Abdominal Pain : Can t Miss Diagnosis. Common causes of abdominal pain. Abdominal pain: Can t miss diagnosis

Transcription

1 A.W. Saleh Curacao, November 2014 Common causes of abdominal pain Localized to quadrant Appendicitis Bowel obstruction Diverticulitis Ectopic pregnancy Hernia IBD IBS Kidney stones Meckel s diverticulitis Mesenteric adenitis Mittelschmerz Ovarian cyst Ovarian torsion PID/ovarian abces Psoas Abces Abortion Diffuse Acute pancreatitis Bowel obstruction Dissecting aorta Early appendicitis Gastroenteritis IBD IBS Mesenteric infarct/ischemia Peritonitis Ruptured abdominal aneurysm Sickle cell crisis FMF Acute Abdominal Pain < 1-2 weeks duration 10% of admissions to Emergency dept % admitted (of these 50 % etiology remains undetermined) Exclude Life threatening etiology Most common immediately life threatening abdominal pain Perforated bowel Mesenteric ischemia (embolus/incarceration) Ruptured abdominal aneurysm Dissecting aorta 1

2 Classic types of pain Visceral pain Referred pain Visceral pain - Distension, inflammation or ischemia of solid or hollow viscous organs (slow transmitting autonomic C neurons) - Irritation of peritoneal membrane localized to dermatome above site of stimulus; initially unilateral (fast transmitting A neurons ) Functional divergence pain cannot be localized by patient : Upper, mid or lower abdomen physiologic responses : change in pulse, RR, muscle tone, motor and secretory reflexes Referred pain - Pain perceived at a site distant from the source of stimulus ; usually lateralized. Embryonic sharing of dermatome Aspects of pain that are helpful in determining cause of pain: Time to onset Migration of pain Pain rhythm Quality of pain Intra abdominal - Gastrointestinal, genitourinary, gynecologic or vascular emergency Extra abdominal - Cardiac, pulmonary, abdominal wall, toxic, metabolic and neurologic disease 2

3 Extra abdominal /Cause Unknown - Metabolic : (keto)acidosis, hypercalcemia, porfyria - Neurologic : diabetes, nerve compression syndrome - Toxic : medication, venom Aging population : Beware of more than one abdominal problem Time to diagnosis is crucial in outcome Uncomplicated recovery Otherwise may lead to : - Invalidity - Dependence on life support - Death Approach to patient with abdominal pain : Is this pain caused by a serious possibly life threatening complication? Focused assessment Focused assessment of abdominal pain Anamnesis : Different aspects of pain, associated symptoms, time span, medication, intoxications, antecedents) Physical exam: Anxiety, tachycardia, hypotension, pallor, tachypnea, temperature. Abdominal inspection, auscultation, percussion and exam of ext.genitalia Myths Rebound tenderness in peritonitis. 25 % false positive rate. Better: rigidity and cough pain (1.) Analgesics, especially Opiate, should never be administered prior to evaluation (2.) All patients should undergo a digital rectal exam (3.) Ref 1. Liddington et al, Br. J. Surg Wolfe et al, J Emerg Med Manimaran et al, Ann R. Coll Surg Engl 2004 Lab tests: Bloodcount, renal function, livertests, CRP, LDH,CK,Lipase, urinetests. (Troponin, EKG) WBC -at presentation- has poor differentiating power between serious disease or other ( 25% elevated WBC ) 1,2 WBC and CRP: Repeat Ref. 1. Lukens et al, Ann Emerg Med 1993 ; 2. Cardall et al, Acad Emerg Med

4 No doubt of acute abdomen proceed to additional workup and appropriate therapy Possibly acute abdomen observe and re-evaluate after 6-8 hours! Additional work-up Plain abdominal x-ray Low diagnostic yield. Never as stand alone Boermeester MA, OPTIMA study group; Am J Emer Med 2011 Ultrasound Abdomen (can miss perforation) Contrast enhanced CT scan abdomen (greatest sensitivity in confirming serious abdominal disease) Abdominal tap Patient case Woman 79 yrs Intermittent abdominal pain for 3 weeks Anorexia and weightloss over past 2 months Rx: NSAID for pain Presenting at Emergency with increased abdominal pain and distension of abdomen Physical Exam : Alert, but weak, elderly woman RR 130/70 mmhg, puls 100/min Heart/lungs normal Abdomen distended with diffuse pain on palpation no rigidity Additional tests: Hemoglobin 10 g% WBC 7 x 10 Creatinine 15 mg/l CRP 2.0 mg % Plain Abdominal X-ray: Initial interpretation: Distended colon Diagnosis : Volvulus of sigmoid Endoscopic desufflation performed 10 hrs after admission less distension of abdomen and somewhat reduction in pain Patient transferred from surgical ward to internal med Next day (Monday morning) : Abdomen distended, same diffuse pain New Lab and plain x-ray of abdomen requested 4

5 WBC 18 x 10 CRP 25 mg% 1 st plain abdominal x-ray: Suspicion of free air, distension of colon 2 nd Plain abdominal x-ray : No free air reported, distension of intestines Clinical course: Patient in shock, cardiac arrest, resuscitation unsuccesfull Autopsy: Two gastric ulcers, one perforated Septic peritonitis Several intrahepatic masses due to cholangiocarcinoma and pathologic lymphnodes upper abdomen Plain x ray : Confusing /no significant help Re-appraisal of abdominal symptoms by surgeon and WBC after 6-8 hrs CT scan / Ultrasound Conclusions Approach by making sure to exclude life-threatening etiology If in doubt : re-evaluate after 6-8 hours Consider CT scan and or ultrasound (not plain x-ray) Do not forget to alleviate pain Classic types of pain Visceral pain - Distension, inflammation or ischemia of solid or hollow viscous organs Referred pain (slow transmitting autonomic C neurons) Upper / mid / lower abdomen - Irritation of peritoneal membrane localized to dermatome above site of stimulus; initially unilateral (fast transmitting A neurons ) - Produces symptoms, not physical signs usually lateralized (embryonic sharing of dermatome ) 5