approach to the patient with acute abdominal pain
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Approach to the patient with acute abdominal pain. Asisst. Prof. Dr.Özlem Tanrıöver Yeditepe University Medical Faculty Department of Family Medicine. Abdominal Anatomy. Four quadrants: Right Upper Quadrant Right Lower Quadrant Left Upper Quadrant - PowerPoint PPT PresentationTRANSCRIPT
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Approach to the patient with acute abdominal pain
Asisst. Prof. Dr.Özlem Tanrıöver Yeditepe University Medical FacultyDepartment of Family Medicine
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Abdominal Anatomy
Four quadrants: – Right Upper Quadrant – Right Lower Quadrant – Left Upper Quadrant – Left Lower Quadrant
Three central areas: – Epigastric – Periumbilical – Suprapubic
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Abdominal Anatomy
Right upper quadrant Liver, Head of Pancreas,
Kidney and Lung Right lower quadrant
Appendix, Ureter, Bladder, Colon, Gonads
Left upper quadrantHeart, Spleen, Body of
pancreas, Kidney, Stomach, Lung
Left lower quadrantUreter, bladder, colon, gonads
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The History and Physical in Perspective
70% of diagnoses can be made based on history alone.
90% of diagnoses can be made based on history and physical exam.
Expensive tests often confirm what is found during the history and physical.
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Types of Abdominal Pain
Pain from Hollow Viscera – crampy/paroxismal – often poorly localized – related to peristalsis – patient writhing on exam table
Pain from Peritoneal Irritation – steady/constant – often localized – patient lies still with knees up
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Key Historical Points - Bowel and Bladder
Nausea, Vomitting, Diarrhea, Constipation Frank Blood, "Coffee Grounds" Emesis,
Black Stools Urinary Frequency, Urgency, Discomfort
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Key Historical Points - Reproductive
Sexual Activity, Contraception, Last Menstrual Period
Always Consider Pregnancy in Reproductive Age Women
Have a Low Threshold for Pregnancy Testing
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Gastrointestinal Review of Systems
Trouble swallowing Heartburn Loss of appetite Nausea Change in bowel habits Blood in stool Dark tarry stools Constipation Diarrhea Abdominal pain Jaundice Fever or chills
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Ask the following questions:
Where is the pain? Has the pain changed its location since it
started? Do you feel the pain in any part of your
body? How long have you had the pain? Have you had recurrent episodes of
abdominal pain?
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Ask the following questions:
Did the pain start suddenly? Can you describe the pain? Is it sharp, burning,
cramping? Is the pain continuous? What makes it worse, or better? Is the pain associated with nausea, vomiting,
sweating, constipation, diarrhea, bloody stools, abdominal distention, fever, chills, eating?
If the patient is a woman; When was your last period?
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Abdominal Pain
Location Other symptoms Character Factors that aggravate or alleviate Timing Environment Severity
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Common causes of acute abdominal pain
Peptic Ulcer Disease Cancer of Stomach Pancreas, Colon Biliary Colic Acute Cholecystitis Acute Appendicitis Acute Diverticulitis Intestinal Obstruction Mesenteric Ischemia Irritable Bowel Syndrome Inflammatory Bowel Dis. Hepatitis Gastroenteritis
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Peptic Ulcer Disease or Dispepsia
Ulcer begins in liningof stomach or duodenum. Helicobacter pyloriinfection is often present. Dyspepsia morecommon ages 20- 29,gastric ulcer in thoseover 50 and duodenalulcer ages 30 – 60.
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Peptic Ulcer Disease or Dispepsia
Pain is epigastric and may radiate to the back.
Variable, gnawing, burning, boring, aching or hungerlike.
Timing is intermittent. Duodenal ulcer
more likely nocturnal. Food and antacids may relieve
duodenal ulcer pain. Accompaning symptoms
include nausea, vomiting, belching, bloating, heartburn
and weight loss.
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Pancreatitis
Inflammation of thepancreatic tissue oftendue to gallstones oralcohol abuse. Pain is epigastric andmay radiate to the back. Pain onset is acute andpain is steady. Pain may be worse whensupine and relieved withleaning forward. Associated with nausea,vomiting, abdominaldistention and fever.
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Biliary Colic and Acute Cholecystitis
Due to obstruction of thecystic duct or common bileduct by a gallstone. Pain is epigastric or rightupper quadrant and mayradiate to the right scapulaor shoulder. The pain is steady andaching. Biliary colic may startsuddenly and subside thenrecur whereas cholecystitisis more steady. Associated with anorexia,nausea, vomiting andfever.
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Classic Presentations – Acute Cholecystitis
Localized or diffuse RUQ pain
Radiation to right scapula
Vomitting and constipation
Low grade fever
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Acute Diverticulitis
Inflammation of acolonic saclike mucosalOutpouching through the colonicmuscle. Pain is in the leftlower quadrant. The pain may beginas cramps thenbecome steady. It is associate withfever, constipation andsometimes, brief diarrhea.
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Acute Appendicitis
Acute distention orobstruction of the appendix. Pain often begins as poorly localized periumbilical pain
followed by right lower quadrant pain.
Becomes more steady andsevere with time. Pain is worse withmovement or cough. Pain is associated withanorexia, nausea, andpossibly vomiting whichtypically follow the onset ofpain.
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Classic Presentations - Acute Appendicitis
Diffuse periumbilical pain and anorexia early Pain localizes to RLQ as peritonitis develops Low grade fever, nausea and vomitting may
not be present Xrays and other tests are often negative
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Psoas Sign
This is a test for appendicitis. Place your hand above the patient's right
knee. Ask the patient to flex the right hip
against resistance. Increased abdominal pain indicates a
positive psoas sign.
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Obturator Sign
This is a test for appendicitis. Raise the patient's right leg with the knee
flexed. Rotate the leg internally at the hip. Increased abdominal pain indicates a
positive obturator sign
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Rovsing's Sign
Tenderness felt in the RLQ when palpation is performed on the left is called Rovsing’s sign and suggests appendicitis.
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Classic Presentations - Acute Renal Colic
Severe flank pain Radiation to groin Vomitting and urinary
symptoms Blood in the urine
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Inflammatory Bowel DiseaseUlcerative Colitis
Inflammation of colon Soft bloody stools Insidious onset Associated with crampy lower or
generalized abdominal pain, anorexia,
weakness and fever Often begins in young people
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Inflammatory Bowel DiseaseCrohn’s Disease
Chronic inflammation of the bowel wall,typically involving the terminal ileum and/orproximal colon Stools loose but not as bloody Insidious onset Associated with crampy periumbilical or rightlower quadrant pain with anorexia, low feverand/or weight loss. Perianal or perirectal abcesses and fistulascommon May begin in youth or later.
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Physical Examination
Pelvic Genital Rectal exam on every patient with severe abdominal pain
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Laboratory Evaluation
CBC, Urine Analysis, Electrolytes Urine and serum pregnancy test in all
women of reproductive age with lower abdominal pain
Liver Function Tests , amylase/lipase on all with upper abdominal pain
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Radiographic Evaluation
Plain radiograph – upright and supine abdomen and chest x-ray
Ultrasound on patients with biliary and pelvic symptoms
CT Abdomen and Pelvis – evaluates vasculature, inflammation and solid
organs
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The differentialdiagnosis
Acute Cholecystitis – cystic duct obstructed, RUQ pain ? R scapula – LFTS, amylase
Acute Appendicitis – anorexia, N/V and vague periumbilical pain – 6-8 hrs pain migrates to RLQ, fever – Progresses to localized peritoneal irritation – CT useful in diagnosis
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The differential
Pancreatits Acute Diverticulitis
– most commonly in sigmoid colon – symptoms related to inflammation or obstruction – CT useful early to r/o absess, Endoscopy
contraindicated ? wait 4-6 wks – Rx bowel rest, IV abx, surgery for failures
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Pregnancy appendicitis, cholecystitis, pyelonephritis,
adnexal problems (ovarian torsion, ovarian cyst rupture) appendicitis 7/1000 pregnancies
3% fetal loss with surgery, but 20% with perforated appendix
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Summary
Obtain detailed history Careful exam Consider patient circumstances (diabetes,
age, previous ab surgery) Early thorough work-up (labs/x-rays) Frequent evaluation of progression
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Rebound Tenderness
This is a test for peritoneal irritation. Warn the patient what you are about to
do. Press deeply on the abdomen with your
hand. After a moment, quickly release pressure. If it hurts more when you release, the
patient has rebound tenderness
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Psoas Sign
This is a test for appendicitis. Place your hand above the patient's right
knee. Ask the patient to flex the right hip
against resistance. Increased abdominal pain indicates a
positive psoas sign.
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Obturator Sign
This is a test for appendicitis. Raise the patient's right leg with the knee
flexed. Rotate the leg internally at the hip. Increased abdominal pain indicates a
positive obturator sign
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Rovsing's Sign
Tenderness felt in the RLQ when palpation is performed on the left is called Rovsing’s sign and suggests appendicitis.