Abdo Pain – rules & regulations Mark Hartnell 2010 Aims    Simple rules which might help in patients with abdominal pain Talk about some myths and realities Discuss some practical “how to’s” in day to day treatment Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub What is an acute abdomen?       Mechanical Inflammatory Vascular Also cancer sometimes Congenital trauma Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub Patient demographics   3 big considerations: OLD (?50 for this purpose)   YOUNG   >65 twice chance of needing surgery Congenital and more appendicitis FEMALE (child bearing age)  Pregnant TPO, NSAP more likely Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub Symptoms  Location of visceral pain:      The only reason we ever learnt embryology Foregut = epigastric Midgut = periumbilical Hindgut = suprapubic Parietal / peritoneal pain localises Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub Associated symptoms    Vomiting – before or after pain onset is important, after pain more likely surgical Constipation does not help unless absolute Helpful features – diarrhoea, jaundice, haematuria, haematemesis, malaena Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub ‘High yield’ questions      More serious – older age, less than 48H, constant pain, no previous episode Past abdominal surgery & link to BO ↑ # serious PHx of: ca, diverticulosis, pancreatitis, kidney failure, gallstones, IBD Patients on AB’s, steroids: ‘masking’ Starting centrally, migrating to RIF highly specific for appendicitis Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub More ‘High Yield’ questions    Hx of valvular heart disease, IHD, AF, HTN correlates with risk of gut ischaemia Alcohol intake: cirrhosis, hepatitis, pancreatitis HIV: drug-related pacreatitis, infections Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub Signs - Vital signs  Tachycardia and hypotension   Tachypnoea     Hypovolaemia and sepsis Acidosis (necrosis, inflammation) Hypoxaemia Response to pain Temperature  Intra-abdominal infections Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub Signs - Vital signs     Many, many myths and pitfalls: Hypothermia in septic elderly patients Tachycardia may not feature early in hypovolaemia DO NOT assume lack of vital sign response means pain not genuine  THERE IS NO CORRELATION Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub Examination - abdo      LOOK first, expose and position GO VERY VERY VERY SLOWLY Start away from the painful area Re-examine: eg. after analgesia Psoas sign has good PPV for appendicitis?   Pt on side, extend hip Absence of severe RLQ pain almost rules out appendicitis Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub Rectal exam     Looking – fissures, fistula, external piles Not very useful overall – bleeding, prostatitis, perianal disease Might find – pale stools, blood, malaena, rectal mass Proven NOT to be useful in appendicitis Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub Investigations - bloods  HARTNELL ABDO BLOOD RULE:     Pancreatitis in particular can surprise Clotting very rarely useful    DO AN FBE, U&E, LFT AND LIPASE OR NOTHING (vast majority!!!) maybe in suspected significant hepatic disease Amylase has no value if lipase available Lactate some use in ischaemia, old patients  ONLY THE SICK ONES FOR SERIAL CHECKS Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub Xrays   CXR is low radiation, quite sensitive for free gas, rules out pneumonia Abdominal films can find:      Foreign bodies, obstruction, volvulus Are NOT a very good test in obstruction Should NOT be used for undifferentiated pain Large radiation dose cf to CXR In some situations going straight to CT better Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub Xrays    A better test in possible obstruction if adhesion related Much more likely to definitively manage based on the Xray alone Can ASK a surgical question prior to ordering Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub ultrasound   RUQ pain (stones, cholecystitis, CBD block) Obstructive uropathy (eg. pregnant)   AAA – determines aortic size, not leak     Normal sized aorta does not leak or rupture! Some role in abdominal mass evaluation Children (again, no radiation) finds:   Not stones but complications, no radiation pyloric stenosis, intussusception, appendicitis Evaluating hernias Looking for collections (good alternative to CT) Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub CT     Non-contrast image of choice renal colic Useful in pancreatitis (severity, some planning of surg Mx, talk to them first!) Intra-abdominal sepsis and trauma Pre-operative most patients except where too unstable Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub Management – symptom control  Never withhold analgesia to avoid “masking the diagnosis”   Consider NSAID’s ONLY when treating suspected renal colic (& maybe biliary)   IF ANYTHING IT HELPS! Does increase bleeding times Don’t give buscopan except for mild colicky pain (or pt.s you don’t like) Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub Antinausea agents    Undifferentiated nausea reasonable to use metoclopramide, avoid in young, give slowly, works quickly if at all – move on… Remember promethazine as an option Ondansetron / granisetron next Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub disposition   Think about having some patients reevaluated in 8-12 hours Safe for discharge includes      Benign abdominla examination Normal vital signs Controlled pain and nausea Able to eat and drink Discharge of pt.s early in appendicitis OK Last updated: 13 Dec 2012 Ballarat Grampians Emergency Medicine Training Hub