diagnosis and management of acute abdominalpain
TRANSCRIPT
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Diagnosis and Management of Diagnosis and Management of Acute Abdominal PainAcute Abdominal Pain
Dimitri Raptis and Alec EngledowDimitri Raptis and Alec Engledow
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Definition1
• Acute abdominal pain (AAP):– Presentation of previously undiagnosed
abdominal pain– Lasting 1/52 or < – Prior to a clinical encounter in 10 or 20 care
1De Dombal FT. Diagnosis of acute abdominal pain. New York: Churchill Livingstone; 1991.
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Introduction• > 1000 causes exist2
– NSAP (34%)– Acute appendicitis (28%)– Acute chlecystitis (10%) – SBO (4%)– Perforated PU (3%)– Pancreatitis (3%)– Diverticular disease (2%) – Others (13%)
• 20-40% admission rates• 50-65% inaccurate initial diagnosis
2De Dombal FT, Margulies M. Acute abdominal pain. Surgery1996;
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Pathophysiology• Visceral pain
– Distention, inflammation or ischaemia in hollow viscous & solid organs
– Localisation depends on the embryologic origin of the organ:
• Forgut to epigastrium• Midgut to umbilicus• Hindgut to the hypogastric
region• Parietal pain
– is localised to the dermatome above the site of the stimulus.
• Referred pain – produces symptoms, not signs
e.g. tenderness
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Generalized AP• Perforation
• AAA
• Acute pancreatitis
• DM
• Bilateral pleurisy
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Central AP• Early appendicitis
• SBO
• Acute gastritis
• Acute pancreatitis
• Ruptured AAA
• Mesenteric thrombosis
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Epigastric pain• DU / GU
• Oesophagitis
• Acute pancreatitis
• AAA
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RUQ pain• Gallbladder disease
• DU
• Acute pancreatitis
• Pneumonia
• Subphrenic abscess
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LUQ pain• GU• Pneumonia• Acute pancreatitis • Spontaneous splenic
rupture• Acute perinephritis• Subphrenic abscess
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Suprapubic pain• Acute urinary retention• UTIs • Cystitis • PID• Ectopic pregnancy • Diverticulitis
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RIF pain• Acute appendicitis• Mesenteric adenitis (young)• Perf DU• Diverticulitis • PID• Salpingitis• Ureteric colic • Meckel’s diverticulum • Ectopic pregnancy • Crohn’s disease• Biliary colic (low-lying gall
bladder)
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Loin pain• Muscle strain• UTIs• Renal stones• Pyelonephritis
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LIF pain• Diverticulitis• Constipation• IBS• PID• Rectal Ca• UC• Ectopic pregnancy
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Limitations
• Limitations based on the relationship between – Overlying tenderness – Underlying surgical disease
• 35% of intra-operative diagnoses are considered to have had atypical presentations3
3Staniland, JR, Br Med J 3:393, 1972
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Key points on history
• Site• Nature & character • Duration• Intensity • Precipitating & relieving factors• Associated symptoms
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Classification by nature
• Colicky pain– Baseline of no pain in true colic– IBS– Bowel obstruction
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Nagging & Grumbling
• Biliary colic
• Cholecystitis
• PID
• UTI
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Stabbing
• AAA
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Burning or boring
• PUD
• Oesophagitis
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Gnawing
• Pancreatitis
• Pancreatic Ca
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Associated symptoms
• Fever
• Genitourinary
• Gynaecological
• Vascular
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PMSH
• Previous episodes of AP
• Investigations
• Operations
• Chronic disease
• Immunosuppression
• Medications (NSAIDs)
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Physical examination
• OBS are important
• Observation– Bending Forward: Chronic Pancreatitis– Jaundiced: CBD obstruction– Dehydrated: Peritonitis, Small Bowel
obstruction
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Systemic Examination
Abdomen:• Inspection
- Scaphoid or flat in peptic ulcer- Distended in ascites or intestinal
obstruction- Visible peristalsis in a thin or malnourished
patient (with obstruction)
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Systemic Examination
Palpation • Check for Hernia sites• Tenderness• Rebound tenderness• Guarding- involuntary spasm of muscles
during palpation• Rigidity- when abdominal muscles are tense
& board-like. Indicates peritonitis.
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Systemic Examination
• Local Right Iliac Fossa tenderness:– Acute appendicitis– Acute Salpingitis in females
• Low grade, poorly localized tenderness:– Intestinal Obstruction
• Tenderness out of proportion to examination:– Mesenteric Ischemia– Acute Pancreatitis
• Flank Tenderness:– Perinephric Abscess– Retrocaecal Appendicitis
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Important Signs in Patients with Abdominal Pain
Sign Finding Association
Cullen's sign Bluish periumbilicaldiscoloration
Retroperitoneal haemorrhage
Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy rupture
McBurney's sign Tenderness located 2/3 distance fromanterior iliac spine to umbilicus on right side
Appendicitis
Murphy's sign Abrupt interruption of inspiration on palpationof right upper quadrant
Acute cholecystitis
Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis
Obturator's sign Internal rotation of flexed right hip causingabdominal pain
Appendicitis
Grey-Turner's sign
Discoloration of the flank Retroperitoneal haemorrhage
Chandelier sign Manipulation of cervix causes patient to liftbuttocks off table
Pelvic inflammatory disease
Rovsing's sign Right lower quadrant pain with palpation of the left lower quadrant
Appendicitis
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Physical examination
• Auscultation – BS– > 2min to confirm absent – High pitched, hyperactive or tinkling– Bruit in epigastrium
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Systemic Examination
PR Examination:
- tenderness
- induration
- mass
- frank blood
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Systemic Examination
PV Examination
- Bleeding
- Discharge
- Cervical motion tenderness
- Adnexal masses or tenderness
- Uterine Size or Contour
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Surgical Myths• Rebound tenderness, considered the clinical indicator
of peritonitis, has a high (25%) false -ve rate4 • Rigidity, referred tenderness & cough pain are
sufficient evidence for peritonitis5 • Except for detection of blood, routine PR exams add
little to clinical assessment6
• Administration of analgesics prior to surgical consultation does not obscure the diagnosis, but
improves accuracy7
4Liddington, MI and Thomson, WH, Br J :795, 19915Bennett, DH Br Med J 308:1336, 19946Manimaran, N et al. Ann Roy Col Surg Engl 86:292 20047Brewster, GS et al. 2000 West J Med 172:209
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Initial management
• 1st 20 sec there are only 3 diagnoses: – Very ill:
• Going to die? • ask for help & resus
– ill: • stable for couple h? • Urgent investigations, initial diagnosis & management
– Reasonably well: • Investigate as appropriate • formulate diagnosis.
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Initial management
• ABCDE
• Resuscitation & analgesia (opioid IV)
• Full monitoring (including UO)
• Low threshold in seeking senior help
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Investigations
• FBC (Hb & WCC) • Amylase (Pancreatitis) • U&Es, LFTs • Clotting (acute pancreatitis, sepsis, DIC, liver disease) • Glucose (BM) • G&S (X-match if necessary) • ABG • ECG • Cardiac enzymes (if appropriate)
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Investigations
• Attention to the WCC as a screening test only if substantially elevated. – 25% of patients with elevated WCC do not
have different outcomes from those with a normal WCC8
• FBC has a limited clinical utility
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Investigations
• Urinalysis– Cheap– Simple & readily available test– High yield when results fit with the clinical
scenario – MSU
• Pregnancy test
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Investigations
• Radiology– Erect CXR– Supine AXR– USS (?gynae pathology) – IVU (renal/ureteric colic)
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Investigations
• Plain X-rays have limited utility in the evaluation of AAP – Low diagnostic yield– High incidence of misleading incidental
findings– Lack of impact on management – Exception: Bowel obstruction or perforation
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CT scanning• No significant
advantage in DD of AAP
• Delay of necessary treatment
• Routine use not justified
• Hx taking & physical examination are the basis of correct diagnosis8
• Hx, physical examination & lab investigations are often non-specific
• CT is now 1st-line imaging modality in pts with APP.
• MDCT is now faster with thinner slices
• High diagnostic accuracy9
8Keeman JN, New diagnostic imaging technology offten offers no advantage in the differential diagnosis of acute abdomen. Ned Tijdschr Geneeskd. 1999. Nov. 6:143(45):2225-9
9Leschka et al,Multi-detector computer tomography of acute abdomen. Eur Radiol. Dec;15(12):2435-47. 2005
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Laparoscopy10,11 • Early diagnostic laparoscopy may result in:
– accurate, – prompt, – efficient management of AAP
• Reduces the rate of unnecessary laparotomy • Increases the diagnostic accuracy• May be a key to solving the diagnostic
dilemma of NSAP.
10Golash and Willson. Early laparoscopy as a routine procedure in the management of acute abdominal pain: a review of 1320 patients. Surg Endosc. 2005 Jul;19(7):882-511Keller et al. Diagnostic laparoscopy in acute abdomen. Chirurg. 2006 Nov;77(11):981-5
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Suggestions
• Audit of all patients referred with AAP to assess: – Initial diagnosis – Choice & diagnostic efficacy of
investigations– Treatment– Timing (length of stay) – Cost effectiveness
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Thank you