Abdo Pain rules & regulations. Mark Hartnell 2010

Transcription

1 Abdo Pain rules & regulations Mark Hartnell 2010

2 Aims Simple rules which might help in patients with abdominal pain Talk about some myths and realities Discuss some practical how to s in day to day treatment

3 What is an acute abdomen? Mechanical Inflammatory Vascular Also cancer sometimes Congenital trauma

4 Patient demographics 3 big considerations: OLD (?50 for this purpose) >65 twice chance of needing surgery YOUNG Congenital and more appendicitis FEMALE (child bearing age) Pregnant TPO, NSAP more likely

5 Symptoms Location of visceral pain: The only reason we ever learnt embryology Foregut = epigastric Midgut = periumbilical Hindgut = suprapubic Parietal / peritoneal pain localises

6 Associated symptoms Vomiting before or after pain onset is important, after pain more likely surgical Constipation does not help unless absolute Helpful features diarrhoea, jaundice, haematuria, haematemesis, malaena

7 High yield questions More serious older age, less than 48H, constant pain, no previous episode Past abdominal surgery & link to BO # serious PHx of: ca, diverticulosis, pancreatitis, kidney failure, gallstones, IBD Patients on AB s, steroids: masking Starting centrally, migrating to RIF highly specific for appendicitis

8 More High Yield questions Hx of valvular heart disease, IHD, AF, HTN correlates with risk of gut ischaemia Alcohol intake: cirrhosis, hepatitis, pancreatitis HIV: drug-related pacreatitis, infections

9 Signs - Vital signs Tachycardia and hypotension Hypovolaemia and sepsis Tachypnoea Acidosis (necrosis, inflammation) Hypoxaemia Response to pain Temperature Intra-abdominal infections

10 Signs - Vital signs Many, many myths and pitfalls: Hypothermia in septic elderly patients Tachycardia may not feature early in hypovolaemia DO NOT assume lack of vital sign response means pain not genuine THERE IS NO CORRELATION

11 Examination - abdo LOOK first, expose and position GO VERY VERY VERY SLOWLY Start away from the painful area Re-examine: eg. after analgesia Psoas sign has good PPV for appendicitis? Pt on side, extend hip Absence of severe RLQ pain almost rules out appendicitis

12 Rectal exam Looking fissures, fistula, external piles Not very useful overall bleeding, prostatitis, perianal disease Might find pale stools, blood, malaena, rectal mass Proven NOT to be useful in appendicitis

13 Investigations - bloods HARTNELL ABDO BLOOD RULE: DO AN FBE, U&E, LFT AND LIPASE OR NOTHING (vast majority!!!) Pancreatitis in particular can surprise Clotting very rarely useful maybe in suspected significant hepatic disease Amylase has no value if lipase available Lactate some use in ischaemia, old patients ONLY THE SICK ONES FOR SERIAL CHECKS

14 Xrays CXR is low radiation, quite sensitive for free gas, rules out pneumonia Abdominal films can find: Foreign bodies, obstruction, volvulus Are NOT a very good test in obstruction Should NOT be used for undifferentiated pain Large radiation dose cf to CXR In some situations going straight to CT better

15 Xrays A better test in possible obstruction if adhesion related Much more likely to definitively manage based on the Xray alone Can ASK a surgical question prior to ordering

16 ultrasound RUQ pain (stones, cholecystitis, CBD block) Obstructive uropathy (eg. pregnant) Not stones but complications, no radiation AAA determines aortic size, not leak Normal sized aorta does not leak or rupture! Some role in abdominal mass evaluation Children (again, no radiation) finds: pyloric stenosis, intussusception, appendicitis Evaluating hernias Looking for collections (good alternative to CT)

17 CT Non-contrast image of choice renal colic Useful in pancreatitis (severity, some planning of surg Mx, talk to them first!) Intra-abdominal sepsis and trauma Pre-operative most patients except where too unstable

18 Management symptom control Never withhold analgesia to avoid masking the diagnosis IF ANYTHING IT HELPS! Consider NSAID s ONLY when treating suspected renal colic (& maybe biliary) Does increase bleeding times Don t give buscopan except for mild colicky pain (or pt.s you don t like)

19 Antinausea agents Undifferentiated nausea reasonable to use metoclopramide, avoid in young, give slowly, works quickly if at all move on Remember promethazine as an option Ondansetron / granisetron next

20 disposition Think about having some patients reevaluated in 8-12 hours Safe for discharge includes Benign abdominla examination Normal vital signs Controlled pain and nausea Able to eat and drink Discharge of pt.s early in appendicitis OK