Diagnosis and Management of Acute Abdominal Pain PDF

Diagnosis and Management of Acute Abdominal Pain  1 Definition Acute abdominal pain (AAP): – Presentation of previously undiag...

Diagnosis and Management of Acute Abdominal Pain  1 Definition Acute abdominal pain (AAP): – Presentation of previously undiagnosed abdominal pain – Lasting 1/52 or < – Prior to a clinical encounter in 10 or 20 care 1 De Dombal FT. Diagnosis of acute abdominal pain. New York: Churchill Livingstone; 1991.  Introduction > 1000 causes exist2 – Non specific SAP (34%) – Acute appendicitis (28%) – Acute chlecystitis (10%) – SBO (4%) – Perforated PU (3%) – Pancreatitis (3%) – Diverticular disease (2%) – Others (13%) 20-40% admission rates 50-65% inaccurate initial diagnosis 2 De Dombal FT, Margulies M. Acute abdominal pain. Surgery1996;  Pathophysiology Visceral pain – Distention, inflammation or ischaemia in hollow viscous & solid organs – Localisation depends on the embryologic origin of the organ: Forgut to epigastrium Midgut to umbilicus Hindgut to the hypogastric region Parietal pain – is localised to the dermatome above the site of the stimulus. Referred pain – produces symptoms, not signs e.g. tenderness  Generalized AP Perforation AAA Acute pancreatitis DM Bilateral pleurisy  Central AP Early appendicitis SBO Acute gastritis Acute pancreatitis Ruptured AAA Mesenteric thrombosis  Epigastric pain DU / GU Oesophagitis Acute pancreatitis AAA  RUQ pain Gallbladder disease DU Acute pancreatitis Pneumonia Subphrenic abscess  LUQ pain GU Pneumonia Acute pancreatitis Spontaneous splenic rupture Acute perinephritis Subphrenic abscess  Suprapubic pain Acute urinary retention UTIs Cystitis PID Ectopic pregnancy Diverticulitis  RIF pain Acute appendicitis Mesenteric adenitis (young) Perf DU Diverticulitis PID Salpingitis Ureteric colic Meckel’s diverticulum Ectopic pregnancy Crohn’s disease Biliary colic (low-lying gall bladder)  Loin pain Muscle strain UTIs Renal stones Pyelonephritis  LIF pain Diverticulitis Constipation IBS PID Rectal Ca UC Ectopic pregnancy  Limitations Limitations based on the relationship between – Overlying tenderness – Underlying surgical disease 35% of intra-operative diagnoses are considered to have had atypical presentations3 3 Staniland, JR, Br Med J 3:393, 1972  Key points on history Site Nature & character Duration Intensity Precipitating & relieving factors Associated symptoms  Classification by nature Colicky pain – Baseline of no pain in true colic – IBS – Bowel obstruction  Nagging & Grumbling Biliary colic Cholecystitis PID UTI  Stabbing AAA  Burning or boring PUD Oesophagitis  Gnawing Pancreatitis Pancreatic Ca  Associated symptoms Fever Genitourinary Gynaecological Vascular  PMSH Previous episodes of AP Investigations Operations Chronic disease Immunosuppression Medications (NSAIDs)  Physical examination OBS are important Observation – Bending Forward: Chronic Pancreatitis – Jaundiced: CBD obstruction – Dehydrated: Peritonitis, Small Bowel obstruction  Systemic Examination Abdomen: Inspection - Scaphoid or flat in peptic ulcer - Distended in ascites or intestinal obstruction - Visible peristalsis in a thin or malnourished patient (with obstruction)  Systemic Examination Palpation Check for Hernia sites Tenderness Rebound tenderness Guarding- involuntary spasm of muscles during palpation Rigidity- when abdominal muscles are tense & board-like. Indicates peritonitis.  Systemic Examination Local Right Iliac Fossa tenderness: – Acute appendicitis – Acute Salpingitis in females Low grade, poorly localized tenderness: – Intestinal Obstruction Tenderness out of proportion to examination: – Mesenteric Ischemia – Acute Pancreatitis Flank Tenderness: – Perinephric Abscess – Retrocaecal Appendicitis  Important Signs in Patients with Abdominal Pain Sign Finding Association Cullen's sign Bluish periumbilical Retroperitoneal haemorrhage discoloration Kehr's sign Severe left shoulder pain Splenic rupture Ectopic pregnancy rupture McBurney's sign Tenderness located 2/3 distance from anterior iliac spine to umbilicus on right side Appendicitis Murphy's sign Abrupt interruption of inspiration on palpation Acute cholecystitis of right upper quadrant Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis Obturator's sign Internal rotation of flexed right hip causing Appendicitis abdominal pain Grey-Turner's Discoloration of the flank Retroperitoneal haemorrhage sign Chandelier sign Manipulation of cervix causes patient to lift Pelvic inflammatory disease buttocks off table Rovsing's sign Right lower quadrant pain with palpation of Appendicitis the left lower quadrant  Physical examination Auscultation – BS – > 2min to confirm absent – High pitched, hyperactive or tinkling – Bruit in epigastrium  Systemic Examination PR Examination: - tenderness - induration - mass - frank blood  Systemic Examination PV Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour  Surgical Myths Rebound tenderness, considered the clinical indicator of peritonitis, has a high (25%) false -ve rate4 Rigidity, referred tenderness & cough pain are sufficient evidence for peritonitis5 Administration of analgesics prior to surgical consultation does not obscure the diagnosis, but improves accuracy6 4 Liddington, MI and Thomson, WH, Br J :795, 1991 5 Bennett, DH Br Med J 308:1336, 1994 6 Brewster, GS et al. 2000 West J Med 172:209  Initial management 1st 20 sec there are only 3 diagnoses: – Very ill: Going to die? ask for help & resus – ill: stable for couple h? Urgent investigations, initial diagnosis & management – Reasonably well: Investigate as appropriate formulate diagnosis.  Initial management ABCDE Resuscitation & analgesia (opioid IV) Full monitoring (including UO) Low threshold in seeking senior help  Investigations FBC (Hb & WCC) Amylase (Pancreatitis) U&Es, LFTs Clotting (acute pancreatitis, sepsis, DIC, liver disease) Glucose (BM) G&S (X-match if necessary) ABG ECG Cardiac enzymes (if appropriate)  Investigations Attention to the WCC as a screening test only if substantially elevated. – 25% of patients with elevated WCC do not have different outcomes from those with a normal WCC8 FBC has a limited clinical utility  Investigations Urinalysis – Cheap – Simple & readily available test – High yield when results fit with the clinical scenario – MSU Pregnancy test  Investigations Radiology – Erect CXR – Supine AXR – USS (?gynae pathology) – CT KUB/IVU (renal/ureteric colic)  Investigations Plain X-rays have limited utility in the evaluation of AAP – Low diagnostic yield – High incidence of misleading incidental findings – Lack of impact on management – Exception: Bowel obstruction or perforation  CT scanning No significant Hx, physical advantage in DD of examination & lab AAP investigations are Delay of necessary often non-specific treatment CT is now 1st-line Routine use not imaging modality in justified pts with APP. Hx taking & physical MDCT is now faster examination are the with thinner slices basis of correct High diagnostic diagnosis8 accuracy9 8 9 Keeman JN, New diagnostic imaging technology offten offers Leschka et al,Multi-detector computer tomography of acute no advantage in the differential diagnosis of acute abdomen. abdomen. Eur Radiol. Dec;15(12):2435-47. 2005 Ned Tijdschr Geneeskd. 1999. Nov. 6:143(45):2225-9  10,11 Laparoscopy Early diagnostic laparoscopy may result in: – accurate, – prompt, – efficient management of AAP Reduces the rate of unnecessary laparotomy Increases the diagnostic accuracy May be a key to solving the diagnostic dilemma of NSAP. 10 Golash and Willson. Early laparoscopy as a routine procedure in the management of acute abdominal pain: a review of 1320 patients. Surg Endosc. 2005 Jul;19(7):882-5 11 Keller et al. Diagnostic laparoscopy in acute abdomen. Chirurg. 2006 Nov;77(11):981-5