Presentation on theme: "Vishal Bhella, MD, CCFP PGY3, Academic Family Medicine"— Presentation transcript:
1Vishal Bhella, MD, CCFP PGY3, Academic Family Medicine Acute Abdominal PainVishal Bhella, MD, CCFPPGY3, Academic Family Medicine
2Objectives Review relevant history for abdominal pain presentations Review differentials for various abdominal pain presentationsReview some common and important presentations
3HistoryOnset – What was the patient doing when the symptoms started? Acute versus Gradual?Provoking/Palliative factors – Factors that exacerbate or improve symptoms for example food, antacids, exertion, defecation?Quality – Characteristics of pain/symptoms – Is it sharp or dull? Is it constant or it comes and goes?
4History continuedRegion/Radiation – Can you point with one finger where it hurts the most? Does the pain radiate or move anywhere else?Severity - On a scale of 1 to 10, how would you rate your level of discomfort right now? Using the same scale, how would you rate your discomfort when it first began?Timing - When did the symptoms first begin? Have you ever experienced these symptoms before? If so, when?
5History continuedAssociated symptoms: fevers, chills, weight loss/gain, nausea, vomiting, diarrhea, constipation, melena, jaundice, change of colour of urine or stoolPast medical and surgical historyFamily historyAlcohol intake/SmokingMedications including NSAIDSWomen: Menstrual history, ?Pregnancy
6Is this a surgical abdomen? The 'surgical abdomen' can be usefully defined as a condition with a rapidly worsening prognosis in the absence of surgical interventionTwo syndromes that constitute urgent surgical referrals are complete obstruction and peritonitis.Patients with peritonitis tend to lie very still to minimize discomfortPeritonitis manifests on physical examination as rebound tenderness, or pain upon removal of pressure rather than application of pressure to the abdomen.Rigidity and tenderness with percussionOften patients will be guarding during physical examination.
7ObstructionObstruction presents as pain with anorexia, bloating, nausea and vomiting along with constipation and obstipationPatients who have evolved from partial to complete bowel obstruction may present with weeks of vague abdominal pain, followed by a sudden deteriorationTypically in cases of surgical abdomen – pain is severe and it can be associated with unstable vital signs, fever, and dehydration.
8InvestigationsPatients with a surgical abdomen – consider the following laboratory measurements:CBC, Electrolytes, BUN, creatinine, and glucoseLFTs: Aminotransferases, alkaline phosphatase, and bilirubinLipaseUrinalysis, Pregnancy test in women of childbearing potentialIn the presence of fever or unstable vital signs, blood and urine cultures should be performed.Abdominal radiograph: proximally dilated loops of bowel are the hallmark of intestinal obstruction, and free intra-peritoneal air can confirm a suspicion of hollow organ perforationIn the case of suspected partial or complete intestinal obstruction, a CT scan of the abdomen is more sensitive than plain abdominal radiographsUltrasound a good initial test to assess - ?Appendicitis/Intra-pelvic pathology/Abdominal abscess
9Case 1 Mr. D is a 46 year old man complaining of stomach pain Subacute onset of epigastric pain, stable vitals, mild to moderate discomfort
10DyspepsiaDyspepsia is a group of symptoms which alerts physicians to consider diseases of the upper gastrointestinal tract including - upper abdominal discomfort, nausea, bloating, fullness and early satiety amongst others
11Dyspepsia Eliminate precipitating agents – NSAIDS, Alcohol Consider trial of PPI or H2 receptor antagonist for 4 weeksH. Pylori treatment - HP-PAC-(lansoprazole, amoxicillin, clarithromycin package)Timely investigations including endoscopy is indicated forNew onset symptoms over age 50Alarm featuresFailure to respond to pharmacotherapy
12Case 2 Mr. P is a 50 year old man complaining of nausea and vomiting Relatively sudden onset, no appetite, history of alcohol use
13PancreatitisSudden onset epigastric pain associated with nausea, vomiting, anorexia – think pancreatitisRisk factors for pancreatitisGallstonesAlcohol useRecent ERCPTraumaLab findings: High amylase/lipaseTreatment: NPO/hydration/analgesia/antibioticsMay need urgent ERCP
17CholecystitisThe patient with acute cholecystitis usually presents with unremitting and intensifying pain at the right side of the abdomen, often associated with fever and vomiting.Indicators such as right upper quadrant pain and Murphy’s sign (i.e., inspiratory arrest with palpation of the right upper quadrant) are present in about one half of older patientsComplications include acute ascending cholangitis, gallbladder perforation, emphysematous cholecystitis, bile peritonitis, and gallstone ileus.Acute ascending cholangitis :Charcot’s triad (i.e., fever, jaundice, and right upper quadrant pain). The majority of patients have an elevated alkaline phosphatase level, 50 percent have positive blood cultures, and approximately 40 percent have hyperbilirubinemia.Reynold’s pentad (i.e., Charcot’s triad plus shock and mental status changes.
19Case 4Mrs. P is a 35 year old female with left sided pain, fever, nausea.Pain is worst in left flank, having nausea, with a couple of episodes of emesis, decreased appetite
20PyelonephritisTypical microorganisms: E.coli, Klebsiella, Proteus, Enterococcus, S. SaprophyticusSymptoms – Fever, chills, nausea, vomiting, myalgia, malaise, CVA tenderness or exquisite flank pain, lower urinary tract symptoms (urgency, frequency, dysuria)Tx with day course of Septra. Ciprofloxacin x 7 days has activity against PseudomonasIV antibiotics in severe cases. Switch to oral when tolerating po intake
22Case 5Mr. A is a 67 year old gentleman with sudden onset severe abdominal pain.Pain severe, sharp, mid to upper abdominal pain. Mr. A looks very unwell, is hypotensive and exhibits signs of shock and peritonitis. A pulsatile abdominal mass is noted.
23AAA AAA dissection is a life threatening emergency Some other differentials in such a presentation includePerforated PUDAppendicitis/diverticulitis with perforationMesenteric ischemiaAlways remember to r/o AAA and mesenteric ischemia in an elderly presenting with moderate- severe abdominal pain
24Periumbilical Pain Colonic: early appendicitis Gastric: esophagitis, gastritis, peptic ulcer, small-bowel mass or obstructionVascular: aortic dissection, mesenteric ischemia
25Case 6Ms. A is an 18 year old female presenting with nausea, vomiting and abdominal painAcute onset, slight fever, significant right lower quadrant pain
26Appendicitis Abdominal pain with anorexia, nausea and vomiting Classic pattern is pain initially periumbilical, constant, dull, poorly localized and then localized over McBurney’s pointCBC may show leukocytosisβ-hCG in women to rule out ectopic pregnancyManagement: Hydrate, correct electrolyte abnormalities, appendectomy
28Case 7 Mrs. D is a 60 year old woman presenting with LLQ pain. Elderly woman with subacute onset of abdominal pain, localized peritoneal signs, lack of severe systemic symptoms
29Diverticulitis Key learning points: Some differentials to consider: Generally a disease of the elderly, 20% < 50Distinguish between complicated vs. uncomplicated diverticulitis, complicated is characterized by:Large abscess > 4cm (requires CT-guided drainage generally)Generalized peritoneal signsFistula formations: colovesical (male), colovaginal, colocutaneousSome differentials to consider:Intra-abdominal abscessMesenteric ischemiaOvarian cysts (consider malignancy in post-menopausal women)Renal colic, pyelonephritis/UTI
30Diverticulitis Require broad-spectrum antibiotics 7-10d: Outpatient: ciprofloxacin + metronidazoleInpatient: 3rd generation cephalosporin/fluoroquinolne + metronidazoleCT is best imaging modalityRecurrence rate for 1st-timers ~ 60-70%; ~20% of initial presentations require surgical intervention
32Case 8Ms. P is a 19 year old female complaining of not feeling well and having lower abdominal pain.LMP 1 week ago, is sexually active – uses OCP for birth control but no other protection. Cervical motion tenderness on pelvic exam
33PIDCase presents woman of child bearing age with lower abdo pain and risk factors for STI.Consider Pelvic Inflammatory Disease in this setting.Note that 1 out of 3 women with PID have a fever. As well, difficult to rule in or out PID based on history, physical or lab work.Should rule out ectopic pregnancy, ovarian abscess and appendicitis. Some other considerations include:Ovarian torsionCystitisLarge bowel: constipation, mesenteric adenitis, inflammatory bowel diseaseUrinary stone – bladder stone (uncommon)
34PID Diagnostic Considerations: Only 1/3 women with PID have fever No history/physical/lab test can definitively rule in/out PIDMinimal criteria:Lower abdo painAdnexal tendernessCervical motion tendernessAdditional criteria:Fever > 38.3 ESR, CRPSwabs/urine confirm Gonorrhea/ChlamydiaTransvaginal U/S – fluid filled tubes, tubo-ovarian complexEndometritis from endometrial biopsy / laparoscopy
35PID Management: Determine if needs admission: Surgical emergencies such as appendicitis cannot be excluded.PregnantNo response to oral antimicrobial therapyUnable to follow or tolerate an outpatient oral regimenSevere illness, nausea and vomiting, or high feverTubo-ovarian abscessThink of Gonorrhea, Chlamydia, and anerobesOutpatient therapy:1st: Ceftriaxone 250 mg IM X1, doxycycline 100 mg po bid 14d +/- metronidazole 500 mg po bid 14d2nd: Ofloxacin 400 mg po bid 14d +/- metronidazole 500 mg po bid 14d, OR Levofloxacin 500 mg po od 14 d +/- metronidazole 500 mg po bid 14d
37Case 9Ms I is a 70 year old female who presents with rapid onset of severe periumbilical abdominal pain, which is out of proportion to findings on physical examination. Nausea and vomiting are present.
38Intestinal IschemiaAcute abdomen with metabolic acidosis = Ischemic bowel until proven otherwise.Risk factors: Atrial Fibrillation, CHF, Peripheral Vascular Disease, or a history of hypercoagulability, Atherosclerotic diseaseCommon sites: Superior Mesenteric Artery supplied territory “watershed” areas of colon - splenic flexure, left colon, sigmoid colonLab investigations: Leukocytosis. Serum lactate elevation. Amylase, LDH, CK, ALPContrast CTCT angiography is gold standard for acute arterial ischemiaTreatment: Fluid resuscitation, NPO, antibiotics, Laparotomy
39Case 10Mr. M is a 55 year old man with vague, constant, upper abdominal discomfortSudden onset while doing errands, some SOB, worse with continued exertion, settles slightly at complete rest. Physical exam - no palpable abdominal pain.
40Cardiac painMYCARDIAL INFARCTION – Topic for another lecture.
41Differential Diagnosis Should Include Extra-Abdominal Sources Toxic, MSK, Trauma, PsychCardiac, RespiratoryMetabolic, VascularSpecific diseasesGynecological, GI,Genitourinary,VascularOrgans within eachsystem