Symptoms and Signs in Acute Abdominal Pain

Aims & Objectives Describe types of pain Evaluate features of abdominal pain Outline a plan for investigation List some special circumstances Explore differentials Debunk a few myths Highlight pitfalls

Pain Type Site Duration Aggravating / Relieving factors Character Radiation Associated Phenomena

Types of Pain Visceral pain: Referred Pain: dull, poorly localized pain in midline epigastrium, periumbilical region or lower midabdomen crampy, burning and gnawing Referred Pain: pain felt in areas remote to the disease organ (subphrenic abscess felt as shoulder pain)

Chronology Sudden onset, well localized = intra-abdominal catastrophe perforated viscus, mesentaric infarction ruptured aneurysm Progression appendicitis increases, gastroenteritis decreases, colic crescendo/decrescendo Duration hours to days more severe than pain lasting weeks

Site May not be specific Pain of diaphragmatic irritation may present as shoulder pain Changes in location may be marker of progression Appendicitis - McBurney’s point Perforated ulcer - vague pain to peritonitis

Aggravating and Relieving factors Peritonitis  lie motionless Renal colic  writhe, unable to find comfortable position Fatty foods  biliary colic Pain improves with eating  DU Worse with eating  GU, mesenteric ischemia

Intensity and character Perception of intensity is dependent on point of reference of patient Not very useful Treat ‘Patient is always right’

Obtaining a history PMH ROS bowel obstruction, renal colic, PID tend to recur ROS fever, chills  infectious nausea, vomiting with no flatus  bowel obstruction dysuria, pregnancy, menstrual history

Physical Examination

Physical Examination Still patient  peritonitis Writhing patient  colic, bowel obstruction Look for medical causes - lower lobe pneumonia - myocardial Infarction Remember the old and the young may present very atypically elderly, diabetics, immunocompromised may present with minimal symptoms

Physical Examination Severe tenderness with rigidity  peritonitis  surgical colleagues Mild tenderness  gastroenteritis Palpate from areas of least pain to areas with most pain Peritonitis (shake bed, deep breath) Pelvic, Genital and Rectal exam on every patient with severe abdominal pain

Investigations

Investigations FBC U&E Pregnancy test in all women of reproductive age with abdominal pain LFTs, amylase on patients with upper abdominal pain

Diagnostic Imaging Plain Film Consider erect chest x-ray Consider abdomen (will it really make a difference? ) Ultrasound for patients with biliary or pelvic symptoms CT Abdomen and Pelvis evaluates vasculature, inflammation and solid organs

The differential.. Acute Cholecystitis Acute Appendicitis cystic duct obstructed, RUQ pain  R scapula Murphy’s sign, LFTS, amylase Acute Appendicitis anorexia, N/V and vague periumbilical pain 6-8 hrs pain migrates to RLQ, fever Progresses to localized peritoneal irritation

The differential (cntd) Pancreatitis Inflammatory bowel disease Acute Diverticulitis most commonly in sigmoid colon symptoms related to inflammation or obstruction Consider CT useful early to r/o abscess

The differential (cntd) Bowel Obstruction 70% of cases in adults are post-op adhesions, incarcerated hernias bilious vomiting, feculent vomiting  distal obstruction X-rays  dilated bowel with fluid levels Perforated DU usually in the anterior duodenal bulb usually sudden acute pain with peritonitis Chest x-ray may show free air under diaphragm

The differential (cntd) Acute mesenteric ischemia intestinal angina (pain with eating) “vasculopath” (cad, pvd, abdo bruits etc) acute onset of periumbilical abdominal pain out of proportion to physical findings Consider if atrial fibrillation acidosis may herald intestinal infarction surgery if acute vascular occlusion noted

The differential (cntd) AAA acute onset of tearing abdominal pain tender abdominal mass in 90% triad of hypotension, pulsatile mass and abdominal pain noted in 75% Alert surgeons/anaesthetist/theater Others: endometriosis, salpingitis, tubo-ovarian absess, ovarian cysts or torsion, ectopic pregnancy

Special Circumstances Pregnancy appendicitis, cholecystitis, pyelonephritis, adnexal problems (ovarian torsion, ovarian cyst rupture) appendicitis 7/1000 pregnancies 3% fetal loss with surgery, but 20% with perforated appendix

Special Circumstances Very Young appendicitis and abdominal trauma secondary to NAI PID, Meckel’s diverticulum, cystitis, enteritis, IBD Very Old symptoms may be subtle compulsive evaluation

Special Circumstances Immuno-compromised chemotherapy, organ transplants, immunosupression for autoimmune disease, AIDS symptoms are subtle unique to immunocompromised host (neutropenic enterocolitis, GVH, CMV infections, KS, lymphoma/leukemia obstruction)

Chronic Abdominal Pain 15% of population complain of recurrent chronic abdominal pain Abdominal pain lasting > 6 months IBS Women 70% of all IBS patients obtain history of abuse (physical/sexual) exhaustive work-up usually negative

Any Questions ?

Summary Obtain detailed history Careful examination and re-examination Consider patient co-morbidity Prompt, appropriate investigations Ask for help if confused!!

Upper G.I. Haemorrhage

Causes Oesophageal Mallory Weiss Tumour Oesophagitis Varices Peptic Ulcer Disease NSAIDs Aorto-eneteric fistula

Clinical Presentation Melaena Haematemesis Hypovolaemia Anaemia History of recent abdo pain History of NSAIDs

Primary Assessment A B C

Primary Assessment Protect airway against aspiration Pulse Blood pressure Respiratory Rate Look for indicators of cause

Resuscitation Oxygen Cardiac Monitor Widebore Cannulation Restore intravascular volume Warmed saline Blood Insert CVP Insert urinary catheter

Resuscitation Consider FFP Consider platelets Endoscopy Early surgical referral +/- Surgery

Secondary Assessment Good History Drug History Jaundice Other medical problems PR

Secondary Assessment FBC Gp and X-match Coag Screen U&E LFTs CXR ECG

Definitive Care Early endoscopy +/- surgery Severe continuous bleeding 60 years with > 4 units transfusion < 60 years with > 8 units transfusion

Adverse prognostic factors Age > 60 Signs of hypovolaemia Hb <10gm Severe co-existent disease Continued bleeding or re-bleeding Varices

Any Questions ?

Summary Is the airway at risk ? Is oxygenation adequate ? Are there signs of circulatory failure ? Early attention to electrolytes Attention to fluid balance Early referral