Emergency g y Care Institute

g
y
Emergency
Care Institute
NSW
Abdominal pain
Abdominal Pain
Objectives
 Common abdominal problems
 Appendicitis
A
di i i
 Hernia
 Gastrointestinal foreign bodies
 Gastrointestinal haemorrhage
Upper
 Lower
L



Renal colic
Urinaryy retention
Index
Emergency Abdominal Pain
Peritoneum
Index
Stereotypes of pain onset and associated pathologies
Common abdominal
History presentations
Sudden onset ((full pain
in
p
seconds)
Rapid
- hours))
p onset (minutes
(
Gradual onset ((hours))
Perforated ulcer
Strangulated hernia
Appendicitis
Mesenteric infarction
Volvulus
Strangulated hernia
Ruptured AAA
Intussusception
Peptic ulcer disease
R t d ectopic
Ruptured
t i pregnancy
A t pancreatitis
Acute
titi
I fl
Inflammatory
t
b
bowell di
disease
Ovarian torsion or ruptured cyst
Biliary colic
Mesenteric lymphadenitis
Pulmonary embolism
Diverticulitis
Cystitis / urinary retention
AMI
Ureteric / renal colic
Salpingitis / prostatitis
Possible causes of pain by location
Common
abdominal
presentations
History
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)
[Pancreas, spleen, L kidney]
Gastritis,
Gastritis acute pancreatitis,
pancreatitis splenic pathology,
pathology L lower lobe pneumonia
Left lower quadrant (LLQ) [Sigmoid
/ descending colon, fallopian tube,
ovary, ureter]
t ]
Diverticulitis, ectopic pregnancy, tubo-ovarian abscess, ruptured ovarian
cyst, ovarian torsion
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 ulcer
appendicitis.
Suprapubic / lower abdominal
Ectopic pregnancy, mittelschmerz, ruptured ovarian cyst, pelvic
inflammatory disease, endometriosis, urinary tract infection
Stereotypical location of pain and embryonic derivatives
Common abdominal
History presentations
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
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
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
Common Abdominal Presentations
Appendicitis
“…in every case the seat of greatest pain,
determined by
y the p
pressure off one finger,
f g ,
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
Abdominal pain
Worrying stats
 Common and urgent surgical illness
 Severall manifestations
f
with
h much
h overlap
l with
h other
h
clinical syndromes - high degree of suspicion!
 Significant
Si ifi
t morbidity,
bidit iincreasing
i with
ith di
diagnostic
ti
delay
 No single sign
sign, symptom
symptom, or diagnostic test
accurately confirms the diagnosis of appendicitis in all
cases
 Peak age 11-20
Abdominal pain
Worrying stats
 Incidence 25/10,000 (10-17), 1-2/10,000 (<4)
 Lifetime
f
risk
k 8.6% risk
k for
f males,
l 6.7% for
f ffemales
l
 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
Abdominal pain
Worrying stats
 Variable positions (relevant to presentation)
 Retrocaecall in 30%
 Pelvic in 30%
 Subcaecal in 2%
 RUQ in 4%
 Anterior in 1%
Abdominal pain
Pathophysiology
 Usually luminal obstruction, possibly following viral




GI illness
ill
Distension due to ongoing epithelial secretion
I
Increased
d pressure iinhibits
hibit llymphatic
h ti / venous
drainage
Bacterial invasion
Progressive oedema with eventual obstruction of
arterial blood flow
Abdominal pain
Complications
 Acute
 Perforation
f
 Abscess formation
 Peritonitis
 Long term
 Adhesions
 Infertility (females)
 Mortality as previously mentioned
Abdominal pain
History
 Classic history - anorexia + periumbilical pain,
ffollowed
ll
db
by nausea, RLQ pain
i and
d vomiting
iti - 50%
of cases.
 Migration of pain from periumbilical area to RLQ most discriminating feature of patient's history sensitivity and specificity ~ 80%
Abdominal pain
History extremes of age (Bad)
Children
 Incidence low in <2
 Almost
Al
all
ll iinitially
i i ll misdiagnosed
i di
d
 Perforation rates
 90% infants <1
 80% aged
g 1-4
4
 10-20% adolescents
 Incidence peaks in late teens
Elderly
 5-10%
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

Abdominal pain
Examination
Most specific physical findings
 Rebound tenderness - remember y
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


Abdominal pain
Examination
 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
b
sign
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


Abdominal pain
Investigation
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
Abdominal pain
Investigation











CT 3
Varying trial results
N
Non-enhanced
h
d CT - 211 patients
i
- 87%
8 % sensitive,
i i 97%
% specific.
ifi Addition
Addi i off IV and
d orall 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
Recent
studies
di - noncontrast helical
h li l CT in
i adults
d l - 91-96%
6% sensitive,
i i 92-100%
% specific
ifi
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
patients
i
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
Abdominal pain
Management

Watch and wait
Antibiotic, watch and wait ( cef and met), this is increasing
S i urgent S
Semi
Surgical
i l
Urgent surgical

Fear of the negative laparotomy is almost greater than fear of complications



PROPERTIES
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Abdominal Pain
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Index
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Common Abdominal Presentations
Hernia
 ‘A protrusion of a viscous from its proper cavity. The
protruded
t d d parts
t are generally
ll contained
t i d iin a sac-like
lik
structure, formed by the membrane with which the
cavity is naturally lined
lined’ Astley
Astley-Cooper
Cooper 1804
 Several different types of abdominal wall hernia exist,
with various names
 Usually encountered in routine examination or when
complications of hernia occur
Common Abdominal Presentations
Hernia – Types of hernia
 Inguinal
 Di
Direct
 Indirect
 Femoral
 Incisional
 Umbilical / paraumbilical
 Obturator
 Spigelian
Common Abdominal Presentations
Hernia – Types of hernia
 Clinical presentation
 Reducible
d bl
 Irreducible
 Incarcerated
 Strangulated
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Probable upper
Probable lower
GIT sourcepresentations
GIT source
abdominal
Clinical indicator
Common
Haematemesis
Almost certain
Gastrointestinal
haemorrhageRare
Melaena
Probable
Possible
Haematochezia
Possible
Probable
Blood streaked stool
Rare
Almost certain
Occult blood in stool
Possible
Possible
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Common Abdominal Presentations
Summary
 Careful history including any changes from normal





bowell h
b
habits
bit
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