Emergency Care Institute NSW. Abdominal pain

Transcription

1 Emergency Care Institute NSW Abdominal pain

2 Abdominal Pain Objectives Common abdominal problems Appendicitis i i Hernia Gastrointestinal foreign bodies Gastrointestinal haemorrhage Upper Lower Renal colic Urinary retention Index

3 Emergency Abdominal Pain Peritoneum Index

4 Stereotypes of pain onset and associated pathologies Common abdominal presentations History Sudden onset (full pain in Rapid onset (minutes -hours) Gradual onset (hours) seconds) Perforated ulcer Strangulated hernia Appendicitis Mesenteric infarction Volvulus Strangulated hernia Ruptured AAA Intussusception Peptic ulcer disease Ruptured 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

5 Possible causes of pain by location Common abdominal presentations Location History Associated pathologies Right upper quadrant (RUQ) [Liver, R kidney, gallbladder] Right lower quadrant (RLQ) [Ascending colon, appendix, fallopian tube, ovary, ureter] Left upper quadrant (LUQ) [Pancreas, spleen, L kidney] Left lower quadrant (LLQ) [Sigmoid / descending colon, fallopian tube, ovary, ureter] Midline or periumbilical Flank Front to back Suprapubic / lower abdominal Acute cholecystitis, biliary colic, duodenal ulcer, R lower lobe pneumonia, acute hepatitis Appendicitis, ectopic pregnancy, tubo-ovarian abscess, ruptured ovarian cyst, ovarian torsion, distal ileitis Gastritis, acute pancreatitis, splenic pathology, L lower lobe pneumonia Diverticulitis, ectopic pregnancy, tubo-ovarian abscess, ruptured ovarian cyst, ovarian torsion Appendicitis (early), gastroenteritis, mesenteric adenitis, myocardial ischaemia or infarction. pancreatitis Abdominal aortic aneurysm leak / rupture, ureteric / renal colic, pyelonephritis Acute pancreatitis, abdominal aortic aneurysm leak / rupture, retrocaecal appendicitis. Posterior duodenal ulcer Ectopic pregnancy, mittelschmerz, ruptured ovarian cyst, pelvic inflammatory disease, endometriosis, urinary tract infection

6 Stereotypical location of pain and embryonic derivatives Common abdominal presentations History Location of pain Organs Embryonic derivative Nerve supply Epigastrium Stomach, first two parts of duodenum, liver, gallbladder, pancreas Foregut Vagus nerve (parasymathetic) Greater thoracic splanchnic nerves (sympathetic) Periumbilical Third and fourth part of Midgut Vagus nerve the duodenum, jejunum, (parasymathetic) ileum, caecum, appendix, Greater thoracic ascending colon, first two splanchnic nerves thirds of transverse colon (sympathetic) Hypogastrium Distal one third of transverse colon, descending and sigmoid colon, rectum and upper portion of anal canal, reproductive organs (ovaries, fallopian tubes, uterus, seminal vesicles, prostate), bladder Hindgut, genitourinary Pelvic splanchnic nerves (parasymathetic) Lesser thoracic splanchnic nerves (sympathetic) Index

7 Common Abdominal Presentations Appendicitis in every case the seat of greatest pain, determined by the pressure of one finger, has been very exactly between an inch and a half to two inches from the anterior spinous process of the ileum on a straight line drawn from 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 pathognomonic of appendicitis Charles McBurney, 1889 to the New York Surgical Society Index

8 Abdominal pain Worrying stats Common and urgent surgical illness Several manifestations with much overlap with other clinical syndromes - high degree of suspicion! Significant ifi morbidity, increasing i with diagnostic delay No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendicitis in all cases Peak age 11-20

9 Worrying stats Abdominal pain Incidence 25/10,000 (10-17), 1-2/10,000 (<4) Lifetime risk 8.6% risk kfor 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 diagnosis Appendix perforation associated with a significant increase - in morbidity and mortality rates Mortality >20% in patients over 70yrs

10 Abdominal pain Worrying stats Variable positions (relevant to presentation) Retrocaecal in 30% Pelvic in 30% Subcaecal in 2% RUQ in 4% Anterior in 1%

11 Abdominal pain Pathophysiology Usually luminal obstruction, possibly following viral GI illness Distension due to ongoing epithelial secretion Increased pressure inhibits lymphatic / venous drainage Bacterial invasion Progressive oedema with eventual obstruction of arterial blood flow

12 Abdominal pain Complications Acute Perforation Abscess formation Peritonitis Long term Adhesions Infertility (females) Mortality as previously mentioned

13 History Abdominal pain Classic history - anorexia + periumbilical pain, followed by nausea, RLQ pain and vomiting - 50% of cases. Migration of pain from periumbilical area to RLQ - most discriminating feature of patient's history - sensitivity and specificity ~ 80%

14 Abdominal pain History extremes of age (Bad) Children Incidence low in <2 Almost all initially i i misdiagnosed d Perforation rates 90% infants <1 80% aged % adolescents Incidence peaks in late teens Elderly 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

15 Abdominal pain Examination Most specific physical findings Rebound tenderness - remember you do not have to use traditional (cruel) 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

16 Examination Abdominal pain 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 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 sign 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

17 Investigation Abdominal pain FBC? 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

18 Abdominal pain Investigation CT 3 Varying trial results Non-enhanced CT -211 patients - 87% sensitive, i 97% specific. Addition i of IV and oral contrast agent increased sensitivity to 96-98% pediatric patients, non-enhanced CT 66% sensitive; 90% with IV contrast pediatric patients, non-enhanced CT 87.5% sensitive, 98.7% specificity Recent studies - noncontrast helical l CT in adults % sensitive, i % specific Noncontrast CT in children 66% sensitive, increased to 90% with intravenous contrast material Helical CT with rectal contrast in children - sensitivity of Reduced negative laparotomy rate and appendiceal perforation rate when pelvic CT used in selected patients 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

19 Abdominal pain Management Watch and wait Antibiotic, watch and wait ( cef and met), this is increasing Semi urgent Surgical Urgent surgical Fear of the negative laparotomy is almost greater than fear of complications

20 Introduction CT obdo, showing appendicitis PROPERTIES Allow user to leave interaction: Show Next Slide Button: Completion Button Label: After viewing all the steps Show upon completion Next Slide ~ Properties.. J Edit in Engage J

21 ( ) 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 IS ory U'll.iil-41fa11r.'!Sr.m PROPERTIES Allow user to leave interaction: Show Next Slide Button: Completion Button Label: After viewing all the steps Show upon completion Next Slide ~ Properties.. J Edit in Engage J

22 Abdominal Pain Index-return Index

23 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 On passing, 'Finish' button: Goes to Next Slide On failing, 'Finish' button: Goes to Next Slide Properties... Allow user to leave quiz: After user has completed quiz [~ User may view slides after quiz: At any time User may attempt quiz: Unlimited times J I r ~ Edit in QuiZ/Tiaker l

24 Common Abdominal Presentations Hernia A protrusion of a viscous from its proper cavity. The protruded d parts are generally contained in a sac-like structure, formed by the membrane with which the cavity 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

25 Common Abdominal Presentations Hernia Types of hernia Inguinal Direct Indirect Femoral Incisional Umbilical / paraumbilical Obturator Spigelian

26 Common Abdominal Presentations Hernia Types of hernia Clinical presentation Reducible Irreducible Incarcerated Strangulated

27 ( ) (~~~~~~~~~ ~ 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 PROPERTIES Allow user to leave interaction: Show Next Slide Button: Completion Button Label: After viewing all the steps Show upon completion Next Slide ~ Properties.. J Edit in Engage J

28 Clinical indicator Probable upper GIT source Probable lower GIT source Common abdominal presentations Haematemesis Gastrointestinal Almost certain haemorrhagerare Melaena Probable Possible Haematochezia Possible Probable Blood streaked stool Rare Almost certain Occult blood in stool Possible Possible

29 ( ) (~~~~~~~~~ -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) --flo! "' IS ory PROPERTIES Allow user to leave interaction: Show Next Slide Button: Completion Button Label: After viewing all the steps Show upon completion Next Slide ~ Properties.. J Edit in Engage J

30 ( ) 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 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 c omplete 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 with a risk free 3-4 days. Common causes: Hypercalciuria Hyperuricosuria PROPERTIES Allow user to leave interaction: Show Next Slide Button: Completion Button Label: After viewing all the steps Show upon completion Next Slide ~ Properties.. J Edit in Engage J

31 Common Abdominal Presentations Summary Careful history including any changes from normal bowel habits Careful examination including full exposure and rectal and vaginal examinations as clinically indicated Give adequate analgesia always Continuing observation of trends in pain or physiology is one of our best diagnostic tools Err on the side of caution Always advocate for the patient