THE APPROACH TO THE PATIENT WITH ACUTE ABDOMINAL PAIN

Transcription

1 THE APPROACH TO THE PATIENT WITH ACUTE ABDOMINAL PAIN Nick D Ardenne Sheba Medical Center, Internal Medicine Department St. George s University of London

2 MANAGEMENT IN THE ED ABCs of Resuscitation AIRWAY: Consider definitive airway to prevent aspiration of blood BREATHING Supplemental Oxygen Continuous pulse oximetry

3 MANAGEMENT IN ED CIRCULATION Cardiac monitoring Volume replacement Crystalloids 2 large-bore intravenous lines (18g or larger) Blood Products General guidelines for transfusion Active bleeding Failure to improve perfusion and vital signs after the infusion of 2 L of crystalloid Lower threshold in the elderly NOT BASED ON INITIAL HEMATOCRIT ALONE Coagulation factors replaced as needed Urinary catheter with hypotension to monitor output

4 HISTORY Once the patient is stable. Presenting complaint will lead to direction of questions FEMALES PREGNANT UNTIL PROVEN OTHERWISE. Dysphagia Is there pain? Is there a feeling of obstruction? Is food regurgitated? If so, how long after swallowing? Bowel Function How often? What is the consistency? Is there any urgency or faecal incontinence? Is defaecation painful (dyschezia)? Is there tenesmus? Is there blood or mucus (call it slime to the patient) in the stool? If there is blood is it always there or just occasionally? Is it mixed in with the stool or separate and splashes the pan? This will help indicate if the bleeding is from low down or higher up. What is the colour of the motion?

5 HISTORY GU symptoms Dysuria, frequency, urgency, hematuria, incontinence Gynecological symptoms Vaginal discharge, vaginal bleeding, Last menses, sexual activity, contraception, h/o PID or STDs, h/o ovarian cysts, past gynecological surgeries, pregnancies Vascular h/o MI, heart disease, a-fib, anticoagulation, CHF, PVD, Fam Hx of AAA

6 HISTORY Is appetite good? Ask about smoking and alcohol consumption. Drugs If there is proctitis, a delicate enquiry as to the person's sexual orientation may be required in both males and females. Does the patient eat a normal diet? Changes in eating habits may have resulted from the symptoms. Note family history. Ask about foreign travel and living abroad. Travellers' diarrhoea is just one possibility. Many other exotic diseases can be acquired.

7 WHAT KIND OF PAIN IS IT? Visceral Involves hollow or solid organs; midline pain due to bilateral innervation Steady ache or vague discomfort to excruciating or colicky pain Poorly localized Parietal Involves parietal peritoneum Localized pain Causes tenderness and guarding which progress to rigidity and rebound as peritonitis develops Referred Produces symptoms not signs Based on developmental embryology

8 MOVING ON TO THE PHYSICAL EXAM General Pallor, diaphoresis, general appearance, level of distress or discomfort, is the patient lying still or moving around in the bed Vital Signs Orthostatic VS when volume depletion is suspected Cardiac Arrhythmias Lungs Pneumonia Back CVA tenderness Pelvic exam CMT Vaginal discharge Culture Adenexal mass or fullness

9 ABDOMINAL EXAM Inspection: Hands- divided into nails (leukonychia, koilonychia, clubbing) and palms (palmer erythema, Dupuytren s) Hepatic flap Arms- Bruising, muscle wasting, excoriations Axillae- lymphadenopathy, acanthosis nigricans Face- Eyes (jaundice, anaemia, xanthelasma), Mouth (angular stomatitis, gums, breath, tongue) Chest/Neck- Troisier s Sign, gynacomastia Abdomen- scars, distension, pulsations, caput medusa, peristaltic waves, striae, stomas- many types, grey-turner sign etc

10 PALPATION Nipples to knees Supine patient, one pillow Squat or raise bed Ask for discomfort Light and deep palpation Aorta, Liver, Spleen, kidneys. Hernia Offices. Should be examined thoroughly Especially looking for strangulation

11 PERCUSSION & AUSCULTATION Determine the boarders of the liver. Percussion of the bladder to determine volume can be useful Ascites Shifting dullness Fluid thrill Auscultation Bowel sounds Bruits Venous hums

12 ABDOMINAL FINDINGS Guarding Voluntary Contraction of abdominal musculature in anticipation of palpation Diminish by having patient flex knees Involuntary Reflex spasm of abdominal muscles aka: rigidity Suggests peritoneal irritation Rebound Present in 1 of 4 patients without peritonitis Pain referred to the point of maximum tenderness when palpating an adjacent quadrant is suggestive of peritonitis Rovsing s sign in appendicitis Rectal exam Little evidence that tenderness adds any useful information beyond abdominal examination Gross blood or melena indicates a GIB

13 DIFFERENTIAL DIAGNOSIS Use history and physical exam to narrow it down Rule out life-threatening pathology Majority of the time you will send the patient home with a diagnosis of nonspecific abdominal pain. 90% will be better or asymptomatic at 2-3 weeks

14 DIFFERENTIAL DIAGNOSIS G a s t r i t i s, i l e i t i s, c o l i t i s, e s o p h a g i t i s U l c e r s : g a s t r i c, p e p t i c, e s o p h a g e a l B i l i a r y d i s e a s e : c h o l e l i t h i a s i s, c h o l e c ys t i t i s H e p a t i t i s, p a n c r e a t i t i s, C h o l a n g i t i s S p l e n i c i n f a r c t, S p l e n i c r u p t u r e P a n c r e a t i c p s u e d o c ys t H o l l o w v i s c o u s p e r f o r a t i o n B o w e l o b s t r u c t i o n, v o l v u l u s D i v e r t i c u l i t i s A p p e n d i c i t i s O v a r i a n c ys t O v a r i a n t o r s i o n H e r n i a s : i n c a r c e r a t e d, s t r a n g u l a t e d K i d n e y s t o n e s P ye l o n e p h r i t i s H yd r o n e p h r o s i s I n f l a m m a t o r y b o w e l d i s e a s e : c r o h n s, U C G a s t r o e n t e r i t i s, e n t e r o c o l i t i s p s e u d o m e m b r a n o u s c o l i t i s, i s c h e m i a c o l i t i s T u m o r s : c a r c i n o m a s, l i p o m a s M e c k e l s d i v e r t i c u l u m T e s t i c u l a r t o r s i o n E p i d i d y m i t i s, p r o s t a t i t i s, o r c h i t i s, c ys t i t i s C o n s t i p a t i o n A b d o m i n a l a o r t i c a n e u r ys m, r u p t u r e s a n e u r ys m A o r t i c d i s s e c t i o n M e s e n t e r i c i s c h e m i a O r g a n o m e g a l y H e m i l i t h i n f e s t a t i o n P o r p h y r i a s A C S P n e u m o n i a A b d o m i n a l w a l l s yn d r o m e s : m u s c l e s t r a i n, h e m a t o m a s, t r a u m a, N e u r o p a t h i c c a u s e s : r a d i c u l a r p a i n N o n - s p e c i f i c a b d o m i n a l p a i n G r o u p A b e t a - h e m o l y t i c s t r e p t o c o c c a l p h a r yn g i t i s R o c k y M o u n t a i n S p o t t e d F e v e r T o x i c S h o c k S yn d r o m e B l a c k w i d o w e n v e n o m a t i o n D r u g s : c o c a i n e i n d u c e d - i s c h e m i a, e r yt h r o m y c i n, t e t r a c y c l i n e s, N S A I D s M e r c u r y s a l t s A c u t e i n o r g a n i c l e a d p o i s o n i n g E l e c t r i c a l i n j u r y O p i o i d w i t h d r a w a l M u s h r o o m t o x i c i t y A G A : D K A, A K A A d r e n a l c r i s i s T h yr o i d s t o r m H yp o - and h yp e r c a l c e m i a S i c k l e c e l l c r i s i s V a s c u l i t i s I r r i t a b l e b o w e l s yn d r o m e E c t o p i c p r e g n a n c y P I D U r i n a r y r e t e n t i o n I l e u s, O g i l v i e s yn d r o m e

15 WHAT KIND OF IMAGING SHOULD YOU ORDER? Acute Abdominal series 3 views: upright chest, flat view of abdomen, upright view of abdomen Limited utility: restrict use to patients with suspected obstruction or free air/ perforation Ultrasound Good for diagnosing AAA but not ruptured AAA Good for pelvic pathology CT abdomen/pelvis Noncontrast for free air, renal colic, ruptured AAA, (bowel obstruction) Contrast study for abscess, infection, inflammation, unknown cause MRI Most often used when unable to obtain CT due to contrast issue

16 CASE #1 72 yo M with hx of CAD on aspirin and Plavix with several days of dull upper abd pain and now with worsening pain in entire abdomen today. Some relief with food until today, now worse after eating lunch. Med Hx: CAD, HTN, CHF Surg Hx: appendectomy Meds: Aspirin, Plavix, Metoprolol, Lasix Social hx: smokes 1ppd, denies alcohol or drug use, lives alone

17 CASE #1 EXAM T: 99.1, HR: 70, BP: 90/45, R: 22, O2sat: 96% room air General: elderly, thin male, ill-appearing CV: normal Lungs: clear Abd: mildly distended and diffusely tender to palpation, +rebound and guarding Rectal: blood-streaked heme + brown stool What is the ddx & management?

18 PEPTIC ULCER DISEASE Risk Factors H. pylori NSAIDs Smoking Hereditary Clinical Features Burning epigastric pain Sharp, dull, achy, or empty or hungry feeling Relieved by milk, food, or antacids Awakens the patient at night Nausea, retrosternal pain and belching are NOT related to PUD Atypical presentations in the elderly Physical Findings Epigastric tenderness Severe, generalized pain may indicate perforation with peritonitis Occult or gross blood per rectum or NGT if bleeding

19 PEPTIC ULCER DISEASE Diagnosis Rectal exam for occult blood CBC Anemia from chronic blood loss LFTs Evaluate for GB, liver and pancreatic disease Definitive diagnosis is by EGD or upper GI barium study Acute Abdomen Series Treatment Empiric treatment Avoid tobacco, NSAIDs, aspirin PPI or H2 blocker Immediate referral to GI if: >45 years Weight loss Long h/o symptoms Anemia Persistent anorexia or vomiting Early satiety GIB

20 Here is the patient s x-ray.

21 PERFORATED PEPTIC ULCER Abrupt onset of severe epigastric pain followed by peritonitis IV, oxygen, monitor CBC, T&C, Lipase Acute abdominal x-ray series Lack of free air does NOT rule out perforation Broad-spectrum antibiotics Surgical consultation

22 CASE #2 35 yo healthy F to ED c/o nausea and vomiting since yesterday along with generalized abdominal pain. No fevers/chills, +anorexia. Last stool 2 days ago. Med Hx: negative Surg Hx: s/p hysterectomy (for fibroids) Meds: none, Allergies: NKDA Social Hx: denies alcohol, tobacco or drug use Family Hx: non-contributory

23 CASE #2 EXAM T: 36.9, HR: 100, BP: 130/85, R: 22, O2 sat: 97% room air General: mildly obese female, vomiting CV: normal Lungs: clear Abd: moderately distended, hypoactive bowel sounds, no rebound or guarding What is your differential and what next?

24 ERECT AXR

25 BOWEL OBSTRUCTION Mechanical or nonmechanical causes #1 - Adhesions from previous surgery #2 - Groin hernia incarceration Clinical Features Crampy, intermittent pain Periumbilical or diffuse Inability to have BM or flatus N/V Abdominal bloating Sensation of fullness, anorexia Physical Findings Distention Tympany Absent, high pitched or tinkling bowel sound or rushes Abdominal tenderness: diffuse, localized, or minimal

26 BOWEL OBSTRUCTION Diagnosis CBC and electrolytes electrolyte abnormalities WBC >20,000 suggests bowel necrosis, abscess or peritonitis Abdominal x-ray series Flat, upright, and chest x-ray Air-fluid levels, dilated loops of bowel Lack of gas in distal bowel and rectum CT scan Identify cause of obstruction Delineate partial from complete obstruction Treatment Fluid resuscitation NGT Analgesia Surgical consult Hospital observation for ileus OR for complete obstruction Peri-operative antibiotics

27 CASE #6 48 yo obese F with one day hx of upper abd pain after eating, does not radiate, is intermittent cramping pain, +N/V, no diarrhea, subjective fevers. No prior similar symptoms. Med hx: denies Surg hx: denies No meds or allergies Social hx: no alcohol, tobacco or drug use

28 CASE #3 EXAM T: 100.4, HR: 96, BP: 135/76, R: 18, O2 sat: 100% room air General: moderately obese, no acute distress CV: normal Lungs: clear Abd: moderately TTP RUQ, non-distended, normal bowel sounds

29 Case #3..help

30 CHOLECYSTITIS Clinical Features RUQ or epigastric pain Radiation to the back or shoulders Dull and achy sharp and localized Pain lasting longer than 6 hours N/V/anorexia Fever, chills Physical Findings Epigastric or RUQ pain Murphy s sign Patient appears ill Peritoneal signs suggest perforation

31 CHOLECYSTITIS Diagnosis CBC, LFTs, Lipase Elevated alkaline phosphatase Elevated lipase suggests gallstone pancreatitis RUQ US Thicken gallbladder wall Pericholecystic fluid Gallstones or sludge Sonographic murphy sign HIDA scan more sensitive & specific than US Treatment Surgical consult IV fluids Correct electrolyte abnormalities Analgesia Antibiotics Ceftriaxone 1 gram IV If septic, broaden coverage to zosyn, unasyn, imipenem or add anaerobic coverage to ceftriaxone NGT if intractable vomiting H&P and laboratory findings have a poor predictive value if you suspect it, get the US

32 Just a few more to go. Ovarian torsion Testicular torsion GI bleeding Abd pain in the Elderly

33 ABDOMINAL PAIN IN THE ELDERLY Mortality rate for abdominal pain in the elderly is 11-14% Perception of pain is altered Altered reporting of pain: stoicism, fear, communication problems Most common causes: Cholecystitis Appendicitis Bowel obstruction Diverticulitis Perforated peptic ulcer Don t miss these: AAA, ruptured AAA Mesenteric ischemia Myocardial ischemia Aortic dissection

34 ABDOMINAL PAIN IN THE ELDERLY Appendicitis do not exclude it because of prolonged symptoms. Only 20% will have fever, N/V, RLQ pain and WBC Acute cholecystitis most common surgical emergency in the elderly. Perforated peptic ulcer only 50% report a sudden onset of pain. In one series, missed diagnosis of PPU was leading cause of death. Mesenteric ischemia we make the diagnosis only 25% of the time. Early diagnosis improves chances of survival. Overall survival is 30%. Increased frequency of abdominal aortic aneurysms AAA may look like renal colic in elderly patients

35 MESENTERIC ISCHEMIA Consider this diagnosis in all elderly patients with risk factors Atrial fibrillation, recent MI Atherosclerosis, CHF, digoxin therapy Hypercoagulability, prior DVT, liver disease Severe pain, often refractory to analgesics Relatively normal abdominal exam Embolic source: sudden onset (more gradual if thrombosis) Nausea, vomiting and anorexia are common 50% will have diarrhea Eventually stools will be guiaic-positive Metabolic acidosis and extreme leukocytosis when advanced disease is present (bowel necrosis) Diagnosis requires mesenteric angiography or CT angiography

36 ABDOMINAL AORTIC ANEURYSM Risk increases with age, women >70, men >55 Abdominal pain in 70-80% (not back pain!) Back pain in 50% Sudden onset of significant pain Atypical locations of pain: hips, inguinal area, external genitalia Syncope can occur Hypotension may be present Palpation of a tender, enlarged aorta on exam is an important finding May present with hematuria Suspect it in any older patient with back, flank or abdominal pain especially with a renal colic presentation Ultrasound can reveal the presence of a AAA but is not helpful for rupture. CT abd/pelvis without contrast for stable patients. High suspicion in an unstable patient requires surgical consult and emergent surgery.

37 GI BLEEDING Upper Proximal to Ligament of Treitz Peptic ulcer disease most common Erosive gastritis Esophagitis Esophageal and gastric varices Mallory-Weiss tear Lower Hemorrhoids most common Diverticulosis Angiodysplasia

38 LABS AND IMAGING Type and crossmatch: Most important! Other studies: CBC, BUN, creatinine, electrolyte, coagulation studies, LFTs Initial Hct often will not reflect the actual amount of blood loss Abdominal and chest x-rays of limited value for source of bleed Nasogastric (NG) tube Gastric lavage Angiography Bleeding scan Endoscopy/colonoscopy

39 ABDOMINAL PAIN CLINICAL PEARLS Significant abdominal tenderness should never be attributed to gastroenteritis Incidence of gastroenteritis in the elderly is very low Always perform genital examinations when lower abdominal pain is present in males and females, in young and old In older patients with renal colic symptoms, exclude AAA Severe pain should be taken as an indicator of serious disease Pain awakening the patient from sleep should always be considered signficant Sudden, severe pain suggests serious disease Pain almost always precedes vomiting in surgical causes; converse is true for most gastroenteritis and NSAP Acute cholecystitis is the most common surgical emerg in the elderly A lack of free air on a chest xray does NOT rule out perforation Signs and symptoms of PUD, gastritis, reflux and nonspecific dyspepsia have significant overlap If the pain of biliary colic lasts more than 6 hours, suspect early cholecystitis.