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Approach to Abdominal Pain in Emergency Medicine

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by

Sam Kim

on 20 November 2012

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Transcript of Approach to Abdominal Pain in Emergency Medicine

by Samuel Kim Approach to Abdominal Pain in Emergency Medicine WHY IS IT IMPORTANT? One of the most common complaints TYPES OF ABDOMINAL PAIN Visceral (Splanchnic) SOURCES
OF
ABDOMINAL PAIN INTRAABDOMINAL THE ACUTE ABDOMEN HISTORY Often obscure etiology (up to 42%) Commonly misdiagnosed (up to 30%) Somatic (Parietal) Referred Pain VISCERAL PAIN Cause: stretching of autonomic nerve fibers surrounding a hollow or solid viscus (commonly obstruction) Description: crampy, colicky, gaseous, intermittent, ill-defined Early sign of many disorders:
Appendicitis
Cholecystitis
Bowel obstruction
Renal colic SOMATIC PAIN Cause: pain fibers in the parietal peritoneum are irritated
-Chemical
-Bacterial infections Foregut Structures
Stomach
Duodenum
Pancreatic-biliary tree
Location
Epigastric Description: sharp, constant, well-localized tenderness to the disease or source REFERRED PAIN Pain felt from a distance from the diseased organ or original source Examples: Diaphragmatic irritation--> supraclavicular area Ureteral colic--> lower quadrants, genitalia or inner thigh Pancreatic pain--> middle back EXTRAABDOMINAL METABOLIC NEUROGENIC INTRAABDOMINAL PAIN PERITONEAL INFLAMMATION Causes
Aseptic causes (gastric or pancreatic juice, bile, blood, urine)
Bacterial causes (Pneumococcus, Streptococcus, E. coli, Mycobacterium tuberculosis)
Acute abdomen (appendicitis, cholecystitis) Peritoneal inflammation
Obstruction of hollow organs
Vascular disorders INTRAABDOMINAL PAIN OBSTRUCTION OF A HOLLOW ORGAN Characteristics
Colicky abdominal pain
Nausea and vomiting Causes
Adhesions from prior surgery
Hernias
Neoplasms
Volvulus INTRAABDOMINAL PAIN VASCULAR DISORDERS Characteristics:
Diffuse pain out of proportion to physical exam Causes:
Bowel infarction/ischemia
Aortic dissection/leakage/rupture HIGH MORTALITY Characteristics
Localized tenderness
Rebound tenderness Clues:
Fever
Acidosis
Shock
Hematemesis and loose, bloody stools (late) Abdominal wall
Intrathoracic
Pelvic EXTRAABDOMINAL ORIGIN ABDOMINAL WALL PAIN Causes:
Muscle strain
Hematoma
Contusion Clue: worsened by abdominal
wall muscle contraction EXTRAABDOMINAL ORIGIN INTRATHORACIC DISEASE Causes:
Pneumonia
Pulmonary embolism
Pneumothorax
Esophageal disease
Acute MI Clues:
Children (pneumonia)
Elderly (acute MI) Consider an EKG for patients >40 with upper abdominal pain! EXTRAABDOMINAL ORIGIN PELVIC SOURCES Causes:
Salpingitis
Tubo-ovarian abscess
Ovarian cyst/rupture/torsion
Abortion
Ectopic pregnancy PELVIC PAIN MISINTERPRETED AS ABDOMINAL PAIN! METABOLIC ORIGIN Causes
Diabetic ketoacidosis
Sickle cell crisis
SLE
Heavy metal intoxication
Polyarteritis nodosa
Porphyria
Spider/scorpion bites NEUROGENIC SOURCES Causes
Spinal disc disease
Herpes zoster (pre-eruption)
Syphilis (tabes dorsalis) PHYSICAL & HISTORY Remember SAMPLE or
ChLORIDEPP? Use it to guide the physical exam! Has this happened before? PHYSICAL SEVERAL HELPFUL HINTS Peritonitis: restricted movement, rebound tenderness
Visceral pain: colicky, severe pain; fidgets for comfort
Volume depletion: tachycardia, hypotension, orthostatic changes
High fever+shaking chills: pyelonephritis & pneumonia Retroperitoneal bleeding or necrotizing pancreatitis Distinguish between general discomfort vs tenderness Signs for appendicitis:
RLQ tenderness
Rovsing's sign
Iliopsoas sign
Obturator sign Murphy's sign: cholecystitis Grey Turner sign Cullen sign LABS AND IMAGING Order what's necessary!
It should confirm what you already suspect! REGION-SPECIFIC APPROACH RUQ DIFFERENTIAL DIAGNOSIS Biliary colic, acute cholecystitis
Fatty food intolerance, steatorrhea, loose or clay-colored stools, referred pain to right shoulder
Acute cholangitis
Charcot's Triad: fever, jaundice, RUQ pain
Acute hepatitis
Hepatomegaly, fever, N/V/D, radiating and worsening pain Right lower lobe pneumonia
Diaphragmatic irritation (RUQ or referred pain
CHF
Increased JVP, pitting edema, dyspnea
Right renal colic
Stone in calyx
Referred pain along back, genitals or inner thigh LUQ DIFFERENTIAL DIAGNOSIS RLQ DIFFERENTIAL DIAGNOSIS LLQ DIFFERENTIAL DIAGNOSIS Pancreatitis
Low grade fever, N/V, sharp pain (epigastric, referred to center of back)
Gastritis/PUD
Gnawing pain in epigastic or LUQ depending on where the ulcer is, gastric ulcers get better with food, duodenal ulcers get better without food
Splenic rupture
LUQ and left flank pain (since it’s in the retroperitoneal area)- hx may involve mono or trauma Fractured ribs
Sharp pain, pleuritic pain (pain on deep inhalation)
Pneumonia
Irritation of the diaphragm (esp from the left lower lobe) Diverticular disease
Usu age 60+, becoming more in younger (40’s), increasing pain assoc. with constipation, getting worse. Fever in diverticulitis
Inflammatory bowel disease
Looking for UC, younger (teens and 20’s), bloody diarrhea
Large bowel obstruction
Distended abdomen, not passing flatus, hypoactive
Renal colic
Back pain to flank and inguinal pain Twisted ovarian cyst
Testicular torsion
Endometriosis
Leaking aneurysm
Incarcerated, strangulated
groin hernia
PID
Bowel perforation Twisted ovarian cyst
Testicular torsion
Endometriosis
Leaking aneurysm
Meckel's diverticulitis
Cecal diverticulitis
Incarcerated, strangulated
groin hernia
PID
Bowel perforation Appendicitis
Tenderness at McBurney's point, obturator sign, iliopsoas sign, Rovsing's sign
Ruptured ectopic pregnancy
Triad: vaginal bleeding, pain, amenorrhea
Renal colic
Back pain to flank and inguinal pain CBC (+/- diff)
CMP/BMP
Lipids
UA (+/- C&S)
bHCG
Pregnancy test Enzymes
Lipase
Amylase
BNP
Troponin
CPK/CK Imaging
X-ray
CT (stable)
MRI
U/S (chole, uterus, unstable) Midgut Structures
Small bowel
Ascending/transverse colon
Location
Periumbilical area Hindgut Structures
Descending colon
Location
Suprapubic region or lower back The End Any questions? FLANK PAIN DIFFERENTIAL DIAGNOSIS Pyelonephritis
Renal abscess
Nephrolithiasis
Ureterolithiasis Retrocecal appendicitis
Retroperitoneal bleeding
Herniated disc
Radiculitis
Herpes zoster THE IMMEDIATE LIFE THREATS ABDOMINAL AORTIC ANEURYSM Kehr's Sign (spleen to left shoulder) SPLENIC RUPTURE ECTOPIC PREGNANCY MYOCARDIAL INFARCTION S- Signs and symptoms
A- Allergies
M- Medications
P- Past medical/family history
L- Last oral intake
E- Events
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