Diagnosis and Management of Acute Abdominal Pain

1
Diagnosis and Management of Acute Abdominal Pain

• Dimitri Raptis and Alec Engledow

2
(No Transcript)
3
Definition1

• Acute abdominal pain (AAP)
• Presentation of previously undiagnosed abdominal
  pain
• Lasting 1/52 or lt
• Prior to a clinical encounter in 10 or 20 care

1De Dombal FT. Diagnosis of acute abdominal pain.
New York Churchill Livingstone 1991.
4
Introduction

• gt 1000 causes exist2
• NSAP (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

2De Dombal FT, Margulies M. Acute abdominal
pain. Surgery1996
5
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

6
Generalized AP

• Perforation
• AAA
• Acute pancreatitis
• DM
• Bilateral pleurisy

7
Central AP

• Early appendicitis
• SBO
• Acute gastritis
• Acute pancreatitis
• Ruptured AAA
• Mesenteric thrombosis

8
Epigastric pain

• DU / GU
• Oesophagitis
• Acute pancreatitis
• AAA

9
RUQ pain

• Gallbladder disease
• DU
• Acute pancreatitis
• Pneumonia
• Subphrenic abscess

10
LUQ pain

• GU
• Pneumonia
• Acute pancreatitis
• Spontaneous splenic rupture
• Acute perinephritis
• Subphrenic abscess

11
Suprapubic pain

• Acute urinary retention
• UTIs
• Cystitis
• PID
• Ectopic pregnancy
• Diverticulitis

12
RIF pain

• Acute appendicitis
• Mesenteric adenitis (young)
• Perf DU
• Diverticulitis
• PID
• Salpingitis
• Ureteric colic
• Meckels diverticulum
• Ectopic pregnancy
• Crohns disease
• Biliary colic (low-lying gall bladder)

13
Loin pain

• Muscle strain
• UTIs
• Renal stones
• Pyelonephritis

14
LIF pain

• Diverticulitis
• Constipation
• IBS
• PID
• Rectal Ca
• UC
• Ectopic pregnancy

15
Limitations

• Limitations based on the relationship between
• Overlying tenderness
• Underlying surgical disease
• 35 of intra-operative diagnoses are considered
  to have had atypical presentations3

3Staniland, JR, Br Med J 3393, 1972
16
Key points on history

• Site
• Nature character
• Duration
• Intensity
• Precipitating relieving factors
• Associated symptoms

17
Classification by nature

• Colicky pain
• Baseline of no pain in true colic
• IBS
• Bowel obstruction

18
Nagging Grumbling

• Biliary colic
• Cholecystitis
• PID
• UTI

19
Stabbing

• AAA

20
Burning or boring

• PUD
• Oesophagitis

21
Gnawing

• Pancreatitis
• Pancreatic Ca

22
Associated symptoms

• Fever
• Genitourinary
• Gynaecological
• Vascular

23
PMSH

• Previous episodes of AP
• Investigations
• Operations
• Chronic disease
• Immunosuppression
• Medications (NSAIDs)

24
Physical examination

• OBS are important
• Observation
• Bending Forward Chronic Pancreatitis
• Jaundiced CBD obstruction
• Dehydrated Peritonitis, Small Bowel obstruction

25
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)

26
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.

27
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

28
(No Transcript)
29
Physical examination

• Auscultation
• BS
• gt 2min to confirm absent
• High pitched, hyperactive or tinkling
• Bruit in epigastrium

30
Systemic Examination

• PR Examination
• - tenderness
• - induration
• - mass
• - frank blood

31
Systemic Examination

• PV Examination
• - Bleeding
• - Discharge
• - Cervical motion tenderness
• - Adnexal masses or tenderness
• - Uterine Size or Contour

32
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
• Except for detection of blood, routine PR exams
  add little to clinical assessment6
• Administration of analgesics prior to surgical
  consultation does not obscure the diagnosis, but
  improves accuracy7

4Liddington, MI and Thomson, WH, Br J 795,
1991 5Bennett, DH Br Med J 3081336,
1994 6Manimaran, N et al. Ann Roy Col Surg Engl
86292 2004 7Brewster, GS et al. 2000 West J Med
172209
33
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.

34
Initial management

• ABCDE
• Resuscitation analgesia (opioid IV)
• Full monitoring (including UO)
• Low threshold in seeking senior help

35
Investigations

• FBC (Hb WCC)
• Amylase (Pancreatitis)
• UEs, LFTs
• Clotting (acute pancreatitis, sepsis, DIC, liver
  disease)
• Glucose (BM)
• GS (X-match if necessary)
• ABG
• ECG
• Cardiac enzymes (if appropriate)

36
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

37
Investigations

• Urinalysis
• Cheap
• Simple readily available test
• High yield when results fit with the clinical
  scenario
• MSU
• Pregnancy test

38
Investigations

• Radiology
• Erect CXR
• Supine AXR
• USS (?gynae pathology)
• IVU (renal/ureteric colic)

39
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

40
CT scanning

• No significant advantage in DD of AAP
• Delay of necessary treatment
• Routine use not justified
• Hx taking physical examination are the basis of
  correct diagnosis8

• Hx, physical examination lab investigations are
  often non-specific
• CT is now 1st-line imaging modality in pts with
  APP.
• MDCT is now faster with thinner slices
• High diagnostic accuracy9

8Keeman JN, New diagnostic imaging technology
offten offers no advantage in the differential
diagnosis of acute abdomen. Ned Tijdschr
Geneeskd. 1999. Nov. 6143(45)2225-9
9Leschka et al,Multi-detector computer tomography
of acute abdomen. Eur Radiol. Dec15(12)2435-47.
2005
41
Laparoscopy10,11

• 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.

10Golash and Willson. Early laparoscopy as a
routine procedure in the management of acute
abdominal pain a review of 1320 patients. Surg
Endosc. 2005 Jul19(7)882-5 11Keller et al.
Diagnostic laparoscopy in acute abdomen. Chirurg.
2006 Nov77(11)981-5
42
Suggestions

• Audit of all patients referred with AAP to
  assess
• Initial diagnosis
• Choice diagnostic efficacy of investigations
• Treatment
• Timing (length of stay)
• Cost effectiveness

43
Thank you