Prasit acute abdomen
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Acute abdomen for EP Prasit Wuthisuthimethawee Department of Emergency Medicine Prince of Songkla University
Transcript of Prasit acute abdomen
Acute abdomen for EP
Prasit WuthisuthimethaweeDepartment of Emergency MedicinePrince of Songkla University
Male 34 years old
No underlying dis.
Check up at GP
During took blood examination abd pain & syncope
Objectives
Abdominal pain pathway
Critical points for assessing abdominal pain
Epidemiology
4-10 % of all emergency department visit
50 % have clearly diagnosis
15-30% require surgical procedure esp. elderly
Acute appendicitis is the most common
Epidemiology
Unique in Pediatric and Elderly
Acute abdominal pain among elderly patients
3 years, 831 cases
Non-specific 22-24%
Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%)less peritoneal signs
Laurell H, Hansson LE, Gunnarsson U.Gerontology. 2006;52(6): 339-44
Emergency department diagnosis of acute abdominal pain in elderly patients
1 year retrospective review, 378 cases
Non-specific (35.2%), acute gastritis/gastroenteritis (10.6%), and biliary tract dis. (8.2%)
Othong R, Wuthisuthimethawee P, Vasinanukorn PSongkla Med J vol. 28 No 1 Jan-Feb 2010
Non-specific; 90% dissolved, 5.4% Sx.
Predictor for an intensive care or specific treatment inthe elderly patients with acute abdominal pain
1 year retrospective review, 386 cases
Dyspepsia (21.8%), non-specific (17.6%) and acute gastroenteritis (8.8%)
Worapraatya P, Wuthisuthimethawee P, Vasinanukorn P
Male, BT < 38, PR >90, abnormal abd contour, andLocalize tenderness or guarding
Pain pathway
Abdominal pain pathway
3 type; visceral, somatic, and referred pain
Abdominal pain pathway
Visceral pain
Wall or capsule of solid organs/bowel
Midline, dull, archy and cramping pain
Autonomic; pallor, diaphoresis, nausea, and vomiting
Abdominal pain pathway
Somatic pain
Parietal peritoneum
Sharp, discrete, and localized
Tenderness, guarding, and rebound
Abdominal pain pathway
Somatic pain
Abdominal pain pathway
Referred pain
Cutaneous site distant from the diseased organ
Diaphragm C3-5: neck and shoulder pain
Abdominal pain pathway
Referred pain
Critical points for assessing abdominal pain
Life threatening conditions
Vascular disease
Acute myocardial infarction
Ruptured ectopic pregnancy
Perforated visceral organs
Life threatening conditions
Intestinal obstruction
Acute hemorrhagic pancreatitis
Esophageal rupture
Aim
Surgical or Non-surgical
Physical examination
Accuracy 55-65% with final diagnosis
Reexamination and observation
Technique !
Physical examination
Bowel sound
Little diagnostic value
Physical examination
Do not forget PR
Physical examination
Analgesic ?
Analgesia on abdominal examination
Analgesia is safe in abdominal pain
Br J Surg. 2003 Jan;90(1):5-9
Effect on diagnostic efficiency of analgesia for
undifferentiated abdominal pain
Analgesia on abdominal examination
Reexam in 60 minutes
Prospective, double-blind clinical trial
No differences with respect to changes in physical
examination or diagnostic accuracy
J Am Coll Surg. 2003 Jan;196(1):18-31
Effects of morphine analgesia on diagnostic accuracy in
Emergency Department patients with abdominal pain:
a prospective, randomized trial
Analgesia on abdominal examination
Opioid improve patients comfort and does not retard decision to treat
Cochrane Database Syst Rev. 2007 Jul 18;(3): CD005660
Analgesia in patients with acute abdominal pain
Analgesia on abdominal examination
8-18 years old, 90 patients
Randomized double-blind placebo-controlled trial
Morphine did not delay surgical decision,
not more effective than placebo to diminishing pain
Ann Emerg Med. 2007 Oct;50(4):371-8.
Epub 2007 Jun 27
Efficacy and impact of intravenous morphine before surgical
consultation in children with right lower quadrant pain
suggestive of appendicitis: a randomized controlled trial
Buscopan ?
Medication on abdominal examination
Clinical assessment
Reassessment
Clinical assessment
Patient’s quantification of pain is unreliable
Clinical assessment
Corticosteroids and immunosuppressants
Clinical assessment
Chronic dis.: CRF
Clinical assessment
Fever ?
Clinical assessment
Prior abdominal surgery
Clinical assessment
Hernia
Genitalia
Clinical assessment
Peripheral pulse
Clinical assessment
Menstrual history
Urine pregnancy test
Clinical assessment
WBC 30% in abdominal pain of unknown etiology
Clinical assessment
20% of pancreatitis
have normal amylase
Clinical assessment
20% of pancreatitis
have normal amylase
Clinical assessment
Lactase and mesenteric ischemia
100% sensitive and 42% specific
Clinical assessment
Film acute abdomen
10-38% confirm diagnosis
Gallstone Ileus
Portal vein gas
Clinical assessment
USG and CT scan
Angiogram
Tech99m RBC scan
Clinical assessment
Myocardial infarction, pneumonia, or pulmonary embolus can present as abdominal pain
Clinical assessment
Psychiatric disorder
The last diagnosis
Mamagement
Bowel rest +/- decompression
IV resuscitation with correct electrolyte
Antiemesis ? Analgesia ? Antibiotic ?
Pre-op in surgical case
Uncertain Diagnosis
Observation
Review the cause
Consultation
Uncertain Diagnosis
When in doubt, don’t send them out!
Cope’s Early Diagnosis of the Acute
Abdomen, 20th ed.. New York, Oxford
University Press, 2000.
Case 1
Male 34 years old
No underlying dis.
Check up at GP
During took blood examination abd pain & syncope
Case 1
At ER
Sweating, looked pale
V/S BP 95/60 P 112 RR 26
Abd: tenderness at RLQ, guarding ?
What is diagnosis ?
Case 2
Female 53 years old
LLQ abdominal pain for 1 day
V/S BP 140/80 P 90 RR 24
Underlying HT
Case 2
Abd: LLQ pain, guarding ?CVA: tenderness Lt.
Diclofenac improved
Recurrent 2 times in 3 days
UA: microscopic hematuria
What is diagnosis ?
Hematuria may be seen in
abdominal aortic aneurysm (30%)
Case 3
Female 47 years old
RLQ abdominal pain for 1 day
V/S BP 130/80 P 82 RR 22
No known underlying dis.
Case 3
Abd: RLQ pain, guarding ?,CVA: not tender
CBC: leukocytosisUA: WNL
What is diagnosis ?
?
Clinical assessment
ขอบคุณครับ
Special sign
Iliopsoas and Obturator
< 10% in appendicitis
Special sign
Fist Percussion
Special sign
Rovsing’s Sign
Only 5% of patients
High-Yield historical questions
How old are you ?
Which came first-pain or vomiting ?
How long have you had the pain ?
Have you ever had abdominal surgery ?
High-Yield historical questions
Is the pain constant or intermittent ?
Have you ever had this before ?
Do you have a history of cancer diverticulosis ?
Do you have HIV ?
High-Yield historical questions
How much alcohol do you drink per day ?
Are you pregnant ?
Are you taking antibiotic or steroid ?
Did the pain start centrally and migrate ?
Do you have a history of CAD, HT, AF ?
Etiology and clinical course of abdominal painIn senior patients; a prospective, multicenter study
3 years, 831 cases
Non-specific 22-24%
Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%)less peritoneal signs
Lewis LM, Banet GA, Blenda M, et al.J Gerontol A Biol Sci Med Sci. 2005
