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Acute Abdominal Pain in ED : 

Acute Abdominal Pain in ED Collected by Dr.M.Srinivas Naik M.D Ayu. msnaik108@ymail.com

Acute Abdominal Pain, Cause ? A Dilemma for Doctors : 

Acute Abdominal Pain, Cause ? A Dilemma for Doctors It’s not so important to identify a cause of abdominal pain as to recognize a surgical abdomen.

The Epidemiology of Acute Abdominal Pain : 

The Epidemiology of Acute Abdominal Pain 5-10% of all ED visits. Among them, 14-40% patients need surgical intervention. Challenge for emergency physician (EP): 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 : 

Three Subgroups of Patients with Abdominal Pain Who deserve Particular Focus The elderly. The immunocompromised. (e.g. HIV) Women of childbearing age.

The Most Important Concept for EP in Approaching Abdominal Pain : 

The Most Important Concept for EP in Approaching Abdominal Pain To Differentiate Who is the patient of acute abdomen? What are the probable diagnoses you have in mind? Why do you consider such diagnosis? How do you prove it? When will you consult surgeon for operation?

Causes of Acute Abdominal Pain in the ED : 

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 <1 (Brewer et al., 1979; Scand J Gastroenterol)

Acute Abdominal Pain in Patients Under and Over Age 50 : 

Nonspecific abd. pain 39.5 Appendicitis 32.5 Cholecystitis 6.3 Obstruction 2.5 Pancreatitis 1.6 Diverticular disease <0.1 Cancer <0.1 Hernia <0.1 Vascular <0.1 Acute Abdominal Pain in Patients Under and Over Age 50 Cholecystitis 20.5 Nonspecific abd. Pain 15.7 Appendicitis 15.2 Obstruction 12.5 Pancreatitis 7.3 Diverticular disease 5.5 Cancer 4.1 Hernia 3.1 Vascular 2.3 Under 50 (6317 cases), % Over 50 (2406 cases), % (Telfer et al., 1988; Scand J Gastroenterol)

Important Extra-abdominal Causes of Abdominal Pain : 

Important Extra-abdominal Causes of Abdominal Pain 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 Pneumonia Pulmonary embolism Herniated thoracic disc (neuralgia) Genitourinary Testicular torison Renal colic Infectious Strep pharyngitis (more often in children) Rocky Mountain Spotted Fever Monocucleosis Abdominal wall Muscle spasm Muscle hematoma Herpes zoster Emerg Med Clin North Am 1989; 7: 721-740

Three Types of Abdominal Pain : 

Three Types of Abdominal Pain Visceral Pain Somatic (Parietal) Pain Referred Pain

The Physiology and Mechanisms of Abdominal Pain : 

The Physiology and Mechanisms of Abdominal Pain Visceral Pain Within the muscular walls of hollow organs and the capsules of solid organs. Stimulated primarily by stretching, distension, and excessive contractions. Characteristically deep, dull, aching or cramping, and poorly localized. Usually felt in the midline, unaccompanied by tenderness.

The Physiology and Mechanisms of Abdominal Pain : 

The Physiology and Mechanisms of Abdominal Pain Somatic (Parietal) Pain Afferent fibers: from T6 to L1, more localized. Characteristically sharper, aggravated by stimulation of the parietal peritoneum with movement, coughing, or walking. True parietal pain surgical cause of abdominal pain.

The Physiology and Mechanisms of Abdominal Pain : 

The Physiology and Mechanisms of Abdominal Pain Referred Pain Pain felt a site other than that of the primary noxious stimulus. Occurs in an area supplied by the same neurosegment as the involved organ. Most visceral pain is of this type. Usually intense and most often secondary to an inflammatory lesion. Subdiaphragm disorder~shoulder pain Biliary tract disorder~right shoulder pain Small bowel disorder~back pain

High-Yield Historical Questions : 

High-Yield Historical Questions 1. How old are you? (Advanced age mean increased risk) 2. Describe the position, character,and migration of the pain sudden coupled with weakness or fainting, less acute but still abrupt onset ,or begin gradually and maximize slowly Is the pain constant or intermittent? (Constant pain is worse) Have you ever had this before? (No prior episodes is worse) Did the pain start centrally and migrate to the right lower quadrant? (High specificity for appendicitis) 3. Have you noticed specific aggravating or relieving factors? (Eating, defecation or fleatus) 4. Have you ever had abdominal surgery? (Consider obstruction in patients who report previous abdominal surgery)

High-Yield Historical Questions : 

High-Yield Historical Questions 5. Do you have nausea, vomiting, diarrhea or bowel habit change? (D/D true diarrhea, overflow incontinence or tenesmus) 6. Do you have HIV? (Consider occult and unusual infection, 30% mortality of surgical treatment) 7. How much alcohol do you drink per day? (Consider pancreatitis, hepatitis, or cirrhosis) 8. Are you pregnant? (Test for pregnancy-consider ectopic pregnancy, menstrual history, sexual exposure history) 9. Are you taking antibiotics or steroids? (These may mask infection) 10. Do you have a history of vascular or heart disease, hypertension, or atrial fibrillation? (Consider mesenteric ischemia and abdominal aneurysm)

The Important Physical Examination of Acute Abdomen : 

The Important Physical Examination of Acute Abdomen General Facial expression, diaphoresis, pallor, and degree of agitation Vital signs BT > 40 °C or < 35° C  consider abdominal sepsis Tachypnea, bradypnea or tachycardia

The Important Physical Examination of Acute Abdomen : 

The Important Physical Examination of Acute Abdomen Inspection Auscultation Hyperactive BS, hypoactive BS or silent BS Pulsatile bruit Palpation – the most critical step Goal: To define an anatomic area of maximal tenderness. Where is the tender point? Is there muscle guarding or rigidity? Only 21% > 70 y patients with PPU present with epigastric rigidity. Is there rebounding pain? Rectal digital examination

Laboratory Examination : 

Laboratory Examination CBC&DC Serum electrolyte Urinalysis ß-HCG – woman of childbearing age Bilirubin, Alk-p, ALT, AST, G-GT – RUQ pain, jaundice Amylase, lipase – epigastralgia PT, APTT EKG, CK – epigastralgia with aged patient

Indications for Abdominal Plain Films : 

Indications for Abdominal Plain Films Suspected Diagnosis Clinical Findings Perforated viscus* Sudden-onset pain Rigid abdomen Decreased bowel sounds Bowel obstruction* Prior abdominal surgery Abdominal distension Abnormal bowel sounds High risk for obstruction or volvulus Foreign body Mental retardation Psychosis Suspicion of rectal foreign body Ann intern Med 1982; 97: 257-261

Important Imaging Studies for Acute Abdomen : 

Important Imaging Studies for Acute Abdomen Standing CXR and left decubitus KUB (repeated if necessary)-----HOP Ultrasound: for solid organs. CT of abdomen for abscess, free air, vessel, tumor and ischmial bowel. Angiography: Especially in non-diagnostic ischemial bowel.

The Roles and Diagnosis of Ultrasound for EP : 

The Roles and Diagnosis of Ultrasound for EP Diverticulitis (?) Appendicitis (O) Salpingitis (O) Ovarian cyst (O) Ectopic pregnancy (O) Fecal impaction (X) Perforated ulcer (X) Cholecystitis (O) Pancreatitis (O) Pyelonephritis (O) Abdominal aneurysm (O) Renal colic (O) Kang et al., 1989 (Appendicitis) Chern et al., 1997 (Psoas muscle abscess) Yen et al., 1999 (Renal abscess)

Dangerous Mimics : 

Dangerous Mimics True Diagnosis Initial Misdiagnosis Appendicitis Gastroenteritis, PID, UTI Ruptured abdominal Renal colic, diverticulitis, lumbar strain aortic aneurysm Ectopic pregnancy PID, UTI, corpus luteum cyst Diverticulitis Constipation, gastroenteritis, pyelonephritis Perforated viscus PUD, pancreatitis, nonspecific abdominal pain Bowel obstruction Constipation, gastroenteritis, nonspecific abdominal pain Mesenteric ischemia Gastroenteritis, constipation, ileus small bowel obstruction Incarcerated or Ileus or small bowel obstruction strangulated hernia Shock or sepsis from Urosepsis or pneumonia (in elderly) perforation, bleed, abdominal infection

Five Major Categories of Acute Abdomen (BIOPI) : 

Five Major Categories of Acute Abdomen (BIOPI) Bleeding or rupture of vessels or tumor Ischemia or Infarction Obstruction Perforation Inflammation

The Demography of 271 Pitfalls in Acute Abdomen in VGH-Taipei from Sep. 1992 to Jan. 1996 : 

The Demography of 271 Pitfalls in Acute Abdomen in VGH-Taipei from Sep. 1992 to Jan. 1996 Male : Female 212 (78%) : 59 (22%) Age 63.118.7 Year

The Percentage of Pitfalls in Five Categories of Acute Abdomen in VGH-Taipei from Sep. 1992 to Jan. 1996 : 

Inflammation 142 (52%) Perforation 46 (17%) Bleeding or rupture of vessels or tumor 33 (13%) Obstruction 27 (10%) Ischemia or Infarction 17 (6%) Miscellaneous 6 (2%) The Percentage of Pitfalls in Five Categories of Acute Abdomen in VGH-Taipei from Sep. 1992 to Jan. 1996 No (%)

The Common Pitfalls Generated by : 

The Common Pitfalls Generated by Can’t detect abnormalities by history taking & physical examination. Inadequate history and physical examination are the most common sources of error in diagnosing a surgical cause of abdominal pain. Up to 1/3 of presentations are atypical Pain perception and the muscular response to peritoneal irritation may be altered in the elder patients. Misinterpretation of laboratory data. Inadequate information supply from image studies. Insufficient consultation and team work. Misjudgement of timing for operation.

Common Pitfalls in Acute Appendicitis : 

Common Pitfalls in Acute Appendicitis 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. DD: True diarrhea or tenesmus. Rovsing sign, Iliopsoas sign, Obturator sign Murphy sequence appears in only 22% elderly. Perforation rate about 60% (age > 60 Y/O)

Delayed Appendectomy for Appendicitis: Causes and Consequences : 

Delayed Appendectomy for Appendicitis: Causes and Consequences More than 72 h from initial symptoms to operation. Delay in diagnosis: 15/40 (37.5%) was attributed to factors controlled by patient. 25/40 (62.5%) by physician. Perforation (90%), postoperative complications (60%) and length of stay were related to the delay in diagnosis. (Von Titte et al., Am. J. Emerg. Med. 1996; 14: 620-2)

Common Pitfalls in Acute Appendicitis : 

Common Pitfalls in Acute Appendicitis Rupture Appendicitis may present as diffused peritonitis or intestinal obstruction. Caution is advised in evaluating the young, the elderly, pregnant women, and women of childbearing age. The diagnosis is often elusive, and many patients proceed to perforation. When in doubt, admit the patient for observation and sequential physical examination.

Common Pitfalls in Acute Cholecystitis : 

Common Pitfalls in Acute Cholecystitis Not considering symptomatic gallstones in patients with mild or atypical presentations of nausea, dyspepsia, chest pain, mild fever of unknown origins, AMS, no significant abdominal tenderness. Silent abdominal pain in DM, elderly, debilitated, or NSAID or narcotics for pain relieve patients. Failure to recognize acute gallbladder disease in pregnancy.

Common Pitfalls in Acute Cholecystitis : 

Diffuse tenderness and positive rebounding pain without free air in CXR or decubitus KUB may indicate acute cholecystitis with rupture. Failure to obtain timely surgical consultation. Common Pitfalls in Acute Cholecystitis

Common Pitfalls in Abdominal Aortic Aneurysm : 

Common Pitfalls in Abdominal Aortic Aneurysm AAAs are frequently misdiagnosed, especially in the obese, any palpable abdominal pulsation----- suspected of being an AAA, even if a mass cannot be clearly discerned. Back pain or flank pain is common symptom. Peritoneal signs may not be present unless free rupture into the abdominal cavity. EPs May misdiagnoses of AAA, such as renal colic or lumbosacral disk disease.

Common Pitfalls in Abdominal Aortic Aneurysm : 

Common Pitfalls in Abdominal Aortic Aneurysm Sound practice to perform a PE specifically aimed at ruling out an aneurysm in all patients > 50 who present with abdominal or back pain. Not incidental finding, Any back or abdominal pain in the presence of a pulsatile abdominal mass should be considered to be due to an expanding or leaking aneurysm unless there is overwhelming evidence to the contrary.

Common Pitfalls in Abdominal Aortic Aneurysm : 

S/S of Shock AAA rupture (80% without S/S before rupture) KUB: enlarged & unusually calcified mass (65% of patients with symptomatic AAA) Rapid bedside ultrasonography: unstable Pts, 100% sensitivity, obesity or bowel gas may make the study difficulty to perform, rupture cannot be reliably seen CT: stable Pts Early surgical consultation Common Pitfalls in Abdominal Aortic Aneurysm

Common Pitfalls in Bowel Obstruction : 

Common Pitfalls in Bowel Obstruction Delays in diagnosing intestinal obstruction and obtaining surgical consultation result in poor patient outcome. Patient procrastination in seeking medical attention compounds the problem. Thus, the goal of intervention before strangulation may not be achieved in time to avoid catastrophic consequence. Another common pitfall is the failure to replenish lost fluid and electrolytes. Uncorrected losses result in a poor surgical candidate and contribute to increased morbidity and mortality.

Common Pitfalls in Mesenteric Ischemia and Infarction : 

Common Pitfalls in Mesenteric Ischemia and Infarction The most common pitfall in mesenteric ischemia is, ironically, failure to make the diagnosis while the patient is still living or salvageable. Underlying diseases: Af, Severe CHF, RHD, Coagulopathy. CT-Angiography: 82% sensitivity for mesenteric infarction vs 87.5% in angiography.(Radiology 197: 79-82, 1995)

Common Pitfalls in Mesenteric Ischemia and Infarction : 

Common Pitfalls in Mesenteric Ischemia and Infarction Perhaps the greatest pitfall is reluctance to obtain angiography. Early radiographic consultation and refusal to “wait until morning” are essential to a good outcome.

Emergency Department Evaluation of Acute Abdomen : 

Emergency Department Evaluation of Acute Abdomen History and PE repeatedly. Menstruation history (LMP, ovulation, sexual exposure), Rapid pregnancy test: women of childbearing age. Lab: CBC, liver panel, EKG for elderly. Plain KUB: helpful in obstruction; 40% patients invisible free air. Ultrasound and CT scan: aneurysm, cholelithiasis, ectopic pregnancy, and ureterolithiasis.

Emergency Department Management of Acute Abdomen : 

Emergency Department Management of Acute Abdomen IV volume replacement and NG decompression Antibiotics: indicated if infection is suspected. Narcotic analgesia (?) Timing (?) Pro: Humane; permit a more accurate history and PE. Morphine (2-5 mg IV) Con: Surgeon is hostile to this approach, consultation immediately.

Special Consideration in Evaluation of Acute Abdomen in Elderly : 

History Hard to take due to hearing loss, dementia, old CVA. More patience and diligence. Consulting primary care physician, families, and reviewing medical records. The elderly patient with abdominal pain may have a potentially lethal process despite a nonspecific or even relatively benign examination and normal laboratory studies Special Consideration in Evaluation of Acute Abdomen in Elderly

Slide 40: 

Special Consideration in Evaluation of Acute Abdomen in Elderly Physical Examination To examine the entire patient. Tachycardia or tachypnea pain, early sepsis, hypoxia, volume depletion, acidosis and hemorrhage. Auscultation: bruits and bowel sound. Palpation: pulsatile mass Check for hernia. All have digital examination.

Slide 41: 

Special Consideration in Evaluation of Acute Abdomen in Elderly Laboratory Studies EKG for upper abdominal pain, nausea, or vomiting elderly. WBC: commonly normal, should not be used as a criterion of infection. Arterial blood gas.

Special Consideration in Management of Acute Abdomen in Elderly : 

Disposition Surgical consultation and admission: Persistent abdominal pain > 6 h. ED observation: Several hours for unclear diagnosis Discharge patients: A follow-up appointment within 12 to 24 h must be arrange. Family members instruction: Revisit immediately for any worsening of pain or change in status. Special Consideration in Management of Acute Abdomen in Elderly

The Identification of High Risk Patients with Acute Abdomen : 

The Identification of High Risk Patients with Acute Abdomen Elderly > 65 y S/S of Shock Peritoneal sign (+) silent bowel sound Pulsatile mass Refractory pain post Tx Elevation of Band WBC Fever cause ? Or BTI Hypothermia Acute renal failure Not post-surgical obstruction

Sample Discharge Instructions for the Patient with Abdominal Pain : 

Sample Discharge Instructions for the Patient with Abdominal Pain Pain that gets worse or moves to just one spot. Pain that gets worse if you cough or sneeze. Pain that does not get better in 24 hours. Inability to keep down liquids--especially if you are making less urine. Fainting.

Sample Discharge Instructions for the Patient with Abdominal Pain : 

Sample Discharge Instructions for the Patient with Abdominal Pain Blood in the vomit or stool. High fever or shaking chills. Swelling of the abdomen. Any new or worsening problem. Remember that the ED is open 24 hours a day, every day, and we are always glad to see you.

Than Q : 

Than Q