Abdominal pain Flashcards
Case
General Data:
Our patient is J.C., a 18yr /F from Makati who was brought to the
OPD due to abdominal pain.
History of Present Illness
The patient presented with a 6-hour history of moderate pain in
the right upper abdomen that began after eating dinner and
radiates through to her back. This pain gradually increased before
becoming constant over the last few hours. She has had previous
episodes of similar pain since 1 month ago for which she has not
sought medical advice. She was only self-medicated with
omeprazole 20mg/cap OD and Buscopan which afforded
temporary relief.
Ancillary History
Past Medical History: No previous hospitalizations or surgery, (-
)no history of asthma ,
Family Medical History: (-) Family history of bronchial asthma or
malignancy, (+) family history of sickle cell disease, (+) family
history of DM and hypertension
Birth and Maternal History: Born FT to an 28 year old primigravid,
with no fetomaternal complications.
Immunization history: given BCG x 1 dose, OPV x 3 doses,
Hepatitis B x 2 doses, DPT x 3 doses , measles x 1 dose c/o the
local health center. No other immunizations were given.
Nutritional History: breastfed for 5 months , non-picky eater
Developmental History: sits with support at 8 yr old, walks with
support and one-word sentences at 1 yr old
HEADSSS: 1st year college student with average scholastic
performance, lives with parents and 1 sibling, no extracurricular
activities and prefers to stay at home, likes to cook at home,
denies illicit drug use/ smoking/ previous heterosexual
relationship, drives own car with seatbelt, no suicidal ideations
PHYSICAL EXAMINATION
General Survey
Awake, not in cardiorespiratory distress
Anthropometrics
Weight =79 kgs, height =160 cm, BMI = 30
Vital signs
BP 120/90 HR 92 bpm RR 32 bpm T 36.5C O2 sats (room air) =
100%
Skin
No rash, no jaundice
Head and Neck
Pink conjunctivae, anicteric sclerae, (-) nasal congestion, (-)
cervical lymphadenopathies
Chest and Lungs
Equal chest expansion, (-) retractions, (-)rales, (-) wheezes
Cardiac
Adynamic precordium, distinct heart sounds, normal rate and
regular rhythm, no murmurs
Abdomen
Normoactive bowel sounds, (+) tenderness to palpation in the
right upper quadrant , (-) guarding or rebound tenderness, (-)
hepatomegaly, intact Traube’s space
Extremities
Full and equal pulses, (-) edema/cyanosis/clubbing, CRT less than
2 sec
LABORATORY RESULT:
CBC
WBC 4 x109/L
RBC 3.1x109/L
Hgb 110 g/L
Hct 0.38%
MCV 85fL
MCH 25 pg
Platelets 350x109/L
Neut% 0.7
Lymph% 0.3
Mono% 0.0
Eo% 0.0
Baso% 0.0
Serum amylase: normal
Serum lipase: normal
Urinalysis: normal
Stool exam with FOBT: no ova or parasite seen, negative FOBT
Plain Abdominal xray: normal, no ileus
HBT UTZ: Normal liver, distended GB with reflective echo lodged
in its head measuring 1.8cm, wall not thickened, biliary tree not
dilated
(1) What is your primary working impression?
Primary Working Impression
* Cholesterol cholelithiasis
Basis for Diagnosis
(1) History
* 18/F
* (+) symptoms worsen with meals
* RUQ pain with radiation to the back
* (+) sedentary lifestyle
* Not relieved by PPI or antacids
* No vomiting, nausea or febrile episodes
(2) Physical Examination
* Obese with BMI 30
* (+) tenderness to palpation in the right
upper quadrant
* (-) guarding or rebound tenderness
* No hepatomegaly
* No jaundice, no fever
What are your differential diagnosis for this case?
- Cholecystitis
Rule in:
-Abdominal pain RUQ
rule out:
-No fever
-marked RUQ tenderness
(Murphy’s sign)
-leukocytosis. Some patients
progress to sepsis if chronic - Choledocholithiasis
-abdominal pain RUQ
Rule out: -Charcot’s triad of biliary
pain, jaundice, and fever is absent
-CBC usually shows
leukocytosis - Acute pancreatitis
Rule in:
- Persistent abdominal pain radiating to the back
Rule out:
-History includes nausea,
vomiting, fever, respiratory distress
-PE will show guarding,
tenderness
-With skin bruising (Cullen and Turner sign)
elevated serum lipase and amylase - Peptic ulcer
-epigastric pain
Rule out: -Worse on awakening or
before meals
-Relieved by antacids - urolithiasis
-abdominal pain
Rule out:
-Progressive, severe pain
-Pain more common in flank to inguinal region
Less likely Dx
Less Likely DDX:
* Mittelshmerz
* constipation
(2) What is your plan of management for this patient?
a. Diagnostic Tests/Labs
* Clinical Diagnosis
* Gall bladder ultrasound
o Method of choice
* Plain abdominal radiograph- may reveal
opaque calculi, but radiolucent (cholesterol)
stones are not visualized
* Hepatobiliary scintigraphy - valuable
adjunct in that failure to visualize the
gallbladder provides evidence of
cholecystitis
* CBC – Normal
b. Management
b.1. Goals of Management:
Pharmacologic Management
* Pain control
* hydration
Non-pharmacologic management
* Surgical:
Laparoscopic cholecystectomy - routinely
performed in symptomatic infants and
children with cholelithiasis. Common bile
duct stones are unusual in children,
occurring in 2–6% of cases with
cholelithiasis, often in association with
obstructive jaundice and pancreatitis.
Operative cholangiography - should be done
at the time of surgery to detect
unsuspected common duct calculi
Endoscopic retrograde cholangiography
with extraction of common duct stones -
option before laparoscopic cholecystectomy
in older children and adolescents.
b.2. Anticipatory care
* Proper nutrition
* Adolescent vaccination
* Cardiometabolic risk for hypertension, DM
Common causes
0-2mos:
Serious –> NEC
Adhesions
Less serious– > Colic
Infant dyschezia
3-12mos:
serious–>Foreign body
Trauma
less serious–> Constipation
AGE
Viral illness
Dietary protein
allergy
UTI
1-5yo:
serious–>Appendicitis
FB
Intussusception
Trauma
less serious–>Constipation
AGE
Viral illness
Pharyngitis
UTI
PN
6-12yo:
serious–>Appendicitis
Adhesions
DKA
Trauma
IBD
less serious–> Constipation
AGE
Viral illness
Pharyngitis
UTI
PN
Differentials for RUQ pain
gastritis,PUD, cholecystitis, cholangitis, cholelithiasis, pneumonia, peritonitis
Differentials for epigastric pain
Hepatobiliary disorders
GERD, esophagitis, gastritis, PUD, pancreatitis
Differentials for LUQ pain
Gastrits, PUD, esophagitis, pneumonia, splenic infarction, hemorrhage, trauma
Differentials for periumbical pain
intussusception
appendicitis
peritonitis
intestinal parasitism
gastroenteritis
Differentials for RLQ
appendicitis
mesenteric adenitis
Meckel’s diverticulum
pyelonephritis, renal calculi
ureteropelvic junction
obstruction
ovarian torsion/cyst, abscess
PID
Differentials for hypogastric pain
cystitis
bladder anomalies
Sigmoid volvulus
PID
differentials for LLQ pain
pyelonephritis
renal calculi
Ureteropelvic junction obstruction
ovarian torsion cyst, abscess, PID
Most common cause of acute surgical condition in children
Appendicitis
Pathophysiology of appendicitis
Patho:
- Appendiceal luminal obstruction (secondary to
inspissated fecal material/LNE/parasites) –> inc
intraluminal P à inc bacterial proliferation, inc mucus
secretion, inc venous congestion, inc edema –>
ischemia of bowel wall –> gangrenous appendicitis –>
appendiceal perforation
Clinical manifestations of acute appendicitis
CM “PANT”
1. Pain, abdomen – usually 1st sx, vague, poorly localized,
colicky, periumbilical à after 12-24h, RLQ severe pain
exacerbated by movt
2. Anorexia – classic and consistent
3. Nausea, vomiting
4. T (fever) – LG
5. Malaise
6. Perforation – usually after 36-48h abdominal distention
7. Hyperactive à hypoactive BS
8. Localized abd tenderness – single most reliable finding
9. Dunphy signs – RLQ pain after coughing
10. Rovsing sign – referred rebound tenderness
11. Psoas sign – pain on active R thigh flexion/passive
extension of hip = retrocecal appendix
12. Obturator sign – abductor pain after internal rotation
of flexed thigh = pelvic appendicitis
13. Abdominal guarding
14. Rebound tenderness – red flag. Indication for surgical
consult. 50% Sn, 60% Sp
Mc Burney’s point – junction of lateral and middle 1/3 of line
joining ASIS and umbilicus
What are the diagnostics for acute appendicitis?
Dx
1. CBC – N/mildly elev with L shift (11-16K, PMN >7500,
elev WBC > 10K, 20K (perforated)
2. UA – few WBC, RBC, no bact. To r/o UTI
>5 wbc/hpf bacteriuria common after 48 hrs
3. Serum amyloid A protein
4. CT scan – gold standard; appendiceal diameter >6mm,periappendicial inflammation (fat streaking, phlegmon, fluid collection, extraluminal gas), appendiceal wall
thickness >1mm, adenopathy, abscess, non-filling of
appendiceal lumen, appendicolith
5. UTZ – appendiceal diameter >6cm, target sign with 5 concentric layers, distention/obstruction of lumen, high echogenicity surrounding the appendix, appendiceal wall thickness > 2mm, absence of appendiceal stasis, periappendiceal/ perivascular free fluid, appendicolith
Management of acute appendicitis
Mgt
1. Prompt appendectomy – within 23-24h
2. Abx: cefoxitin 80-100 mkd q6-8 IV – not perforated
If perforated: Piperacillin-Tazobactam 300-400 mkd IV q6/8
Ticarcillin/Clavulanate 200 mkd q6 IV
Ceftriaxone 50-75 mkd IV q12/24
Metronidazole 30 mkd IV/po q6
3. Non-operative treatment (NOT) – indicated for:
a. abdominal pain <48h
b. WBC <18,000/uL
c. normal CRP
d. No appendicolith on imaging
e. appendix diameter <1.1cm on imaging
f. not yet ruptured based on clinical findings
- in-px broad spectrum abx x 1-2d: Piperacillintazobactam,
ceftriaxone + metronidazole, ciprofloxacin
18-30 mkd q8 IV + metronidazole
Until there is resolution of sx and WBC is N
Followed by 7-10d of oral abx: co-amoxiclav 30-40 mkd q8-12, ciprofloxacin 20-40 mkd q12 + metronidazole 30 mkd q8
Complication
- MC: wound infection, intraabdominal abscess
Etiopathogenesis of intestinal obstruction
Etiopatho
- Accumulation of food, gas, and intestinal secretions proximal to the point of obstruction causes bowel distention
- Distention leads to dec intestinal absorption, inc fluid and electrolyte secretion, and isotonic intravascular depletion
- Intestinal contractions initially inc, then hypoactive BS persist
- Classified as:
o Intrinsic – atresia, stenosis, meconium ileus,
aganglionic megacolon
o Extrinsic – malrotation, constricting bands,
intra-abdominal hernias, duplications
- Atresia: complete obstruction of bowel lumen
- Stenosis: partial block of luminal contents
What are the clinical manifestations of intestinal obstruction?
- Classic – nausea and vomiting, abdominal distention, obstipation
- High obstruction – large volume, frequent, bilous emesis, intermittent pain in epigastrium or periumbilical area, relieved by vomiting
- Low obstruction – moderate/marked distention with emesis that is progressively feculent, diffuse pain over entire abdomen
Diagnostics for intestinal obstruction
Radiograph
*Essential xray views in intestinal obstruction:
1. Plain supine/upright/decubitus xrays
2. cross-table lateral view: distended bowel above the obstruction with fluid level and gas in the distended loops
*Abdominal xray findings in obstruction:
1. poor gas distribution or gasless
2. smooth bowel walls like sausage
3. preferential dilatation of the bowel proximal to the obstruction
4. many dilated air fluid levels in a given loop at the different heights (candy cane)
5. dilated loops in “stepladder” fashion
*Pneumoperitoneum may be seen in perforation (free air in the subphrenic area or over the liver in the left lateral decubitus position)
*ground-glass appearance in the RLQ with trapped air bubbles seen in meconium ileus
Management of intestinal obstruction
Mgt
1. Fluid resuscitation
2. NGT decompression
3. Cultures, abx
4. Surgery – for strangulation
5. Conservative measures for adhesions or strictures
6. Water soluble contrast enemas – for malrotation, meconium
ileus/plug, intussusception (dx and tx)
What is Intussusception?
- Portion of alimentary tract is telescoped into an
adjacent segment - MC cause of intestinal obstruction 3mos-6yo (some 5mos to 3yrs), M>F
- MC abdominal emergency <2yo
Patho
- Untreated intussusception –> infarction –> perforation –>peritonitis –>death
- Upper portion of bowel (intussusceptum) invaginatesinto lower part (intussuscipiens) dragging itsmesentery along with it into the
enveloping loop
- Mesentery constricts and obstructs venous return
- Intussusceptum engorges leading to edema and
bleeding from the mucosa
- Idiopathic (90%), adenovirus
- Lead point: Meckel’s diverticulum, swollen peyer’s
patches, polyp
- Ileocolic (MC), cecocolic, ileoileal
What are the clinical manifestations?
CM
1. Usually preceded by hx of infection
2. Triad: pain, palpable sausage-shaped abdominal mass (RUQ),
bloody/currant jelly stool
3. Severe paroxysmal colicky pain with straining effort, recurs
at freq intervals
4. Comfortable and playing child in between paroxysms of
pain, becoming progressively lethargic
5. Child usually has straining efforts with legs and knees flexed
and loud crying
6. Vomiting (early phase), later becomes bilous vomiting
7. Lethargy
4. Sausage-shaped mass RUQ or epigastrium
5. If not reduced, a shock-like state, with fever and peritonitis
6. Currant jelly stool (60%)
7. DRE: bloody mucus
What are the diagnostics for Intussusception?
- Abdominal UTZ – screening 98-100% sn, 98% sp.
- Doughnut or target lesion (transverse view)
- Tubular mass (longitudinal view) - Pneumatic or contrast enema – dx and tx.
- Coiled spring sign: thin rim of barium trapped around the invaginating part within the intussuscipiens - Plain abd XR: vague and nonspecific. A density in the area of intussusception
Management of Intussusception
Mgt:
1. Reduction of acute intussusceptions ASAP
2. Hydrostatic reduction after under fluoroscopy/UTZ (if no signs of shock, peritoneal irritation, or intestinal
perforation)
3. Pneumatic/air reduction
4. Surgical reduction – if with refractory shock, bowel necrosis or perforation, peritonitis, multiple
recurrences
5. 4-10% can have spontaneous reduction
6. Recurrence rate 10%, post reduction 2-5%, postresection 0%.
What is malrotation?
MALROTATION
- Incomplete rotation of the intestine during fetal
development which is completed by 3 mos AOG
- MC: failure of the cecum to move into the RLQ
- Majority present within the 1st YOL
Embryology:
- Early fetal life: midgut attach to yolk sac and loops
outward
- 10th week: bowel reenters abdomen, rotates counterclockwise
until cecum reaches RLQ
- Incomplete rotation:
o Cecum near RUQ
o Duodenum in front of mesenteric artery
o Extremely narrow mesenteric root
o Susceptible to volvulus
o Abnormal mesenteric attachments (Ladd
bands) –> partial obstruction
