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Abdominal Pain

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Abdominal Aortic Aneurysm AAA AAA: Diagnosis and Management CT of Rupturing AAA: Cases Differential? Slide 32 Selections from Diffuse pain : Mesenteric ... – PowerPoint PPT presentation

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Title: Abdominal Pain


1
Abdominal Pain
LSU Medical Student Clerkship, New Orleans, LA
2
Historical Elements
  • O- onset
  • P-provocation /palliation
  • Q- quality/quantity
  • R- region/radiation
  • S- severity/scale
  • T- timing/time of onset

3
Physical Exam
General Appearance and Vitals (sick vs Not
sick) Abdominal exam-Inspection (scars, masses,
ecchymosis, distention)-Auscultation (bowel
sounds, bruits),-Percussion (organomegaly,
dullness)-Palpation (tenderness, guarding,
rebound, referred pain, masses)-Don't forget GU,
Rectal and Pelvic
4
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5
Visceral Pain
Stretching of hollow viscus or capsule of solid
viscus Visceral fibers enter the spinal cord at
several levels leading to poorly localized,
poorly characterized pain. (dull, cramping,
aching)
6
Visceral Pain
Visceral pain can be localized by the sensory
cortex to an approximate spinal cord level
determined by the embryologic origin of the organ
involved. Foregut organs (stomach, duodenum,
biliary tract) produce pain in the epigastric
region Midgut organs (most small bowel,
appendix, cecum) cause periumbilical
pain Hindgut organs (most of colon, including
sigmoid) as well as the intraperitoneal portions
of the genitourinary tract cause pain initially
in the suprapubic or hypogastric area.
7
Parietal Pain
Parietal abdominal pain is caused by irritation
of fibers that innervate the parietal peritoneum
Parietal pain, in contrast to visceral pain,
can be localized to the dermatome superficial to
the site of the painful stimulus. As the
underlying disease process evolves, the symptoms
of visceral pain give way to the signs of
parietal pain, causing tenderness and guarding.
As localized peritonitis develops further,
rigidity and rebound appear.
8
Referred Pain
  • Pain or discomfort that is perceived at a site
    distant from the affected organ because of
    overlapping transmission pathways
  • Also reflects embryologic origin
  • subdiaphragmatic irritation -gt ipsilateral
    supraclavicular or shoulder pain gynecologic
    pathology -gt back or proximal lower extremity
    painbiliary tract disease -gt right infrascapular
    painmyocardial ischemia -gtmidepigastric, neck,
    jaw, or upper extremity painureteral obstruction
    -gt ipsilateral testicular pain

9
Radiology Plain Films
  • Advantages Quick, easy, non-invasive, lower
    radiation, lower cost, can be done at bedside and
    can help make decisions in certain disease
    states.
  • Disadvantages
  • Only useful in certain conditions otherwise
    low yield, difficult to position sick patients.

10
Radiology Plain Films
  • When are they useful?
  • Obstruction/Ileus
  • Volvulus (cecal and sigmoid)
  • Free air
  • Radiopaque foreign bodies
  • Constipation?

11
Plain Films Small bowel obstruction
12
Cecal Volvulus and Sigmoid Volvulus
13
Pneumoperitoneum
14
Iron Overdose
  • Remember the radiopaque foreign bodies
    mneumonic
  • BAT CHIPS
  • BariumAntihistaminesTricyclic
    antidepressantsChloral hydrate, calcium,
    cocaineHeavy metalsIodinePhenothiazine,
    potassiumSlow-release (enteric coated)

15
Radiology Ultrasound
  • Advantages Can be done at bedside, easy to
    learn, repeatable, no radiation, cheap, can be
    used in pregnancy, patient does not need to leave
    the department
  • Disadvantages Highly dependent on users skill
    level. Limited by body habitus and bowel gas

16
Radiology Ultrasound
  • What conditions is it most useful for?
  • Gallbladder disease
  • AAA
  • Hydronephrosis
  • Volume status
  • Ob/Gyn (Ectopic, IUP, Ovarian pathology)
  • Appendicitis (particularly in children)

17
Ultrasound Cholecystitis
18
Ultrasound AAA
19
Ultrasound Appendicitis
20
Radiology CT
  • Advantages Highly diagnostic for most disease
    processes. High yield exam. Helpful with
    multiple, competing diagnoses.
  • Disadvantages Time. Cost. Radiation. Contrast
    exposure (for IV contrast). Patient should be
    stable to go to CT.

21
Laboratory
  • The labs you order should be used confirm or
    exclude specific diagnoses suspected by your
    history and physical examination.
  • CBC, CMP, Amylase, Lipase and UA are routinely
    ordered as belly labs but should not be ordered
    blindly.
  • The studies you obtain (labs and imaging) should
    be ordered with the intention of changing your
    management of the patient. They should not be
    ordered just because the patient is in the ED.

22
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23
Cases
  • A 60 y/o male presents after a syncopal event
    with a complaint of abdominal pain.
  • His pain is poorly localized but radiating to his
    back.
  • His history is significant for HTN and tobacco
    abuse.
  • His vitals are normal and his physical exam
    reveals only the following

24
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25
What is on the differential?
  • Pancreatitis
  • Mesenteric Ischemia
  • MI
  • Gallbladder Disease
  • GERD
  • Obstruction
  • Peritonitis
  • PE
  • PUD
  • AAA
  • Valvular Insufficiency
  • Perforated Viscus

26
Abdominal Aortic Aneurysm
  • What happens
  • The media weakens over time, the vessel dilates
    and expands over time. As the vessel weakens and
    expands, rupture becomes more likely.
  • The larger it becomes, the more likely is the
    rupture.

27
AAA
  • Fun facts
  • They are typically infrarenal
  • gt3cm at this level is a AAA
  • Age, Family history, Atherosclerotic risk
    factors, infection, trauma, connective tissue
    disease are risk factors.
  • Rupture is associated with 80-90 mortality.
  • Vital signs can be normal. For now.

28
AAA Diagnosis and Management
  • HP May not be symptomatic until the rupture
  • Syncope and Abdominal pain
  • Cullens sign and Grey Turners sign
  • Imaging U/S 100 sensitive when the aorta is
    visualized.
  • CT requires a stable patient but is also highly
    sensitive and is better at detecting rupture and
    retroperitoneal fluid.
  • Treatment is surgical!! Despite what surgery
    tells you There is no such thing as a stable
    rupture.
  • EDs role is maintaining hemodynamic stability
    with blood products SBP 90-100mg until surgery.

29
CT of Rupturing AAA
30
Cases
  • A 75 year old male presents with diffuse, severe
    abdominal pain after having a bloody bowel
    movement.
  • His history is significant for A. Fib and CHF.
  • His vitals show hypotension and tachycardia.
  • You palpate a soft abdomen but even the lightest
    touch causes him extreme pain.
  • You stabilize him and send him to the CT film

31
Differential?
  • Lower GI Bleed
  • Brisk Upper GI bleed
  • Mesenteric Ischemia
  • Peritonitis
  • Diverticulitis
  • Aorto-enteric Fistula
  • Small Bowel Obstruction
  • Large Bowel Obstruction

32
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33
Selections from Diffuse pain Mesenteric
Ischemia
  • What happens Most commonly from emboli but can
    be from thrombus or low-flow state to mesenteric
    vasculature which leads to ischemia of the bowel.
  • Death of bowel leads to bacterial translocation
    which leads to peritonitis, sepsis, hemodynamic
    instability and death.

34
Imaging
  • XR pneumatosis intestinalis, air in the portal
    vein, pneumobilia, perforation.
  • US Pneumatosis, decreased flow.
  • CT The test of choice and the gold standard.
    Can determine etiology and extent of involvement,
    thus determining course of treatment. Requires a
    stable patient!
  • MR No advantage over CT

35
Mesenteric Ischemia Diagnosis and Management
  • Begins with history/physical and a high degree of
    clinical suspicion.
  • Initial treatment is resuscitative and
    supportive. What does that actually mean?
  • Early surgical consult.
  • May require IR depending on etiology of ischemia.

36
Cases
  • A 23 year old female presents with severe,
    intermittent right lower quadrant pain associated
    with nausea and vomiting.
  • She has no medical history.
  • Her vital signs reveal tachycardia but are
    otherwise normal.
  • Physical exam shows a soft abdomen, RLQ TTP
    without peritoneal signs. Pelvic (which is part
    of the physical exam), shows scant discharge.
  • If you could only order one test, what would it
    be?
  • What is on your differential?

37
Differential
  • Ectopic Pregnancy
  • Ruptured Ovarian Cyst
  • Appendicitis
  • Right-sided diverticulitis
  • TOA
  • Ovarian Torsion
  • Nephrolithiasis
  • Pyelonephritis
  • Endometriosis
  • UTI
  • Heterotopic pregnancy
  • Terminal ileitis

38
Ovarian Torsion
39
Increased ovarian volume (gt15cc), multiple
follicles and decreased blood flow.
40
Cases
  • A 24 y/o male presents with rapid onset,
    non-radiating, diffuse abdominal pain.
  • He has no medical or surgical history.
  • He is tachycardic and tachypneic.
  • His exam reveals a distended abdomen which is
    diffusely tender. He has decreased bowel sounds.

41
Differential?
  • Appendicitis
  • Bowel Obstruction
  • Testicular torsion
  • Perforated Viscus
  • Colitis
  • PUD
  • Peritonitis
  • Mesenteric Ischemia

42
What happens and what it looks like
43
Compared to a Sigmoid Volvulus
44
Obstructions Small and Large Bowel
  • Small
  • Adhesions
  • Hernias
  • Masses
  • Large
  • Masses
  • Diverticulitis
  • Sigmoid Volvulus

45
Treatment
  • NPO
  • NasoGastric Tube suction.
  • Fluid and Electrolyte repletion
  • Antibiotics
  • Surgical consult

46
Pitfalls
  • Incomplete exams (rectals, pelvics and genital
    exams)
  • Incomplete histories
  • Missing abnormal vitals
  • Relying on labs
  • Relying on imaging
  • Not performing serial exams
  • Elderly, the young, the pregnant, altered or
    psychiatric patients
  • Constipation GERD Gastroenteritis and UTI

47
Other conditions
  • Systemic
  • DKA
  • Alcoholic ketoacidosis
  • Uremia
  • Sickle cell disease
  • Porphyria
  • SLE
  • Vasculitis
  • Glaucoma
  • Hyperthyroidism
  • Toxic
  • Methanol poisoning
  • Heavy metal toxicity
  • Scorpion bite
  • Black widow spider bite
  • Thoracic
  • Myocardial infarction/ Unstable angina
  • Pneumonia
  • Pulmonary embolism
  • Herniated thoracic disc (neuralgia)
  • Genitourinary
  • Testicular torison
  • Renal colic
  • Infectious
  • Strep pharyngitis (more often in children)
  • Rocky Mountain Spotted Fever
  • Monocucleosis
  • Abdominal wall
  • Muscle spasm
  • Muscle hematoma
  • Herpes zoster

48
References
  • Me.
  • SBO PICTURE http//www.healthhype.com/partial-and
    -complete-bowel-obstruction-symptoms-and-treatment
    .html
  • CECAL VOL. http//bestpractice.bmj.com/best-practi
    ce/monograph/877/resources/image/bp/2.html
  • Sigmoid http//www.learningradiology.com/archives
    2008/COW20338-Sigmoid20volvulus/sigmoidvolcorrec
    t.htm
  • Pneumoperitnoeum http//new.medicalfinals.co.uk/?
    p425
  • Foreign bodies http//lifeinthefastlane.com/2009/
    10/top-ten-foreign-bodies/
  • Gallbladder http//imaging.consult.com/imageSearc
    h?queryimpactionsqyTypeANDglobal_searchSearch
    modalitythestruenormalVariantImagefalsegrou
    pByNodenoneanatomicRegionmodalityFilterUltras
    ound
  • AAA http//www.keepingyouwell.com/CareAndServices
    /VascularLabServices/AbdominalAorticAneurysms.aspx
  • Appendix 1 http//imagingsign.wordpress.com/categ
    ory/ultrasound/
  • Appendix 2 http//www.madisonradiologists.com/Svc
    CTAbdominalPain.htm
  • CT AAA http//radiographics.rsna.org/content/20/3
    /725/F44.expansion
  • Cullens http//www.gastrointestinalatlas.com/Eng
    lish/Jejuno_and_Ileum/Etc__Etc_/etc__etc_.html
  • Portal air http//www.nzma.org.nz/journal/119-124
    6/2343/
  • Ovarian torsion http//medchrome.com/major/gynaeo
    bstr/complications-of-ovarian-cyst/
  • Ovarian torsion U/S http//www.med-ed.virginia.ed
    u/courses/rad/edus/index13.html
  • Cecal volvulus diagram http//imaging.consult.com
    /image/topic/dx/Gastrointestinal?titleColonic20O
    bstructionimagefig11locatorgr11piiS1933-0332
    (06)70677-2
  • Cecal volvulus drawing http//www.radiologyassist
    ant.nl/en/4542eeacd78cf
  • Sigmoid volvulus illustration http//alharthy.com
    /
  • Sigmoid X ray http//rad.usuhs.edu/medpix/topic_d
    isplay.html?recnum1608pt_id10030imageid
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