Abdo Pain Dubbo - NSW Agency for Clinical … colon, descending and sigmoid Hindgut, genitourinary Pelvic splanchnic nerves (parasymathetic) Lesser thoracic colon, rectum and upper

Emergency g yCare Institute

NSW

Abdominal pain

Objectives

Abdominal PainObjectives

Common abdominal problemsA di i i Appendicitis

Hernia Gastrointestinal foreign bodies Gastrointestinal foreign bodies Gastrointestinal haemorrhage

UpperL Lower

Renal colic Urinary retentiony

Index

Emergency Abdominal PainPeritoneumPeritoneum

Index

Common abdominal presentationsHistoryStereotypes of pain onset and associated pathologies

Sudden onset (full pain in Rapid onset (minutes - hours) Gradual onset (hours)( pseconds)

p ( ) ( )

Perforated ulcer Strangulated hernia Appendicitis

Mesenteric infarction Volvulus Strangulated hernia

Ruptured AAA Intussusception Peptic ulcer disease

R t d t i A t titi I fl t b l diRuptured ectopic pregnancy Acute pancreatitis Inflammatory bowel disease

Ovarian torsion or ruptured cyst Biliary colic Mesenteric lymphadenitis

Pulmonary embolism Diverticulitis Cystitis / urinary retention

AMI Ureteric / renal colic Salpingitis / prostatitis

Common abdominal presentationsHistoryPossible causes of pain by location

Location Associated pathologies

Right upper quadrant (RUQ) [Liver, R kidney, gallbladder]

Acute cholecystitis, biliary colic, duodenal ulcer, R lower lobe pneumonia, acute hepatitis

Right lower quadrant (RLQ) [Ascending colon, appendix, fallopian tube, ovary, ureter]

Appendicitis, ectopic pregnancy, tubo-ovarian abscess, ruptured ovarian cyst, ovarian torsion, distal ileitis

Left upper quadrant (LUQ) Gastritis acute pancreatitis splenic pathology L lower lobe pneumoniaLeft upper quadrant (LUQ) [Pancreas, spleen, L kidney]

Gastritis, acute pancreatitis, splenic pathology, L lower lobe pneumonia

Left lower quadrant (LLQ) [Sigmoid / descending colon, fallopian tube,

t ]

Diverticulitis, ectopic pregnancy, tubo-ovarian abscess, ruptured ovarian cyst, ovarian torsion

ovary, ureter]

Midline or periumbilical Appendicitis (early), gastroenteritis, mesenteric adenitis, myocardial ischaemia or infarction. pancreatitis

Flank Abdominal aortic aneurysm leak / rupture, ureteric / renal colic, pyelonephritis

Front to back Acute pancreatitis, abdominal aortic aneurysm leak / rupture, retrocaecal appendicitis Posterior duodenal ulcerappendicitis. Posterior duodenal ulcer

Suprapubic / lower abdominal Ectopic pregnancy, mittelschmerz, ruptured ovarian cyst, pelvic inflammatory disease, endometriosis, urinary tract infection

Common abdominal presentationsHistoryStereotypical location of pain and embryonic derivatives

Location of pain Organs Embryonic derivative Nerve supply

Epigastrium Stomach, first two parts of duodenum, liver,

gallbladder, pancreas

Foregut Vagus nerve (parasymathetic)Greater thoracic gallbladder, pancreas Greater thoracic

splanchnic nerves (sympathetic)

Periumbilical Third and fourth part of Midgut Vagus nerve Periumbilical Third and fourth part of the duodenum, jejunum, ileum, caecum, appendix, ascending colon, first two thirds of transverse colon

Midgut Vagus nerve (parasymathetic)Greater thoracic

splanchnic nerves (sympathetic)

Hypogastrium Distal one third of transverse colon,

descending and sigmoid

Hindgut, genitourinary Pelvic splanchnic nerves (parasymathetic)Lesser thoracic descending and sigmoid

colon, rectum and upper portion of anal canal, reproductive organs

(ovaries, fallopian tubes, uterus, seminal vesicles,

Lesser thoracic splanchnic nerves

(sympathetic)

uterus, seminal vesicles, prostate), bladder

Index

Appendicitis

Common Abdominal PresentationsAppendicitis“…in every case the seat of greatest pain, determined by the pressure of one finger,y p f f g ,has been very exactly between an inch and a half to two inches from the anterior spinousprocess of the ileum on a straight line drawnprocess of the ileum on a straight line drawnfrom that process to the umbilicus. Taken in connection with the history of the case and the other well known signs, I look upon as almost other well known signs, I look upon as almost pathognomonic of appendicitis…”

Charles McBurney, 1889 to the New York Surgical Society

Index

Worrying stats

Abdominal painWorrying stats

Common and urgent surgical illnessl f h h l h h Several manifestations with much overlap with other

clinical syndromes - high degree of suspicion!Si ifi t bidit i i ith di ti Significant morbidity, increasing with diagnostic

delay No single sign symptom or diagnostic test No single sign, symptom, or diagnostic test

accurately confirms the diagnosis of appendicitis in all cases

Peak age 11-20

Worrying stats


Incidence 25/10,000 (10-17), 1-2/10,000 (<4)f k k f l f f l Lifetime risk 8.6% risk for males, 6.7% for females

Previous similar pain in ~30-70% of cases Perforation rate is -higher among patients <18yrs

and patients >50yrs, possibly because of delays in diagnosisdiagnosis

Appendix perforation associated with a significant increase - in morbidity and mortality ratesincrease in morbidity and mortality rates

Mortality >20% in patients over 70yrs

Worrying stats


Variable positions (relevant to presentation)l Retrocaecal in 30%

Pelvic in 30% Subcaecal in 2% RUQ in 4% Anterior in 1%

Pathophysiology

Abdominal painPathophysiology

Usually luminal obstruction, possibly following viral GI ill GI illness

Distension due to ongoing epithelial secretionI d i hibit l h ti / Increased pressure inhibits lymphatic / venous

drainage Bacterial invasion Bacterial invasion Progressive oedema with eventual obstruction of

arterial blood flowarterial blood flow

Complications

Abdominal painComplications

Acutef Perforation

Abscess formation Peritonitis Long term Adhesions Infertility (females) Mortality as previously mentioned

History

Abdominal painHistory

Classic history - anorexia + periumbilical pain, f ll d b RLQ i d iti 50%followed by nausea, RLQ pain and vomiting - 50% of cases.

Migration of pain from periumbilical area to RLQ Migration of pain from periumbilical area to RLQ -most discriminating feature of patient's history -sensitivity and specificity ~ 80%sensitivity and specificity 80%

History extremes of age (Bad)

Abdominal painHistory extremes of age (Bad)Children Incidence low in <2

Al ll i i i ll i di d Almost all initially misdiagnosed Perforation rates 90% infants <1 80% aged 1-4g 4 10-20% adolescents Incidence peaks in late teensElderly 5 10% aged over 60yrs 5-10% aged over 60yrs >50% of all deaths Most cases perforated at operation 50% post operative complication rate Fibrosed appendiceal wall Impaired blood flow 2° to atherosclerosis Poor immune system 1/3 complain of constipation 1/3 complain of constipation

Examination

Abdominal painExaminationMost specific physical findings Rebound tenderness - remember you do not have to use traditional (cruel) y ( )

techniques to elicit rebound , use percussion tenderness Rigidity Guarding RLQ tenderness present in 96%, but nonspecific Positive cough sign (sharp pain in the RLQ elicited by a voluntary cough)

?helpful in diagnosis of localised peritonitis RLQ pain in response to percussion of a remote quadrant of the abdomen, or to

firm percussion of the patient's heel, suggests peritoneal inflammation

Examination

Abdominal painExamination Markle sign - pain elicited in the abdomen when standing patient drops from

standing on toes to the heels with a jarring landing - is stated to be very sensitive for localising true peritonitis

Psoas sign - indicator of irritation to hip flexors in the abdomen - psoas lies under appendix; passive extension of the thigh of a patient with knees extended. pain is positive psoas signpain is positive psoas sign

Obturator sign - indicator of irritation to obturator internus in the abdomen -obturator comes into contact with appendix on hip rotation; pain is positive obturator signb g

Rectal examination - inconsistent literature, but not probably not useful in patients with clear history and examination suggesting appendicitis. May be useful in equivocal cases. Paediatric PR examination is left to the surgeon who may operate

Investigation

Abdominal painInvestigationFBC ? 80-85% WBC >10,000 & neutrophilia (NØ) >75% in 78% adults with appendicitis <4% WBC <10,000 & NØ <75% Many nonspecific results with either WBC or NØ changes Inconclusive evidence in elderly and children Inexpensive, rapid, widely available but findings nonspecific; 4% of cases missed Does not rule out appendicitis

CRP ? Acute phase reactant synthesized by the liver in response to bacterial infection. -in 6-12 hrs of acute tissue

inflammation Adults - normal CRP 100% negative predictive value if symptoms >24 hrs Low specificity 50-87%, as CRP does not distinguish between bacterial infections May be used as part of a triple screen (WCC, neutrophilia, CRP) May rule out appendicitis in some patients

Urinalysis ? ~1/3 patients with acute appendicitis complain of dysuria / right flank pain 1 in 7 had pyuria >10 WBC / high power field, and 1 in 6 patients >3 RBC per high power field Diagnosis of appendicitis should not be dismissed due to the presence of urological symptoms

or abnormal urinalysis Does not rule out appendicitis

Investigation

Abdominal painInvestigation CT 3 Varying trial results

N h d CT i 8 % i i % ifi Addi i f IV d l Non-enhanced CT - 211 patients - 87% sensitive, 97% specific. Addition of IV and oral contrast agent increased sensitivity to 96-98%

2004 - pediatric patients, non-enhanced CT 66% sensitive; 90% with IV contrast 2005 - 112 pediatric patients, non-enhanced CT 87.5% sensitive, 98.7% specificity

R di h li l CT i d l 6% i i % ifi Recent studies - noncontrast helical CT in adults - 91-96% sensitive, 92-100% specific Noncontrast CT in children 66% sensitive, increased to 90% with intravenous contrast material Helical CT with rectal contrast in children - sensitivity of 95-97 Reduced negative laparotomy rate and appendiceal perforation rate when pelvic CT used in selected

ipatients Study of asymptomatic volunteers undergoing pelvic CT - 42% "abnormal" appendiceal diameter of >6

mm and 78% did not fill after oral contrast Bottom line - CT is useful, but NOT an ED rule out test, and should NOT delay surgical review

USS -is operator and patient factor dependent. Not seeing an appendix does not rule out appendicitis. Need CT after a negative USS. ?

Plain abdominal X-ray - insensitive, nonspecific, and not cost-effective. X

Management

Abdominal painManagement Watch and wait Antibiotic, watch and wait ( cef and met), this is increasing

S i S i l Semi urgent Surgical Urgent surgical

Fear of the negative laparotomy is almost greater than fear of complications

PROPERTIESAllow user to leave interaction: After viewing all the stepsShow ‘Next Slide’ Button: Show upon completionCompletion Button Label: Next Slide

Introduction

CT obdo, showing appendicitis

~ ® Properties.. J Edit in Engage J


(

• Common and urgent surgical illness • Several manifestations with much overlap with other clinical syndromes - high

degree of suspicion! • Significant morbidity, increasing with diagnostic delay

)

• No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendicitis in all cases

• Peak age 11-20

IS ory

U'll.iil-41fa11r.'!Sr.m-----------------------------1


Abdominal PainIndex returnIndex-return

Index

PROPERTIESOn passing, 'Finish' button: Goes to Next SlideOn failing, 'Finish' button: Goes to Next SlideAllow user to leave quiz: After user has completed quizUser may view slides after quiz: At any timeUser may attempt quiz: Unlimited times

Pregnant woman RLQ pain t '~PI!NBff r ef r ,.)

A 25 year old woman presents with R lower quadrant pain she is 14 weeks pregnant, she has R lower quadrant tenderness and has anorexia and low grade fever. What investigations do you do? Select the best answers.

D Urinalysis

D FBC, EUC, CRP, LFTs, lipase

D D Dimer

D Pelvic ultrasound and ask tor the radiographer to look tor the apppendix

D Abdominal xray

..... .....

[~ Properties ... J r ~ Edit in QuiZ/Tiaker l I

Hernia

Common Abdominal PresentationsHernia

‘A protrusion of a viscous from its proper cavity. The t d d t ll t i d i lik protruded parts are generally contained in a sac-like

structure, formed by the membrane with which the cavity is naturally lined’ Astley-Cooper 1804cavity is naturally lined Astley Cooper 1804

Several different types of abdominal wall hernia exist, with various names

Usually encountered in routine examination or when complications of hernia occur

Hernia Types of hernia

Common Abdominal PresentationsHernia – Types of hernia

InguinalDi Direct

Indirect

Femoral Femoral Incisional Umbilical / paraumbilical Umbilical / paraumbilical Obturator Spigelian Spigelian

Hernia Types of hernia

Common Abdominal PresentationsHernia – Types of hernia

Clinical presentationd bl Reducible

Irreducible Incarcerated Strangulated


( )

(~~~~~~~~~ ~ Common presentation to ED for evaluation

• Foreign bodies (FBs) in the upper GIT are usually swallowed. purposefully or accidentally

• Presentations range from patient in extremis to patient with subtle I chronic findings with no clear history

• Patients can often localise oropharyngeal and upper 1/3 oesophageal foreign bodies.

• lower 2/3 oesophagus FBs are difficult to localise

• Scratches I abrasions to mucosal surface can create a foreign body sensation

• Chronic foreign bodies or perforations can cause infections in surrounding soft tissues of the throat and neck

• Oesophagus has 3 areas of narrowing -

........... -·


Common abdominal presentationsClinical indicator Probable upper

GIT sourceProbable lower

GIT source

Gastrointestinal haemorrhageHaematemesis Almost certain Rare

Melaena Probable Possible

Haematochezia Possible Probable

Blood streaked stool Rare Almost certain

Occult blood in stool Possible PossibleOccult blood in stool Possible Possible


( )

(~~~~~~~~~ • -20% of all GIT haemorrhage r.ao«GII~c>l.l!lJ "'

• Mortality dependent on • Age • multi-organ system disease • need for transfusion >5 units • need for surgery • recent physiological stress (trauma. sepsis

etc)

IS ory

--flO! "'



(

The pain is very severe. and its important not forget that just because we find the diagnosis and treatment options basic that the symptoms are very significant to the patient.

)

The lifetime rate of kidney stones in the general population is approximately 12% for men and 4% for women and this approximately doubles with history of renal colic in a family member. Peak incidence 35-45. Renal failure is not common there are risks for it though: Solitary kidney. diabetes. staghorn calculi. spinal injury, recurrent stones with infection. When renal failure is a c oncern the after risk assessment rehydration is the key for management of this. Studies in animals have suggested that renal damage may begin within 24 hours of a complete obstruc tion and permanent kidney deterioration starts within 5-14 days. agreement in the literature is not good as to the exact time. but we can be comfortable w ith a risk free 3-4 days.

Common causes: • Hypercalciuria • Hyperuricosuria


Summary

Common Abdominal PresentationsSummary

Careful history including any changes from normal b l h bitbowel habits

Careful examination including full exposure and rectal and vaginal examinations as clinically indicatedand vaginal examinations as clinically indicated

Give adequate analgesia always Continuing observation of trends in pain or physiology Continuing observation of trends in pain or physiology

is one of our best diagnostic tools Err on the side of cautionErr on the side of caution Always advocate for the patient

Documents

Abdo Pain Dubbo - NSW Agency for Clinical … colon, descending and sigmoid Hindgut, genitourinary Pelvic splanchnic nerves (parasymathetic) Lesser thoracic colon, rectum and upper