Upload
arumi-hamasaki
View
23
Download
17
Tags:
Embed Size (px)
DESCRIPTION
bbb
Citation preview
Non Surgical Approach of Abdominal Pain
dr. Putut Bayupurnama, Sp.PD-KGEHDiv. Gastroenterology & Hepatology Bag/SMF Ilmu Penyakit Dalam RSUP Dr Sardjito/FK-UGM
Simposium 5
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Non Surgical Approach of Abdominal PainPutut Bayupurnama
Div. Gastroenterology & Hepatology
Bag/SMF Ilmu Penyakit Dalam
RSUP Dr Sardjito/FK-UGM,
Yogyakarta
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Introduction
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Abdominal pain
• a complaint seen commonly in
the outpatient setting
• may often be a symptom of a disease process with a benign course
• it may also herald a severe, life-threatening condition
• demands prompt recognition and management
• general understanding of abdominal anatomy, physiology, and pathophysiology is vital
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
The abdominal organs
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Three Types of Abdominal Pain
1. Visceral
• Autonomic nerves
• Poorly localized
• Dull ache, colicky
• Location is often midline
• Felt in the abdominal wall in the area of embryonic origin of the pain
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Cont…
2. Somatic
• Typically sharp
• well localized
• Irritation of the parietal peritoneum
• parietal innervation is unilateral
• Felt directly over area of inflammation
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Cont…
3. Referred pain
• felt in cutaneous site distant from diseased organ
• visceral afferents carrying stimuli from a diseased organ enter the spinal cord at the same level as somatic afferents
• typically well localized
• Awareness of the anatomy and innervation of the abdominal viscera allows one to formulate a differential diagnosis of abdominal pain based on the location and distribution of the pain
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
History
• Where is your pain? Has it always been there?
• Does the pain radiate anywhere?
• How did the pain begin (sudden vs. gradual onset)? How long have you had the pain?
• What does the pain feel like?
• On a scale of 0–10, how severe is the pain?
• Does anything make the pain better or worse?
• Have you had the pain before?
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
History cont…
• Although location of abdominal pain guides the initial evaluation, associated signs and symptoms can help narrow the differential diagnosis
• change in bowel habit, blood loss per rectum
• Presence of nausea/vomiting, fullness, bloating, belching, early satiety, are signs of an upper GI cause (dyspeptic symptoms)
• Respiratory symptoms point to basal pneumonia causing diaphragmatic irritation
• Dysuria or haematuria indicates a renal cause
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Physical Examination
• General appearance
• patient with peritonitis often lies completely
• a patient with renal colic may writhe in pain
• Vital Signs
• Abdomen
• Inspection
• Auscultation
• Percussion
• Palpation
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Differential Diagnosis Abdominal Pain based on
Region
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
The position of abdominal pain usedabdomen region
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Peptic Ulcer
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Experimental pain in the stomachDrewes AM et al. Gut 1997;41-753-757
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Differential Diagnosis: RUQ pain
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Differential Diagnosis: LUQ and Epigastric pain
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Differential Diagnosis: RLQ Pain
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Gynecologic Causes of RLQ Pain
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Differential Diagnosis: LLQ
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Differential Diagnosis: Periumbilical
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Pain Patterns of
Abdominal Disease
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009Substernal Epigastric
Onset Chronic Acute Acute Acute
Disease / diagnosis
Refluks esofagitis
Perforated duodenal ulcer
Cholecystitis Pancreatitis
Pain quality Burning; after meal / at night
Severe, ± history of chronic ulcerpain
Steady / biliary colic
Steady
Pain referral Left arm ± back Tip of scapula Back
Pain progression
Upper chest Rapid, over entire abdomen
Intensity increases steady over hours to RUQ
± peritoneal sign
Associated finding
Guarding ; free peritonel air
Fever, gall stone,
Nausea,vomiting
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Epigastric
Onset chronic chronic chronic
Disease / diagnosis
Duodenal ulcer Gastric ulcer Non ulcer dyspepsia
Pain quality Gnawing, burning before meals/ at night
Gnawing, worsened by food
Same as duodenal ulcer, ± bloating
Pain referral ± Back Occasionally to the back
None
Pain progression
None None None
Associated finding
Temporary relief with food or antacids
± relief by antacids
± relief with food or antacid
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Periumbilical
Onset Acute Acute Acute Chronic Chronic
Disease / diagnosis
Appendici-tis
Small bowel obstruction
Intestinal infarction
Inflammatory bowel disease
Intestinalangina
Pain quality
Cramping, steady
Cramping Severe, aching, diffuse
Cramping, achingin LQ
Colickly, aching, diffuse
Pain referral
± Back or groin
Back None None None
Pain progression
Localization to RLQ
None If Tx is delayed, peritonitis
None Pain relief 1-2 hour
Associated finding
Referredpercusion tenderness to RLQ
Peristaltic >, nausea, vomite, delated bowel
Unimpressive, occult blood stool,peristaltic -
Diarrhea, blood+pus stool, urgency,tenesmus
Weight loss
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Lower Quadrant
Onset Acute Acute Chronic Chronic
Disease / diagnosis
Diverticulitis Colon obstruction
Dissecting aortic aneurysm
Irritable bowel syndrome
Pain quality Steady, aching, LLQ
Crampy Sudden, severe, tearing, peri umbilical
Cramping, steady or itermittent
Pain referral Back Back Flank, inguinal region
None
Pain progression
None None None None
Associated finding
Palpableinflamatory mass, fever, constipation, leucocytosis
Vomiting, constipation, distention, peristaltic >
Shock, abdominal bruit, abdomnal mass
Cosntipation, diarrhea, bloating
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Diagnostic Tools :
• Laboratory tests
• Transabdominal Ultrasonography
• Endoscopy : Upper, Lower, and Enteroscopy
• Endoscopic Ultrasonography
• CT-Scan, MRCP
• ERCP : Diagnostic and Therapeutic
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Abdominal pain management :
• Dyspeptic Symptoms :
• Proton pump inhibitor
• Pro kinetic
• Antidepressant
• Non-dyspeptic symptoms :
• based on etiology
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Abdominal pain should be referred :
• No improvement after empiric treatment
• Abdominal pain with emergency :
• Acute appendicitis
• Acute pancreatitis (lipase > 3 times normal value)
• Ileus
• Peritonitis
• Decreased body weight, GI tract bleeding, chronic diarrhea
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Take Home Message
• Abdominal pain typically, but not always, has characteristic locations : right upper, right lower, epigastric, periumbilical, left upper, left lower, and diffuse
• The location of pain is a useful starting point and will guide further evaluation
• Performing a thorough history and physical evaluation will allow the practitioner to generate a differential diagnosis that will guide further laboratory, imaging, and management decisions
Simposium Kedokteran Nasional Clinical Updates 2015|14-15 Maret 2015|FK UGM 1983 & 2009
Terima Kasih