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Abdominal Pain

Abdominal Pain. Dr Murgatroyd FY2. Aims . General approach to abdominal pain Shorts cases. Remember Not all abdominal pain is abdominal in origin (MI, pneumonia) Always consider gynaecological causes .

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Abdominal Pain

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  1. Abdominal Pain Dr Murgatroyd FY2

  2. Aims • General approach to abdominal pain • Shorts cases

  3. Remember Not all abdominal pain is abdominal in origin (MI, pneumonia) Always consider gynaecological causes Multiple causes ranging from acute life threatening surgical emergencies (AAA) to more benign conditions requiring non urgent investigation and treatment (constipation)

  4. General principles • Always use ABCDE in all acutely unwell patient • Think of important diagnosis and rule them out • Have a low threshold for basic investigations • Call for help early

  5. Abdominal pain- History • Pain - SOCRATES • Vomiting • Bile • Coffee ground • Fresh blood • Defecation • Constipation or diarrhoeoa • Absolute constipation, colicky pain and vomiting suggests GI obstruction • PMH • Previous surgery (adhesions)

  6. Assessing Pain • Site: where, local/ diffuse, • Onset: rapid/ gradual, pattern, worse/ better, • Character:sharp/ dull/ stab/ burn/ cramp/ crushing. • Radiation • Alleviating factors, • Time course: when last felt well, chronic: why came now. • Exacerbating factors, "What are you doing when it comes on?". • Severity: scale of 1-10.

  7. Examination • ABCDE approach in any acutely unwell patients • General Appearance • Lies perfectly still with inflammation, peritonitis (appendicitis) • Restless, writhing in obstruction (renal colic) • Abdominal exam • Inspection (scars, distention, stigma of chronic liver disease) • Palpation (guarding, rebound tenderness, masses) • Percussion (tympanic, dullness) • Auscultation (silent abdo in peritonitis, tinkling high pitched in obstruction) • Abdominal signs- • Rovsing's sign – pain in RIF on palpation of the LIF (appendicitis) • Murhpies sign- cholecystitsis • PR

  8. Initial management and Investigations • Obs • IV access • Resuscitation • Analgesia • Bloods • FBC, U&E’s, LFT’s, CRP, clotting, LFT’s, amylase, group and save, blood cultures (if spiking) • ABG’s • Urinalysis • Imaging • Erect chest and abdominal X-ray • US • CT

  9. Short cases

  10. what are these signs and what is the cause? How would you score its severity?

  11. Pancreatitis Scoring (Modified Glasgow Score) • PaO2 < 8kPa (60mmhg) • Age > 55 years  • Neutrophils: (WBC >15 x109/l  • Calcium < 2mmol/l • Renal function: (Urea > 16mmol/l) • Enzymes: (AST/ALT > 200 iu/L or LDH > 600 iu/L) • Albumin < 32g/l  • Sugar: (Glucose >10mmol/L) A score of three or more indicates severe pancreatitis

  12. Please see this man with loin pain • 56 yr man • L loin pain sudden onset this am • Vomiting, not drank much • Morphine settled pain • BP 140/86 HR 90 • Temp 36.7 • Dipstick +++ blood, nil else • KUB done

  13. Renal Colic • XRAY

  14. L1/L2 Junction Tips of transverse processes Stone Sacroiliac joint Curves medially, Lateral to curve of sacrum Enters bladder near sacro-coccygeal junction. Level with Ischial spines Phlebolith

  15. You are the FY1 on call for general surgery • Asked to see Mrs Smith who is complaining of abdominal pain and ‘scoring’

  16. Medications • Bisoprosol 10mg od • Aspirin 75mg od • Simvastatin 40mg • Ibuprofen 400mg PRN(qds) • Paracetamol 1g qds • Oromorph 10mg prn • 63 female • admission with ischemic foot ?thrombolysis • PMH • IHD • PVD • Arthritis

  17. How would you approach this patient?

  18. Always approach acutely unwell patients using a systematic method • A- airway • B- breathing • C- circulation • D- disability • E- exposure • Immediate treatment • Initial tests and investigations • reassess

  19. Should you be concerned about this patient? • A- talking in full sentences. • B- RR 24. SATS 92% • C- looks cold and clammy. BP 85/50. HR 110 • D- (A)VPU. BM 5.9 • E- Guarding and rebound, most tender in epigastric and umbilical areas

  20. ….. Yes ! This patient has an acute abdomen and shocked. Requires immediate resuscitation and investigation

  21. what does the X- ray show? What is the possible cause in this case?

  22. What signs and symptoms would this patient have?

  23. Small bowel obstruction • Small bowel should be no more than 35mm in diameter • valvulae conniventes of the small bowel tranverse the completely across the bowel • The three commonest causes of small bowel obstruction are: • Surgical adhesions • Herniae • Intraluminal mass eg, small bowel lymphoma or gallstone (in gallstone ileus)

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