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Abdominal PainAbdominal Pain
William Beaumont HospitalWilliam Beaumont Hospital
Department of Emergency MedicineDepartment of Emergency Medicine
Abdominal PainAbdominal Pain
• One of the most common chief complaints
• Confounders making diagnosis difficult • Age• Corticosteroids• Diabetics• Recent antibiotics
PitfallsPitfalls
• Consider non-GI causes• Acute MI (inferior), ectopic pregnancy, DKA, sickle
cell anemia, porphyria, HSP, acute adrenal insufficiency
• History• Location• Quality• Severity• Onset• Duration• Aggravating and alleviating factors• Prior symptoms
HistoryHistory
• Sudden onset – perforated viscusSudden onset – perforated viscus
• Crushing – esophageal or cardiac diseaseCrushing – esophageal or cardiac disease
• Burning – peptic ulcer diseaseBurning – peptic ulcer disease
• Colicky – biliary or renal diseaseColicky – biliary or renal disease
• Cramping – intestinal pathology Cramping – intestinal pathology
• Ripping – aneurismal ruptureRipping – aneurismal rupture
Physical ExamPhysical Exam
• AbdomenAbdomen• InspectionInspection• Bowel soundsBowel sounds• Tenderness (rebound, guarding)Tenderness (rebound, guarding)
• Extra-abdominal examExtra-abdominal exam• LungLung• CardiacCardiac• PelvicPelvic• GUGU• Rectal Rectal
LabsLabs
• Beta-hCGBeta-hCG
• WBC – poor sensitivity and specificityWBC – poor sensitivity and specificity
• LFTs – hepatobiliaryLFTs – hepatobiliary
• Lipase – pancreaticLipase – pancreatic
• Electrolytes – CO2Electrolytes – CO2
• Lactic acidLactic acid
• Urinalysis – BEWAREUrinalysis – BEWARE
ImagingImaging
• Acute Abdominal Acute Abdominal SeriesSeries• Free airFree air• Bowel gasBowel gas
• KUBKUB• Poor screening testPoor screening test
• UltrasoundUltrasound
• Biliary diseaseBiliary disease• AAAAAA• Free fluid or airFree fluid or air• Pelvic pathologyPelvic pathology
• CTCT• AppendicitisAppendicitis• DiverticulitisDiverticulitis
Case #1Case #1
• 79 yo female presents with aching sharp pain 79 yo female presents with aching sharp pain in the epigastrium and right upper quadrant in the epigastrium and right upper quadrant ½ hour after eating. Pain radiates to the back. ½ hour after eating. Pain radiates to the back. +N, –V+N, –V
• Differential diagnosis?Differential diagnosis?
• Testing?Testing?
Upper Abdominal PainUpper Abdominal Pain
• Biliary disease
• Hepatitis
• Pancreatitis
• PUD/gastritis/esophagitis
• AAA
• Pneumonia (RLL)Pneumonia (RLL)
• PyelonephritisPyelonephritis
• Acute MIAcute MI
• AppendicitisAppendicitis
• Fitz-Hugh CurtisFitz-Hugh Curtis
Gallstone Risk FactorsGallstone Risk Factors
• Female 4:1Female 4:1
• FertileFertile
• FortyForty
• FatFat
• Family historyFamily history
• Others:Others:• Crohns, UC, SCA, thalassemia, rapid Crohns, UC, SCA, thalassemia, rapid
weight loss, starvation, TPN, elevated weight loss, starvation, TPN, elevated TGs, cholesterolTGs, cholesterol
CholelithiasisCholelithiasis
• History: History: • RUQ/epigastric painRUQ/epigastric pain• Nausea/vomiting with fatty mealsNausea/vomiting with fatty meals• Similar episodes in pastSimilar episodes in past
• PE: RUQ tendernessPE: RUQ tenderness
• Labs: may be normalLabs: may be normal
• ECG: consider in older patientsECG: consider in older patients
• Imaging: test of choice = USImaging: test of choice = US
Cholelithiasis: TreatmentCholelithiasis: Treatment
SymptomaticSymptomatic
• Pain control
• Anti-emetics
• Consult general surgery• 90% with recurrent
symptoms
• 50% develop acute cholecystitis
AsymptomaticAsymptomatic
• Incidental findingIncidental finding
• 15-20% become 15-20% become symptomaticsymptomatic
• Outpatient elective Outpatient elective surgery ifsurgery if• Frequent, severe Frequent, severe
attacksattacks
• DiabeticDiabetic
• Large calculiLarge calculi
Acute CholecystitisAcute Cholecystitis
• Sudden gallbladder inflammation
• Bacterial infection in 50-80%• E. coli, Klebsiella, Enterococci
• History/PE:• Fever, tachycardia, RUQ tenderness• Murphy’s sign – low sensitivity
• Labs:• Elevated WBC with left shift• LFTs – large elevation CBD stone
Acute Cholecystitis: Acute Cholecystitis: ImagingImaging
• KUB – stones only seen ~ 10%• Air in biliary tree gangrenous
• CT scan – sensitivity 50%
• Ultrasound – sensitivity 90-95%• Gallstones (absent in biliary stasis)• Thickened gallbladder wall• Pericholecystic fluid
• HIDA scan – negative scan rules out diagnosis• Positive = no visualization of the GB
Acute CholecystitisAcute Cholecystitis
Acute Cholecystits: Acute Cholecystits: TreatmentTreatment
• Admit
• NPO
• IVF
• Pain control
• Anti-emetics
• Antibiotics
• Surgical consult
HepatitisHepatitis
• ViralViral• Hepatitis AHepatitis A• RNA, fecal-oralRNA, fecal-oral
• Hepatitis BHepatitis B• DNA, STD/parenteralDNA, STD/parenteral• Chronic hepatitis Chronic hepatitis
(10%) (10%) • Hepatitis CHepatitis C• RNA, blood borneRNA, blood borne• Chronic hepatitis Chronic hepatitis
(50%), cirrhosis (50%), cirrhosis (20%)(20%)
• Hepatitis DHepatitis D• RNA, co-infects Hep RNA, co-infects Hep
BB
• BacterialBacterial
• AlcoholicAlcoholic
• ImmuneImmune
• MedicationsMedications
Hepatitis: DiagnosisHepatitis: Diagnosis
• History: History: • Malaise, low-grade fever, anorexiaMalaise, low-grade fever, anorexia• Nausea/vomiting, abd pain, diarrheaNausea/vomiting, abd pain, diarrhea• Jaundice (altered MS, liver failure)Jaundice (altered MS, liver failure)
• Labs:Labs:• ALT and AST (10-100x normal)ALT and AST (10-100x normal)
• AST > ALT – alcoholic hepatitisAST > ALT – alcoholic hepatitis• Elevated bilirubinElevated bilirubin• Abnormal PTAbnormal PT• Hepatitis panelHepatitis panel• Tylenol levelTylenol level
Hepatitis: TreatmentHepatitis: Treatment
• Symptomatic – IVF, electrolytes
• Remove toxins – ETOH, acetaminophen
• Admit if altered MS or coagulopathy
PancreatitisPancreatitis
• Autodigestion of pancreatic tissueAutodigestion of pancreatic tissue
• B – BiliaryB – Biliary
• A – AlcoholA – Alcohol
• D – DrugsD – Drugs
• S – Scorpion biteS – Scorpion bite
• H – HyperTG, HyperCaH – HyperTG, HyperCa
• I – Idiopathic, InfectionI – Idiopathic, Infection
• T – TraumaT – Trauma
Pancreatitis: History and Pancreatitis: History and PhysicalPhysical
• History:History:• Boring pain in LUQ or epigastriumBoring pain in LUQ or epigastrium• ConstantConstant• Radiates to mid-backRadiates to mid-back• Nausea, vomitingNausea, vomiting
• PE:PE:• Epigastric or LUQ tendernessEpigastric or LUQ tenderness• Grey-Turner or Cullen signGrey-Turner or Cullen sign
Gray-Turner signGray-Turner sign
• Flank ecchymosisFlank ecchymosis
• Intraperitoneal bleeding Intraperitoneal bleeding
• Hemorrhagic pancreatitisHemorrhagic pancreatitis
• Ruptured abdominal aortaRuptured abdominal aorta
• Ruptured ectopic Ruptured ectopic pregnancy pregnancy
Cullen's SignCullen's Sign
Pancreatitis: DiagnosisPancreatitis: Diagnosis
• Lipase – most specificLipase – most specific
• Ranson’s criteria – predicts outcomeRanson’s criteria – predicts outcome• Acutely: >55 yo, glucose > 200, WBC >16k, ALT Acutely: >55 yo, glucose > 200, WBC >16k, ALT
> 250, LDH > 350> 250, LDH > 350• 48 hrs: HCT decreases > 10%, BUN rises > 5, 48 hrs: HCT decreases > 10%, BUN rises > 5,
Ca < 8, pO2 < 60, base deficit >4, fluid Ca < 8, pO2 < 60, base deficit >4, fluid sequestration > 6Lsequestration > 6L• 3-4 criteria – 15% mortality3-4 criteria – 15% mortality• 5-6 criteria – 40% mortality5-6 criteria – 40% mortality• 7-8 criteria – 100% mortality7-8 criteria – 100% mortality
Pancreatitis: ImagingPancreatitis: Imaging
• Plain films – sentinel loop (local ileus)
• Ultrasound – poor (biliary tree)
• CT scan with contrast
Pancreatitis: TreatmentPancreatitis: Treatment
• NPO
• IVF
• Pain control
• Antiemetics
• Antibiotics if gallstones or septic
• Surgical consult• If gallstones, abscess, hemorrhage or pseudocyst
• ERCP if CBD stone
Gastritis/PUDGastritis/PUD
• Duodenal 80%; gastric 20%
• Etiology: • H pylori, NSAIDS, zollinger-ellison
syndrome, smoking, ETOH, FHx, male, stress
• H pylori – 95% duodenal; 85% gastric
• History: • Epigastric constant, gnawing pain• Food lessens – duodenal• Food worsens – gastric
Peptic Ulcer DiseasePeptic Ulcer Disease
• Workup:Workup:• HemoglobinHemoglobin• PT/PTT – if bleedingPT/PTT – if bleeding• Lipase – rule out pancreatitisLipase – rule out pancreatitis• Hemoccult stool – rule out GI bleedHemoccult stool – rule out GI bleed
• Treatment: Treatment: • Antacids (GI cocktail)Antacids (GI cocktail)• PPIPPI• Outpatient endoscopyOutpatient endoscopy• H. pylori testingH. pylori testing
Perforated ViscusPerforated Viscus
• Rare in small bowel and mid-gutRare in small bowel and mid-gut
• History: abrupt onset painHistory: abrupt onset pain
• Diagnosis: upright CXRDiagnosis: upright CXR
• Treatment: Treatment: • IVFIVF• IV antibioticsIV antibiotics• NG tubeNG tube• OROR
Questions on Questions on Upper Abdominal Pain?Upper Abdominal Pain?
Let’s Move On DownLet’s Move On Down
Case #2Case #2
• History: 35 y/o female c/o 1 day of History: 35 y/o female c/o 1 day of periumbilical aching pain. +N,+V, +D, +F, +C, periumbilical aching pain. +N,+V, +D, +F, +C, +anorexia. Today, she has crampy lower +anorexia. Today, she has crampy lower abdominal pain. No urinary sx. abdominal pain. No urinary sx.
• Exam: afebrile, bilateral lower quadrant Exam: afebrile, bilateral lower quadrant tenderness (R > L), no rebound or guarding. tenderness (R > L), no rebound or guarding.
• Other questions?Other questions?
• Differential diagnosis?Differential diagnosis?
• Testing?Testing?
Lower Abdominal PainLower Abdominal Pain
• AppendicitisAppendicitis
• DiverticulitisDiverticulitis
• UTI/PyleonephritisUTI/Pyleonephritis
• Renal colicRenal colic
• Torsion/TOA/PIDTorsion/TOA/PID
• Ectopic pregnancyEctopic pregnancy
AppendicitisAppendicitis
• Incidence – 6%Incidence – 6%
• Mortality – 0.1%Mortality – 0.1%• Perforation 2-6% (9% elderly)Perforation 2-6% (9% elderly)
• All ages – peak 10 – 30 yoAll ages – peak 10 – 30 yo
• Difficult diagnosis:Difficult diagnosis:• Young and oldYoung and old• Pregnant (RUQ)Pregnant (RUQ)• ImmunocompromisedImmunocompromised
AppendicitisAppendicitis
• Abdominal pain (98%)Abdominal pain (98%)• Periumbilical migrating to RLQ < 48 hrsPeriumbilical migrating to RLQ < 48 hrs
• Anorexia 70%Anorexia 70%
• Nausea, vomiting 67%Nausea, vomiting 67%
• Common misdiagnosis – gastroenteritis, Common misdiagnosis – gastroenteritis, UTIUTI
AppendicitisAppendicitis
•PE: PE: • RLQ tenderness 95%RLQ tenderness 95%• Rovsing: RLQ pain palpating LLQRovsing: RLQ pain palpating LLQ• Psoas: R hip elevation, extension Psoas: R hip elevation, extension • Obturator: flexion, internal rotationObturator: flexion, internal rotation
Appendicitis: DiagnosisAppendicitis: Diagnosis
•Labs: Labs: • WBC > 10k – 75%WBC > 10k – 75%• UA – sterile pyuriaUA – sterile pyuria
• Imaging: Imaging: • UltrasoundUltrasound• CT scanCT scan• MRIMRI
Appendicitis: TreatmentAppendicitis: Treatment
• IV fluidsIV fluids
• NPONPO
• AnalgesiaAnalgesia
• AntibioticsAntibiotics
• Surgery consultSurgery consult
DiverticulitisDiverticulitis
• Inflammation of a diverticulum (herniation of mucosa through defects in bowel wall)
• Sigmoid colon is the most common site
• History: • L > R• 3% under 40• LLQ pain with BMs• N/V/constipation
• PE: LLQ tenderness
• Diagnosis: clinical, CT
Diverticulitis: TreatmentDiverticulitis: Treatment
•Admit if fever, abscess, elderlyAdmit if fever, abscess, elderly• NPONPO• IV fluidsIV fluids• IV antibioticsIV antibiotics
• Ciprofloxacin AND metronidazoleCiprofloxacin AND metronidazole• Surgical consultationSurgical consultation
Case #3Case #3
• History: 80 y/o male c/o nausea and History: 80 y/o male c/o nausea and crampy abdominal pain x 1 day. Emesis crampy abdominal pain x 1 day. Emesis which was bilious and is now malodorous which was bilious and is now malodorous and brown. and brown.
• PE: Diffusely tender, distended, with PE: Diffusely tender, distended, with hyperactive bowel sounds. hyperactive bowel sounds.
• Differential Diagnosis?Differential Diagnosis?
• Workup?Workup?
Differential DiagnosisDifferential Diagnosis
• Small bowel obstructionSmall bowel obstruction
• Large bowel obstructionLarge bowel obstruction
• Sigmoid volvulusSigmoid volvulus
• Cecal volvulusCecal volvulus
• HerniaHernia
• Mesenteric ischemiaMesenteric ischemia
• GI BleedGI Bleed
Small Bowel ObstructionSmall Bowel Obstruction
• Etiology• Adhesions (>50%)• Incarcerated hernia• Neoplasms• Adynamic ileus – non mechanical
• Abd trauma (post op), infection, hypokalemia, opiates, MI, scleroderma, hypothyroidism
• Rare: intusseception, bezoar, Crohn’s disease, abscess, radiation enteritis
Large Bowel ObstructionLarge Bowel Obstruction
• Etiology• Tumor
• Left obstruct• Right bleeding
• Diverticulitis• Volvulus• Fecal impaction• Foreign body
Bowel obstructionBowel obstruction
• Pathophysiology: Pathophysiology: 33rdrd spacing spacing bowel wall bowel wall ischemia ischemia perforates, perforates, peritonitis peritonitis sepsis sepsis shock shock
• History: crampy, colicky diffuse abdominal History: crampy, colicky diffuse abdominal pain, vomiting (feculent), no flatus or BMpain, vomiting (feculent), no flatus or BM
• PE: abdominal distension, high pitched BS, PE: abdominal distension, high pitched BS, diffuse tendernessdiffuse tenderness
• Diagnosis: AAS shows air fluid levels with Diagnosis: AAS shows air fluid levels with dilated boweldilated bowel• SB > 3cm; LB > 10cmSB > 3cm; LB > 10cm
SBO: ImagingSBO: Imaging
SBO: TreatmentSBO: Treatment
• IV fluids!
• Correct electrolyte abnormalities
• NPO
• NG tube
• Broad spectrum antibiotics if peritonitis
• Surgery consult
Sigmoid VolvulusSigmoid Volvulus
• History: History: • Elderly, bedridden, psychiatric ptsElderly, bedridden, psychiatric pts• Crampy lower abdominal pain, vomiting, Crampy lower abdominal pain, vomiting,
dehydration, obstipationdehydration, obstipation• Prior h/o constipationPrior h/o constipation
• PE: PE: • Diffuse abdominal tendernessDiffuse abdominal tenderness• DistensionDistension
Sigmoid VolvulusSigmoid Volvulus
Sigmoid Volvulus: Imaging Sigmoid Volvulus: Imaging and Treatmentand Treatment
• AAS: dilated loop of colon on leftAAS: dilated loop of colon on left
• Barium enema: “bird’s beak” Barium enema: “bird’s beak”
• WBC > 20k: suggests strangulationWBC > 20k: suggests strangulation
• CT scan CT scan
• TreatmentTreatment• IVFIVF• Surgical consultSurgical consult• Antibiotics if suspect perforationAntibiotics if suspect perforation
Cecal volvulusCecal volvulus
• Most common in 25-35 year olds
• No underlying chronic constipation
• History:• Severe, colicky abd pain• Vomiting
• PE:• Diffusely tender abdomen• Distension
Cecal VolvulusCecal Volvulus
• KUB:KUB:• Coffee bean – large Coffee bean – large
dilated loop colon in dilated loop colon in midabdomenmidabdomen
• Empty distal bowelEmpty distal bowel
• Treatment: Treatment: • SurgerySurgery• Mortality –10-15% if Mortality –10-15% if
bowel viable; 30-bowel viable; 30-40% if gangrene40% if gangrene
HerniasHernias
• Inguinal (most common) 75%• Indirect 50% vs. direct 25%• Men > women• High risk incarceration in kids
• Femoral 5% - women > men• Incisional 10%• Umbilical – newborns, women > men
• Incarcerated – unable to reduce• Strangulated – incarcerated with vascular
compromise
HerniasHernias
• Clinical presentations:Clinical presentations:• Most are asymptomaticMost are asymptomatic• Leads to SBO sxsLeads to SBO sxs• Peritonitis and shock – if strangulationPeritonitis and shock – if strangulation
• TreatmentTreatment• Reduce if non-tender – trendelenberg, Reduce if non-tender – trendelenberg,
sedation, warm compressessedation, warm compresses• Do not reduce if possible dead bowelDo not reduce if possible dead bowel• Admit via OR if strangulationAdmit via OR if strangulation
Mesenteric IschemiaMesenteric Ischemia
• EtiologyEtiology• 50% arterial emboli50% arterial emboli• 20% non-occlusive disease (CHF, sepsis, 20% non-occlusive disease (CHF, sepsis,
shock)shock)• 15% arterial thrombi15% arterial thrombi• 5% venous occlusion5% venous occlusion
• Mortality rates 70-90% - delayed Mortality rates 70-90% - delayed diagnosisdiagnosis
Mesenteric IschemiaMesenteric Ischemia
• Pathophysiology: impaired blood supply Pathophysiology: impaired blood supply from SMA, IMA, celiac trunk from SMA, IMA, celiac trunk adynamic adynamic ileus ileus mucosal infarction & 3 mucosal infarction & 3rdrd spacing spacing bacterial invasion bacterial invasion sepsis sepsis shock shock
• History:History:• Acute, severe, colicky, poorly localized painAcute, severe, colicky, poorly localized pain• Postprandial painPostprandial pain• Nausea, vomiting and diarrheaNausea, vomiting and diarrhea
Mesenteric Ischemia: Mesenteric Ischemia: DiagnosisDiagnosis
• Pain out of proportion to exam!
• Heme positive stools (>50%)• May present as LGIB
• Peritonitis and shock• Late findings
• WBC > 15k
• Metabolic acidosis• Lactic acid – high sensitivity, not specific
Mesenteric Ischemia: Mesenteric Ischemia: DiagnosisDiagnosis
• CT scan• Bowel wall edema/gas, +/- mesenteric
thrombus• Normal CT does NOT rule out
• Plain films – late findings• Portal venous gas• Pneumatosis intestinalis
• Treatment: • IVF• NG tube • IV antibiotics• IR consult for angiography• Surgical consult
GI hemorrhage: GI hemorrhage: Upper GIB vs. Lower GIBUpper GIB vs. Lower GIB
• History:History:• Hematemesis seen in 50% UGIBHematemesis seen in 50% UGIB• MelenaMelena
• 70% UGIB70% UGIB• 30% LGIB 30% LGIB
• Hematochezia – LGIB vs. rapid UGIBHematochezia – LGIB vs. rapid UGIB• Ask about:Ask about:
• NSAID, ASA, ETOH, Plavix, warfarinNSAID, ASA, ETOH, Plavix, warfarin• Night sweats, weight loss, bowel changes Night sweats, weight loss, bowel changes
malignancymalignancy• Iron, bismuth – guaiac negative, black stoolsIron, bismuth – guaiac negative, black stools
GI hemorrhageGI hemorrhage
• Consider with chief complaints: • Weakness• SOB• Dizzy• Abdominal pain
• PE: orthostatics, abdomen, rectal• Conjunctival pallor• Cool, clammy skin• Spider angiomata, palmer erythema,
jaundice, bruises liver disease
GIB: DiagnosisGIB: Diagnosis
• Hemoccult – iodide, methylene blue and red meat cause false pos
• Labs:• CBC (Hg < 8)• PT• T & S• Increased BUN (blood, hypovolemia)
• ECG – rule out silent MI (anemia)
• NG tube – rule out UGI bleed
Upper GI Hemorrhage: Upper GI Hemorrhage: EtiologyEtiology
• PUD 60%PUD 60%
• Gastritis/esophagitis 15%Gastritis/esophagitis 15%
• Varices – portal HTN, liver diseaseVarices – portal HTN, liver disease
• Mallory-Weiss Mallory-Weiss
• Aortoenteric fistula – H/o AAA repairAortoenteric fistula – H/o AAA repair
• Other: Stress ulcers, malignancy, AVM, ENT Other: Stress ulcers, malignancy, AVM, ENT bleeds, hemoptysisbleeds, hemoptysis
Lower GI Hemorrhage: Lower GI Hemorrhage: EtiologyEtiology
• Hemorrhoids – most common overallHemorrhoids – most common overall
• Diverticulosis – most common severe cause Diverticulosis – most common severe cause LGIBLGIB
• AngiodysplasiaAngiodysplasia
• Polyps/cancerPolyps/cancer
• Rectal diseaseRectal disease
• IBDIBD
GIB: TreatmentGIB: Treatment
• Unstable:Unstable:• IV x 2, O2, monitorIV x 2, O2, monitor• Blood products – FFP, pRBCs, plateletsBlood products – FFP, pRBCs, platelets• NG tube with lavage if upper GIB suspectedNG tube with lavage if upper GIB suspected
• Upper GI bleed Upper GI bleed GI for endoscopy GI for endoscopy
• Lower GI bleed Lower GI bleed GI and/or surgery GI and/or surgery consultsconsults
• Tagged red blood cell study – need 0.1 Tagged red blood cell study – need 0.1 – 0.2 ml/min of hemorrhage– 0.2 ml/min of hemorrhage
GIB: TreatmentGIB: Treatment
• Colonscopy – ligate or sclerose Colonscopy – ligate or sclerose diverticulosis, AVM bleedsdiverticulosis, AVM bleeds
• EGD – band ligation or sclerose varicesEGD – band ligation or sclerose varices
• Octreotide – varices, PUDOctreotide – varices, PUD
• Vasopressin – varicesVasopressin – varices
• Sengstaken-Blakemore tube – varicesSengstaken-Blakemore tube – varices
GIB: Surgical IndicationsGIB: Surgical Indications
• Hemodynamically unstable
• Unresponsive to endoscopy, IV fluids, and correction of coagulopathy
• Transfused > 5units in 4-6 hrs
• Mortality 23% if emergent surgery
GIB: DispositionGIB: Disposition
• Admit• Any UGIB• Any hemodynamic instability• Significant LGIB
• Observation• LGIB with stable vital signs and HgB
• Discharge home• Hemorrhoid bleed, rectal negative with
normal HgB
Case #4Case #4
• 70 y/o male with HTN, DM c/o acute onset right flank pain. Pain is sharp and crampy, radiates to the groin. He is pale, diaphoretic. Abdomen is soft, diffusely tender, no rebound or guarding.
• What are you thinking and what are you going to do?
Differential DiagnosisDifferential Diagnosis
• Renal colicRenal colic
• Mesenteric ischemiaMesenteric ischemia
• PUD with perforationPUD with perforation
• GI bleedGI bleed
• DiverticulitisDiverticulitis
• CholecystitisCholecystitis
• PancreatitisPancreatitis
• Low back painLow back pain
AAAAAA
• 4 male: 1 female4 male: 1 female
• Peak incidence 70 yoPeak incidence 70 yo
• 98% infrarenal (50% involve iliacs)98% infrarenal (50% involve iliacs)
• 33% of cases initially misdiagnosed33% of cases initially misdiagnosed• Renal colic, low back painRenal colic, low back pain
• Risk factors: HTN*, smoking, COPD, Risk factors: HTN*, smoking, COPD, diabetes, hyperlipidemia, connective diabetes, hyperlipidemia, connective tissue disease (Marfan’s, Ehlers-danlos)tissue disease (Marfan’s, Ehlers-danlos)
AAA: PathophysiologyAAA: Pathophysiology
• Atherosclerosis causes loss of elastin Atherosclerosis causes loss of elastin and collagen in aortic walland collagen in aortic wall
• Normal aorta diameter = 2 cmNormal aorta diameter = 2 cm
• Uncommon to rupture if < 5 cmUncommon to rupture if < 5 cm• Elective repairElective repair• 30% of aneurysms >5 cm rupture within 30% of aneurysms >5 cm rupture within
5 years5 years
AAAAAA
• History: History: • Sudden onset severe constant mid-Sudden onset severe constant mid-
abdomen or back painabdomen or back pain• Pain may radiate to the thigh or testesPain may radiate to the thigh or testes• Back/flank pain – retroperitoneal ureteral Back/flank pain – retroperitoneal ureteral
irritationirritation
• PE:PE:• Pulsatile mass 50-90%Pulsatile mass 50-90%• Abdominal distension due to RP or IP bloodAbdominal distension due to RP or IP blood• Abdominal bruit 3-8%Abdominal bruit 3-8%• Blue toe syndrome 5% due to emboliBlue toe syndrome 5% due to emboli
AAA: DiagnosisAAA: Diagnosis
• ECG
• Plain films• R/o free air or SBO• Calcified aorta
• US• Helpful to
diagnosis• Does not
delineate rupture or leaking aneurysm
• CTCT• Evaluates size, Evaluates size,
leakage and leakage and extentextent
• AngiographyAngiography• May miss AAA if May miss AAA if
mural thrombusmural thrombus
AAAAAA
AAA: TreatmentAAA: Treatment
• Asymptomatic patient• Incidental finding• <4 cm – repeat US Q6 months• >4 cm – elective repair
• Symptomatic patient• CT to confirm diagnosis (if stable)• 2 large bore IVs• T&C• pRBC - ~8 units• Admit via OR (vascular surgery consult)
AAA: MortalityAAA: Mortality
• Elective repair – 4%Elective repair – 4%
• Post rupture – 45%Post rupture – 45%• Normal BP – 20%Normal BP – 20%• Hypotensive, responds to volume – 40%Hypotensive, responds to volume – 40%• Hypotensive, incomplete response 60%Hypotensive, incomplete response 60%• Hypotensive, no urinary output – 80%Hypotensive, no urinary output – 80%
The EndThe EndAny Questions?Any Questions?
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