Acute abdomen first aid 高醫外傷科 林杏麟

外科? 內科? The critical distinction, then, is not between acute and nonacute pain, but between surgical and nonsurgical conditions.

外科 serious condition : arises suddenly and is continuous, progressively worse, and long lasting, begins during inactivity; and is not near the umbilicus

Gastrointestinal Tract Appendicitis, acute* Meckel's diverticulitis* Perforated bowel* Perforated peptic ulcer* Small and large bowel obstruction* Strangulated hernia* Diverticulitis Gastritis Gastroenteritis Inflammatory bowel disease Mesenteric lymphadenitis

Liver, Spleen, and Biliary Tract Cholangitis, acute* Cholecystitis, acute* Hepatic abscess* Ruptured hepatic tumor* Ruptured spleen* Biliary colic Hepatitis, acute Splenic infarct

Peritoneum Intra-abdominal abscess* Primary peritonitis Tuberculous peritonitis

Pancreas Pancreatitis, acute

Urinary Tract Cystitis, acute Pyelonephritis, acute Renal infarct Ureteral or renal colic

Female Reproductive System Ruptured ectopic pregnancy* Ruptured ovarian follicular cyst* Twisted ovarian tumor* Dysmenorrhea Endometriosis Salpingitis, acute

Vascular System Ischemic colitis, acute* Mesenteric thrombosis* Ruptured arterial aneurysm

Retroperitoneum Retroperitoneal hemorrhage

Miscellaneous Precompetition anxiety Trauma

Appendicitis, acute Constant pain, progressively more severe; begins in periumbilical region, moves to right lower quadrant; nausea, vomiting, and anorexia follow pain; low-grade fever; patient appears ill

Cholecystitis, acute Constant pain in right upper quadrant, onset often postprandial; nausea and vomiting; tenderness in right upper quadrant and right shoulder; splinting on right side

Perforated peptic ulcer Sudden onset of pain in midepigastrium that spreads and is aggravated by movement; patient appears acutely ill and is reluctant to move; rigid abdomen; grunting respiration; bowel sounds absent

Ectopic pregnancy Pain sudden, severe, and persistent, generally following a missed or abnormal period, typically epigastric; often associated with hypotension and tachycardia

Ovarian cyst Pain constant with sharp, sudden onset; usually in ipsilateral hypogastrium; may have nausea and vomiting following the pain

Pelvic inflammatory disease Pain at end of or shortly after normal menstrual period; bilateral lower quadrant pain aggravated by cervical manipulation; anorexia, nausea, and vomiting rare; possible cervical discharge; fever

Urinary calculus Pain location changes with movement of stone, may radiate to testicle, groin of involved side; pain very severe; patient cannot get comfortable

History and PE

Mode of onset, progression, character, and severity of pain surgical etiology: sudden in onset, severe or explosive, progressive, continuous, and lasts more than 6 hours generally. nonsurgical diagnosis: gradual in onset, mild to moderate in intensity, intermittent, recurrent, or resolves partially or completely in less than 6 hours.

Colic pain Pain arising in a hollow, tubular structure, such as the ureter, intestine, biliary radicles, or fallopian tubes, may be continuous or intermittent

Activity during which pain was first noted Surgical etiology: awakens the patient or begins during relative inactivity Nonsurgical diagnosis: during or closely following strenuous activity--or after eating

Initial location of pain the farther from the umbilicus the pain localizes, the greater the chance that a surgical condition exists. Epigastrium: foregut derivatives (stomach, duodenum, biliary tract, and pancreas) or the spleen presents. periumbilical area: midgut derivatives (jejunum, ileum, proximal third of the colon, and appendix). Hypogastrium: embryonic hindgut (distal two-thirds of the colon), internal reproductive organs (ovaries, fallopian tubes, uterus, seminal vesicles, and prostate), and the urinary bladder.

Shifting pain When the original inflammation extends to the parietal peritoneum. Appendicitis initially causes pain in the periumbilical area. Then, after 4 to 6 hours, the inflammation extends to the regional peritoneal surface and is perceived in the right lower quadrant.

Associated symptoms In surgical conditions, pain may be followed by nausea, vomiting, and anorexia. In nonsurgical conditions nausea, vomiting, and anorexia typically precede pain. Clinical experience: vomiting in the obese patient is an ominous symptom and suggests serious abnormalities.

Fever is a common finding in patients who have abdominal pain. However, fever and chills is rarely seen in surgical processes. This combination suggests infection in the urinary tract, respiratory system, etc.

Obstipation--nonpassage of both stool and gas--however, always suggests a surgical problem. Diarrhea, especially with cramps, indicates gastroenteritis and other nonsurgical conditions like inflammatory bowel disease.

What aggravates the pain Always ask first about which activities aggravate the pain. (One can generally assume that the opposite will ease the pain.) If the patient hears questions about what eases the pain, he or she may perceive it as minimizing the problem and become defensive. Coughing, sneezing, rapid movements, and walking, especially down stairs, can cause peritoneal irritation. Musculoskeletal pain is often relieved by changing position. A bowel movement often eases the pain of gastroenteritis, but the pain may promptly recur.

Men who do experience abdominal pain have a higher incidence of surgical disease.

Medications and supplements Aspirin and other nonsteroidal anti-inflammatory drugs, erythromycin, potassium, and salt tablets commonly cause gastric irritation and abdominal pain.

nonsurgical diagnosis Previous episodes, family history of similar problems, peers with the same symptoms, food intolerance, allergies, sudden changes in training or diet, and travel to regions with endemic disease.

Physical Exam Pointers vital signs, inspection, auscultation, light touch, palpation, percussion, and rectovaginal exam

keys to the physical exam tell the patient Auscultation should precede other modalities farthest from the site of maximal pain ask the patient questions and have him or her answer during palpation rebound tenderness Any pain elicited in the obese patient is significant