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About Abdominal Pain PowerPoint Presentation

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On : Mar 14, 2014

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  • Slide 1 - Approach to Acute Abdominal Pain Richard W. Stair, MD
  • Slide 2 - Acute Abdominal Pain Approximately 5-10% of ED visits 5 million visits annually Most common diagnosis is nonspecific abdominal pain ( ie, “I dunno!”) Sex and age shift the likelihood of certain diagnoses
  • Slide 3 - Abdominal Pain for the AgesCommon Etiologies 0-2 years - colic, gastroenteritis, viral illness, constipation 2-12 years - appendicitis, functional disorders, gastroenteritis, constipation, viral illness, toxins, UTI Teens - as in 2-12 plus dysmenorrhea, PID, Mittleshmerz, pregnancy, ovarian cyst
  • Slide 4 - Abdominal Pain for the AgesUncommon Etiologies 0-2 years - Hirschsprung’s disease, incarcerated hernia, intussusception, malabsorption, appendicitis, volvulus, milk allergy 2-12 - CF, DM, IBD, Meckel’s diverticulum, ovarian/testicular torsions Teens - colitis, DM, endometriosis, epidydimitis, cholecystitis, IBD, torsion
  • Slide 5 - BEWARE - Abdominal Pain in the Elderly Many more vague presentations Comorbid diseases Morbidity and mortality rise EXPONENTIALLY after age 50 Twice as likely to need surgery after age 65 Diminished pain sensation
  • Slide 6 - Acute Abdominal Pain and Sex Men more frequently seen in the ED, and more likely to have a perforated viscus Women are more likely to have cholecystitis, diverticulitis, and be D/C’d with nonspecific AP
  • Slide 7 - What’s the Problem Imprecise pain generation and transmission to the CNS Comorbid diseases, developmental stage of patient, medications, social factors The key is understanding types of pain visceral somatic referred
  • Slide 8 - Visceral Pain Generated by stretch receptors in the walls of hollow viscus and the capsules of solid organs Fibers return to various levels of the sympathetic trunk on BOTH sides of the spinal cord Poorly described, achy, crampy, diffuse
  • Slide 9 - Visceral Pain Levels of visceral innervation C3-5 - liver, spleen, diaphragm, pericardium T5-9 - gallbladder, stomach, pancreas, small intestine T10-11 - colon, appendix, pelvic viscera T11-L1 - sigmoid colon, renal capsules, ureters, testes S2-4 - urinary bladder
  • Slide 10 - Somatic Pain Fibers arise from the parietal peritoneum, the rrot of the mesentery, and the anterior abdominal wall Innervation corresponds to dermatomes entering cord unilaterally Usually sharp, well localized
  • Slide 11 - Referred pain Caused by overlap of nerve fibers from different locations returning to the spinal cord at the same area Pain sensed distal to site of problem Example - L shoulder pain with ruptured spleen, remember spleen’s capsular fibers enter cord at C3-5
  • Slide 12 - Abdominal Pain - HistoryThink “OLD CARS” O - onset L - location D - duration C - character A - aggravating/alleviating factors, - associated symptoms R - radiation S - severity
  • Slide 13 - History - More Info PMH - prior episodes; prior medical conditions making some diagnoses more common PSH - adhesions #1 cause SBO Medications - NSAIDS, Abx Social - drugs, withdrawal, foreign bodies Gyn/Urol - timing of periods, bleeding, testicular pain, bloody urine
  • Slide 14 - Physical Exam VITALS General - appears sick or in obvious pain Inspection - bruises, scars, distension Auscultation - hyper, normal, none Palpation - pain vs. tenderness start away from painful area, guarding, etc Extra-abdominal exam
  • Slide 15 - Physical Exam Signs Murphy’s Rovsing’s Iliopsoas Obturator
  • Slide 16 - Ancillary Tests CBC - lacks sensitivity and specificity Labs should be DIRECTED Urine dipsticks Urine hCG
  • Slide 17 - Imaging Plain films - obstruction, free air, air-fluid levels, foreign bodies CT scanning Ultrasound Nuclear medicine scans (HIDA) Endoscopy
  • Slide 18 - DDx - RUQ pain Pneumonia PE hepatitis cholecystitis biliary colic PUD Pancreatitis renal stone pyelonephritis retrocecal appendix heart failure MI
  • Slide 19 - DDx - LUQ pain Gastritis gastric ulcer pancreatitis renal stone pyelonephritis Pneumonia PE splenic rupture splenic enlargement diverticulitis
  • Slide 20 - DDx - RLQ pain Appendicitis cholecystitis diverticulitis renal stone AAA mesenteric adenitis regional enteritis Meckel’s diverticulum Testicular torsion epidydimitis salpingitis ectopic pregnancy ovarian cyst Mittleschmertz TOA cystitis prostatitis
  • Slide 21 - DDx - LLQ pain AAA renal stone diverticulitis perforation volvulus salpingitis ectopic pregnancy Ovarian cyst Mittleschmertz TOA cystitis prostatitis testicular torsion epidydimitis
  • Slide 22 - Management of Acute Abdominal Pain IV access Fluids Emesis Control Analgesia Antibiotics Consultants
  • Slide 23 - ACEP Clinical Policy on Acute Abdominal Pain - Oct 2000 Evidence based guidelines and options for many Emergency Department presentation
  • Slide 24 - Abdominal Pain - Disposition Operating Room Hospital Bed Home with abdominal warnings Remember to beware of the extremes of age
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