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Abdominal Pain

Abdominal Pain. AMY LITTLE, MD ALBANY MEDICAL CENTER. GOALS. Review the anatomy of the abdomen Quadrants Peritoneal vs. Retroperitoneal Solid vs. Hollow organ Vascular structures Assessment (History and Physical Exam) Management Abdominal trauma Special situations. The Abdomen.

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Abdominal Pain

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  1. Abdominal Pain AMY LITTLE, MD ALBANY MEDICAL CENTER

  2. GOALS • Review the anatomy of the abdomen • Quadrants • Peritoneal vs. Retroperitoneal • Solid vs. Hollow organ • Vascular structures • Assessment (History and Physical Exam) • Management • Abdominal trauma • Special situations

  3. The Abdomen • Everything between diaphragm and pelvis • Injury and illness can be very difficult to assess because of large variety of structures

  4. Abdominal Anatomy • Abdomen divided into four quadrants by body mid-line, horizontal plane through umbilicus • Organs can be located by quadrant

  5. Abdominal Anatomy • Right Upper Quadrant • Liver • Gall Bladder • Right Kidney • Ascending Colon • Transverse Colon

  6. Abdominal Anatomy • Left Upper Quadrant • Spleen • Stomach • Pancreas • Left Kidney • Transverse Colon • Descending Colon

  7. Abdominal Anatomy • Right Lower Quadrant • Ascending Colon • Appendix • Right Ovary (female) • Right Fallopian Tube (female)

  8. Abdominal Anatomy • Left Lower Quadrant • Descending Colon • Sigmoid colon • Left Ovary (female) • Left Fallopian Tube (female)

  9. Abdominal Anatomy • Periumbilical area • Located around (peri) the navel (umbilicus) • Small bowel lies in all quadrants in periumbilical area • Suprapubic area • Located just above pubic bone • Urinary bladder, uterus lie in this area

  10. Abdominal Cavity • Peritoneum = abdominal cavity lining • Divides abdomen into two spaces • Peritoneal cavity • Retroperitoneal space (retro=behind)

  11. Retroperitoneal Pancreas Kidney Ureter Inferior vena cava Abdominal aorta Urinary bladder Reproductive organs Peritoneal Spleen Liver Stomach Gall bladder Bowel Abdominal Anatomy NOTE: Disease or injury of retroperitoneal organs often causes back pain.

  12. Abdominal Anatomy • REVIEW: Organs are classified by • Quadrant, periumbilical, or suprapubic • Peritoneal or retroperitoneal • Organs can also be classified as: • Solid • Hollow • Majorvascular

  13. Solid Organs • Liver • Spleen • Kidney • Pancreas NOTE: When solid organs are injured, they bleed heavily and cause shock.

  14. Solid Organs • Liver • Largest abdominal organ • Most frequently injured • Fractures of ribs 8-12 on right side • Bleeding can be either: • Slow, contained under capsule • Free into peritoneal cavity

  15. Solid Organs • Spleen • Frequently injured with trauma ribs 9-11 on left side • Bleeds easily • Capsule around spleen tends to slow development of shock • Rapid shock onset when capsule ruptures

  16. Solid Organs • Pancreas • Lies across lumbar spine • Sudden deceleration produces straddle injury • Very little hemorrhage • Leakage of enzymes digests structures in retroperitoneal space, causes volume loss, shock

  17. Solid Organs • Kidney • Retroperitoneal • Vulnerable to trauma (blunt & penetrating), infection, obstruction, chronic disease • Tenderness: Lower ribs, upper L-spine, flank • Pain: groin, shoulder, back, flank

  18. Hollow Organs • Stomach • Gall bladder • Large, small intestines • Ureters, urinary bladder, urethra Rupturecauses content spillage&inflammationof peritoneum.

  19. Hollow Organs • Stomach • Acid, enzymes • Immediate peritonitis • Pain, tenderness, guarding, rigidity

  20. Hollow Organs • Colon • Spillage of bacteria • May take 6 hrs to develop peritonitis • Small Bowel • Fewer bacteria • May take 24-48 hours to develop peritonitis

  21. Hollow Organs: Urinary System • Ureters • Penetrating injury • Bladder • Blunt injury (seatbelts, pelvic fracture) • Urethra • Straddle injury Signs and Symptoms • Abnormal urination (Urgency, Inability, Dysuria, Hematuria) • Blood at external meatus • Perineal bruising (butterfly bruise) • Scrotal hematoma • Shock • Abdominal distension

  22. Major Vascular Structures • Aorta • Inferior vena cava • Major branches Injury can cause severe blood loss;exsanguination (bleeding out).

  23. QUESTIONS about Abdominal Anatomy?

  24. ASSESSMENT of Abdominal Pain History LOCATION • Where do you hurt? • Know locations of major organs • But realize abdominal pain locations do not always correlate well with source

  25. ASSESSMENT of Abdominal Pain QUALITY • What does pain feel like? • Steady pain - inflammatory process • Crampy pain - obstructive process

  26. ASSESSMENT of Abdominal Pain ONSET • Was onset of pain gradual or sudden? • Sudden = perforation, hemorrhage, infarct • Gradual = peritoneal irritation, hollow organ distension

  27. ASSESSMENT of Abdominal Pain RADIATION • Does pain radiate (travel) anywhere? • Right shoulder, angle of right scapula = gall bladder • Left shoulder = spleen, stomach • Around flank to groin = kidney, ureter

  28. ASSESSMENT of Abdominal Pain • DURATION • > 6 hour duration = ? surgical significance • ASSOCIATED SYMPTOM: • Nausea &/or vomiting? Bloody? “Coffee Grounds”? Any blood in GI tract = Emergency until proven otherwise

  29. ASSESSMENT of Abdominal Pain • Change in urinary habits? Urine appearance? • Change in bowel habits? Diarrhea? Appearance of bowel movements? Melena? Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss.

  30. ASSESSMENT of Abdominal Pain • Females • Last menstrual period? • Abnormal vaginal bleeding? In females, abdominal pain = Gynecological problem until proven otherwise.

  31. PHYSICAL EXAM • General Appearance • Lies perfectly still inflammation = peritonitis • Restless, writhing obstruction • Abdominal distension? • Ecchymosis around umbilicus, flanks?

  32. PHYSICAL EXAM • Vital signs • Tachycardia = Early shock &/or pain (more important than BP) • Rapid shallow breathing = peritonitis

  33. PHYSICAL EXAM • Palpate each quadrant • Work toward area of pain • Warmhands • Patient on back, knee bent (if possible) • Note tenderness, rigidity, involuntary guarding, voluntary guarding, masses • Bowel sounds (?)

  34. Management • Airway • High concentration O2 • Anticipate vomiting • Anticipate hypovolemia • Need PIV, IVF • Nothing by mouth except medications

  35. Management • Consider referred cardiac pain: • Adults > 30 • Diabetics • History of cardiac problems • In females, consider gynecological problems, especially ruptured ectopic pregnancy (surgical emergency)

  36. QUESTIONS about general assessment or management?

  37. REVIEW: GOALS • Review the anatomy of the abdomen • Quadrants • Peritoneal vs. Retroperitoneal • Solid vs. Hollow organ • Vascular structures • Assessment (History and Physical Exam) • Management NEXT: • Abdominal trauma • Special situations

  38. Abdominal Trauma • Most survive to reach hospital • Most common factors leading to death • Failure to adequately evaluate • Delayed resuscitation • Inadequate volume replacement • Inadequate/missed diagnosis • Delayed surgery

  39. High Index of Suspicion in Trauma • Mechanism • Unexplained hypovolemic shock • Signs of injured abdomen • Management

  40. Mechanism • Look for signs of injury • Bruises • Tire marks • Obvious open injuries • Trauma to lower chest, back, flank, buttocks, and perineum • Injury above umbilicus also involves chest until proven otherwise

  41. Unexplained Shock • Assess vital signs; skin color, temperature; capillary refill • Tachycardia; restlessness; cool, moist skin • In trauma, signs of shock suggest abdominal injury if no other obvious causes present • Assume any abdominal injury is serious until proven otherwise!

  42. Signs of Injured Abdomen • Diffuse tenderness • Pain • Pain referred to shoulder = Organ under diaphragm involved (?spleen) • Pain referred to back = Retroperitoneal organ involved (?kidney)

  43. Abdominal Trauma Management • Less important to diagnose exact injury • Treat clinical findings (open wounds, hypotension/tachycardia) • Management same regardless of specific organ(s) injured

  44. Abdominal Trauma Management • Airway • C-Spine if mechanism indicates • High flow O2 • Assist ventilations if needed • Give nothing by mouth • (?) MAST may be helpful in slowing intraabdominal bleeding with shock

  45. Special situations in Abdominal Pain • Impaled objects • Evisceration • Trauma to the reproductive system • Sexual assault

  46. Impaled Object • Leave in place • Shorten if necessary for transport • Leave part of object exposed

  47. Evisceration • With large laceration abdominal contents may spill out • Do NOTtry to replace

  48. Evisceration • Cover exposed organs with saline moistened multi-trauma dressing • Do NOT use 4 x 4s • Cover first dressing with second DRY dressing or aluminum foil

  49. Reproductive System Trauma • Can occur to both external and internal reproductive systems • External • More common • Pain, extensive bleeding • Internal • Less frequently injured • Treat like blunt or penetrating soft tissue injuries elsewhere on body

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