Abdominal Pain I – Upper Abdominal pains EMC SDMH 2015

Objectives Understand the nature of visceral abdominal pain and radiation patterns Be able to develop differentials for pain affecting Epigastrium, Right upper, Left upper quadrants and Flanks To briefly review the nature and management of Biliary disorders Briefly review Pancreatitis Briefly review ED approach to dyspepsia Briefly review Aortic aneurysm rupture

Pain modalities in the abdomen Visceral ‘aching, cramping, dull’ Poorly localised – typically midline  ‘Colicky’ Parietal Somatic, sharp, well localised  ‘Peritonitic’ Referred Ureteric  teste/vulva Cardiac  epigastrium, arm, back Diaphragmatic  shoulder tip

Differentials for upper abdominal pain Always consider renal/ureteric pathology in R+L UQ AAA rupture may be peri umbilical or epigastric in nature

Biliary Disorders Cholelithiaisis Cholecystitis Cholangitis (Pancreatitis)

Biliary Disorders – ‘Biliary colic’ Attack of colicky RUQ pain lasting <6 hrs No associated systemic involvement Most commonly due to stones No defining lab features. Abnormalities can be absent even with obstructed GB Inpatient surgical referral necessary if persistent pain Outpatient referral if pain resolves and tolerant of diet

Biliary disorders – Cholecystitis Unremitting RUQ pain > 6 hrs Almost always associated with stones Fever 40% Nausea 70% RUQ tenderness/‘Murphys +ve’ 80% Labs – Leukocytosis – 63% Abnormal LFT – 70% (specificity 42%) CRP – 97% specificity 76%...but only if.. Combined with USS(94% and 78% by itself!) Inpatient surgical referral IV a/b, analgesia, IVF hydration Beware gangrenous GB/perforation in elderly

Cholangitis Fever, abdominal pain, jaundice (90%, 70%, 60% presence) – Charcot triad + Altered mental state , sepsis = Reynold pentad Consider in altered mental state/sepsis differential May rapidly progress to septic shock Biliary stasis key pathology Stones 50%, malignancy 10-20%, stricture/stent 30-40% Labs – FBC - WCC elevation; thrombocytopaenia UEC - Renal impairment LFT – Obstructive picture – bilirubin elevation diagnostic Imaging – Abdominal USS CBD dilation +/- stone, obstruction ED – IV fluids, IV Tazocin Definitive treatment = Early CBD decompression (ERCP) – transfer out

Pancreatitis Sudden onset epigastric pain, boring, constant nature Dx – 2 of 3; Clinical picture Biomarker elevation – Lipase or Amylase Imaging evaluation +ve Gallstones/Alcohol 90% cases Labs – Lipase dx if >2 x ULN, Amylase 3 x Imaging not routinely required Severity – no useful ED scoring system Age, Shock, Hypoxia, Renal failure, DIC, Acidosis. APACHE > 7, Ransons >3 often used Management– Fluids, analgesia, NBM. No role for antibiotics. Surgical admission +/- ICU if moderate/severe

Dyspepsia + Reflux Epigastric burning, dull ache, colicky pain or fullness. Associated with nausea +/- vomiting Avoid accepting ‘heartburn’ ‘indigestion’ as patient descriptions Usually few ‘hard’ physical signs; beware abnormal vital signs Aim to exclude serious differentials Biliary pathology Small bowel obstruction Pancreatitis Perforation Myocardial ischaemia AAA No specifically useful labs or imaging for ‘rule-in’ Clinical diagnosis and therefore higher risk. Dyspepsia – 10-20% PU; 10-20% gastritis; 50-60% nil endoscopic findings Dyspepsia with Reflux – 33% esophagitis at endoscopy (but 80% response rate to therapy) ED management – Analgesia/Antacids. Trial PPI +/- H2 Antagonist Discharge for outpatient GP follow up for empirical treatment or ‘test and treat’ approach once symptomatically controlled

Abdominal Aortic Aneurysm Older individual >60 yrs age Sudden onset epigastric, abdominal back or flank pains – severe Beware ‘renal colic’ in over 65 yr old Fall or syncope Vitals may be normal to start Will generally appear ‘unwell’ Pulsatile mass present only 60% time Labs – Massive transfusion protocol Imaging – Bedside USS ED management – IV access x 2 Minimal volume resuscitation Emergency transport to TWH Vascular OT via ambulance

Questions?

Summary Consider pain character to decide if pain is visceral or parietal Localise to quadrant to narrow diagnosis, but be aware of variation Be aware of ability to be led astray by labs in RUQ pathology – get an USS (bedside) Keep cholangitis in mind in your septic screen; appreciate it’s ability to deteriorate Don’t get too concerned about pancreatitis scores in ED; if marked clinical or biochemical abnormality consider ICU Dyspepsia is challenging! Be careful not to label too early. AAA at SDMH requires rapid diagnosis and emergency transport