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Approach to Abdominal Pain in the Emergency Department Sezgin Sarıkaya, Assoc. Prof. MD, MBA Department of Emergency Medicine Yeditepe University.

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Presentation on theme: "Approach to Abdominal Pain in the Emergency Department Sezgin Sarıkaya, Assoc. Prof. MD, MBA Department of Emergency Medicine Yeditepe University."— Presentation transcript:

1 Approach to Abdominal Pain in the Emergency Department Sezgin Sarıkaya, Assoc. Prof. MD, MBA Department of Emergency Medicine Yeditepe University

2 Introduction At the end of this lecture you should: At the end of this lecture you should: Understand the generation and presentation of types of abdominal pain Understand the generation and presentation of types of abdominal pain Develop critical elements of the history and physical for AP Develop critical elements of the history and physical for AP Apply knowledge of utility of testing to diagnostic approach Apply knowledge of utility of testing to diagnostic approach Apply management principles to patient care in the ED Apply management principles to patient care in the ED

3 The Epidemiology of Acute Abdominal Pain 5-10% of all ED visits. 5-10% of all ED visits. Among them, 14-40% patients need surgical intervention. Among them, 14-40% patients need surgical intervention. Most common diagnosis is NONSPECIFIC (ie, “I dunno”) Most common diagnosis is NONSPECIFIC (ie, “I dunno”) Challenge for emergency physician (EP) : Challenge for emergency physician (EP) : About 1/3 have an atypical presentation. About 1/3 have an atypical presentation. If misdiagnosis, mortality rate 2.5 times higher than correct diagnosis in the elderly. If misdiagnosis, mortality rate 2.5 times higher than correct diagnosis in the elderly.

4 Three Subgroups of Patients with Abdominal Pain Who deserve Particular Focus Elderly/ nursing home patients Elderly/ nursing home patients Immunocompromised (e.g. HIV) Immunocompromised (e.g. HIV) Women of childbearing age. Women of childbearing age. Post operative patients Post operative patients Infants Infants

5 The Most Important Concept for EP in Approaching Abdominal Pain To Differentiate To Differentiate Who is the patient of acute abdomen? Who is the patient of acute abdomen? What are the probable diagnoses you have in mind? What are the probable diagnoses you have in mind? Why do you consider such diagnosis? Why do you consider such diagnosis? How do you prove it? How do you prove it? When will you consult surgeon for operation? When will you consult surgeon for operation?

6 Causes of Acute Abdominal Pain in the ED Cause Percentage of Cases Nonspecific abdominal pain41-46 Appendicitis4-24 Cholecystitis2.5-9 Gastroenteritis 7 Salpingitis2-7 UTI3-5 Small-bowel obstruction2.5-4 Renal colic1.5-4 Constipation 2 Pancreatitis1-2 Diverticulitis1-2 Abdominal aneurysm, ectopic pregnancy <1 (Brewer et al., 1979; Scand J Gastroenterol)

7 Abdominal Pain Across the Ages Ages 0-2 Ages 0-2 Colic, GE, viral illness, constipation Colic, GE, viral illness, constipation Ages 2-12 Ages 2-12 Functional, appendicitis, GE, toxins Functional, appendicitis, GE, toxins Teens to adults Teens to adults Addition of genitourinary problems Addition of genitourinary problems Elderly Elderly Beware of what seems like everything! Beware of what seems like everything!

8 Important Extra-abdominal Causes of Abdominal Pain Systemic Systemic DKA DKA Alcoholic ketoacidosis Alcoholic ketoacidosis Uremia Uremia Sickle cell disease Sickle cell disease Porphyria Porphyria SLE SLE Vasculitis Vasculitis Glaucoma Glaucoma Hyperthyroidism Hyperthyroidism Toxic Toxic Methanol poisoning Methanol poisoning Heavy metal toxicity Heavy metal toxicity Scorpion bite Scorpion bite Black widow spider bite Black widow spider bite Thoracic Thoracic Myocardial infarction/ Unstable angina Myocardial infarction/ Unstable angina

9 Important Extra-abdominal Causes of Abdominal Pain Pneumonia Pneumonia Pulmonary embolism Pulmonary embolism Herniated thoracic disc (neuralgia) Herniated thoracic disc (neuralgia) Genitourinary Genitourinary Testicular torsion Testicular torsion Renal colic Renal colic Infectious Infectious Strep pharyngitis (more often in children) Strep pharyngitis (more often in children) Rocky Mountain Spotted Fever Rocky Mountain Spotted Fever Mononucleosis Mononucleosis Abdominal wall Abdominal wall Muscle spasm Muscle spasm Muscle hematoma Muscle hematoma Herpes zoster Herpes zoster Emerg Med Clin North Am 1989; 7:

10 Abdominal Pain in the Elderly Diminished sensation of pain in the elderly Diminished sensation of pain in the elderly Comorbid diseases Comorbid diseases Polypharmacy Polypharmacy Combinations of above result in many more vague, nonspecific presentations Combinations of above result in many more vague, nonspecific presentations Twice as likely to require surgery with presentation over age 65 Twice as likely to require surgery with presentation over age 65

11 What’s the Problem Imprecise pain generation and transmission to the central nervous system Imprecise pain generation and transmission to the central nervous system Comorbid diseases Comorbid diseases Developmental stage Developmental stage Medications Medications Social factors Social factors

12 Understanding the Types of Abdominal Pain Visceral Visceral Stretch fibers in capsules or walls of hollow viscus that enter both sides of spinal cord Stretch fibers in capsules or walls of hollow viscus that enter both sides of spinal cord Somatic Somatic Fibers dermatomally distributed and enter unilaterally in the spinal cord Fibers dermatomally distributed and enter unilaterally in the spinal cord Referred Referred Overlap of fibers from other locations Overlap of fibers from other locations

13 Understanding the Types of Abdominal Pain Visceral Visceral Crampy, achy, diffuse, Crampy, achy, diffuse, Poorly localized Poorly localized Somatic Somatic Sharp, lancinating Sharp, lancinating Well localized Well localized Referred Referred Distant from site of generation Distant from site of generation Symptoms, but no signs Symptoms, but no signs

14 Understanding the Types of Abdominal Pain Location, location, location Location, location, location Organs and their corresponding fiber entry to the spinal cord Organs and their corresponding fiber entry to the spinal cord C3-5 – liver, spleen, diaphragm C3-5 – liver, spleen, diaphragm T5-9 – gallbladder, stomach, pancreas, small intestine T5-9 – gallbladder, stomach, pancreas, small intestine T10-11– colon, appendix, pelvic viscerat11-l1 – sigmoid, renal capsules, ureters, gonads T10-11– colon, appendix, pelvic viscerat11-l1 – sigmoid, renal capsules, ureters, gonads S2-4 - bladder S2-4 - bladder

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16 Visceral

17 Somatic

18 History Taking in Abdominal Pain Presentations “ OLD CARS” “ OLD CARS” O- onset O- onset L- location L- location D- duration D- duration C- character C- character A-alleviating/aggravating factors A-alleviating/aggravating factors associated symptoms associated symptoms R- radiation R- radiation S- severity S- severity

19 History Taking for Abdominal Pain Presentations PMH PMH Similar episodes in past Similar episodes in past Other medical problems that increase disease likelihood of problems (ex: DM and gastroparesis) Other medical problems that increase disease likelihood of problems (ex: DM and gastroparesis) PSH PSH Adhesions, hernias, tumors Adhesions, hernias, tumors MEDS MEDS Abx, NSAIDS, acid blockers, etc Abx, NSAIDS, acid blockers, etc GYN/URO GYN/URO LMP, bleeding, discharge LMP, bleeding, discharge Social Social Tob/EtoH/drugs/home situation/agenda Tob/EtoH/drugs/home situation/agenda

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23 Physical Exam in Abdominal Pain Presentations Inspection Inspection Distention, scars, bruises Distention, scars, bruises Auscultation Auscultation Present, hyper, or absent Present, hyper, or absent Actually not that helpful! Actually not that helpful! Palpation Palpation Often the most helpful part of exam Often the most helpful part of exam Tenderness versus pain Tenderness versus pain Start away from painful area first Start away from painful area first Guarding, rebound, masses Guarding, rebound, masses

24 Physical Exam in Abdominal Pain Presentations Signs Signs Mc burney Mc burney Murphy’s Murphy’s Extra-abdominal exam Extra-abdominal exam Pelvic or scrotal exams Pelvic or scrotal exams Lungs, heart Lungs, heart Remember it’s a patient, not a part Remember it’s a patient, not a part Rectal Rectal Adds very little (despite the angst) beyond gross blood or melena Adds very little (despite the angst) beyond gross blood or melena

25 Laboratory Testing Everybody likes a CBC, but… Everybody likes a CBC, but… Lacks sensitivity, no specificity Lacks sensitivity, no specificity Little to no change in diagnostic probabilities Little to no change in diagnostic probabilities Should not dramatically alter approach (tender is still tender) Should not dramatically alter approach (tender is still tender)

26 Laboratory Testing Directed approach to lab studies Directed approach to lab studies There are no “standard belly labs” There are no “standard belly labs” Pregnancy test in women of child bearing age Pregnancy test in women of child bearing age Urine dipsticks Urine dipsticks

27 Imaging Plain films Plain films Free air, obstruction, air-fluid, FBs Free air, obstruction, air-fluid, FBs Ultrasound Ultrasound Rapid “yes or no” ED evaluations Rapid “yes or no” ED evaluations Formal studies Formal studies May add doppler May add doppler Computed Tomography Computed Tomography Revolutionized acute care Revolutionized acute care Often better than we are! Often better than we are!

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30 Common Diagnoses by Quadrant RUQ RUQ Cholecystitis Cholecystitis Biliary colic Biliary colic Hepatitis Hepatitis Pancreatitis Pancreatitis Renal stones Renal stones PUD PUD Pneumonia Pneumonia P E P E M I M I LUQ LUQ Gastritis Gastric ulcer Pancreatitis Splenomegaly Splenic rupture Renal stone Pneumonia P E M I

31 Common Diagnoses by Quadrants RLQ RLQ Appendicitis Appendicitis Renal stone Renal stone Ovarian cyst Ovarian cyst Torsion Torsion Epididymitis Epididymitis Ectopic Ectopic IBD IBD AAA AAA UTI UTI LLQ LLQ Diverticulitis Renal stone Ovarian cyst Torsion Epididymitis Ectopic IBD AAA UTI

32 Dangerous Mimics True DiagnosisInitial Misdiagnosis AppendicitisGastroenteritis, PID, UTI Ruptured abdominalRenal colic, diverticulitis, lumbar strain aortic aneurysm Ectopic pregnancyPID, UTI, corpus luteum cyst DiverticulitisConstipation,GE,pyelonephritis Perforated viscusPUD, pancreatitis, nsp abdominal pain Bowel obstructionConstipation, gastroenteritis,nonspecific abdominal pain Mesenteric ischemiaGE, constipation, ileus small bowel obstruction Incarcerated or Ileus or small bowel obstruction strangulated hernia Shock or sepsis fromUrosepsis or pneumonia (in elderly) perforation, bleed, abdominal infection

33 Five Major Categories of Acute Abdomen (BIOPI) Bleeding or rupture of vessels or tumor Bleeding or rupture of vessels or tumor Ischemia or Infarction Ischemia or Infarction Obstruction Obstruction Perforation Perforation Inflammation Inflammation

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. 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. 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. Murphy sequence appears in only 22% elderly. Perforation rate about 60% (age > 60 Y/O) Perforation rate about 60% (age > 60 Y/O)

35 Management of Abdominal Pain Always right to start with ABC’s Always right to start with ABC’s IV access IV access Fluid administration Fluid administration Antiemetics Antiemetics Analgesics Analgesics Directed testing and imaging Directed testing and imaging Re-evaluations Re-evaluations Antibiotics Antibiotics Consultants Consultants Surgeons, OB/GYN, urologists, cardiologists, etc Surgeons, OB/GYN, urologists, cardiologists, etc

36 Disposition of Abdominal Pain Patients Operating Room Operating Room Hospital bed/observation Hospital bed/observation Serial labs Serial labs Serial exams Serial exams Home with abdominal warnings Home with abdominal warnings The art of emergency medicine The art of emergency medicine 3 components of discharge plan 3 components of discharge plan Document, document, document Document, document, document

37 TEŞEKKÜRLER TEŞEKKÜRLER SORU VE KATKI SORU VE KATKI


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