1. Symptoms and Signs in Acute Abdominal Pain

3. 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

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

5. 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)

6. 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

7. 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

8. 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

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

10. 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

11. Physical Examination

12. 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

13. 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

14. Investigations

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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)

25. 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

26. Any Questions ?

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

28. Upper G.I. Haemorrhage

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

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

31. Primary Assessment A B C

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

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

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

35. Secondary Assessment Good History Drug History Jaundice
Other medical problems PR

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

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

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

39. Any Questions ?

40. 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