Transcript abdominal pain

ABDOMINAL PAIN
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TEACHING POINTS
 Define abdominal pain
 Discuss clinical evaluation of patients with
acute abdominal pain
 Elucidate on the common causes of acute
abdominal pain
 Give indications for surgical intervention
Case 1: 19 year old male came in due to
epigastric pain,vomiting and fever which
later localized at the right lower quadrant.
PE showed tenderness over the right lower
quadrant with (+) Rovsing’s sign. CBC
showed leucocytosis with segmenter
predominance. The most probable diagnosis
in this case would be:
A.
B.
C.
D.
Acid peptic disease
Acute appendicitis
Acute cholecystitis
Acute Pancreatitis
Acute appendicitis
 Most common surgical disease of the
abdomen.
 Appendiceal inflammation is associated
with obstruction in 50 to 80% of cases,
usually in the form of a fecalith and, less
commonly, a gallstone, tumor, or ball of
worms (Oxyuriasis vermicularis).
Acute appendicitis
 It is mainly a disease of adolescents and
young adults, but it may occur in any
age group and affects males slightly
more than females.
 Atypical presentation in the very young
and the very old.
 Difficulty in the dx in retrocecal
appendix
Symptoms can be characterized by the
mnemonic PANT
(Pain followed by Anorexia followed
by Nausea and then by Temperature
elevation)
 OTHER SIGNS that may be present:
– ILEOPSOAS SIGN
– OBTURATOR SIGN
– ROVSING’S SIGN
Acute appendicitis
Inflamed appendix
UTZ in appendicitis
Acute appendicitis
CT scan in appendicitis
w/ fecalith & abscess
Appendicitis with
fecalith
Acute appendicitis
Ova
Adult E. vermicularis
Appendicitis due to
E. Vermicularis
Acute appendicitis
Lap appendectomy
Appendiceal stump
Acute appendicitis
CASE 2.A 42 year old stout female came in
due to severe epigastric and RUQ colicky
abdominal pain a few hours PTA after eating
cheeseburger. History further showed that
she had recurrent bouts of post prandial
abdominal pain over the past several
months. PE showed epigastric and RUQ
abdominal tenderness with Murphy’s sign.
The most probable cause in this case would
be:
A.
B.
C.
D.
Gastroesophageal reflux disease (GERD)
Acute cholecystitis
Acute appendicitis
Mesenteric vascular ischemia
In Acute Cholecystitis:
Pain may subside 6 hours from onset but
persists in cholecystitis
Precipitated by a fatty meal
Colicky and may radiate to R shoulder
Murphy’s sign is common in those with
cholecystits
Acute cholecystitis
Acute cholecystitis
Acute cholecystitis
Different types of Gallstones
Acute cholecystitis
Laparoscopic picture of distended GB
What is the complication of Acute
cholecystitis presenting with RUQ
abd. pain, fever and jaundice, with
elevated Alkaline phosphatase,
dilated CBD on UTZ?
A. Gallstone ileus
C. Acute pancreatitis
D. Ascending cholangitis
D.Acute viral hepatitis
Ascending cholangitis
Acute cholangitis is a bacterial infection
superimposed on an obstruction of the
biliary tree most commonly from a
gallstone, but it may be associated with
neoplasm or stricture.
Ascending cholangitis
Charcot’s triad:
RUQ pain
Jaundice
Fever
Ascending cholangitis
 RUQ pain
 Jaundice
 Fever
 Hypotension (septic shock)
 Sensorial changes
Reynold’s pentad
40% mortality
Ascending cholangitis
Ascending cholangitis
Transabdominal
Ultrasound
Endoscopic
Ultrasound
CASE 3. A 38 year old laborer came in at 4
am at the ER due to severe epigastric pain
radiating to the back associated with
vomiting. History revealed that he had a
bout of drinking spree the night before. PE
revealed tenderness over the epigastric
and left upper quadrant. CBC showed
leukocytosis, and serum Amylase was 10
times elevated.His BP was 80/50. The most
probable cause in this case would be:
A.
B.
C.
D.
Peptic ulcer disease
Acute appendicitis
Intestinal obstruction
Acute pancreatitis
Acute pancreatitis may be
characterized by the ff:
Hypotension may be related to
extravasation of intravascular fluid or
hemorrhage or both.
Grey-Turner's sign & Cullen's sign may
be present in some patients
Grey Turner’s sign
Grey Turner’s sign
Grey Turner’s sign
Cullen’s sign
Ranson’s criteria
Evaluate on admission on Admission:
 Age > 55
 WBC > 16,000
 Glucose > 200 mg/dl [ 10 (SI) ]
 LDH > 350 IU
 AST > 250 IU
Ranson’s criteria
Evaluate 48 hours after admission.
 Hct drop > 10%
 BUN increase > 5mg/dl (> 1.79 SI)
 Ca < 8 mg/dl (< 2 SI)
 Arterial pO2 < 60 mmHg
 Base deficit (24 - HCO3) = > 4
 Fluid needs > 6L
Ranson’s criteria
 Ranson score of 0-2 , 1%mortality
 Ranson score of 3-5, 10%-20% mortality
 Ranson score of >5 has more than 50%
mortality and is associated with more systemic
complications
Acute pancreatitis
Penetrating duodenal ulcer
may cause pancreatitis
Acute pancreatitis
Acute pancreatitis
Acute pancreatitis
DEFINITON
 Stedman’s Medical Dictionary,27th edition
Acute Abdomen: “any serious acute intraabdominal condition attended by
pain,tenderness, and muscular rigidity for
which emergency surgery must be
considered”
ACUTE ABDOMINAL PAIN
-REFERS TO PAIN LESS THAN 24 HRS
-25% of general surgical
admissions,present primarily with acute
abdominal pain
-MAIN ISSUE:
-how to distinguish conditions that
require surgery from those that can be
treated non-operatively
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APPROACH TO PATIENTS WITH
ACUTE ABDO.PAIN (AAP)
Essence: establish the diagnosis as
precisely and expeditiously as possible
Acute abdomen =/Surgical Abdomen
History and PE-give as diagnosis in 6575%
– Will dictate APPROPRIATE MANAGEMENT
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Abdominal Pain
3 Distinct Types of Pain
 Visceral – arises in abd. organs invested with
visceral peritoneum; dull, poorly localized; high
threshold
 Somatic – arising from abd. wall esp. parietal
peritoneum, resp. diaphragm; slow to adaptation;
sharp, well-localized, easily described
 Referred
– pain referred to anatomically distant sites, more
superficial and usually dermatom
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Abdominal Pain
 Sensitive to:
– Ischemia
– Stretching of capsule of solid organs
– Increased tension in wall of hollow viscus
– Chemical irritation of peritoneum
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Abdominal Pain
Important questions to ask:
 Where is the pain localized?
 What’s the quality of the pain?
 How intense is the pain?
 What’s the chronology/timing of the pain?
 Are there alleviating/aggravating factors?
 How about other associated symptoms?
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Abdominal Pain
PAIN LOCALIZATION:
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Abdominal Pain
PAIN LOCALIZATION:
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Abdominal Pain
PROGRESSION: RADIATION OF
ABDOMINAL PAIN
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Abdominal Pain
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Abdominal Pain
HISTORY
 Alleviating factors
Lying still
Vomiting
Antacids
Food
Bowel movement
Medications
Withdrawal of milk
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Aggravating Factors
Movement
Coughing
Respiration
Food – greasy, milk
Alcohol
Fasting
Stress
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Abdominal Pain
Other Symptoms – nausea, vomiting,
fever, diarrhea, chills
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Abdominal Examination
MAKE SURE TO DO A THOROUGH P.E!
 General assessment/Vital signs
– Is the patient in “ shock”?,acidotic?
– Restless?Lying still?Doubling-up?Jaundiced?




Inspection
Auscultation
Palpation
Percussion
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Abdominal Examination
INSPECTION:
– Distention –> bowel obstruction, ascites
– Visible bowel loops –> bowel obstruction
– Scars –> adhesions, incisional hernia
– Areas of hemorrhage (Grey-Turners,Cullens)
– Assymetry->mass,abscess
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Abdominal Examination
AUSCULTATION:
– Bowel sounds
 Active – high pitched /”metallic”–> bowel
obstruction
 Absent –> peritonitis/ paralytic ileus
– Bruits – aorta, iliac->aneurysm
– Breath Sounds –> look for basal pneumonia
with referred pain to abdomen
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Abdominal Examination
 PALPATION
– Note for definite “peritoneal irritation” signs
 Direct and rebound tenderness(peritonitis)
 Murphy’s sign(acute cholecytitis)
 Obturator/Iliopsoas sign/Rovsing’s(acute
appendicitis)
 Involuntary muscle guarding/board -like
rigidity(perforation)
– CAUTION:P.E findings NOT PRONOUNCED IN
ELDERLY,DIABETICS,MENTALLY-CHALLENGED
Abdominal Pain
This is a test for peritoneal irritation. Palpate deeply and
then quickly release pressure. If it hurts more when you
release, the patient has rebound tenderness.
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Abdominal Examination
PERCUSSION
– Gentle percussion detects rebound
tenderness ->peritonitis
– Shifting dullness identifies fluid –>ascites,
blood, pus
– Loss of liver dullness –> perforated bowel
– CVA tenderness->perinephric
abscess/pyelonephritis
– Generalized tympanyileus/obstruction
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Abdominal Pain
CVA tenderness is often associated with renal disease.
Use the heel of your closed fist to strike the patient firmly
over the costovertebral angles.
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Abdominal Examination
RELEVANT THINGS TO CONSIDER:
Do inguinal/rectal exam in males
Consider pelvic/rectal exam in females
Disorder of the chest often manifest with abdominal
symptoms(referred pain)
Use low threshold for admitting elderly for
observation/surgical evaluation
e.g Mesenteric ischemia-abdominal p.e not
commensurate to degree of pain
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MEDICAL  SURGICAL
 Peptic ulcer disease
 Cholelithiases
 Acute edematous
pancreatitis
 Colon diverticulitis
 Typhoid ileitis
 Dx initially as “Ileus”
 Dx initially as “APD”
 Perforated peptic ulcer
 Calculous cholecystitis
 Severe necrotizing
pancreatitis
 Diverticular perforation
 Typhoid w/ perforation
 Intestinal obstruction
 Acute appendicitis
Laboratory Tests
Simple frequently performed tests:
 complete blood count
 Electrolytes,bun,creatinine
 liver enzymes
 pancreatic enzymes (amylase and lipase)
 urinalysis
Radiographic Studies
Plain x-rays of the abdomen
– Air-fluid levels in intestinal obstruction
– “Pneumoperitoneum” in perforated viscus
– may show calcified kidney/gallstone in
patients with colic
Barium Studies( UGIS,Ba.Enema)
-don’t use if perforation is suspected
Radiographic Studies
 Abdominal Ultrasound
– useful in diagnosing gallstones, cholecystitis .appendicitis,
or ruptured ovarian cysts
 Computerized Tomography (CT)
– useful in diagnosing pancreatitis, pancreatic cancer,
appendicitis, and diverticulitis, as well as in diagnosing
abscesses in the abdomen
– special CT scans of the abdominal blood vessels can detect
diseases of the arteries that block the flow of blood to the
abdominal organs
– helpful in diagnosing diseases in the small bowel such as
Crohn's disease
 Magnetic Resonance Imaging (MRI)
– useful in diagnosing gallstones that have passed out of the
gallbladder and are obstructing the bile duct
Endoscopic Procedures
 Esophagogastroduodenoscopy (EGD)
– useful for detecting ulcers, gastritis, or stomach cancer
 Colonoscopy
– is useful for diagnosing infectious colitis, ulcerative colitis,
colon cancer
 Endoscopic ultrasound (EUS)
– useful in diagnosing pancreatic cancer or gallstones if the
standard ultrasound or CT or MRI scans fail to detect them
 Capsule enteroscopy
– takes pictures of the entire small bowel
– can be helpful in diagnosing Crohn's disease, small bowel
tumors, and bleeding lesions not seen on x-rays or CT
scans
 ERCP
– Main indication now is THERAPEUTIC,spec. for
patients with Ascending cholangitis
 Sphincterotomy with stone extraction
 Stenting for those with biliary strictures
ACTUAL CHALLENGE
 “ OBSCURE” DIAGNOSIS DESPITE
“EXHAUSTIVE” EVALUATIONS-( 40%)
– So-called “grayzone” areas
 TOSS-UP BETWEEN MEDICAL
OBSERVATION ( for how long?)AND
SURGICAL EXPLORATION
 SOME CASES LABELLED INITIALLY AS A
“NON-SURGICAL” EVENTUALLY TURNED
OUT TO BE SURGICAL ABDOMEN IN THE
END
 THUS,IT IS IMPERATIVE FOR THE
INTERNIST AND THE SURGEON TO BE
IN CONSTANT COMMUNICATION WITH
REGARD TO STATUS OF THE PATIENT
RECOMMENDATIONS :2 OPTIONS
 If patient is stable,REPETITIVE
EXAMINATIONS/ASSESSMENTS over
time may eventually clinch the diagnosis
and be treated appropriately
 If patient is hemodynamically
unstable,deteriorating and diagnostic
uncertainty remains,surgical exploration /
diagnostic laparoscopy may be the option
Abdominal Pain
Symptoms Suggestive of a Surgical Abdomen
 Pain > 6 hrs.
 Pain precedes nausea, vomiting, fever
 Pain is sudden, severe, continuous or
progressive
 Pain that awakens patient or begins during
relative inactivity
 Pain with anorexia
 Pain with obstipation
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SIGNS TO LOOK FOR:(case-case)




DIRECT/REBOUND TENDERNESS
INVOLUNTARY MUSCLE GUARDING
RIGID ABDOMEN
HYPOACTIVE TO ABSENT BOWEL
SOUNDS
 PROGRESSIVE DISTENTION/ASCITES
 CHARCOT’S TRIAD/REYNOLD’S PENTAD
IF SURGERY IS CONTEMPLATED:
 MAKE SURE TO EXPLAIN TO THE
PATIENT/RELATIVE THE PROCEDURE
TO BE DONE, THE
REASONS,PROS/CONS,ETC.
 BE AWARE OF MEDICO-LEGAL
IMPLICATIONS (SPECIALLY WHEN
SURGERY FAILS TO IDENTIFY THE
ETIOLOGY!)
ADVERSE EFFECTS OF
UNREQUITED PAIN
 Has adverse
PHYSICAL,PSYCHOLOGICAL,ECONOMIC
consequences
– Involuntary splinting of resp.muscle->pooling of
secretions->pneumonia,atelectasis
– Increased “stress” hormones->protein
catabolism,glycogenolysis,hypertension
– Depression,anxiety,hopelessness
– Longer hospital stay->more expenses
Abdominal Pain
Summary:
 Thorough history and P.E with appropriate
use of ancillary procedures clinches
diagnosis in majority of cases
 Proper treatment will depend on accurate
diagnosis
 Not all with acute abdominal pain is
surgical
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THE END