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7/28/2019 Presentasi Abdominal Pain Non Trauma
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Diagnosis and Management ofAbdominal Pain (non-trauma)
Ema Dianita
Agil Wijaya
Sharanraj
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- Durasi : acute ; chronic- Pathophys : visceral, parietal, reffered
- Location : upper, low, right, left, epigastrial, umbilical;
Klasifikasi Abdominal Pain :
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Acute abdominal pain
(AAP): Presentation of previously undiagnosed abdominal pain
lasting 1 week or less NSAP (34%)
Acute appendicitis (28%)
Acute chlecystitis (10%)
SBO (4%)
Perforated PU (3%)
Pancreatitis (3%)
Diverticular disease (2%)
1De Dombal FT. Diagnosis of acute abdominal pain. New York: Churchill Livingstone; 1991.
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Chronic Abdominal Pain
Irritable bowel syndrome
Chronic pancreatitis
Diverticulosis
Gastroesophageal reflux disease (GERD)
Inflammatory bowel disease
Duodenal ulcer
Gastric ulcer
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Classification on Abdominal
Pain Three main categories of abdominal
pain:
1. Intra-abdominal (arising from within the
abd cavity / retroperitoneum) involves:
GI (Appendicitis, Diverticulitis, etc, etc, etc) GU (Renal Colic, etc, etc, etc)
Gyn (Acute PID, Pregnancy, etc)
Vascular systems (AAA, Mesenteric Ischemia, etc)
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Classification on Abdominal
Pain2. Extra-abdominal (less common) involves:
Cardiopulmonary (AMI, etc)
Abdominal wall (Hernia, Zoster etc) Toxic-metabolic (DKA, OD, lead, etc)
Neurogenic pain (Zoster, etc)
Psychic (Anxiety, Depression, etc)
3. Nonspecific Abd pain not well explained
or described.
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Pathophysiology
Visceral pain Distention, inflammation or
ischaemia in hollow viscous& solid organs
Localisation depends on theembryologic origin of the
organ: Forgut to epigastrium
Midgut to umbilicus
Hindgut to thehypogastric region
Parietal pain
is localised to thedermatome above the siteof the stimulus.
Referred pain
produces symptoms, notsigns e.g. tenderness
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Generalized AP Perforation
Acute pancreatitis
Bilateral pleurisy Generalized peritonitis
Acute Pancreatitis
Sickle Cell Crisis
Mesenteric Thrombosis
Gastroenteritis
Metabolic disturbances
Dissecting or Rupturing Aneurysm
Intestinal Obstruction
Psychogenic illness
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Central AP
Early appendicitis
SBO (small bowl obs)
Acute gastritis
Acute pancreatitis Ruptured AAA
Mesenteric
thrombosis
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Epigastric pain
DU / GU
Oesophagitis
Acute pancreatitis
AAA
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RUQ pain
Gallbladder disease
DU
Acute pancreatitis
Pneumonia Subphrenic abscess
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LUQ pain
GU
Pneumonia
Acute pancreatitis
Spontaneous splenic
rupture
Acute perinephritis
Subphrenic abscess
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Suprapubic pain Acute urinary retention
UTIs
Cystitis
PID
Ectopic pregnancy
Diverticulitis
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LRQ pain Acute appendicitis
Mesenteric adenitis (young) Perf DU
Diverticulitis
PID
Salpingitis
Ureteric colic
Meckels diverticulum
Ectopic pregnancy
Crohns disease
Biliary colic (low-lying gallbladder)
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Loin pain Muscle strain
UTIs
Renal stones
Pyelonephritis
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LLQ pain Diverticulitis
Constipation
IBS
PID
Rectal Ca
UC
Ectopic pregnancy
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Abdominal pain yang sering
mengancam jiwa
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Key points on history
Onset
Duration
Site, reffered
Nature & character
Intensity
Precipitating & relieving factors
Associated symptoms
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Associated symptoms
Fever
Genitourinary
Gynaecological
Vascular
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Physical examination
OBS are important
Observation
Bending Forward: Chronic Pancreatitis
Jaundiced: CBD obstruction
Dehydrated: Peritonitis, Small Bowel
obstruction
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Systemic Examination
Abdomen:
Inspection
- Scaphoid or flat in peptic ulcer- Distended in ascites or intestinal
obstruction
- Visible peristalsis in a thin or malnourishedpatient (with obstruction)
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Physical examination
Auscultation
BS
> 2min to confirm absent
High pitched, hyperactive or tinkling
Bruit in epigastrium
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Systemic Examination
Palpation
Check for Hernia sites
Tenderness
Rebound tenderness
Guarding- involuntary spasm of musclesduring palpation
Rigidity- when abdominal muscles are tense& board-like. Indicates peritonitis.
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Systemic Examination
Local Right Iliac Fossa tenderness: Acute appendicitis
Acute Salpingitis in females
Low grade, poorly localized tenderness: Intestinal Obstruction
Tenderness out of proportion to examination: Mesenteric Ischemia
Acute Pancreatitis
Flank Tenderness: Perinephric Abscess
Retrocaecal Appendicitis
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Important Signs in Patients with Abdominal Pain
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Important Signs in Patients with Abdominal Pain
Sign Finding Association
Cullen's sign Bluish periumbilicaldiscoloration
Retroperitoneal haemorrhage
Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy rupture
McBurney's sign Tenderness located 2/3 distance fromanterior iliac spine to umbilicus on right side Appendicitis
Murphy's sign Abrupt interruption of inspiration on palpationof right upper quadrant
Acute cholecystitis
Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis
Obturator's sign Internal rotation of flexed right hip causingabdominal pain
Appendicitis
Grey-Turner's
sign
Discoloration of the flank Retroperitoneal haemorrhage
Chandelier sign Manipulation of cervix causes patient to liftbuttocks off table
Pelvic inflammatory disease
Rovsing's sign Right lower quadrant pain with palpation ofthe left lower quadrant
Appendicitis
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Systemic Examination
PR Examination:
- tenderness
- induration
- mass
- frank blood
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Systemic Examination
PV Examination
- Bleeding
- Discharge
- Cervical motion tenderness
- Adnexal masses or tenderness
- Uterine Size or Contour
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Initial management
1st 20 sec there are only 3 diagnoses: Very ill:
Going to die?
ask for help & resus
ill: stable for couple h?
Urgent investigations, initial diagnosis & management
Reasonably well: Investigate as appropriate
formulate diagnosis.
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Initial management
ABCDE
Resuscitation & analgesia (NSAID,
antispasme,opioid IV)
Full monitoring (including Urine Output)
Low threshold in seeking senior help
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Management
Hemodinamic unstable :
Managemen in critical care area
Monitoring ABC (airway, oksigenasi, EKG dll)
IV line ( fluid chalange 1 L kristaloin if no IMA susp) Lab
Antibiotic IV if sepsis
X ray (thorax, abdmenKUB)
ECG
NMB (nill by mouth)
Cateter
consult
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Management
Hemodinamic stable :
Managemen in intermediate care area
IV line
Lab berdasar klinis Antibiotic IV if sepsis
X ray (thorax, abdmenKUB)
ECG
NMB (nill by mouth)
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Investigations
CBC (Hb & WCC)
Amylase (Pancreatitis)
U&Es, LFTs Clotting (acute pancreatitis, sepsis, DIC, liver disease)
Glucose
GxM
ABG
ECG
Cardiac enzymes (if appropriate)
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Investigations
Attention to the WCC as a screening
test only if substantially elevated.
25% of patients with elevated WCC do nothave different outcomes from those with a
normal WCC8
CBC has a limited clinical utility
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Investigations
Urinalysis
Cheap
Simple & readily available test
High yield when results fit with the clinical
scenario
Pregnancy test
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Investigations
Radiology
PA CXR
3 positions AXR
USG
IVU (renal/ureteric colic)
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Investigations
Plain X-rays have limited utility in the
evaluation of AAP
Low diagnostic yield High incidence of misleading incidental
findings
Lack of impact on management Exception: Bowel obstruction or perforation
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CT scanning
No significantadvantage in DD of
AAP
Delay of necessarytreatment
Routine use notjustified
Hx taking & physical
examination are thebasis of correctdiagnosis
Hx, physicalexamination & labinvestigations areoften non-specific
CT is now 1st-lineimaging modality inpts with APP.
MDCT is now fasterwith thinner slices
High diagnosticaccuracy
8Keeman JN, New diagnostic imaging technology offten
offers no advantage in the differential diagnosis of acuteabdomen. Ned Tijdschr Geneeskd. 1999. Nov.
6:143(45):2225-9
9Leschka et al,Multi-detector computer tomography of acute
abdomen. Eur Radiol. Dec;15(12):2435-47. 2005 37
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Laparoscopy
Early diagnostic laparoscopy may result in:
accurate,
prompt,
efficient management of AAP
Reduces the rate of unnecessary laparotomy
Increases the diagnostic accuracy
May be a key to solving the diagnosticdilemma of NSAP.
10Golash and Willson. Early laparoscopy as a routine procedure in the management of acute abdominal pain: a review of 1320 patients. Surg Endosc. 2005
Jul;19(7):882-511Keller et al. Diagnostic laparoscopy in acute abdomen. Chirurg. 2006 Nov;77(11):981-5
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Suggestions
Audit of all patients referred with AAP to
assess:
Initial diagnosis Choice & diagnostic efficacy of
investigations
Treatment
Timing (length of stay)
Cost effectiveness
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Thank you
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