Acute abdomen for EP
Prasit Wuthisuthimethawee Department of Emergency Medicine Prince of Songkla University
Male 34 years old No underlying dis.
Check up at GP During took blood examination abd pain & syncope
Objectives
Abdominal pain pathway
Critical points for assessing abdominal pain
Epidemiology
4-10 % of all emergency department visit 50 % have clearly diagnosis
15-30% require surgical procedure esp. elderly Acute appendicitis is the most common
Epidemiology
Unique in Pediatric and Elderly
Acute abdominal pain among elderly patients
3 years, 831 cases Non-specific 22-24% Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%) less peritoneal signs
Laurell H, Hansson LE, Gunnarsson U. Gerontology. 2006;52(6): 339-44
Emergency department diagnosis of acute abdominal pain in elderly patients
1 year retrospective review, 378 cases Non-specific (35.2%), acute gastritis/gastroenteritis (10.6%), and biliary tract dis. (8.2%)
Non-specific; 90% dissolved, 5.4% Sx.
Othong R, Wuthisuthimethawee P, Vasinanukorn P Songkla Med J vol. 28 No 1 Jan-Feb 2010
Predictor for an intensive care or specific treatment in the elderly patients with acute abdominal pain
1 year retrospective review, 386 cases Dyspepsia (21.8%), non-specific (17.6%) and acute gastroenteritis (8.8%) Male, BT < 38, PR >90, abnormal abd contour, and Localize tenderness or guarding
Worapraatya P, Wuthisuthimethawee P, Vasinanukorn P
Pain pathway
Abdominal pain pathway
3 type; visceral, somatic, and referred pain
Abdominal pain pathway
Visceral pain
Wall or capsule of solid organs/bowel Midline, dull, archy and cramping pain
Autonomic; pallor, diaphoresis, nausea, and vomiting
Abdominal pain pathway
Somatic pain
Parietal peritoneum
Sharp, discrete, and localized
Tenderness, guarding, and rebound
Abdominal pain pathway
Somatic pain
Abdominal pain pathway
Referred pain
Cutaneous site distant from the diseased organ Diaphragm C3-5: neck and shoulder pain
Abdominal pain pathway
Referred pain
Critical points for assessing abdominal pain
Life threatening conditions
Vascular disease Acute myocardial infarction Ruptured ectopic pregnancy Perforated visceral organs
Life threatening conditions
Intestinal obstruction Acute hemorrhagic pancreatitis Esophageal rupture
Aim
Surgical or Non-surgical
Physical examination
Accuracy 55-65% with final diagnosis Reexamination and observation Technique !
Physical examination
Bowel sound Little diagnostic value
Physical examination
Do not forget PR
Physical examination
Analgesic ?
Analgesia on abdominal examination
Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain
Analgesia is safe in abdominal pain
Br J Surg. 2003 Jan;90(1):5-9
Analgesia on abdominal examination
Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial Prospective, double-blind clinical trial
Reexam in 60 minutes
No differences with respect to changes in physical examination or diagnostic accuracy
J Am Coll Surg. 2003 Jan;196(1):18-31
Analgesia on abdominal examination
Analgesia in patients with acute abdominal pain
Opioid improve patients comfort and does not retard decision to treat
Cochrane Database Syst Rev. 2007 Jul 18;(3): CD005660
Analgesia on abdominal examination
Efficacy and impact of intravenous morphine before surgical consultation in children with right lower quadrant pain suggestive of appendicitis: a randomized controlled trial
Randomized double-blind placebo-controlled trial
8-18 years old, 90 patients
Morphine did not delay surgical decision, not more effective than placebo to diminishing pain
Ann Emerg Med. 2007 Oct;50(4):371-8. Epub 2007 Jun 27
Medication on abdominal examination
Buscopan ?
Clinical assessment Reassessment
Clinical assessment
Patients quantification of pain is unreliable
Clinical assessment Corticosteroids and immunosuppressants
Clinical assessment Chronic dis.: CRF
Clinical assessment Fever ?
Clinical assessment Prior abdominal surgery
Clinical assessment Hernia Genitalia
Clinical assessment
Peripheral pulse
Clinical assessment
Menstrual history Urine pregnancy test
Clinical assessment
WBC 30% in abdominal pain of unknown etiology
Clinical assessment
20% of pancreatitis have normal amylase
Clinical assessment
20% of pancreatitis have normal amylase
Clinical assessment
Lactase and mesenteric ischemia
100% sensitive and 42% specific
Clinical assessment
Film acute abdomen 10-38% confirm diagnosis
Gallstone Ileus
Portal vein gas
Clinical assessment
USG and CT scan Angiogram Tech99m RBC scan
Clinical assessment
Myocardial infarction, pneumonia, or pulmonary embolus can present as abdominal pain
Clinical assessment Psychiatric disorder The last diagnosis
Mamagement
Bowel rest +/- decompression IV resuscitation with correct electrolyte Antiemesis ? Analgesia ? Antibiotic ? Pre-op in surgical case
Uncertain Diagnosis
Observation
Review the cause
Consultation
Uncertain Diagnosis
When in doubt, dont send them out!
Copes Early Diagnosis of the Acute Abdomen, 20th ed.. New York, Oxford University Press, 2000.
Case 1
Male 34 years old No underlying dis.
Check up at GP
During took blood examination abd pain & syncope
Case 1
At ER Sweating, looked pale V/S BP 95/60 P 112 RR 26 Abd: tenderness at RLQ, guarding ?
What is diagnosis ?
Case 2
Female 53 years old Underlying HT LLQ abdominal pain for 1 day V/S BP 140/80 P 90 RR 24
Case 2
Abd: LLQ pain, guarding ? CVA: tenderness Lt.
UA: microscopic hematuria
Diclofenac improved
Recurrent 2 times in 3 days
What is diagnosis ?
Hematuria may be seen in abdominal aortic aneurysm (30%)
Case 3
Female 47 years old No known underlying dis. RLQ abdominal pain for 1 day
V/S BP 130/80 P 82 RR 22
Case 3
Abd: RLQ pain, guarding ?, CVA: not tender
CBC: leukocytosis UA: WNL
What is diagnosis ?
Clinical assessment
Special sign Iliopsoas and Obturator < 10% in appendicitis
Special sign Fist Percussion
Special sign Rovsings Sign Only 5% of patients
High-Yield historical questions
How old are you ? Which came first-pain or vomiting ? How long have you had the pain ? Have you ever had abdominal surgery ?
High-Yield historical questions
Is the pain constant or intermittent ? Have you ever had this before ? Do you have a history of cancer diverticulosis ? Do you have HIV ?
High-Yield historical questions
How much alcohol do you drink per day ? Are you pregnant ? Are you taking antibiotic or steroid ? Did the pain start centrally and migrate ?
Do you have a history of CAD, HT, AF ?
Etiology and clinical course of abdominal pain In senior patients; a prospective, multicenter study
3 years, 831 cases
Non-specific 22-24% Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%) less peritoneal signs
Lewis LM, Banet GA, Blenda M, et al. J Gerontol A Biol Sci Med Sci. 2005
