Presentation on theme: "Approach to Abdominal Pain in the Emergency Department"— Presentation transcript:
1 Approach to Abdominal Pain in the Emergency Department Sezgin Sarıkaya, Assoc. Prof. MD, MBADepartment of Emergency Medicine Yeditepe University
2 Introduction At the end of this lecture you should: Understand the generation and presentation of types of abdominal painDevelop critical elements of the history and physical for APApply knowledge of utility of testing to diagnostic approachApply management principles to patient care in the ED
3 The Epidemiology of Acute Abdominal Pain 5-10% of all ED visits.Among them, 14-40% patients need surgical intervention.Most common diagnosis is NONSPECIFIC (ie, “I dunno”)Challenge for emergency physician (EP):About 1/3 have an atypical presentation.If misdiagnosis, mortality rate 2.5 times higher than correct diagnosis in the elderly.
4 Elderly/ nursing home patients Immunocompromised (e.g. HIV) Three Subgroups of Patients with Abdominal Pain Who deserve Particular FocusElderly/ nursing home patientsImmunocompromised (e.g. HIV)Women of childbearing age.Post operative patientsInfants
5 The Most Important Concept for EP in Approaching Abdominal Pain To DifferentiateWho is the patient of acute abdomen?What are the probable diagnoses you have in mind?Why do you consider such diagnosis?How do you prove it?When will you consult surgeon for operation?
6 Causes of Acute Abdominal Pain in the ED Cause Percentage of CasesNonspecific abdominal painAppendicitisCholecystitisGastroenteritis 7SalpingitisUTISmall-bowel obstructionRenal colicConstipationPancreatitisDiverticulitisAbdominal aneurysm, ectopic pregnancy <1(Brewer et al., 1979; Scand J Gastroenterol)
7 Abdominal Pain Across the Ages Colic, GE, viral illness, constipationAges 2-12Functional, appendicitis, GE, toxinsTeens to adultsAddition of genitourinary problemsElderlyBeware of what seems like everything!
8 Important Extra-abdominal Causes of Abdominal Pain SystemicDKAAlcoholic ketoacidosisUremiaSickle cell diseasePorphyriaSLEVasculitisGlaucomaHyperthyroidismToxicMethanol poisoningHeavy metal toxicityScorpion biteBlack widow spider biteThoracicMyocardial infarction/ Unstable angina
9 Important Extra-abdominal Causes of Abdominal Pain PneumoniaPulmonary embolismHerniated thoracic disc (neuralgia)GenitourinaryTesticular torsionRenal colicInfectiousStrep pharyngitis (more often in children)Rocky Mountain Spotted FeverMononucleosisAbdominal wallMuscle spasmMuscle hematomaHerpes zosterEmerg Med Clin North Am 1989; 7:
10 Abdominal Pain in the Elderly Diminished sensation of pain in the elderlyComorbid diseasesPolypharmacyCombinations of above result in many more vague, nonspecific presentationsTwice as likely to require surgery with presentation over age 65
11 What’s the ProblemImprecise pain generation and transmission to the central nervous systemComorbid diseasesDevelopmental stageMedicationsSocial factors
12 Understanding the Types of Abdominal Pain VisceralStretch fibers in capsules or walls of hollow viscus that enter both sides of spinal cordSomaticFibers dermatomally distributed and enter unilaterally in the spinal cordReferredOverlap of fibers from other locations
13 Understanding the Types of Abdominal Pain VisceralCrampy, achy, diffuse,Poorly localizedSomaticSharp, lancinatingWell localizedReferredDistant from site of generationSymptoms, but no signs
14 Understanding the Types of Abdominal Pain Location, location, locationOrgans and their corresponding fiber entry to the spinal cordC3-5 – liver, spleen, diaphragmT5-9 – gallbladder, stomach, pancreas, small intestineT10-11– colon, appendix, pelvic viscerat11-l1 – sigmoid, renal capsules, ureters, gonadsS2-4 - bladder
18 History Taking in Abdominal Pain Presentations “OLD CARS”O- onsetL- locationD- durationC- characterA-alleviating/aggravating factorsassociated symptomsR- radiationS- severity
19 History Taking for Abdominal Pain Presentations PMHSimilar episodes in pastOther medical problems that increase disease likelihood of problems (ex: DM and gastroparesis)PSHAdhesions, hernias, tumorsMEDSAbx, NSAIDS, acid blockers, etcGYN/UROLMP, bleeding, dischargeSocialTob/EtoH/drugs/home situation/agenda
20 Karın boşluğunun (abdominal kavitenin) · Üst sınırı diyafram· Alt sınırı pelvis· Arka sınırı lumbal omurlar· Ön sınırı karın duvarı kasları
21 PERİTON Karın boşluğunu çevreler · Çift katlıdır : Visseral periton PERİTONKarın boşluğunu çevreler· Çift katlıdır : Visseral periton Pariyetal periton· Karın boşluğunu ikiye böler: Peritoneal boşluk Retroperitoneal aralık
22 karın ağrısı olan hastanın tanı ve tedavisi hekimler için hala önemli klinik sorunların başında gelmektedir
23 Physical Exam in Abdominal Pain Presentations InspectionDistention, scars, bruisesAuscultationPresent, hyper, or absentActually not that helpful!PalpationOften the most helpful part of examTenderness versus painStart away from painful area firstGuarding, rebound, masses
24 Physical Exam in Abdominal Pain Presentations SignsMc burneyMurphy’sExtra-abdominal examPelvic or scrotal examsLungs, heartRemember it’s a patient, not a partRectalAdds very little (despite the angst) beyond gross blood or melena
25 Laboratory Testing Everybody likes a CBC, but… Lacks sensitivity, no specificityLittle to no change in diagnostic probabilitiesShould not dramatically alter approach (tender is still tender)
26 Laboratory Testing Directed approach to lab studies There are no “standard belly labs”Pregnancy test in women of child bearing ageUrine dipsticks
27 Imaging Plain films Free air, obstruction, air-fluid, FBs Ultrasound Rapid “yes or no” ED evaluationsFormal studiesMay add dopplerComputed TomographyRevolutionized acute careOften better than we are!
30 Common Diagnoses by Quadrant RUQCholecystitisBiliary colicHepatitisPancreatitisRenal stonesPUDPneumoniaP EM ILUQGastritisGastric ulcerPancreatitisSplenomegalySplenic ruptureRenal stonePneumoniaP EM I
31 Common Diagnoses by Quadrants RLQAppendicitisRenal stoneOvarian cystTorsionEpididymitisEctopicIBDAAAUTILLQDiverticulitisRenal stoneOvarian cystTorsionEpididymitisEctopicIBDAAAUTI
32 Dangerous Mimics True Diagnosis Initial Misdiagnosis Appendicitis Gastroenteritis, PID, UTIRuptured abdominal Renal colic, diverticulitis, lumbar strainaortic aneurysmEctopic pregnancy PID, UTI, corpus luteum cystDiverticulitis Constipation,GE ,pyelonephritisPerforated viscus PUD, pancreatitis, nsp abdominal painBowel obstruction Constipation, gastroenteritis,nonspecific abdominal painMesenteric ischemia GE, constipation, ileus small bowel obstructionIncarcerated or Ileus or small bowel obstructionstrangulated herniaShock or sepsis from Urosepsis or pneumonia (in elderly)perforation, bleed,abdominal infection
33 Five Major Categories of Acute Abdomen (BIOPI) Bleeding or rupture of vessels or tumorIschemia or InfarctionObstructionPerforationInflammation
34 Common Pitfalls in Acute Appendicitis Abdominal pain and tenderness are present in nearly 100% of patients with appendicitis; other clinical features are less reliable.Fever occurs in only 16% of patients with acute appendicitis; its presence is more suggestive of appendiceal perforation.Murphy sequence appears in only 22% elderly.Perforation rate about 60% (age > 60 Y/O)
35 Management of Abdominal Pain Always right to start with ABC’sIV accessFluid administrationAntiemeticsAnalgesicsDirected testing and imagingRe-evaluationsAntibioticsConsultantsSurgeons, OB/GYN, urologists, cardiologists, etc
36 Disposition of Abdominal Pain Patients Operating RoomHospital bed/observationSerial labsSerial examsHome with abdominal warningsThe art of emergency medicine3 components of discharge planDocument, document, document