Transcript Approach to Abdominal Pain in the ED (2)

Approach to Abdominal
Pain in the Emergency
Department
Sezgin Sarıkaya, Assoc.
Prof. MD, MBA
Department of Emergency
Medicine Yeditepe
University
Introduction
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At the end of this lecture you
should:
Understand the generation and
presentation of types of
abdominal pain
 Develop critical elements of the
history and physical for AP
 Apply knowledge of utility of
testing to diagnostic approach
 Apply management principles to
patient care in the ED
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The Epidemiology of Acute
Abdominal Pain
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5-10% of all ED visits.
Among them, 14-40% patients need
surgical intervention.
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Most common diagnosis is NONSPECIFIC
(ie, “I dunno”)
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Challenge for emergency
physician (EP):
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About 1/3 have an atypical presentation.
If misdiagnosis, mortality rate 2.5 times
higher than correct diagnosis in the
elderly.
Three Subgroups of Patients with
Abdominal Pain Who deserve
Particular Focus
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Elderly/ nursing home patients
Immunocompromised (e.g. HIV)
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Women of childbearing age.
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Post operative patients
Infants
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The Most Important Concept
for EP in Approaching
Abdominal Pain
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To Differentiate
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Who is the patient of acute abdomen?
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What are the probable diagnoses you have
in mind?
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Why do you consider such diagnosis?
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How do you prove it?
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When will you consult surgeon for
operation?
Causes of Acute Abdominal
Pain in the ED
Cause
Percentage of Cases
Nonspecific abdominal pain
41-46
Appendicitis
4-24
Cholecystitis
2.5-9
Gastroenteritis
7
Salpingitis
2-7
UTI
3-5
Small-bowel obstruction
2.5-4
Renal colic
1.5-4
Constipation
2
Pancreatitis
1-2
Diverticulitis
1-2
Abdominal aneurysm, ectopic pregnancy
(Brewer et al., 1979; Scand J Gastroenterol)
<1
Abdominal Pain Across the
Ages
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Ages 0-2
 Colic, GE, viral illness, constipation
Ages 2-12
 Functional, appendicitis, GE, toxins
Teens to adults
 Addition of genitourinary problems
Elderly
 Beware of what seems like everything!
Important Extra-abdominal
Causes of Abdominal Pain
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Systemic
 DKA
 Alcoholic ketoacidosis
 Uremia
 Sickle cell disease
 Porphyria
 SLE
 Vasculitis
 Glaucoma
 Hyperthyroidism
Toxic
 Methanol poisoning
 Heavy metal toxicity
 Scorpion bite
 Black widow spider bite
Thoracic
 Myocardial infarction/ Unstable angina
Important Extra-abdominal Causes of
Abdominal Pain
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Genitourinary
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Testicular torsion
Renal colic
Infectious
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Pneumonia
Pulmonary embolism
Herniated thoracic disc (neuralgia)
Strep pharyngitis (more often in children)
Rocky Mountain Spotted Fever
Mononucleosis
Abdominal wall
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Muscle spasm
Muscle hematoma
Herpes zoster
Emerg Med Clin North Am 1989; 7: 21-740
Abdominal Pain in the Elderly
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Diminished sensation of pain in the
elderly
Comorbid diseases
Polypharmacy
Combinations of above result in
many more vague, nonspecific
presentations
Twice as likely to require surgery
with presentation over age 65
What’s the Problem
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Imprecise pain generation and
transmission to the central
nervous system
Comorbid diseases
Developmental stage
Medications
Social factors
Understanding the Types of
Abdominal Pain
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Visceral
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Somatic
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Stretch fibers in capsules or
walls of hollow viscus that enter
both sides of spinal cord
Fibers dermatomally distributed
and enter unilaterally in the
spinal cord
Referred
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Overlap of fibers from other
locations
Understanding the Types of
Abdominal Pain
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Visceral
Crampy, achy, diffuse,
 Poorly localized
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Somatic
Sharp, lancinating
 Well localized
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Referred
Distant from site of generation
 Symptoms, but no signs
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Understanding the Types of
Abdominal Pain
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Location, location, location
Organs and their corresponding fiber
entry to the spinal cord
 C3-5 – liver, spleen, diaphragm
 T5-9 – gallbladder, stomach,
pancreas, small intestine
 T10-11– colon, appendix, pelvic
viscerat11-l1 – sigmoid, renal
capsules, ureters, gonads
 S2-4 - bladder
Visceral
Somatic
History Taking in Abdominal Pain
Presentations
 “OLD CARS”
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O- onset
L- location
D- duration
C- character
A-alleviating/aggravating factors
associated symptoms
R- radiation
S- severity
History Taking for Abdominal Pain
Presentations
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PMH
 Similar episodes in past
 Other medical problems that increase disease
likelihood of problems (ex: DM and
gastroparesis)
PSH
 Adhesions, hernias, tumors
MEDS
 Abx, NSAIDS, acid blockers, etc
GYN/URO
 LMP, bleeding, discharge
Social
 Tob/EtoH/drugs/home situation/agenda
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Physical Exam in Abdominal
Pain Presentations
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Inspection
 Distention, scars,
bruises
Auscultation
 Present, hyper, or
absent
 Actually not that
helpful!
Palpation
 Often the most
helpful part of exam
 Tenderness versus
pain
 Start away from
painful area first
 Guarding, rebound,
masses
Physical Exam in Abdominal Pain
Presentations
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Signs
 Mc burney
 Murphy’s
Extra-abdominal exam
 Pelvic or scrotal exams
 Lungs, heart
 Remember it’s a patient, not a part
Rectal
 Adds very little (despite the angst) beyond
gross blood or melena
Laboratory Testing
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Everybody likes a CBC, but…
Lacks sensitivity, no specificity
 Little to no change in diagnostic
probabilities
 Should not dramatically alter
approach (tender is still tender)
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Laboratory Testing
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Directed approach to lab studies
There are no “standard belly
labs”
Pregnancy test in women of
child bearing age
Urine dipsticks
Imaging
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Plain films
 Free air, obstruction, air-fluid, FBs
Ultrasound
 Rapid “yes or no” ED evaluations
 Formal studies
 May add doppler
Computed Tomography
 Revolutionized acute care
 Often better than we are!
Common Diagnoses by Quadrant
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RUQ
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Cholecystitis
Biliary colic
Hepatitis
Pancreatitis
Renal stones
PUD
Pneumonia
PE
MI
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LUQ
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Gastritis
Gastric ulcer
Pancreatitis
Splenomegaly
Splenic rupture
Renal stone
Pneumonia
PE
MI
Common Diagnoses by
Quadrants
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RLQ
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Appendicitis
Renal stone
Ovarian cyst
Torsion
Epididymitis
Ectopic
IBD
AAA
UTI
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LLQ
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Diverticulitis
Renal stone
Ovarian cyst
Torsion
Epididymitis
Ectopic
IBD
AAA
UTI
Dangerous Mimics
True Diagnosis
Initial Misdiagnosis
Appendicitis
Ruptured abdominal
aortic aneurysm
Ectopic pregnancy
Diverticulitis
Perforated viscus
Bowel obstruction
Gastroenteritis, PID, UTI
Renal colic, diverticulitis, lumbar strain
Mesenteric ischemia
Incarcerated or
strangulated hernia
Shock or sepsis from
perforation, bleed,
abdominal infection
PID, UTI, corpus luteum cyst
Constipation,GE ,pyelonephritis
PUD, pancreatitis, nsp abdominal pain
Constipation, gastroenteritis,nonspecific
abdominal pain
GE, constipation, ileus small bowel
obstruction
Ileus or small bowel obstruction
Urosepsis or pneumonia (in elderly)
Five Major Categories of
Acute Abdomen (BIOPI)
Bleeding or rupture of
vessels or tumor
 Ischemia or Infarction
 Obstruction
 Perforation
 Inflammation
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Common Pitfalls in Acute
Appendicitis
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Abdominal pain and tenderness are
present in nearly 100% of patients with
appendicitis; other clinical features are less
reliable.
Fever occurs in only 16% of patients with
acute appendicitis; its presence is more
suggestive of appendiceal perforation.
Murphy sequence appears in only 22%
elderly.
 Perforation rate about 60% (age > 60
Y/O)
Management of Abdominal
Pain
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Always right to start with ABC’s
IV access
Fluid administration
Antiemetics
Analgesics
Directed testing and imaging
Re-evaluations
Antibiotics
Consultants
 Surgeons, OB/GYN, urologists, cardiologists,
etc
Disposition of Abdominal Pain
Patients
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Operating Room
Hospital bed/observation
Serial labs
 Serial exams
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Home with abdominal warnings
The art of emergency medicine
 3 components of discharge plan
 Document, document, document
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 SORU
VE KATKI