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Acute abdominal pain

Semester 12 2009

Approach to abdominal pain

THOROUGH HISTORY CAREFUL EXAMINATION

Approach to abdominal pain

SELECT INVESTIGATIONS
appropriate to the situation

Remember
epigastric pain may relate to pathology above the diaphragm

Approach to abdominal pain History


Sudden onset
Perforation Torsion/Volvulus

Colicky pain
Hollow viscus obstruction/spasm

Constant pain
Inflammation

Radiation
Shoulder tip/back/loin to groin

Approach to abdominal pain


What tests are available?
Haematology Biochemistry Bacteriological Imaging Special test
Endoscopy/Laparoscopy ECG to exclude cardiac origin of pain

When should they be used?


Be selective

What tests are available?


Haematology FBE
Anaemia WCC

Clotting

What tests are available?


Biochemisrty U&E LFTs Amylase/Lipase CRP Troponin/cardiac enzymes

What tests are available?


Imaging Plain XR U/S CT
With/without contrast

Ultrasound
Cheap Non-invasive No preparation Useful in biliary, renal and gynaecological problems.

Computed tomograms (CT)


Sensitive for free gas Detects inflammatory change Identifies leaks, fluid collections
Consider carefully in female of child bearing age

Computed tomograms (CT)

Case 1
23 male presents with 24 hr history of abdominal pain Pain initially periumbilical and localises to right iliac fossa Temp 37.4 pulse 80 with tenderness guarding and rebound in RIF

Case 1
Haematology
Biochemistry Microbiological Imaging Special

WCC
?? U/S Laparoscopy +/Appendicectomy

Case 1 Management
Consent for appendicectomy
Laparoscopic/open

Antibiotics
Aerobic and anaerobic cover Duration of antibiotics???

Appendicitis
Essentially a clinical diagnosis
Pain RIF tenderness WCC > 12000

Ultrasound and CT
Useful when clinical doubt
Female Atypical history

?Reduces negative appendiciectomy rate

Appendicitis
Essentially a clinical diagnosis
Pain RIF tenderness WCC > 12000

May masquerade as
Gastroenteritis Urinary tract infection Pelvic inflammatory disease (PID) Ovarian pathology (Torsion of testis)

Ultrasound and CT
Useful when clinical doubt
Female Atypical history

?Reduces negative appendiciectomy rate

Appendicitis symptoms
Associated symptoms:
Nausea, vomiting, anorexia. Pain precedes vomiting.

Alleviating factors:
Lying still

Aggravating factors:
Moving, coughing, walking, palpation of abdomen.

Beware:
likely to be classic in the young, the elderly, pregnant women,

The most consistent symptoms/signs are anorexia, RLQ tenderness, rebound tenderness.

ALVARADO SCORING SYSTEM


Features Symptoms Migratory right iliac fossa pain Nausea/vomiting Anorexia Signs Right iliac fossa tenderness Fever >37.30C Rebound pain in right iliac fossa Laboratory test Score

1 1 1

2 1 1

Leucocytosis (>10 X 109/L)


Neutrophilic shift to the left >75% Total score

2
1 10

ALVARADO SCORING SYSTEM

Clinical judgement still required!!

Case 2
18 year old female presents with right sided abdominal pain mid cycle. She is tender in the right iliac fossa with guarding and slight rebound Differential includes ovarian pathology, ectopic pregnancy and appendicitis

Case 2
Haematology
Biochemistry Microbiological Imaging Special

WCC
Pregnancy test Ultrasound Laparoscopy

Case 2 Management
Observe Investigate
U/S

If not resolving
Laparoscopy

Case 2 Ultrasound

Imaging of appendicitis
CT
Sensitivity 85-100%
Beware radiation in young women

US
Sensitivity 74-100% Dedicated units
Sensitivity 89% Specificity 95% PPV 86% NPV 96%

Appendicitis - Aim to minimise perforation and abscess

What to Do to Avoid Missing Appendicitis:

Careful history and examination dont forget PR/PV


If in doubt observe Beware young and elderly

Case 3
35 Y male presents with sudden onset of severe abdominal pain with assoc. shoulder tip pain. O/E distressed lying still tachcardia normotensive

Case 3
Haematology Biochemistry
Microbiological Imaging Special Erect chest ?CT

WCC ?Lipase

Case 3
FBE
Hb 13.9 WCC 15000

Normal biochem. Free gas


Only present in 70-80% perforated ulcers

Case 3 Management
Analgesia Antibiotics N/G tube I/V fluids DVT prophylaxis Theatre

Case 4
54 year old female otherwise well Hysterectomy 15 years previously 24hrs
Colicky abdominal pain Vomiting Distension

O/E not unwell


distended not tender abdomen Hyperactive bowel sounds

Case 4
Haematology
Biochemistry Microbiological Imaging Special

WCC
U&E Supine and erect ?CT -

Case 4

Case 4 Management
Analgesia I/V fluids N/G tube Observation Issues
Signs of strangulation
???Repeat analgesia

Failure to resolve

Laparotomy/laparoscopy

Case 4
Laparotomy if signs of strangulation
CONSTANT PAIN Fever Leucocytosis

Non resolution
CT useful

Beware closed loop obstruction

Case 4b

Case 4b
Diagnosis
LBO

Issues
Pseudo-obstruction Mechanical
Competent ileocaecal valve?
Caecal size

LBO contrast study mechanical V pseudo

Case 4 Management
Mechanical
Stent Hartmanns Colostomy Primary resection

Pseudo
Decompress
Rectal tube Colonoscopy

Pharmacologial
Neostigmine

Case 5
A 43 year old man who is in excellent general health presents with a 2 hour history of severe right loin which radiates to the groin. There is no abdominal tenderness but the patient is visibly distressed.

Case 5
Haematology
Biochemistry Microbiological Imaging Special MSU Plain XR / U/S/ CT KUB

Case 5 Imaging

Management
Analgesia Image Observe Urological intervention if not resolved

Case 6
HISTORY:75 year old man presents with severe epigastric pain radiating to the back.He as no significant past history.
CLINICAL FINDINGS:Normotensive. Tachycardia. Moderate epigastric tenderness. Absent bowel sounds.

Case 6
What is the differential diagnosis?
Pancreatitis Cholecystitis PPU Leaking AAA

Case 6
Haematology
Biochemistry Microbiological Imaging Special

Y
Y N Y N

Case 6 RESULTS
Hb 14 WCC 20.4 urea 15.3 creatinine 0.17 amylase 1435 bilirubin 35 alk phos 250 LDH 250 Ca 1.99

Amylase
Produced in pancreas and salivary glands Normal <200 IU/l Rises with many causes of acute abdominal pain Amylase greater than 1000 IU/l generally considered to be diagnostic of pancreatitis
75% specificity 60% sensitivity

Pancreatitis Trauma to pancreas Perforated ulcer Ischaemic bowel Ectopic pregnancy Pelvic inflammatory disease Abdominal aortic aneurysm Parotitis

Amylase - pancreatitis
Levels rise in first 6-24 hrs Normalise over 5-7 days Can be normal Peak within 48 hrs One piece of information which should be combined with clinical findings and other laboratory findings.

Lipase
Technically more difficult assay but newer assays now making lipase more readily available Originates from pancreas Increases in 4-8 hrs of onset Peaks at 24 hrs Decrease over 8-14 days Increase less frequently associated with non pancreatic abdominal pain

More sensitive and specific than amylase at twice upper limit of normal

Pancreatitis - issues
Establish diagnosis Assess severity
If severe to ICU

Define aetiology
Biliary/alcohol

Support and observe for deterioration

Ultrasound biliary CBD

Pancreatitis - severity scoring


Ranson CRP Organ failure Radiological criteria at 72 hrs CRP >250

Pancreatitis - severity scoring


Ranson
At admission >55 years WCC > 16000 Glucose >200mg/dl LDH > 350 IU/l AST > 250 IU/L During initial 48 hrs Hct decrease >10% BUN increase of >5mgm/l Ca < 8 mg/dl PaO2 < 60mm Hg Base deficit >4mEq/L Fluid sequestration >6 Litres

Computed tomograms (CT) pancreatitis

Case 6 Management
Analgesia I/V fluids
?CVC

IDUC Observe for deterioration


Repeat severity assessment

ICU if severe Consider ERCP Biliary pancreatitis needs cholecystectomy

Approach to abdominal pain THOROUGH HISTORY CAREFUL EXAMINATION


then

SELECT INVESTIGATIONS
appropriate to the patient

OBSERVE if diagnosis not clear

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