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Symptoms and Signs in Acute Abdominal Pain

Symptoms and Signs in Acute Abdominal Pain. Aims & Objectives. Describe types of pain Evaluate features of abdominal pain Outline a plan for investigation List some special circumstances Explore differentials Debunk a few myths Highlight pitfalls. Pain. Type Site Duration

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Symptoms and Signs in Acute Abdominal Pain

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  1. Symptoms and Signs in Acute Abdominal Pain

  2. Aims & Objectives • Describe types of pain • Evaluate features of abdominal pain • Outline a plan for investigation • List some special circumstances • Explore differentials • Debunk a few myths • Highlight pitfalls

  3. Pain • Type • Site • Duration • Aggravating / Relieving factors • Character • Radiation • Associated Phenomena

  4. Types of Pain • Visceral pain: • dull, poorly localized pain in midline epigastrium, periumbilical region or lower midabdomen • crampy, burning and gnawing • Referred Pain: • pain felt in areas remote to the disease organ (subphrenic abscess felt as shoulder pain)

  5. Chronology • Sudden onset, well localized = intra-abdominal catastrophe • perforated viscus, • mesentaric infarction • ruptured aneurysm • Progression • appendicitis increases, • gastroenteritis decreases, • colic crescendo/decrescendo • Duration hours to days more severe than pain lasting weeks

  6. Site • May not be specific • Pain of diaphragmatic irritation may present as shoulder pain • Changes in location may be marker of progression • Appendicitis - McBurney’s point • Perforated ulcer - vague pain to peritonitis

  7. Aggravating and Relieving factors • Peritonitis  lie motionless • Renal colic  writhe, unable to find comfortable position • Fatty foods  biliary colic • Pain improves with eating  DU • Worse with eating  GU, mesenteric ischemia

  8. Intensity and character • Perception of intensity is dependent on point of reference of patient • Not very useful • Treat • ‘Patient is always right’

  9. Obtaining a history • PMH • bowel obstruction, renal colic, PID tend to recur • ROS • fever, chills  infectious • nausea, vomiting with no flatus  bowel obstruction • dysuria, pregnancy, menstrual history

  10. Physical Examination

  11. Physical Examination • Still patient  peritonitis • Writhing patient  colic, bowel obstruction • Look for medical causes - lower lobe pneumonia - myocardial Infarction • Remember the old and the young may present very atypically • elderly, diabetics, immunocompromised may present with minimal symptoms

  12. Physical Examination • Severe tenderness with rigidity  peritonitis  surgical colleagues • Mild tenderness  gastroenteritis • Palpate from areas of least pain to areas with most pain • Peritonitis (shake bed, deep breath) • Pelvic, Genital and Rectal exam on every patient with severe abdominal pain

  13. Investigations

  14. Investigations • FBC • U&E • Pregnancy test in all women of reproductive age with abdominal pain • LFTs, amylase on patients with upper abdominal pain

  15. Diagnostic Imaging • Plain Film • Consider erect chest x-ray • Consider abdomen (will it really make a difference? ) • Ultrasound for patients with biliary or pelvic symptoms • CT Abdomen and Pelvis • evaluates vasculature, inflammation and solid organs

  16. The differential.. • Acute Cholecystitis • cystic duct obstructed, RUQ pain  R scapula • Murphy’s sign, • LFTS, amylase • Acute Appendicitis • anorexia, N/V and vague periumbilical pain • 6-8 hrs pain migrates to RLQ, fever • Progresses to localized peritoneal irritation

  17. The differential (cntd) • Pancreatitis • Inflammatory bowel disease • Acute Diverticulitis • most commonly in sigmoid colon • symptoms related to inflammation or obstruction • Consider CT useful early to r/o abscess

  18. The differential (cntd) • Bowel Obstruction • 70% of cases in adults are post-op • adhesions, incarcerated hernias • bilious vomiting, feculent vomiting  distal obstruction • X-rays  dilated bowel with fluid levels • Perforated DU • usually in the anterior duodenal bulb • usually sudden acute pain with peritonitis • Chest x-ray may show free air under diaphragm

  19. The differential (cntd) • Acute mesenteric ischemia • intestinal angina (pain with eating) • “vasculopath” (cad, pvd, abdo bruits etc) • acute onset of periumbilical abdominal pain out of proportion to physical findings • Consider if atrial fibrillation • acidosis may herald intestinal infarction • surgery if acute vascular occlusion noted

  20. The differential (cntd) • AAA • acute onset of tearing abdominal pain • tender abdominal mass in 90% • triad of hypotension, pulsatile mass and abdominal pain noted in 75% • Alert surgeons/anaesthetist/theater • Others: • endometriosis, salpingitis, tubo-ovarian absess, ovarian cysts or torsion, ectopic pregnancy

  21. Special Circumstances • 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

  22. Special Circumstances • Very Young • appendicitis and abdominal trauma secondary to NAI • PID, Meckel’s diverticulum, cystitis, enteritis, IBD • Very Old • symptoms may be subtle • compulsive evaluation

  23. Special Circumstances • Immuno-compromised • chemotherapy, organ transplants, immunosupression for autoimmune disease, AIDS • symptoms are subtle • unique to immunocompromised host (neutropenic enterocolitis, GVH, CMV infections, KS, lymphoma/leukemia obstruction)

  24. Chronic Abdominal Pain • 15% of population complain of recurrent chronic abdominal pain • Abdominal pain lasting > 6 months • IBS • Women 70% of all IBS patients • obtain history of abuse (physical/sexual) • exhaustive work-up usually negative

  25. Any Questions ?

  26. Summary • Obtain detailed history • Careful examination and re-examination • Consider patient co-morbidity • Prompt, appropriate investigations • Ask for help if confused!!

  27. Upper G.I. Haemorrhage

  28. Causes • Oesophageal Mallory Weiss Tumour Oesophagitis Varices • Peptic Ulcer Disease • NSAIDs • Aorto-eneteric fistula

  29. Clinical Presentation • Melaena • Haematemesis • Hypovolaemia • Anaemia • History of recent abdo pain • History of NSAIDs

  30. Primary Assessment A B C

  31. Primary Assessment • Protect airway against aspiration • Pulse • Blood pressure • Respiratory Rate • Look for indicators of cause

  32. Resuscitation • Oxygen • Cardiac Monitor • Widebore Cannulation • Restore intravascular volume Warmed saline Blood • Insert CVP • Insert urinary catheter

  33. Resuscitation • Consider FFP • Consider platelets • Endoscopy • Early surgical referral • +/- Surgery

  34. Secondary Assessment • Good History • Drug History • Jaundice • Other medical problems • PR

  35. Secondary Assessment • FBC • Gp and X-match • Coag Screen • U&E • LFTs • CXR • ECG

  36. Definitive Care • Early endoscopy • +/- surgery Severe continuous bleeding 60 years with > 4 units transfusion < 60 years with > 8 units transfusion

  37. Adverse prognostic factors • Age > 60 • Signs of hypovolaemia • Hb <10gm • Severe co-existent disease • Continued bleeding or re-bleeding • Varices

  38. Any Questions ?

  39. Summary • Is the airway at risk ? • Is oxygenation adequate ? • Are there signs of circulatory failure ? • Early attention to electrolytes • Attention to fluid balance • Early referral

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