Abdominal & scrotal pain

Transcription

1 Abdominal & scrotal pain Junior Teach Emergency Department 1 Created by SR Bruijns 03/11/2010

2 Objectives Understanding of, and emergency management of Acute abdominal pain Undifferentiated abdominal pain Scrotal pain 2

3 Acute abdominal pain- causes Solid organs Hollow organs Non-organs Vascular Urogenital 3

4 Acute abdominal pain- surgical 4 Pancreatitis, Cholecystitis/ cholangitis/ biliary colic, Bowel obstruction, Diverticular disease, Viscus perforation, Acute appendicitis, (UK, Chröns) Hernia, Ischaemic colitis/ mesenteric ischaemia, Aortic aneurism with dissection or rupture, Renal calculi Testicular tortion

5 Acute abdominal pain- medical 5 Lower lobe pneumonia, DKA, acute intermittent porphyria, adrenal crisis Hepatitis Haematemesis and peptic ulcer disease without perforation, IBS, coeliac disease, (UK, Chröns) Constipation Gastro-enteritis Back ache, hip pain Acute MI Sickle cell crisis Pyelonephritis

6 Acute abdominal pain- approach Priorities in the ED are the same A to E approach Analgesia Formulating a differential diagnosis Investigations Specific management 6

7 Acute abdominal pain- analgesia Sadly undertreated for no apparent reason Pain score <4 less likely to require any analgesia >7 more likely to require IV analgesia No contra-indication to oral analgesia if NBM Analgesia not to be withheld if needed Beware a false sense of security What about buscopan? 7

8 Acute abdominal pain- diagnosis History is cornerstone (including previous admissions) Examination tips Pain location Epigastric Umbilical Suprapubic Right upper quadrant Right lower quadrant (left?) Percussion vs. rebound tenderness 8

9 Acute abdominal pain- diagnosis 9 Referred pain Liver/ billiary tract Pancreas/ gastric Cardiac Typical course: Appendicitis Typical signs Murphy's McBurney s Courvoisier's Rovsing's sign

10 Acute abdominal pain- Labs Directed investigations is essential Typical tests requested FBC (infection/ inflammation) Renal (electrolyte disturbance/ hydration/ function) Blood gas (acid- base/ lactate/ vso 2 ) LFT (function) Amylase (pancreas- not specific though) Pregnancy test 10

11 Acute abdominal pain- radiology Most patients do NOT need plain film radiology Abdominal plain film for: Acute abdominal pain: if bowel obstruction suspected Oesophageal foreign body suspected (depending on local protocol for metal detector) Sharp/poisonous foreign body suspected Erect chest film for: Hollow viscus perforation 11

12 Undifferentiated abdominal pain Only 9% of abdominal pain seen in GP practice is referred to hospital Around 30 to 46% of ED admissions will have no identifiable cause at the time of disposal Around 30% of these patients will require admission 23% of discharged patients (from either ED or hospital) will experience recurrence of symptoms within 5 years And in around 80% of this recurrent group a diagnosis will eventually be made Around 10% will develop cancer Average age is 20, with a slight female skew 12

13 Undifferentiated abdominal pain The commonest diagnoses made eventually is: Viral Enteritis / Infections Mittleschmerz or Mid-Cycle Pain/ Mentrual Pain Irritable Bowel Syndrome/ Intestinal Obstruction Abdominal Aortic Aneurysm Abdominal Migraine Non- Specific Mesenteric Lymphadenitis 13

14 Undifferentiated abdominal pain Retroperitoneal pathology more difficult to diagnose Serious causes of undifferentiated abdominal pain All ages Bowel obstruction Elderly (all below may present with a SOFT abdomen) AAA Mesenteric ischaemia Ischaemic collitis 14

15 Scrotal pain- Torsion of testicle Incidence: <3% in the over 30 age group Course: acute onset Examination: Testicle is firm, tender to palpation and often riding high. Swelling and loss of the cremasteric reflex may be present High index of suspicion- early referral for exploration Time from onset to pain to surgery should be less than 6 hours in order to salvage %. Investigations should not delay urgent surgery 15

16 Scrotal pain- epididymo- orchitis Painful swollen testicle and scrotum with more gradual onset Often has u-dip positive Sexually active: gonococcal/ chlamidia Ceftriaxone and doxycycline Young and elderly: related to urological causes (coliforms) Ciprofloxacin All patients should be referred to GU clinic 16

17 Scrotal pain- trauma Typical findings on surgery: scrotal wall haematomas tunica vaginalis haematoma (haematocele) intratesticular haematoma testicular rupture this is the most serious injury Early surgical review and exploration is often recommended 17

18 Questions Abdominal and scrotal pain 18

19 Summary 19 Acute abdominal pain Approach to differential diagnosis Priorities are the same: ABCDE Early analgesia Directed investigations Undifferentiated abdominal pain Awareness of the commonest serious pathology missed Scrotal pain Time critical management of testicular torsion Epididymo-orchitis: the STD connection Testicular trauma often needs surgical review or at least follow up