Abdominal pain

Question 1

A 78 year old man is brought to ED from a nursing hom. He had a past stroke which left him with left-sided weakness and dysphagia. He is now confused, febrile (38.6), and has been groaning when his abdomen is palpated. He has mild abdominal distension and obvious but variable abdominal tenderness. How would you assess and manage him?

Answer 1

Impression
Concerned about ruling out acute abdomen in this presentation associated with confusion (increasing diagnostic difficulty).

causes of acute abdomen to consider in this patient include;
- Vascular: mesenteric ischaemia, volvulus (sigmoid, caecal), AAA rupture
- Complicated cholecystitis/appendicitis with +/- perforation
- bowel obstruction +/- perf
- intra-abdominal inflammation; diverticulitis, pancreatitis, etc
- other: UTI, urosepsis, bladder retention

Goals
- call for senior input and begin A to E assessment, take collateral hx where possible
- appropriately disposition patient and according to ‘ceiling of care’

Question 2

Abdominal pain - Assessment

Answer 2

Assessment
A
B - SP02/RR monitoring. CXR
C - HR/BP/ECG monitoring for ?HD unstable. IV access, initial bloods: VBG (lactate for ischaemia), FBC, UEC, LFT, Lipase, CRP/ESR, Blood cultures. Consider eFAST scan for intra-abdominal fluid. Upright AXR for ?perf
o consider early administration of broad spectrum ABx given febrile
D - GCS, PEARL
E - look for other injuries/sites of infection

Question 3

Abdominal pain - History

Answer 3

History
Difficult given patient’s pre-existing mental status and current confusion.
- collateral from nursing home
- review existing patient notes for NFR/ACD etc

• sx: pain (SOCRATES), bowel/urinary changes (N/V/D/blood), acute vs gradual onset, localisation vs generalised?
• PSHx, PMHx (known AF for mesenteric ischaemia), medications, allergies, last meal
• Systems review for other localising features

Question 4

Abdominal pain - Examination

Answer 4

Examination
- initial as per A to E

• General appearance + vitals
• Abdo exam: peritonitis (rebound pain) - local vs generalised, distension, shifting dullness
• DRE: blood (late sign in mesenteric ischaemia)
• general inspection for other sites of infection

Question 5

Abdominal pain - Investigations

Answer 5

Investigations
- as per resus
Key
- CXR + AXR (perf, dilated bowel loops)
- abdo U/S if HD unstable
- consider CT abdo if stable for surgical planning

• Pre-op bloods

Question 6

Abdominal pain - Management

Answer 6

Management
Ultimately depends on underlying cause
- early referral for gen surg review for ?definitive surgery

Supportive
- Analgesia, antipyretics
- NBM
- fluids
- IDC
- broad spectrum ABx
- VTE prophylaxis
- consider NFR/ACD etc, ‘ceiling of care’

Definitive (mesenteric ischaemia)
Unstable
- emergency laparotomy with resection or embolectomy
Stable
- balloon angioplasty and stenting
- mechanical thrombectomy

+/ anticoagulation (If venous thrombosis) and other CVD disease risk modifying medications.