Transcript Abdominal Pain and Vascular - Aberdeen Emergency Medicine

Surgical emergencies
Surgical Emergencies
Antony Parsons
November 2007
S J Manou
November 2007
Emergency Medicine LGI
Overview
• Cases (10)
– Acute abdomen
• Break
–
–
–
–
Acute abdomen
Acute scrotum
Acute limb
Et cetera
1400-1500
1500-1515
1515 -1600
• Quiz
1600-1615
•
1630
Taxi
What is surgery?
“The branch of
medicine..
deals with the diagnosis
and treatment..
injury, deformity, and
disease..
by manual and
instrumental means”
The acute abdomen
• Appendicitis
• Bowel Obstruction
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•
•
•
•
Congenital – Atresias, Hirschsprungs, ARM
Meconium Ileus
Hypertrophic Pyloric Stenosis
Intussusception
Hernia
• Testicular Pain
• Medical Causes
• Abdominal Pain
• Vomiting
• crying
• Shock & collapse
• Abdominal Pain – character,
localization, radiation
• Emesis – Projectile, colour, amount
• Bowel Habits – BNO, diarrhoea, colour
of stool
• Flatus
• Activity
• Hydration
• Past History – CF, Surgery
• Birth History – Hypoxia, Diabetic mother,
Meconium, gastroschisis/omphalocele
• Drugs – Steroids
• Family History – Hirschsprungs, CF
• Immunization - intussusception
Hx Abdominal Pain
• Historical Features
– Pain
•
•
•
•
•
onset, & duration
location,
quality,
severity,
aggravating and alleviating factors
– PMHX
• similar symptoms
• Med/ surgical history
• Associated symptoms
– GI- anorexia, nausea, vomiting, diarrhea, constip, bleed po/ pr
– GU-dysuria, urgency, frequency
– Gynecologic system
• LMP, pregnancies, PV vaginal discharge
Surgical Emergencies
Age important:
• ~10% severe abdominal pain in elderly = vascular
cause (e.g. ruptured AAA, mesenteric ischaemia).
• Perforation: DD/carcinoma > appendicitis in elderly
• peritonitis ↑ mortality in elderly.
• Children – appendicitis is common
• Pancreatitis any/medium age group (gallstone >
women or alcohol groups.
• Younger women ?gynaecological causes
Examination- The acute abdomen
•
General appearance
– sweaty, pallor, agitation
•
Vital Signs
•
Abdominal exam
– Inspection
distention, scars, masses
– Palpation- most clinically useful
• Start at point farthest from
maximum pain
• While patient breaths
• Rigidity- involuntary guarding
– reflex spasm of abdominal
muscles
• check for masses, hernias
– +/- PR exam
– +/- GU exam in men
– +/- pelvic exam in women
• ABC
• General Appearance
• Abdominal Distension & movement
• Visible peristalsis
• Palpation – tenderness, rigidity, guarding,
mass
• Auscultation
• PR – Surgical finger only!!
• ABC
• Adequate hydration
• NBM
• AXR
• Early Referral
• NG free drainage
• USG
Abdominal Pain- IX
• Path Labs
– FBC?
– U&E
– CRP?
– Amylase?
– Lipase?
– LFTs ?
• Xray
– Radiographs
• CXR, AXR
Abd Pain - Treatment
• Fluid
– NPO
– IV Fluid
• Analgesics
– Opiates
• Antiemetics
• Antibiotics
• Cefuroxime
• Metronidazole
Abd Pain- Discharge?
• General indications for admission
– Intractable pain or vomiting
– Those who appear acutely ill
– Pts. With a specific diagnosis
– Elderly pts with unclear diagnosis
Case # 1
• 38 year old man presents
with:
-Epigastric pain,
-Vomiting
• What else do you want to
know?
Case # 1 - History
• Sudden onset severe epigastric
pain
• Vomited 3 times
• Pain eased by sitting forward
• Bowels not opened today
• Never had similar episode
• Hypertension, angina, diabetes
• Pub landlord
• Enjoys a pint of mild
Case # 1 Examination
• Pale
• Hypotensive
• Tachycardic
•
•
•
•
•
Rigid abdomen
Generally tender
Guarding
No rebound
BS present
Case # 1
• Differential Diagnosis of Upper Abd Pain?
–
–
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–
–
–
? MI
? RTI
? Gastritis/Perforation?
? Biliary colic
? Hepatitis
? Pancreatitis
• Investigations?
Cardiac
• Hx epigastric pain
• XM
• ECG
Pulmonary
• Hx
– Pain
• ? Pleuritic
• XM
• CXR
Gastritis/ Perf
•
Hx
– Esp alcohol
– Assoc H pylori
– ? GI bleed
•
XM
– Epigastric tenderness
– Po/Pr bleed?
•
Ix
– CXR Erect
•
Rx
– Antacids
– PPI?
•
Refer
– for OGD?
– For Sx?
Other common surgical emergencies
• Gall bladder disease (cholecystitis,
gall stones)
Colicky pain RUQ radiating to back/R
shoulder, N&V, sometimes dark urine,
pale stools & jaundice.
Mgmt – IVF, IV Abx, LFT/U&E/Coag,
Surgeons
• Pancreatitis
Central AP radiating to the back.
Painful supine, ↓sat up/leant
forwards. Risk factors.
Mgmt – NBM/resus, amylase/scoring
Biliary Tract Disease
•
History
– Fat Fertile Forty
– Abd pain
• colicky
– +/-Jaundice
– +/- Rigors
•
XM
– Murphys positive
•
Ix
– FBC, LFT’s
• Should be normal in Bil colic
– Ultrasound
•
Treatment
– IV Fluid,
– Analgesia
• NSAID/
• Morphine?
– Antispasmodics
– Antiemetics
Hepatitis
• History
– Esp. drinkers, infection
– Assoc malaise, anorexia, nausea
– Over days/weeks
• XM
– Jaundice
– Tenderness
• IX
– BM
– LFTs
• Rx
Pancreatitis
• Hx
– 80% caused by alcohol or gallstones
– Pain usually located in upper ½ of abdomen
• XM
– Tenderness diffuse
• IX
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–
–
–
BM
FBC , U&E, LFT
ABG
Best screening test• Lipase? Amylase?
– Consider CT
• Rx
– NPO
– NG
– IV Fluid /Analgesia
Case study # 2
• 69yr ♂
• PC – confusion/unwell
• HPC – recent deterioration & confusion, poor appetite
& ?recent chest infection. Past UTIs.
• PMH – T2DM, Inv Prostate Ca, LVF, Anaemia
• DH – Oral Hypoglycaemics, antiHTN, analgesia
• SH – Lives with family, Normally coherent & mobile.
Case Study #2
• O/E – Obs ↑HR, BP stable, sats>95%, apyrexial, BM
1.0.
• Pt irritable & confused, Chest clear, HS PSM, JVP→,
No ankle oedema, Abdo Soft.
• Dextrose IV stat. IVF slow.
• Bloods – WCC > 20 (neutrophilia), Glucose 0.5, TTU –
weakly positive. CXR - NAD
• IV Abx started
• Referred to medics
Case # 2
• Differential diagnosis of central Abd Pain
– ? Int Obs
– ? Constipation/ Gastroenteritis
– ? Pancreatis
– ? AAA/
– ? Vasc/
– ? Renal colic/
• Investigations?
Other common surgical emergencies
• Bowel obstruction (cancer, hernia,
adhesions)
Colicky pain, bloating, N&V,
constipation/overflow & no flatus.
Mgmt – resusc analgesia, AXR,
NGT/Flatus Tube
• Perforation (PUD, DD, IBD,
cancer)
Sudden severe AP. Systemic
upset, peritonitic.
Mgmt – resusc, ABG, eCXR,
CT/surgery
Surgical Emergencies – Special Considerations
• Vascular
• Ruptured AAA – Triad pain-hypotension-mass.
Pain in abdomen, back or flank (acute, severe
& constant)
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•
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•
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Prevalence ↑ with age & ↑ risk rupture >5.5 cm.
Bedside USS. Contrast CT (stable).
10-25% survive rupture
Resusc: over v under resusc – BP/CVP
Surgical Treatment definitive.
Surgical Emergencies – Special Considerations
• Vascular
• Bowel Ischaemia - Sudden onset severe AP,
postprandial, food fear/↓weight., PR Blood, Pain
out proportion to exam.
• Often other vascular problems e.g. IHD/PVD, valvular
disease & arrhythmias.
• 0.1% admissions.
• Bloods (regular + coag), ABG (↓pH,↑lact), CT (>95%)
• IVF, IV abx, urgent surgical r/v
Intestinal Obstruction
• Hx
– Previous abdominal surgery
– Intermittent/colicky pain
– Generalized or central pain
• XM
– 1/3 have generalized tenderness
– Abdominal distention
• IX AXR
– Loops of air
• RX
– NPO/ NG tube
– IV Fluid
Gastroenteritis
• Hx
– crampy abdominal pain with
– vomiting and diarrhea
• XM
– Usually does not cause significant tenderness on palpation
• Ix
– Stool C&S
– Diagnosis of exclusion
• Rx
– Fluid
– Analgesia
– no antibiotics
– Home/ side room
Constipation
• Hx
– esp. children
• XM
• Dx
– AXR can help
• Rx
– Diet
– Softeners
– Stimulants
Pancreatitis
• Hx
– 80% caused by alcohol or gallstones
– Pain usually located in upper ½ of abdomen
• XM
– Tenderness diffuse
• IX
–
–
–
–
BM
FBC , U&E, LFT
ABG
Best screening test• Lipase? Amylase?
– Consider CT
• Rx
– NPO
– NG
– IV Fluid /Analgesia
Abdominal Aortic Aneurysm
•
Hx
– recent onset of flank, abdominal or low back pain
•
XM
– Less than ½ of patients p/w classic triad
• abdominal pain
• hypotension, and
• pulsatile abdominal mass
•
Diagnosis
– Low suspicion
– US for diameter
– CT scan
•
RX IV
– ? Fluid?
– ?adrenaline?
– Keep BP on low side
Mesenteric ischemia??
•
Hx
– Esp. elderly
•
Xm
– Abdominal tenderness
•
IX
– ABG Hi Lactate
– CT/Angio
•
Rx
– IV Analgesia/Antibiotics
– Radiology
– Surgery
•
NB Beware d/c elderly with abd pain
Renal Colic
•
History
–
–
–
–
–
•
Severe pain
abrupt onset
colicky
Unilateral flank,
radiation to groin,
Examination
– Distress/ sweaty
•
Investigation
– UA- haematuria in 2/3
– KUB- can be normal
– Non-contrast CT
•
RX
– Analgesia
• NSAID/ Morphine
Other Causes of Abdominal Pain
• Metabolic
– DKA
• Sickle Cell Crisis
– Usually due to vaso-occlusion
Case Study #2
• Next day call from Medic SHO – Pt c/o
backache when slightly ↑ coherence.
• Large pulsating abdo mass.
• CT – 12 x 10cm infrarenal AAA, worrying
variable density thrombus layering in sac & dirty
fat around edges (No substantial leak)
• Urgent vascular r/v
• Spotted on MRI >2 wk prior.
• pt for palliative care.
Case # 3
• 26 year old female presents with :
-Lower abdominal pain
What else do you want to know?
Case # 3 History
• Pain in periumbilical area for 3
hours
• Constant ache with intermittent
stabbing
• Score 7/10
• Feels sick
• Dysuria and loose stools for a day
• LMP 1/52 ago, cycle normally
regular
• No PV-bleeding/discharge
• Previous STI
Case # 3: Examination
• Tender around periumbilical
area
• No rebound or guarding
• BS present
• Obs all normal, temp 37.8
Case # 3
• Differential diagnosis of Lower Abd Pain
– Appendicitis?
– UTI?
– Pelvic Inflam Disease?
– Ectopic Pregnancy
– Diverticulitis
• Investigations?
Acute Appendicitis
• 10% of the population develop appendicitis
• 70,000 appendicectomies/yr UK
• ♂>♀
• Appendicectomy ♀> ♂
• ♀ more likely 'normal' appendix removed
• 10-50% normal at removal
• Perforation risk:
– <10 yrs = 50%
– 10-50 yrs = 10%
– >50 yrs = 30%
Appendicitis – Diagnostic Problems
• Clinical diagnosis
– Urinalysis – can be +ve
– PT – Mortality:
ectopic>appendicitis
– USS – ?abscess suspected
– Bloods – Normal WCC ≠ Normal.
• Mgmt – Observe, analgesia, IVF
Surgical Emergencies – Special Considerations
• Females
• PID – Lower AP,↑T°C , vaginal d/c
• (Swabs, IVF, IV Abx, PT)
• Ectopic pregnancy – Lower IF AP, late period,
occasionally vaginal d/c
• (Resus, Blood XM, PT, urgent refer)
• Labour pains – all doctors can get caught out at
some stage
• (Stage pregnancy, careful exam +/- speculum)
Diverticulitis
• “left sided appendicitis”
• Σ colon (95%).
• Prevalence ~35 – 50% by 1970s. 65% 85 yrs+
some form DD.
• <5% of <40 yrs DD.
• L-sided DD> West, R-sided DD> Asia/Africa
• 10-25% diverticulosis pts develop diverticulitis.
Diverticulitis
• Conservative mgmt, bowel rest,
IVF & B.Spec abx.
• Recurring attacks/complications
(peritonitis, abscess, fistula) may
need surgery.
• Low residue diet. Low-fibre diet
gives colon healing time.
• Later high-fiber diet. Lowers
recurrence rate
Appendicitis
•
Hx
– RLQ pain,
– pain that migrates - periumbilical area to RLQ,
– (Excluding appendicitis)
– Absence of RLQ pain/ Previous similar pain
•
XM
– RLQ tenderness
•
IX value of tests?
– FBC? CRP?
– Urinalysis
•
Dx
– 20% of pts. Initial dx. is missed
– Normal appendices found intraoperatively 15-40%
•
Rx
– Observe
– Sx
UTI
• Hx
– Abd pain- loin/suprapubic
• XM
– Tenderness
• Ix
– Urinalysis
• Leucocyte esterase
• MCS
• Rx
– Antibiotics
• Usu Trimethoprim
Pelvic Inflammatory Disease
•
Hx
–
–
–
–
•
XM
–
–
–
–
•
Lower Abdominal pain
Assoc Pelvic Pain
Presence of vaginal discharge
? Risk of STD- 90% are STI
Fever,
Abdominal tender
PV tender
palpable adnexal mass,
IX
– elevated WBC
– Must rule out pregnancy
– Swabs?
• High vaginal and cervical
•
Rx
– Antibiotics (early)
Ectopic Pregnancy
•
Hx
–
–
–
•
XM
–
–
•
Ectopic pregnancy MUST be considered in any woman of childbearing age
Many patients present prior to actual rupture
Poor predictive value of historical “risk factors” and physical exam
Vaginal bleeding may be only abnl. Sign
Diagnosis
–
–
•
Normal
Low BP –when ruptured
DX
–
–
–
–
•
p/w abnormal vaginal bleeding
or abdominal pain,
Nb diarrhea?
Positive pregnancy test
Transvaginal ultrasound
Refer to Gynae /clinic
Ovarian torsion/cyst
• Hx
– (rare)
– Pain
– Sudden unilateral severe
• Xm
– Tender mass on PV
• Ix
– US
• Rx
– SX
Diverticulitis
• Hx
– Esp older population
– Localized LLQ pain
• XM
– Tenderness
• Generalized
• Or LLQ
• Ix
– FBC?
– CT with contrast
• RX
– IV fluid /Anti Bs/Sx
• Complications
– Pericolic abscess
– Peritonitis
– PR-bleeding
Nonspecific Abdominal Pain
• Most common ED diagnosis
• Hx XM
– Nausea is common
– Tenderness usually not severe
– Lab tests usually normal
• Diagnosis of exclusion
• Rx
– Role of CDU protocol
• Prognosis
–
–
–
–
90% pts discharged are better in 2-3 weeks
Small percent readmitted
Some further eval = diagnosis
Key is follow-up- instructions and follow up advice
Case # 3
• Tender around RIF
• No rebound or guarding
• Refered to Surgery
– Pathological appendix found
• Break
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•
•
•
•
•
•
2-10 week old
First born male
Projectile non-bilious vomiting
Hungry dehydrated child, feeds vigorously
Visible gastric peristalsis
Palpable pyloric olive
Hypochloraemic, hypokalaemic metabolic
alkalosis
• Ultrasound diagnostic
• Definitive management - surgery
Case 2
• Three week old male
with bloody stools
and emesis
• On Examinationpale with a soft,
distended abdomen
• 6mo-4years
• Intermittent colicky abdominal pain and vomiting
– beware of the crying child
• Each episode classically last 1-2 min and recurs
every 15-20 min
• Passage of blood - 'red currant jelly' per rectum
• Sausage shaped abdominal mass
• Diagnosis confirmed with water soluble contrast
enema or ultrasound
3 day old baby
progressive
abdominal
distension and
vomiting
Not passed
meconium
• Due to absence of autonomic ganglion
cells in Auerbach's plexus of distal large
intestine
• Male : female ratio 4:1
• 75% cases confined to recto-sigmoid
• 80% present in neonatal period with
delayed passage of meconium
Followed by increasing abdominal
distension and vomiting
• Child is at increased risk of enterocolitis
and perforation
Case 4 –
Inguinal Hernia
Incarcerated –
Intestinal obstruction
• sudden onset of severe unilateral scrotal
pain.
• Past history of similar episodes
• Beware of the crying child!!
• Involved testicle painful to palpation;
frequently elevated in position when
compared with the other side
• Horizontal lie of the testicle
• Erythema and oedema of the scrotum
• no relief of pain upon elevation of scrotum
(elevation may improve the pain in
epididymitis [Prehn sign])
Why do Pediatric Surgeons
always make such a big deal
out of a little yellow or
green emesis?
Because it usually
means bowel
obstruction or
necrosis in children!
Question 2?
Why are Pediatric Surgeons so
interested in flatus?
Contrary to popular
belief, kids with
obstruction can still
have bowel
movements, but they
won’t pass gas!
Case # 4
• Hx
• 20 year old male
• Co R testes pain
– Sudden onset
– Constant waxing / waning
– History of similar episodes in the past
– Assoc abd pain, nausea / vomiting
– recent exercise
Case # 4
• DDx
– Testicular torsion
– Torsion of appendix testes
– Epididymitis
– Orchitis
– Inguinal hernia - strangulated
– Fornier’s gangrene
Genital exam approach
•
Inspect
– Asymmetry
– Swelling
•
Palpate
– Inguinal + Femoral canals
– Spermatic chord and vas deferens
– Cremasteric reflex
– Testes
• Lie (transverse or vertical),
• size,
• tenderness
– Epididymis
– Mass
• ? Can you get your fingers above it,
• ? Tran illuminate
– Glans/ Penile abnormality
Case # 4
• XM
– Abdo
– tender LLQ but no guarding
• Scrotum
– Swollen, tender testicle
– Testes higher horizontal lie
– Absence of cremasteric reflex
Testicular torsion
Hx
Newborns/ Puberty /up to 30
XM
Palpable knot in the spermatic chord
Testicular elevation
Transverse lie of testicles
Loss of crem reflex
Dx clinical
Ix
Doppler color US
Rx
Detorsion
<6hr symptoms 80% ok
6-10hr 20%
Testicular appendix torsion
•Hx
•Peak incidence age 10 – 13,
•precipitated by vigorous activity or trauma
•Onset usually acute
•Pain mild – severe
•XM
•Tender nodule
•Cremasteric reflex intact
•Dx
Blue-dot sign is pathognomonic!!
•RX
•Limit activity
•Indirect ice / heat
•NSAIDS
•Prognosis
•Painful ~ 1 week No long-term damage
Epididymitis
•
Most common in 19 – 40 yo
•
Hx
–
–
–
–
•
XM
–
–
–
–
•
Unprotected sexual activity
Gradual onset of testicular pain
Dysuria / urgency / frequency
Urethral discharge
+/- Fever
Localised epididymal tenderness
Swollen epididymis
+ Cremasteric reflex
DX
– Urine M C+S
•
Rx
– Bed rest
/ Scrotal elevation
– Analgesia
– Antibiotics eg Ciproflox
Orchitis
• Hx
– Young <10
– Assoc Mumps
• XM
– Fever
– +/- parotitis bilateral
– Swollen tender teste(s)
• Dx
– Exclude Torsion/Epidydmitis
– Viral usu
• Rx
– Analgesia
Hernia
• Hx
• Xm
– Inguinal/Femoral
• Dx
– Reducible?
– Irreducible?
– Strangulated?
• Rx
Fournier’s gangrene
• Hx
• Xm
– Fever
– Gangrene
• Dx
• Rx
– Sx
Surgical Emergencies – Special Considerations
• Urological
• Acute urinary retention – Many GU Sx.
Bladder may perforate & Post renal ARF.
• Causes: BPH, Ca Prostate, pelvic
malignancies.
• Tests: post-void scan(bladder scan), PSA,
serum U&E
• Mgmt: SP/PU catheter, Urology r/v
• Renal Colic/Obstructive pyelonephritis –
e.g. calculi
• Tests: U&E, CT/KUB (size ∞ intervention)
• Mgmt: analgesia +/- IV Abx, urology
Surgical Emergencies – Special Considerations
• Urological
• Paraphimosis – If persistent or
ischaemia = urgent
• Manual reduction. If fails urology.
• Educate pt/carers on foreskin care
• Priapism – erect penis does not
become flaccid. Leads to
ischaemia/gangrene
• Causes: haematological (SCD,
leukaemia), neurological (SC
lesions/trauma), medications/drugs (e.g
antipsychotics, cocaine, Viagra unlikely)
• Mgmt: aspiration. Intracavernosal
adrenaline & surgery (urologist)
Greek god Priapus,
myth that he was
punished by other
gods for attempting to
rape a goddess &
given a huge useless
wooden genitals.
Case # 5
•
•
•
•
65 y o male
Smoker
R leg pain
At rest
• Pale leg
Case # 5
• DDx of acute leg pain
– DVT
– Acute Vasc leg
– Sciatica
• Investigation?
Acute Vasc Leg
• Hx
– Pain
• Exercise
• Rest
• XM
– Pallor
– Paralysis
– Parasthesia
– Pulseless
– Perishing cold
Investigation
Ankle-brachial pressure index, ABPI
systolic ankle pressure / systolic brachial pressure.
normal > 1, claudication 0.9-0.6, rest pain 0.3-0.6, impending gangrene 0.3 or less.
Diagnosis
Rutherford Classification
Category
Description
Cap. refill
Paralysis
Sensory
loss
I
IIa
IIb
Viable
Not immediately
threatened
Intact
-
-
Threatened
Salvagable if
treated
Intact/slow
-
Partial
Threatened
Salvagable if
treated
emergently
Slow/absent
Partial
Partial
III
Irreversible
Primary
amputation req.
Absent
Complete
Complete
Rx
• 100% oxygen
• IV fluids
• IV Opiate analgesia
• Vascular input Asap
–
–
–
–
Thrombolysis
Angiography
Embolectomy
Urgent arterial bypass
Case # 6
• Hx
– 20 y.o. IDDM
– C/o thigh pain
• XM
– Swelling
• DDx
– Cellulitis
– Fasciitis
– Abcess
Abcess- Hx XM
• Hx
• XM
– ? fluctuant
– ? crepitus
Abcess- Treatment
• Incise
• Swab
• Drain
• Pack
Thrombosed Pile
• Hx
– PR Pain
– Bleed
• XM
– Cherry
• Rx
– Stop bleeding
Anal Fissure
• Hx
– PR Pain
• Xm
• Rx
– GTN paste
Always inform surgeons early so
they can prepare adequately!
Quiz
Quiz questions
• 1) Which is most specific test for Pancreatitis?
• 2) What may be raised in Mesenteric Ischemia?
• 3) What’s the best way to dx appendicitis?
• 4) Important surgical diagnosis in crying child?
• 5) 80% of testes torsion are salvagable within?
• 6) What is the Ankle-brachial pressure index?
• 7) What can you treat anal fissure with?
Quiz answers
• 1) Lipase
• 2) Lactate
• 3) Clinically
• 4) Intussusception
• 5) 6 hours
• 6) systolic ankle pressure / systolic brachial pressure
• 7) Nitrate paste
Questions ?
Thank you
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