1. 1 Abdominal Pain AMY LITTLE, MD ALBANY MEDICAL CENTER

2. 2 GOALS Review the anatomy of the abdomen  Quadrants  Peritoneal vs. Retroperitoneal  Solid vs. Hollow organ  Vascular structures Assessment (History and Physical Exam) Management Abdominal trauma Special situations

3. 3 The Abdomen Everything between diaphragm and pelvis Injury and illness can be very difficult to assess because of large variety of structures

4. 4 Abdominal Anatomy Abdomen divided into four quadrants by body mid-line, horizontal plane through umbilicus Organs can be located by quadrant

5. 5 Abdominal Anatomy Right Upper Quadrant  Liver  Gall Bladder  Right Kidney  Ascending Colon  Transverse Colon

6. 6 Abdominal Anatomy Left Upper Quadrant  Spleen  Stomach  Pancreas  Left Kidney  Transverse Colon  Descending Colon

7. 7 Abdominal Anatomy Right Lower Quadrant  Ascending Colon  Appendix  Right Ovary (female)  Right Fallopian Tube (female)

8. 8 Abdominal Anatomy Left Lower Quadrant  Descending Colon  Sigmoid colon  Left Ovary (female)  Left Fallopian Tube (female)

9. 9 Abdominal Anatomy Periumbilical area  Located around (peri) the navel (umbilicus)  Small bowel lies in all quadrants in periumbilical area Suprapubic area  Located just above pubic bone  Urinary bladder, uterus lie in this area

10. 10 Abdominal Cavity Peritoneum = abdominal cavity lining Divides abdomen into two spaces  Peritoneal cavity  Retroperitoneal space (retro=behind)

11. 11 Abdominal Anatomy Retroperitoneal  Pancreas  Kidney  Ureter  Inferior vena cava  Abdominal aorta  Urinary bladder  Reproductive organs Peritoneal  Spleen  Liver  Stomach  Gall bladder  Bowel NOTE: Disease or injury of retroperitoneal organs often causes back pain.

12. 12 Abdominal Anatomy REVIEW: Organs are classified by  Quadrant, periumbilical, or suprapubic  Peritoneal or retroperitoneal Organs can also be classified as:  Solid  Hollow  Major vascular

13. 13 Solid Organs Liver Spleen Kidney Pancreas NOTE: When solid organs are injured, they bleed heavily and cause shock.

14. 14 Solid Organs Liver  Largest abdominal organ  Most frequently injured  Fractures of ribs 8-12 on right side  Bleeding can be either: Slow, contained under capsule Free into peritoneal cavity

15. 15 Solid Organs Spleen  Frequently injured with trauma ribs 9-11 on left side  Bleeds easily  Capsule around spleen tends to slow development of shock  Rapid shock onset when capsule ruptures

16. 16 Solid Organs Pancreas  Lies across lumbar spine  Sudden deceleration produces straddle injury  Very little hemorrhage  Leakage of enzymes digests structures in retroperitoneal space, causes volume loss, shock

17. 17 Solid Organs Kidney  Retroperitoneal  Vulnerable to trauma (blunt & penetrating), infection, obstruction, chronic disease  Tenderness: Lower ribs, upper L-spine, flank  Pain: groin, shoulder, back, flank

18. 18 Hollow Organs Stomach Gall bladder Large, small intestines Ureters, urinary bladder, urethra Rupture causes content spillage & inflammation of peritoneum.

19. 19 Hollow Organs Stomach  Acid, enzymes  Immediate peritonitis  Pain, tenderness, guarding, rigidity

20. 20 Hollow Organs Colon  Spillage of bacteria  May take 6 hrs to develop peritonitis Small Bowel  Fewer bacteria  May take 24-48 hours to develop peritonitis

21. 21 Hollow Organs: Urinary System Ureters  Penetrating injury Bladder  Blunt injury (seatbelts, pelvic fracture) Urethra  Straddle injury Signs and Symptoms  Abnormal urination (Urgency, Inability, Dysuria, Hematuria)  Blood at external meatus  Perineal bruising (butterfly bruise)  Scrotal hematoma  Shock  Abdominal distension

22. 22 Major Vascular Structures Aorta Inferior vena cava Major branches Injury can cause severe blood loss; exsanguination (bleeding out).

23. 23 QUESTIONS about Abdominal Anatomy?

24. 24 ASSESSMENT of Abdominal Pain History LOCATION Where do you hurt?  Know locations of major organs  But realize abdominal pain locations do not always correlate well with source

25. 25 ASSESSMENT of Abdominal Pain QUALITY What does pain feel like?  Steady pain - inflammatory process  Crampy pain - obstructive process

26. 26 ASSESSMENT of Abdominal Pain ONSET Was onset of pain gradual or sudden?  Sudden = perforation, hemorrhage, infarct  Gradual = peritoneal irritation, hollow organ distension

27. 27 ASSESSMENT of Abdominal Pain RADIATION Does pain radiate (travel) anywhere?  Right shoulder, angle of right scapula = gall bladder  Left shoulder = spleen, stomach  Around flank to groin = kidney, ureter

28. 28 ASSESSMENT of Abdominal Pain DURATION  > 6 hour duration = ? surgical significance ASSOCIATED SYMPTOM:  Nausea &/or vomiting? Bloody? “Coffee Grounds”? Any blood in GI tract = Emergency until proven otherwise

29. 29 ASSESSMENT of Abdominal Pain Change in urinary habits? Urine appearance? Change in bowel habits? Diarrhea? Appearance of bowel movements? Melena? Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss.

30. 30 ASSESSMENT of Abdominal Pain Females  Last menstrual period?  Abnormal vaginal bleeding? In females, abdominal pain = Gynecological problem until proven otherwise.

31. 31 PHYSICAL EXAM General Appearance  Lies perfectly still inflammation = peritonitis  Restless, writhing obstruction Abdominal distension? Ecchymosis around umbilicus, flanks?

32. 32 PHYSICAL EXAM Vital signs  Tachycardia = Early shock &/or pain (more important than BP)  Rapid shallow breathing = peritonitis

33. 33 PHYSICAL EXAM Palpate each quadrant  Work toward area of pain  Warm hands  Patient on back, knee bent (if possible)  Note tenderness, rigidity, involuntary guarding, voluntary guarding, masses Bowel sounds (?)

34. 34 Management Airway High concentration O 2 Anticipate vomiting Anticipate hypovolemia  Need PIV, IVF Nothing by mouth except medications

35. 35 Management Consider referred cardiac pain:  Adults > 30  Diabetics  History of cardiac problems In females, consider gynecological problems, especially ruptured ectopic pregnancy (surgical emergency)

36. 36 QUESTIONS about general assessment or management?

37. 37 REVIEW: GOALS Review the anatomy of the abdomen  Quadrants  Peritoneal vs. Retroperitoneal  Solid vs. Hollow organ  Vascular structures Assessment (History and Physical Exam) Management NEXT: Abdominal trauma Special situations

38. 38 Abdominal Trauma Most survive to reach hospital Most common factors leading to death  Failure to adequately evaluate  Delayed resuscitation  Inadequate volume replacement  Inadequate/missed diagnosis  Delayed surgery

39. 39 High Index of Suspicion in Trauma Mechanism Unexplained hypovolemic shock Signs of injured abdomen Management

40. 40 Mechanism Look for signs of injury  Bruises  Tire marks  Obvious open injuries Trauma to lower chest, back, flank, buttocks, and perineum Injury above umbilicus also involves chest until proven otherwise

41. 41 Unexplained Shock Assess vital signs; skin color, temperature; capillary refill Tachycardia; restlessness; cool, moist skin In trauma, signs of shock suggest abdominal injury if no other obvious causes present Assume any abdominal injury is serious until proven otherwise!

42. 42 Signs of Injured Abdomen Diffuse tenderness Pain  Pain referred to shoulder = Organ under diaphragm involved (?spleen)  Pain referred to back = Retroperitoneal organ involved (?kidney)

43. 43 Abdominal Trauma Management Less important to diagnose exact injury Treat clinical findings (open wounds, hypotension/tachycardia) Management same regardless of specific organ(s) injured

44. 44 Abdominal Trauma Management Airway C-Spine if mechanism indicates High flow O 2 Assist ventilations if needed Give nothing by mouth (?) MAST may be helpful in slowing intraabdominal bleeding with shock

45. 45 Special situations in Abdominal Pain Impaled objects Evisceration Trauma to the reproductive system Sexual assault

46. 46

47. 47 Impaled Object Leave in place  Shorten if necessary for transport  Leave part of object exposed

48. 48 Evisceration With large laceration abdominal contents may spill out Do NOT try to replace

49. 49 Evisceration Cover exposed organs with saline moistened multi-trauma dressing Do NOT use 4 x 4s Cover first dressing with second DRY dressing or aluminum foil

50. 50 Reproductive System Trauma Can occur to both external and internal reproductive systems  External More common Pain, extensive bleeding  Internal Less frequently injured Treat like blunt or penetrating soft tissue injuries elsewhere on body

51. 51 Male Genitalia Trauma Usually NOT life-threatening Very painful Great source of concern to patient

52. 52 Male Genitalia Trauma Avulsion of skin of penis, scrotum  Cover with a moist, sterile dressing Complete amputation of penis  Treat as any amputated part

53. 53 Male Genitalia Trauma Blunt trauma to penis, scrotum  Apply ice pack Urethral foreign bodies  Do NOT remove Penis entrapped in zipper  If 1 or 2 teeth involved, try to unzip  If more involved, cut zipper out of trousers, transport

54. 54 Female Genitalia Trauma Internal  Rarely injured External  Can cause pain, extensive bleeding  Usually not life- threatening Treat with compresses, pressure

55. 55 Sexual Assault Avoid examining genitalia unless obvious bleeding present Ask patient to NOT wash, douche, urinate, defecate Ask patient NOT to change clothes Record history, but avoid extensive questioning about incident

56. 56 SUMMARY: Abdominal Pain Consider the anatomy In general abdominal pain, note HISTORY In trauma, think about mechanism Management  ANTICIPATE!  Vomiting=airway  Hypovolemia  resuscitation  Appropriate transport

57. 57 THANK YOU FOR YOUR ATTENTION!