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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