1. Dr. Matthew Smith Emergency Specialist

2.  Types of pain  Special Populations  Assessment  History  Examination  Investigations  Differential Diagnosis  Management - overview  Cases ( if time permits)

3. Visceral Parietal Pain Types Of Pain

4. Visceral Pain  Stretching of nerve fibres of walls or capsules of organs  Crampy  Dull  Achy  Often unable to lie still  Bilateral innervation

5. Parietal Pain  Parietal peritoneum irritated  Usually anterior abdominal wall  Localised to the dermatome superficial to the site of painful stimulus

6. Course Visceral Non specific Parietal Localised tenderness Guarding Rigidity Rebound

7. Referred Pain  Examples of referred pain?

8. Special Populations

9. Elderly  May lack physical findings despite having serious pathology  As patients age increases diagnostic accuracy declines  Risk of Vascular Catastrophes  Assume surgical cause until proven otherwise  30-40% of geris with abdo pain need surgery  Biliary tract Disease is the commonest cause  Age > 65 need to think of reasons not to CT!  Mortality is 7% in the over 80’s - equivalent to AMI!

10. Elderly Patient think Nasties!  AAA  Ischaemic Gut  Bowel Obstruction  Diverticulitis  Perforated Peptic Ulcer  Cholecystitis  Appendicitis

11. Women of Childbearing Age  Must Ascertain whether PREGNANT  ALL WOMEN OF CHILDBEARING AGE WITH ABDO PAIN NEED BHCG  Gravid uterus displaces intra-abdominal organs making presentations atypical  Pregnant women still get common surgical abdominal conditions

12. History  What are the key points of the abdominal pain history?

13. History  HPC  Pain  Provocative  Palliative  Quality  Radiation  Symptoms associated with  Timing  Taken for the pain  Consultations/ Presentations Associated Symptoms –  Gastro – intestinal  Genito-urinary  Gynaecologic

14. History  PMH  DM  HT  Liver Disease  Renal Disease  Sexually Transmitted Infections  PSH  Abdominal Surgery  Pregnancies  Deliveries/ Abortions/ Ectopics  Trauma

15. History  Meds  NSAIDs  Steroids  OCP/ Fertility Drugs  Narcotics  Immunosuppressants  Chemotherapy agent  ALLS  Contrast  Analgesic

16. High Yield Questions  Which came first – pain or vomiting?  How long have you had the pain?  Constant or intermittent?  History of cancer, diverticulosis, gall stones,Inflammatory BD?  Vascular history, HT, heart disease or AF?

17. Examination  Lots of information from the end of the bed  Distressed vs. non distressed  Lying still - peritonitis  Writhing – Renal Colic  Vital Signs  NEVER ignore abnormal vital signs!  Always document as part of your assessment

21. Investigations  Bedside  UA  Blood?  Leucocyte Esterase and nitrites  Urine HCG  ECG – anyone with upper abdominal pain or elderly  Bloods  ALL WOMEN OF CHILDBEARING AGE NEED BHCG  What are your differentials?  Avoid machine gun approach!

22. Radiology  CXR –?perforation  ?Extra abdominal pathology  ?Complications of intra-abdominal disease

23. Which of the following is NOT an indication for plain abdominal imaging? 1. Bowel Obstruction 2. Constipation 3. Tracking Renal Calculi 4. Foreign Body

28. Other imaging  USS  Biliary Disease  Good for gynae complaints  Rule out Ectopic pregnancy  Appendicitis in children  No radiation

29.  CT is accurate for diagnosis of  Renal colic  Appendicitis  Diverticulitis  AAA  Intraabdominal Abscesses  Mesenteric Ischaemia  Bowel Obstruction  Avoid repeated CT scans  Limit use in younger patients  Avoid where possible in pregnant females

30. ImagingDose (mSV)CXR equivalents Pelvic XR0.66 Abdominal XR0.77 CT abdo-pelvis14140 CT aortogram24240

31. Management  Resuscitate  Large bore access  N Saline bolus 20ml/kg x 2 if shocked  If bleeding think hypotensive resuscitation  All should be NBM until provisional diagnosis  Ensure normothermia  Maintenance fluids and fluid balance  Analgesia doesn’t mask signs  Use a the pain scale  Morphine titrated to pain. Normally 0.1mg/Kg  Paracetamol adjunct  NSAIDs for renal colic  Correct Electrolytes  Thromboprophylaxis

32. Cases

33. Case 1 21 year old female  24 hour history of vague peri-umbilical abdominal pain.  Moved down to the RIF.  Now constant and sharp.  Associated with 2x vomits and feels flushed  No appetite  Normal Bowels

34. What clinical signs may lead you to a diagnosis of appendicitis? Lie still RIF tenderness Rebound Rovsig’s sign Psoas Sign

35. Imaging?  AXR rarely useful  USS  Not as good as CT  Good for female to exclude gynae pathology  If appendix is visualised is useful  CT  Only if there is doubt about diagnosis  Sensitivity up to 98%  High radiation dose  Diagnose other pathology if no appendicitis  Elderley

37. Management  NBM  Analgesia  Anti-emetic if necessary  Maintenance fluids  IVABs – e.g. Ceftriaxone, Gentamicin and Metronidazole  Surgical Referral

38. Case 2  40 yr old obese female  RUQ pain  Pain is constant  nausea, vomiting  fevers and chills  PMH Asthma  MEDS OCP  SH  Drinks 2 std / week  Smokes 20/day  Nil drugs

39. On Examination  Looks distressed.  Not jaundiced  T 38 C  P 120  BP 100/60  RR 20  Sats 98% RA  Tender in the RUQ and Murphy’s positive.

40. What bloods will you order on this patient?

41.  HB 138  WCC 16.0  Neuts 12.4  Lymph 1.6  EUC Normal  Bil 9 (<18)  ALP 450 (30-130)  GGT 320 (<60)  ALT 41 (5-55)  AST 30 (5-55)  Amylase 28 (<120)  Lipase 40 (<60)

44. Management  NBM  IVF  IV abs –Ampicillin + Gentamicin  Analgesia +- anti emetic  Refer to surgeons

45. Case 3  52 yr old alcoholic  Constant epigastric pain radiating to the back. Worsening over the past 2 days  Improved with sitting up and forwards  Nausea and vomiting  Bowels OK PMH Chronic Airways Limitation Alcoholic Gastritis MEDS Thiamine 100 mg daily SH Boarding house resident Drinks 4 litres wine/day Smokes 20/day

46.  Looks unwell and dehydrated  T38.4C  P105  BP 130/70  RR 18  Sats 93% RA

47.  Reduced AE L base  Tender Epigastrium and RUQ  No guarding/ rebound

48. What blood tests will you order?

49. Blood Results Biochem  Na 129  K 4.0  Cr 62  Ur 8.0  Amylase 1080 (<120)  Lipase 950 (<60)  Bil 11 ( 18)  GGT 900 (<60)  ALP 200 ( < 140)  AST 300 (5-55)  ALT 250 (5-55)  LDH 800( 105-333)  Glucose 15  Alb 23  Ca (Corr) 2.0 Haem  HB 114  WCC 17  Coags Normal

50. What imaging will you perform ( if any)?

51. CXR

52. Imaging  CT  Confirms diagnosis  Identifies complications  Help’s grade severity  Not always necessary in ED  USS  Poor visualisation of pancreas  Good for looking at gall stones/ biliary tree dilatation  CXR  Look for complications  Pleural Effusion, Atelectasis, ARDS

53. Management  O2  NBM  IVF  Analgesia  +-Antibiotics (controversial)  Correct Electrolytes  Thromboprophylaxis  IDC/Art-line/CVC depending on severity  Surgical Admit +_ ICU review

54. Causes  G all stones  E toh  T rauma  S teroids  M umps  A utoimmune  S corpion Bites  H yperlidaemia/hypercalcaemia/hypothermia  E RCP  D rugs

55. Case 4  27 yr old female  6/40  LIF constant severe sharp pain  Radiating to the back  Light bright red PV spotting  Feels light headed  PMH  IVF  Previous D+C x 2  Ovarian Cysts  MEDS Nil  SH Lives with partner  Non-smoker  Non-Drinker

56. On Examination  Looks unwell. Pale, diaphoretic, restless  P 150  BP 70/40  RR 26 Sats  98% RA  Tender and guarding in the LIF  PV  Bright red blood spotting  L adnexal tenderness ++

57. How do you manage this patient?  Panic! ( don’t!)  Call for senior help  Large bore IV access x 2 (16 G or larger)  Urgent Cross Match  Fluid resuscitation  Call O+G urgently  Needs OT immediately

58. Case 5  88 yr old female.  Peri-umbilical, colicky abdominal pain for 2 days  Abdominal distension  Vomits x 10  Reduced flatus and NOB for 2 days.  PMH  Cholecystectomy  appendectomy  TAH BSO  Hypertension

59. On examination  Looks distressed  Lying Still  T 37.5  P 110 sinus  BP 150/80  RR 18  Sats 98% RA  Abdomen  Distended  Generally tender  No guarding rebound or rigidity  High pitched bowel sounds

60. Investigations

61.  EUC/CMP/FBP  AXR  CXR  CT

64. Management  NBM  Fluid resuscitation  Monitor volume status – may have large volume shifts  Correct Electrolytes  Analgesia  NG if vomiting  IV Abs – Amp+Gent+Met  Urgent Surgical consult for OT

65. Small Bowel  Adhesions  Hernias  Polyps  Lymphoma  Adenocarcinoma  Gall Stones  Inflammatory BD

66. Large Bowel  Almost never adhesions or hernia  CARCINOMA  Diverticulitis  Sigmoid Volvulus  Faecal Impaction

67. Case 6  73 yr old male presents with sudden onset of central abdominal pain radiating to the back. He also reports weakness to both legs  PMH  HT  Hypercholesterolemia  Current smoker 30/day  MEDS  Aspirin 100mg Daily  Perindopril 5 mg Daily  Atorvastatin 10 mg Daily  SH  Lives Alone  Fully independent with ADLS  Occasional alcohol

68. Examination  Distressed  P 130  BP 80/60  RR 26 Sats  99% RA  Abdomen  Non-distended  Generally tender  Reduced power 3/5 to hip flexors

69. Bedside Ultrasound 9cm

70. Management of ruptured AAA  Senior help  ABC  Large Bore IV Access x 2  Hypotensive resuscitation  Analgesia  Ensure O neg available  Ensure normothermia  Urgent Vascular Consult  To OT

71. Last Case!  85 yr old male. Nursing home resident  Central Abdominal Pain  Sudden onset. Severe  PMH  Dementia  MI  MEDS  Clopidogrel 75 mg Daily  Metoprolol 25 mg BD  Perindopril 5 mg daily  SH  Mild dementia  Forgetful  Requires some assistance with bathing and toileting  Feeds Self  Walks with frame  Non-smoker  Non-drinker

72. Examination  Looks dry and emaciated  P 120- 140  BP 110/70  RR 30  Sats 96% RA  T 37.4 C  Abdomen  Generally tender  No guarding rigidity or rebound

73. ECG 

74. Differential?

75. ABG  pH 7.10  pCO2 15  P02 80  Bic 8  BE -15  Lactate 10.2

76. Management  02  NMB  IV access  IVF  Analgesia  IV abs  Urgent Surgical Consult  Urgent CT mesenteric angiogram  OT

77. Take Home Message  Exclude life threatening pathology  BHCG in female of child bearing age  Be mindful of radiation exposure  Beware of Abdominal pain in the Elderly  Never ignore abnormal vital signs

78. Mesenteric Ischaemia  Surgical Emergency  Small bowel has warm ischaemic time of 2-3 hours  Rapidly progresses to gangrene, septic shock and death  Need high index of suspicion to diagnose it  Severe pain but little tenderness on examination

79. Case 7  40 yr old male presents with sudden onset of severe R loin to groin pain. Excruciating pain.Coming in waves. Feels nauseated and has vomited x 2.  Patient is agitated, pacing around the room, unable to sit still.  Screaming in pain.  P 120 sinus BP 160/80 T 37.0 C RR 18 Sats 99% RA  R renal angle tender

80. Differential Diagnosis?  Renal Colic  Pancreatitis  Cholecystitis  Appendicitis  Ruptured/leaking AAA

81.  UA  Erythrocytes ++++  No leucocytes  No nitrites

83. Investigations  UA  EUC  FBC  (other bloods if diagnosis unclear)  CT KUB

84. Management  Analgesia  NSAID e.g. PR indomethacin 100 mg 1 st line  Morphine IV titrated to pain  IV fluids – maintenance only  Observe

85. Who should we CT  CT  Ongoing pain  Impaired renal function  Fever  Diagnosis not clear

86. Indications for admission  Infection  Impaired Renal Function  Pain ongoing– needing IV opiates  Stone > 5mm  Obstruction/hydronephrosis on CT  Stag horn Calculus on CT

87. ECG  What does the ECG show? 1. Sinus Tachycardia 2. VT 3. VF 4. Rapid Atrial Fibrillation 5. No idea!

88. ECG 