1 - Acute ABD Pain Flashcards
What is the MC reason for an ER visit in the US?
ABD pain / cramps / spasms / whatever — some kind of abdominal thing
What is often req’d for dx?
Imaging to make a specific dx
Visceral pain
Form the organ
Parietal pain
From the overlying serosa
Referred pain
Felt somewhere else
Causes of visceral pain
Obstruction
Ischemia
Inflammation
Visceral pain feels:
Crampy, dull, achey
Can be either steady or intermittent (colicky)
Is visceral pain highly specific?
No, generalized due to nerve segmental distribution
Body can’t really locate it bc it’s fed by the spinal cord
Epigastric pain
Stomach, 1st / 2nd parts of duodenum, liver, gallbladder, pancreas
Periumbilical pain
Third/fourth parts of duodenum, jejunum, ileum, cecum, appendix, ascending colon, first two-thirds of transverse colon
Suprapubic pain
Last third of transverse colon, descending colon, sigmoid, rectum
Why is parietal pain (somatic pain) more localized?
Irritation of the myelinated fibers that innervate the parietal peritoneum
Can be localized to the dermatome superficial to the painful stimulus
As the dz process evolves:
Sxs change from visceral pain -> parietal pain, causing tenderness and guarding
Pts c peritonitis prefer to remain:
Immobile
Referred pain patterns are based on
Developmental embryology
Referred pain is usually perceived:
Ipsilateral
Only midline if process is midline
Markers high acuity:
I.e. they are not doing well
Age Severe pain c rapid onset Abnormal V/S Dehydration Evidence of visceral involvement
ABD pain then shock?
Suspect bleeding (AAA)
How much blood loss required to see SBP drop?
30-40 percent of normal volume (so, by the time you see a drop in BP, that means they’ve lost a lot (30-40 percent of their blood!))
Does the absence of tachycardia mean their fluid level is good?
No - they could just be compensating in other ways
Tachypnea may indicate
Cardiopulmonary process
Metabolic acidosis
Anxiety
Pain
If you suspect hemorrhage or urgent transfusion is anticipated, what should you order?
Cross-matched blood
How can I quickly measure and visualize the ABD aorta?
Bedside ultrasound
ID a AAA quickly
High-risk groups:
Cognitive impairment Cannot communicate effectively Asplenic patients Neutropenic patients Transplant patients Immunosuppressed
What’s the problem with assessing immunosuppressed?
They can have delayed or atypical presentation
Also, more likely to present c opportunistic infx
What’s the most important measure of immunocompetence in an HIV (+) patient?
CD4 count
If over 200, less likely to have opportunistic stuff
Don’t forget to check what?
SKIN! Color, temp, turgor, perfusion status
Also, targeted heart and lung exam
Distention could mean:
Ascites
Ileus
Obstruction
Volvulus
Obvious masses could mean:
Hernia
Tumor
Aneurysm
Distended bladder
Surgical scars could mean:
Adhesions
Ecchymoses could mean:
Trauma
Bleeding diathesis
Stigmata of liver disease is:
Spider angiomata
Caput medusa
Decreased BS, consider:
Ileus, mesenteric infarction, narcotic use, or peritonitis
Hyperactive BS, consider:
Small bowel obstruction
Abdominal rigidity and involuntary guarding reflex suggests:
Peritoneal irritation
How common is rebound tenderness in appendicitis?
About a third
Lower abd pain in a female?
Its wise to do a pelvic exam in women who have not had a complete hysterectomy
Lower quadrant vs pelvic / suprapubic can be difficult to differentiate
With lower abd pain in males, you also wanna check for:
Hernia
Testicular and prostate exams
What is the main value of the rectal examination?
Detection of grossly bloody, maroon, or melanotic stool
Two main approaches to grouping ABD pain
- By location (quadrant)
2. By presenting symptomalogy
Slide 30
Breakdown of ddx by quadrant
Slides 31-32
Ddx by symptomalogy
Will opioid analgesia obscure exam findings?
No - treat the pain
Consider placing what while waiting for surgical consult?
NG tube (can confirm bleeding, decompress the stomach)
Foley Cath (can relieve bladder obstruction and help gauge renal function by measuring UOP)
What’s the deal with lab tests?
Comprehensive H and P, PE, way more important
Pt’s can have real disease c (-) lab findings
ex. - up to 25% of pts with acute mesenteric ischemia have normal serum lactate initially
Slide 36 and 37
If you suspect this, order that
If suspect pancreatitis , order:
Lipase
Is suspect pregnancy, get
HCG
Abdominal series usually includes:
Upright ABD or upright chest
Plain radiographs to check for:
Obstruction
Sigmoid volvulus
Perforation
Severe constipation
Contrast options:
PO
PR
IV
Protocols vary
Preferred imaging modality for dx’ing kidney and urethral stones
Noncontrast CT
Slides 44 through 49
The super mega chart (don’t need to memorize)
But it helps
If dx is unclear, you should have the pt follow up:
Within 12 hrs
Any woman of reproductive age c hemodynamic collapse?
R/o ectopic pregnancy
Slide 55
Common GYN causes of lower abdominal or pelvic pain
Some of them potentially life-threatening
MC surgical entity in elderly c ABD pain?
Cholecystitis
Concern for bariatric surgery patients?
Enteric leak -> sepsis
Air fluid levels may suggest but don’t confirm:
Obstruction
I’m sorry to hear about your abdominal pain
If you could put down the mountain dew and wipe the Cheetos dust off your hands i’ll be happy to jump right into your emergency
