Abdominal Pain - PowerPoint PPT Presentation

Loading...

PPT – Abdominal Pain PowerPoint presentation | free to download - id: 4452d4-MGUwN



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Abdominal Pain

Description:

Today, she has crampy lower abdominal pain. No urinary sx. Exam: afebrile, bilateral lower quadrant tenderness (R L), no rebound or guarding. Other questions? – PowerPoint PPT presentation

Number of Views:191
Avg rating:3.0/5.0
Slides: 77
Provided by: Collett1
Learn more at: http://beaumontemstudent.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Abdominal Pain


1
Abdominal Pain
  • William Beaumont Hospital
  • Department of Emergency Medicine

2
Abdominal Pain
  • One of the most common chief complaints
  • Confounders making diagnosis difficult
  • Age
  • Corticosteroids
  • Diabetics
  • Recent antibiotics

3
Pitfalls
  • Consider non-GI causes
  • Acute MI (inferior), ectopic pregnancy, DKA,
    sickle cell anemia, porphyria, HSP, acute adrenal
    insufficiency
  • History
  • Location
  • Quality
  • Severity
  • Onset
  • Duration
  • Aggravating and alleviating factors
  • Prior symptoms

4
History
  • Sudden onset perforated viscus
  • Crushing esophageal or cardiac disease
  • Burning peptic ulcer disease
  • Colicky biliary or renal disease
  • Cramping intestinal pathology
  • Ripping aneurismal rupture

5
Physical Exam
  • Abdomen
  • Inspection
  • Bowel sounds
  • Tenderness (rebound, guarding)
  • Extra-abdominal exam
  • Lung
  • Cardiac
  • Pelvic
  • GU
  • Rectal

6
Labs
  • Beta-hCG
  • WBC poor sensitivity and specificity
  • LFTs hepatobiliary
  • Lipase pancreatic
  • Electrolytes CO2
  • Lactic acid
  • Urinalysis BEWARE

7
Imaging
  • Acute Abdominal Series
  • Free air
  • Bowel gas
  • KUB
  • Poor screening test
  • Ultrasound
  • Biliary disease
  • AAA
  • Free fluid or air
  • Pelvic pathology
  • CT
  • Appendicitis
  • Diverticulitis

8
Case 1
  • 79 yo female presents with aching sharp pain in
    the epigastrium and right upper quadrant ½ hour
    after eating. Pain radiates to the back. N, V
  • Differential diagnosis?
  • Testing?

9
Upper Abdominal Pain
  • Biliary disease
  • Hepatitis
  • Pancreatitis
  • PUD/gastritis/esophagitis
  • AAA
  • Pneumonia (RLL)
  • Pyelonephritis
  • Acute MI
  • Appendicitis
  • Fitz-Hugh Curtis

10
Gallstone Risk Factors
  • Female 41
  • Fertile
  • Forty
  • Fat
  • Family history
  • Others
  • Crohns, UC, SCA, thalassemia, rapid weight loss,
    starvation, TPN, elevated TGs, cholesterol

11
Cholelithiasis
  • History
  • RUQ/epigastric pain
  • Nausea/vomiting with fatty meals
  • Similar episodes in past
  • PE RUQ tenderness
  • Labs may be normal
  • ECG consider in older patients
  • Imaging test of choice US

12
Cholelithiasis Treatment
  • Symptomatic
  • Asymptomatic
  • Pain control
  • Anti-emetics
  • Consult general surgery
  • 90 with recurrent symptoms
  • 50 develop acute cholecystitis
  • Incidental finding
  • 15-20 become symptomatic
  • Outpatient elective surgery if
  • Frequent, severe attacks
  • Diabetic
  • Large calculi

13
Acute Cholecystitis
  • Sudden gallbladder inflammation
  • Bacterial infection in 50-80
  • E. coli, Klebsiella, Enterococci
  • History/PE
  • Fever, tachycardia, RUQ tenderness
  • Murphys sign low sensitivity
  • Labs
  • Elevated WBC with left shift
  • LFTs large elevation ? CBD stone

14
Acute Cholecystitis Imaging
  • KUB stones only seen 10
  • Air in biliary tree ? gangrenous
  • CT scan sensitivity 50
  • Ultrasound sensitivity 90-95
  • Gallstones (absent in biliary stasis)
  • Thickened gallbladder wall
  • Pericholecystic fluid
  • HIDA scan negative scan rules out diagnosis
  • Positive no visualization of the GB

15
Acute Cholecystitis
16
Acute Cholecystits Treatment
  • Admit
  • NPO
  • IVF
  • Pain control
  • Anti-emetics
  • Antibiotics
  • Surgical consult

17
Hepatitis
  • Viral
  • Hepatitis A
  • RNA, fecal-oral
  • Hepatitis B
  • DNA, STD/parenteral
  • Chronic hepatitis (10)
  • Hepatitis C
  • RNA, blood borne
  • Chronic hepatitis (50), cirrhosis (20)
  • Hepatitis D
  • RNA, co-infects Hep B
  • Bacterial
  • Alcoholic
  • Immune
  • Medications

18
Hepatitis Diagnosis
  • History
  • Malaise, low-grade fever, anorexia
  • Nausea/vomiting, abd pain, diarrhea
  • Jaundice (altered MS, liver failure)
  • Labs
  • ALT and AST (10-100x normal)
  • AST gt ALT alcoholic hepatitis
  • Elevated bilirubin
  • Abnormal PT
  • Hepatitis panel
  • Tylenol level

19
Hepatitis Treatment
  • Symptomatic IVF, electrolytes
  • Remove toxins ETOH, acetaminophen
  • Admit if altered MS or coagulopathy

20
Pancreatitis
  • Autodigestion of pancreatic tissue
  • B Biliary
  • A Alcohol
  • D Drugs
  • S Scorpion bite
  • H HyperTG, HyperCa
  • I Idiopathic, Infection
  • T Trauma

21
Pancreatitis History and Physical
  • History
  • Boring pain in LUQ or epigastrium
  • Constant
  • Radiates to mid-back
  • Nausea, vomiting
  • PE
  • Epigastric or LUQ tenderness
  • Grey-Turner or Cullen sign

22
Gray-Turner sign
  • Flank ecchymosis
  • Intraperitoneal bleeding
  • Hemorrhagic pancreatitis
  • Ruptured abdominal aorta
  • Ruptured ectopic pregnancy

23
Cullen's Sign
24
Pancreatitis Diagnosis
  • Lipase most specific
  • Ransons criteria predicts outcome
  • Acutely gt55 yo, glucose gt 200, WBC gt16k, ALT gt
    250, LDH gt 350
  • 48 hrs HCT decreases gt 10, BUN rises gt 5, Ca lt
    8, pO2 lt 60, base deficit gt4, fluid sequestration
    gt 6L
  • 3-4 criteria 15 mortality
  • 5-6 criteria 40 mortality
  • 7-8 criteria 100 mortality

25
Pancreatitis Imaging
  • Plain films sentinel loop (local ileus)
  • Ultrasound poor (biliary tree)
  • CT scan with contrast

26
Pancreatitis Treatment
  • NPO
  • IVF
  • Pain control
  • Antiemetics
  • Antibiotics if gallstones or septic
  • Surgical consult
  • If gallstones, abscess, hemorrhage or pseudocyst
  • ERCP if CBD stone

27
Gastritis/PUD
  • Duodenal 80 gastric 20
  • Etiology
  • H pylori, NSAIDS, zollinger-ellison syndrome,
    smoking, ETOH, FHx, male, stress
  • H pylori 95 duodenal 85 gastric
  • History
  • Epigastric constant, gnawing pain
  • Food lessens duodenal
  • Food worsens gastric

28
Peptic Ulcer Disease
  • Workup
  • Hemoglobin
  • PT/PTT if bleeding
  • Lipase rule out pancreatitis
  • Hemoccult stool rule out GI bleed
  • Treatment
  • Antacids (GI cocktail)
  • PPI
  • Outpatient endoscopy
  • H. pylori testing

29
Perforated Viscus
  • Rare in small bowel and mid-gut
  • History abrupt onset pain
  • Diagnosis upright CXR
  • Treatment
  • IVF
  • IV antibiotics
  • NG tube
  • OR

30
Questions on Upper Abdominal Pain?
  • Lets Move On Down

31
Case 2
  • History 35 y/o female c/o 1 day of periumbilical
    aching pain. N,V, D, F, C, anorexia.
    Today, she has crampy lower abdominal pain. No
    urinary sx.
  • Exam afebrile, bilateral lower quadrant
    tenderness (R gt L), no rebound or guarding.
  • Other questions?
  • Differential diagnosis?
  • Testing?

32
Lower Abdominal Pain
  • Appendicitis
  • Diverticulitis
  • UTI/Pyleonephritis
  • Renal colic
  • Torsion/TOA/PID
  • Ectopic pregnancy

33
Appendicitis
  • Incidence 6
  • Mortality 0.1
  • Perforation 2-6 (9 elderly)
  • All ages peak 10 30 yo
  • Difficult diagnosis
  • Young and old
  • Pregnant (RUQ)
  • Immunocompromised

34
Appendicitis
  • Abdominal pain (98)
  • Periumbilical migrating to RLQ lt 48 hrs
  • Anorexia 70
  • Nausea, vomiting 67
  • Common misdiagnosis gastroenteritis, UTI

35
Appendicitis
  • PE
  • RLQ tenderness 95
  • Rovsing RLQ pain palpating LLQ
  • Psoas R hip elevation, extension
  • Obturator flexion, internal rotation

36
Appendicitis Diagnosis
  • Labs
  • WBC gt 10k 75
  • UA sterile pyuria
  • Imaging
  • Ultrasound
  • CT scan
  • MRI

37
Appendicitis Treatment
  • IV fluids
  • NPO
  • Analgesia
  • Antibiotics
  • Surgery consult

38
Diverticulitis
  • Inflammation of a diverticulum (herniation of
    mucosa through defects in bowel wall)
  • Sigmoid colon is the most common site
  • History
  • L gt R
  • 3 under 40
  • LLQ pain with BMs
  • N/V/constipation
  • PE LLQ tenderness
  • Diagnosis clinical, CT

39
Diverticulitis Treatment
  • Admit if fever, abscess, elderly
  • NPO
  • IV fluids
  • IV antibiotics
  • Ciprofloxacin AND metronidazole
  • Surgical consultation

40
Case 3
  • History 80 y/o male c/o nausea and crampy
    abdominal pain x 1 day. Emesis which was bilious
    and is now malodorous and brown.
  • PE Diffusely tender, distended, with hyperactive
    bowel sounds.
  • Differential Diagnosis?
  • Workup?

41
Differential Diagnosis
  • Small bowel obstruction
  • Large bowel obstruction
  • Sigmoid volvulus
  • Cecal volvulus
  • Hernia
  • Mesenteric ischemia
  • GI Bleed

42
Small Bowel Obstruction
  • Etiology
  • Adhesions (gt50)
  • Incarcerated hernia
  • Neoplasms
  • Adynamic ileus non mechanical
  • Abd trauma (post op), infection, hypokalemia,
    opiates, MI, scleroderma, hypothyroidism
  • Rare intusseception, bezoar, Crohns disease,
    abscess, radiation enteritis

43
Large Bowel Obstruction
  • Etiology
  • Tumor
  • Left ? obstruct
  • Right ? bleeding
  • Diverticulitis
  • Volvulus
  • Fecal impaction
  • Foreign body

44
Bowel obstruction
  • Pathophysiology 3rd spacing ? bowel wall
    ischemia ? perforates, ?peritonitis ? sepsis ?
    shock
  • History crampy, colicky diffuse abdominal pain,
    vomiting (feculent), no flatus or BM
  • PE abdominal distension, high pitched BS,
    diffuse tenderness
  • Diagnosis AAS shows air fluid levels with
    dilated bowel
  • SB gt 3cm LB gt 10cm

45
SBO Imaging
46
SBO Treatment
  • IV fluids!
  • Correct electrolyte abnormalities
  • NPO
  • NG tube
  • Broad spectrum antibiotics if peritonitis
  • Surgery consult

47
Sigmoid Volvulus
  • History
  • Elderly, bedridden, psychiatric pts
  • Crampy lower abdominal pain, vomiting,
    dehydration, obstipation
  • Prior h/o constipation
  • PE
  • Diffuse abdominal tenderness
  • Distension

48
Sigmoid Volvulus
49
Sigmoid Volvulus Imaging and Treatment
  • AAS dilated loop of colon on left
  • Barium enema birds beak
  • WBC gt 20k suggests strangulation
  • CT scan
  • Treatment
  • IVF
  • Surgical consult
  • Antibiotics if suspect perforation

50
Cecal volvulus
  • Most common in 25-35 year olds
  • No underlying chronic constipation
  • History
  • Severe, colicky abd pain
  • Vomiting
  • PE
  • Diffusely tender abdomen
  • Distension

51
Cecal Volvulus
  • KUB
  • Coffee bean large dilated loop colon in
    midabdomen
  • Empty distal bowel
  • Treatment
  • Surgery
  • Mortality 10-15 if bowel viable 30-40 if
    gangrene

52
Hernias
  • Inguinal (most common) 75
  • Indirect 50 vs. direct 25
  • Men gt women
  • High risk incarceration in kids
  • Femoral 5 - women gt men
  • Incisional 10
  • Umbilical newborns, women gt men
  • Incarcerated unable to reduce
  • Strangulated incarcerated with vascular
    compromise

53
Hernias
  • Clinical presentations
  • Most are asymptomatic
  • Leads to SBO sxs
  • Peritonitis and shock if strangulation
  • Treatment
  • Reduce if non-tender trendelenberg, sedation,
    warm compresses
  • Do not reduce if possible dead bowel
  • Admit via OR if strangulation

54
Mesenteric Ischemia
  • Etiology
  • 50 arterial emboli
  • 20 non-occlusive disease (CHF, sepsis, shock)
  • 15 arterial thrombi
  • 5 venous occlusion
  • Mortality rates 70-90 - delayed diagnosis

55
Mesenteric Ischemia
  • Pathophysiology impaired blood supply from SMA,
    IMA, celiac trunk ? adynamic ileus ? mucosal
    infarction 3rd spacing ? bacterial invasion ?
    sepsis ? shock
  • History
  • Acute, severe, colicky, poorly localized pain
  • Postprandial pain
  • Nausea, vomiting and diarrhea

56
Mesenteric Ischemia Diagnosis
  • Pain out of proportion to exam!
  • Heme positive stools (gt50)
  • May present as LGIB
  • Peritonitis and shock
  • Late findings
  • WBC gt 15k
  • Metabolic acidosis
  • Lactic acid high sensitivity, not specific

57
Mesenteric Ischemia Diagnosis
  • CT scan
  • Bowel wall edema/gas, /- mesenteric thrombus
  • Normal CT does NOT rule out
  • Plain films late findings
  • Portal venous gas
  • Pneumatosis intestinalis
  • Treatment
  • IVF
  • NG tube
  • IV antibiotics
  • IR consult for angiography
  • Surgical consult

58
GI hemorrhage Upper GIB vs. Lower GIB
  • History
  • Hematemesis seen in 50 UGIB
  • Melena
  • 70 UGIB
  • 30 LGIB
  • Hematochezia LGIB vs. rapid UGIB
  • Ask about
  • NSAID, ASA, ETOH, Plavix, warfarin
  • Night sweats, weight loss, bowel changes ?
    malignancy
  • Iron, bismuth guaiac negative, black stools

59
GI hemorrhage
  • Consider with chief complaints
  • Weakness
  • SOB
  • Dizzy
  • Abdominal pain
  • PE orthostatics, abdomen, rectal
  • Conjunctival pallor
  • Cool, clammy skin
  • Spider angiomata, palmer erythema, jaundice,
    bruises ? liver disease

60
GIB Diagnosis
  • Hemoccult iodide, methylene blue and red meat
    cause false pos
  • Labs
  • CBC (Hg lt 8)
  • PT
  • T S
  • Increased BUN (blood, hypovolemia)
  • ECG rule out silent MI (anemia)
  • NG tube rule out UGI bleed

61
Upper GI Hemorrhage Etiology
  • PUD 60
  • Gastritis/esophagitis 15
  • Varices portal HTN, liver disease
  • Mallory-Weiss
  • Aortoenteric fistula H/o AAA repair
  • Other Stress ulcers, malignancy, AVM, ENT
    bleeds, hemoptysis

62
Lower GI Hemorrhage Etiology
  • Hemorrhoids most common overall
  • Diverticulosis most common severe cause LGIB
  • Angiodysplasia
  • Polyps/cancer
  • Rectal disease
  • IBD

63
GIB Treatment
  • Unstable
  • IV x 2, O2, monitor
  • Blood products FFP, pRBCs, platelets
  • NG tube with lavage if upper GIB suspected
  • Upper GI bleed ? GI for endoscopy
  • Lower GI bleed ? GI and/or surgery consults
  • Tagged red blood cell study need 0.1 0.2
    ml/min of hemorrhage

64
GIB Treatment
  • Colonscopy ligate or sclerose diverticulosis,
    AVM bleeds
  • EGD band ligation or sclerose varices
  • Octreotide varices, PUD
  • Vasopressin varices
  • Sengstaken-Blakemore tube varices

65
GIB Surgical Indications
  • Hemodynamically unstable
  • Unresponsive to endoscopy, IV fluids, and
    correction of coagulopathy
  • Transfused gt 5units in 4-6 hrs
  • Mortality 23 if emergent surgery

66
GIB Disposition
  • Admit
  • Any UGIB
  • Any hemodynamic instability
  • Significant LGIB
  • Observation
  • LGIB with stable vital signs and HgB
  • Discharge home
  • Hemorrhoid bleed, rectal negative with normal HgB

67
Case 4
  • 70 y/o male with HTN, DM c/o acute onset right
    flank pain. Pain is sharp and crampy, radiates to
    the groin. He is pale, diaphoretic. Abdomen is
    soft, diffusely tender, no rebound or guarding.
  • What are you thinking and what are you going to
    do?

68
Differential Diagnosis
  • Renal colic
  • Mesenteric ischemia
  • PUD with perforation
  • GI bleed
  • Diverticulitis
  • Cholecystitis
  • Pancreatitis
  • Low back pain

69
AAA
  • 4 male 1 female
  • Peak incidence 70 yo
  • 98 infrarenal (50 involve iliacs)
  • 33 of cases initially misdiagnosed
  • Renal colic, low back pain
  • Risk factors HTN, smoking, COPD, diabetes,
    hyperlipidemia, connective tissue disease
    (Marfans, Ehlers-danlos)

70
AAA Pathophysiology
  • Atherosclerosis causes loss of elastin and
    collagen in aortic wall
  • Normal aorta diameter 2 cm
  • Uncommon to rupture if lt 5 cm
  • Elective repair
  • 30 of aneurysms gt5 cm rupture within 5 years

71
AAA
  • History
  • Sudden onset severe constant mid-abdomen or back
    pain
  • Pain may radiate to the thigh or testes
  • Back/flank pain retroperitoneal ureteral
    irritation
  • PE
  • Pulsatile mass 50-90
  • Abdominal distension due to RP or IP blood
  • Abdominal bruit 3-8
  • Blue toe syndrome 5 due to emboli

72
AAA Diagnosis
  • ECG
  • Plain films
  • R/o free air or SBO
  • Calcified aorta
  • US
  • Helpful to diagnosis
  • Does not delineate rupture or leaking aneurysm
  • CT
  • Evaluates size, leakage and extent
  • Angiography
  • May miss AAA if mural thrombus

73
AAA
74
AAA Treatment
  • Asymptomatic patient
  • Incidental finding
  • lt4 cm repeat US Q6 months
  • gt4 cm elective repair
  • Symptomatic patient
  • CT to confirm diagnosis (if stable)
  • 2 large bore IVs
  • TC
  • pRBC - 8 units
  • Admit via OR (vascular surgery consult)

75
AAA Mortality
  • Elective repair 4
  • Post rupture 45
  • Normal BP 20
  • Hypotensive, responds to volume 40
  • Hypotensive, incomplete response 60
  • Hypotensive, no urinary output 80

76
The End
  • Any Questions?
About PowerShow.com