1. Abdominal Pain II – Lower abdominal and pelvic pain
EMC SDMH 2015

2. Objectives Briefly revise patterns of pain radiation
Differentials of lower abdominal pain
Review assessment of appendicitis
Review assessment of diverticulitis
Review assessment of types of bowel obstruction
Discuss mesenteric ischaemia
Briefly review ovarian cyst accidents

3. 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

4. Differentials for lower abdominal pain

5. Appendicitis Commonest surgical emergency Typically younger adult
Peak in children 6-9 yrs old
10 % pts > 60yrs age
1:1500 pregnancies
Initial diagnostic accuracy of ~ 85%
Often delayed diagnosis in children, elderly, pregnancy

6. Clinical features HISTORY sens (spec) EXAM RLQ tenderness 96%
Nausea % (30%)
Anorexia % (35%)
RLQ pain % (50%)
Migration % (80%)
Fever % (50%)
Pain generally precedes nausea
Elderly, paediatric more prone to atypical presentations
RLQ tenderness %
Guarding %
Fever %
Rectal exam not helpful
Rovsings, Posas and Obturator signs may be specific, but insensitive

7. Assessment
WCC & CRP?

8. Decision rules Alvarado Score
Stratifies to high, intermediate and low risk appendicitis
When compared to CT evidence
Score %
Score %
Score %
Prospective use of Alavarado <4 to exclude appendicitis ; 28% appendicitis! (Andrew et al 2013)
~ Gestalt assessment 80-85%

9. Imaging Ultrasound CT Scan Operator dependent Sensitivity 75-90%
Specificity %
PPV and NPV 90-95%
Performs better in children
Generally accessible
Sensitivity & specificity 98%
Needs contrast
Radiation dose 8-10mSV

10. Management Early surgical referral
May not require imaging to take to OT
IV Analgesia
IV Fluids
IV antibiotics –
reduces peri-operative complication rate

11. Diverticulitis Increasing prevalence 20% chance of diverticulitis
5% of <40 yrs
30% age 60
70% age 85
20% chance of diverticulitis
10-15% diverticular bleeding
70% asymptomatic lifelong diverticulosis
5% right sided diverticulosis

12. Clinical features History EXAM/LABS Left lower abdo pain (90%)
GI disturbance
diarrhoea 30%,
constipation 50%
Anorexia (~40%)
Nausea (~40%)
Dysuria/Frequency (10%)
Fever (30%)
Abdominal tenderness (90%)
Fever (30%)
Leucocytosis (60%)
Clinical triad of LLQ pain, fever and leucocytosis ~25%

13. Imaging CT scan unequivocal test of choice
Diagnosis and severity grading
Diverticulosis
Uncomplicated Diverticulitis

14. Management Uncomplicated (75%) Complicated (25%)
Inflammation simply confined to diverticulum/lumen wall
Depending upon institutional guidelines -
Immunocompetent
Well appearing
Pain controlled
Self caring
Clear fluid diet
Oral antibiotics(Augmentin Duo) 5-7 days(?)
Analgesia
Outpatient colonoscopy 4-6 weeks
Complicated (25%)
Inflammation and free fluid, abcess, collection, obstruction ,perforation
NBM
IV Fluids +/- resuscitation fluid
IV antibiotics – triple therapy
Targeted surgical treatment depending upon complication

15. Bowel obstructions
Small bowel
Large bowel
Volvulus

16. Bowel obstruction History Exam / LABs
Abdominal pain – cramping/colicky
Distension/bloating
‘Constipation’/nil flatus
Vomiting – only if proximal
Abdominal distension
Variable degree & nature of abdominal tenderness
Bowel sounds variably present/absent
Nil specific lab results – consistent with dehydration
Acid base deficit/lactate elevation may suggest ischemia/sepsis – generally normal

17. Imaging Small bowel obstruction
Centrally located dilated loops of bowel apparent
Air-fluid interface
Dilatation >3 cm in 3 loops
Valvulae conniventes visible
String of beads sign in otherwise gasless abdomen
AXR Sensitivity 50-66%

18. Imaging Large Bowel obstruction
Colonic distension >6 cm (9 cm for cecum)
Collapsed distal colon
Peripherally distributed
Haustra visible

19. Imaging Volvulus – Sigmoid/Caecal Subtype large bowel obstruction.
Characteristic ‘coffee bean’ appearance to dilated bowel for sigmoid
Caecal volvulus less distinctive, but looped away from RIF

20. Management Small bowel (80%) Large bowel (20%) Analgesia NBM.
NGT optional
IV fluids to replace losses
CT scan to establish cause and exclude closed loop obstruction
Adhesions/Herniae (internal/external)commonest causes
Surgical consultation and admission
Analgesia
NBM.
NGT not required
IV fluids to replace losses
CT scan to establish cause
Carcinoma/Diverticular stricture commonest reasons
Sigmoid volvulus and caecal volvulus require urgent decompression to prevent bowel ischemia

21. Acute mesenteric ischaemia
Mesenteric arterial embolus
Mesenteric arterial thrombosis
Mesenteric vein thrombosis
Ischaemic colitis
Typically sudden onset colicky, severe pain; older patient with cardiovascular disease
Little to find on exam – pain out of proportion to findings
Associated forceful offensive diarrhoea; maroon/bloody stool.

22. Management No reliable pathology Imaging Treatment –
Supportive –
Metabolic acidosis +/- lactate (LATE!)
WCC >15
Amylasaemia CK
Imaging
AXR – often normal
CT – SBO; pneumatosis coli; portal vein gas
CT mesenteric angiography gold standard
Treatment –
Laparotomy if appropriate to treat cause
Broad spectrum IV a/b
Mortality 75-90% if infarction fully established
Survival 50% 5 yrs if aggressively managed early

23. Ovarian cyst accidents
Ovarian cyst torsion
Typically premenopausal woman
Commoner with PCOS, OHSS
Cyst >4 cm, R>L incidence
Severe colicky abdominal pain, becoming constant
Pain out of proportion to signs
50% nausea and vomiting
Adnexal mass on USS raises suspicion. Normal flow doesn’t exclude diagnosis
Management = laparoscopic detorsion (90% success rate hrs)

24. Ovarian cyst accidents
Ovarian cyst rupture
Corpus luteal cysts responsible, D20-26 of menses
Mittelschmerz = physiological rupture
Sudden onset of pain, maximal at onset
Secondarily generalised pelvic pain, aching in nature
Variable amount of pain - mild to very severe
Not constitutionally unwell, mild peritonism only.
USS – mild free fluid 40%.
Treatment conservative with analgesia
HAEMORRHAGE – 3% of ruptures – bleeding from corpus luteal cyst; worsening pain with free fluid. Require laparoscopic OT for haemostasis

25. Pelvic Inflammatory Disease
Spectrum of illness from acute bilateral pelvic pain 
Tubo-ovarian abscess and sepsis
Bilateral crampy dull pain <7 days duration. Exacerbated by coitus
75% associated with new PV discharge
Adnexal, uterine or cervical tenderness (95% sensitive). Cervicitis should be present
No pathology reliably rules in or out – inflammatory markers expected to be elevated however.
Swabs for chlamydia, gonococcus
USS demonstrates tubo-ovarian pathology in more unwell individuals (febrile), but often normal
Management
Mild infection – Ceftriaxone 500mg + Azithromycin stat dose, metronidazole 14/7 Repeat dose azithromycin 7/7
Major infection – Ceftriaxone 2 g daily +azithromycin +metronidazole

26. Questions?

27. Summary History remains best predictor in appendicitis.
CRP, WCC may be more useful as rule-out tests
Outpatient treatment feasible for diverticulitis
Be mindful of possibility of closed loop obstruction in SBO and need for surgical intervention early
Acute mesenteric ischaemia – suspect early with pain out of proportion to signs
Ovarian cyst torsion – good prognosis with early OT
Ovarian cyst haemorrhage can complicate of cyst rupture, but requires OT
Don’t forget PID – although can be difficult to diagnose