Acute abdomen for EP

Prasit Wuthisuthimethawee Department of Emergency Medicine Prince 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%)

Non-specific; 90% dissolved, 5.4% Sx.

Othong R, Wuthisuthimethawee P, Vasinanukorn P Songkla Med J vol. 28 No 1 Jan-Feb 2010

Predictor for an intensive care or specific treatment in the elderly patients with acute abdominal pain
1 year retrospective review, 386 cases Dyspepsia (21.8%), non-specific (17.6%) and acute gastroenteritis (8.8%) Male, BT < 38, PR >90, abnormal abd contour, and Localize tenderness or guarding
Worapraatya P, Wuthisuthimethawee P, Vasinanukorn P

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

Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain

Analgesia is safe in abdominal pain

Br J Surg. 2003 Jan;90(1):5-9

Analgesia on abdominal examination

Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial Prospective, double-blind clinical trial

Reexam in 60 minutes
No differences with respect to changes in physical examination or diagnostic accuracy
J Am Coll Surg. 2003 Jan;196(1):18-31

Analgesia on abdominal examination

Analgesia in patients with acute abdominal pain

Opioid improve patients comfort and does not retard decision to treat

Cochrane Database Syst Rev. 2007 Jul 18;(3): CD005660

Analgesia on abdominal examination

Efficacy and impact of intravenous morphine before surgical consultation in children with right lower quadrant pain suggestive of appendicitis: a randomized controlled trial

Randomized double-blind placebo-controlled trial

8-18 years old, 90 patients

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

Medication on abdominal examination

Buscopan ?

Clinical assessment Reassessment

Clinical assessment
Patients 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, dont send them out!

Copes 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 Underlying HT LLQ abdominal pain for 1 day V/S BP 140/80 P 90 RR 24

Case 2
Abd: LLQ pain, guarding ? CVA: tenderness Lt.

UA: microscopic hematuria

Diclofenac improved

Recurrent 2 times in 3 days

What is diagnosis ?

Hematuria may be seen in abdominal aortic aneurysm (30%)

Case 3
Female 47 years old No known underlying dis. RLQ abdominal pain for 1 day

V/S BP 130/80 P 82 RR 22

Case 3
Abd: RLQ pain, guarding ?, CVA: not tender

CBC: leukocytosis UA: WNL

What is diagnosis ?

Clinical assessment

Special sign Iliopsoas and Obturator < 10% in appendicitis

Special sign Fist Percussion

Special sign Rovsings 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 pain In 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