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Acute Appendicitis


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Epidemiology

The incidence of appendectomy appears

to be declining due to more accurate

preoperative diagnosis.

Despite newer imaging techniques, acute

appendicitis can be very difficult to

diagnose.


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Pathophysiology

Acute appendicitis is thought to begin with

obstruction of the lumen

Obstruction can result from food matter,

adhesions, or lymphoid hyperplasia

Mucosal secretions continue to increase

intraluminal pressure


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Pathophysiology

Eventually the pressure exceeds capillary

perfusion pressure and venous and

lymphatic drainage are obstructed.

With vascular compromise, epithelial

mucosa breaks down and bacterial

invasion by bowel flora occurs.


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Pathophysiology

Increased pressure also leads to arterial

stasis and tissue infarction

End result is perforation and spillage of

infected appendiceal contents into the

peritoneum


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Pathophysiology

Initial luminal distention triggers visceral

afferent pain fibers, which enter at the 10th

thoracic vertebral level.

This pain is generally vague and poorly

localized.

Pain is typically felt in the periumbilical or

epigastric area.


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Pathophysiology

As inflammation continues, the serosa and

adjacent structures become inflamed

This triggers somatic pain fibers,

innervating the peritoneal structures.

Typically causing pain in the RLQ


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Pathophysiology

The change in stimulation form visceral to

somatic pain fibers explains the classic

migration of pain in the periumbilical area

to the RLQ seen with acute appendicitis.


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Pathophysiology

Exceptions exist in the classic

presentation due to anatomic variability of

the appendix

Appendix can be retrocecal causing the

pain to localize to the right flank

In pregnancy, the appendix ca be shifted

and patients can present with RUQ pain


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Pathophysiology

In some males, retroileal appendicitis can

irritate the ureter and cause testicular pain.

Pelvic appendix may irritate the bladder or

rectum causing suprapubic pain, pain with

urination, or feeling the need to defecate

Multiple anatomic variations explain the

difficulty in diagnosing appendicitis


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History

Primary symptom: abdominal pain

to 2/3 of patients have the classical

presentation

Pain beginning in epigastrium or

periumbilical area that is vague and hard

to localize


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History

Associated symptoms: indigestion,

discomfort, flatus, need to defecate,

anorexia, nausea, vomiting

As the illness progresses RLQ localization

typically occurs

RLQ pain was 81 % sensitive and 53%

specific for diagnosis


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History

Migration of pain from initial periumbilical

to RLQ was 64% sensitive and 82%

specific

Anorexia is the most common of

associated symptoms

Vomiting is more variable, occuring in

about of patients


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Physical Exam

Findings depend on duration of illness

prior to exam.

Early patients may not have localized

tenderness

With progression there is tenderness to

deep palpation over McBurneys point


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McBurneys point


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Physical Exam

McBurneys Point: just below the middle of

a line connecting the umbilicus and the

ASIS

Rovsings: pain in RLQ with palpation to

LLQ

Rectal exam: pain can be most

pronounced if the patient has pelvic

appendix


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Physical Exam

Additional components that may be helpful

in diagnosis:

rebound tenderness,

voluntary guarding,

muscular rigidity,

tenderness on rectal


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Physical Exam

Psoas sign:

place patient in L lateral decubitus and

extend R leg at the hip. If there is pain

with this movement, then the sign is

positive.


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Physical Exam

Obturator sign:

passively flex the R hip and knee and

internally rotate the hip. If there is

increased pain then the sign is positive


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Physical Exam

Fever: another late finding.

At the onset of pain, fever is usually not

found.

Temperatures >39 C are uncommon in

first 24 h, but not uncommon after rupture

MANTRELS Score


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MANTRELS Score

Established in 1986

Migration of pain

Anorexia

Nausea / vomiting

Tenderness RLQ

Rebound

Elevated temp.

Leukocytosis

Shift to left


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MANTRELS Score, cont'd.

RLQ tenderness and leukocytosis = 2

points each ; all others 1 point

Score of 5 to 6 = possible appendicitisScore of 7 to 8 = probable appendicitis

Score of 9 to 10 = very probable

appendicitis


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Diagnosis

Acute appendicitis should be suspected in

anyone with epigastric, periumbilical, right

flank, or right sided abd pain who has not

had an appendectomy


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Diagnosis

Women of child bearing age need a pelvic

exam and a pregnancy test.

Additional studies: CBC, UA, imaging

studies


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Diagnosis

CBC: the WBC is of limited value.

Sensitivity of an elevated WBC is 70-90%,

but specificity is very low.

But, +predictive value of high WBC is 92%

andpredictive value is 50%

CRP and ESR have been studied with

mixed results


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Diagnosis

UA: abnormal UA results are found in 19-

40%

Abnormalities include: pyuria, hematuria,

bacteruria

Presence of >20 wbc per field should

increase consideration of Urinary tract

pathology


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Diagnosis

Imaging studies: include X-rays, US, CT

Xrays of abd are abnormal in 24-95%

Abnormal findings include: fecalith,appendiceal gas, localized paralytic ileus,

blurred right psoas, and free air

Abdominal xrays have limited use b/c the

findings are seen in multiple other

processes


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Diagnosis

Graded Compression US: reported

sensitivity 94.7% and specificity 88.9%

Basis of this technique is that normal

bowel and appendix can be compressed

whereas an inflamed appendix can not be

compressed

DX: noncompressible >6mm appendix,appendicolith, periappendiceal abscess


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Diagnosis

Limitations of US: retrocecal appendix

may not be visualized, perforations may

be missed due to return to normal

diameter


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Diagnosis

CT: best choice based on availability and

alternative diagnoses.

In one study, CT had greater sensitivity,

accuracy, -predictive value

Even if appendix is not visualized,

diagnose can be made with localized fat

stranding in RLQ.


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Diagnosis

CT appears to change management

decisions and decreases unnecessary

appendectomies in women, but it is not as

useful for changing management in men.

Diff i l Di i


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Differential Diagnosis

Gastroenteritis

Mesenteric

lymphadenitis

PID

Crohn's disease

Diverticulitis

Endometriosis

TOA

Ectopic pregnancy

UTI

Pyelonepritis

Other processes

involving appendix


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Special Populations

Very young, very old, pregnant, and HIV

patients present atypically and often have

delayed diagnosis

High index of suspicion is needed in the

these groups to get an accurate diagnosis


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Treatment

Appendectomy is the standard of care

Patients should be NPO, given IVF, and

preoperative antibiotics

Antibiotics are most effective when given

preoperatively and they decrease post-op

infections and abscess formation


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Treatment

There are multiple acceptable antibiotics

to use as long there is anaerobic flora,

enterococci and gram(-) intestinal flora

coverage

One sample monotherapy regimen is

Zosyn 3.375g or Unasyn 3g

Also, short acting narcotics should beused for pain management

assessment of abdominal pain - emergency care

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