Acute Abdominal Pain (Small Group Session 21) Flashcards
What are the 6 major causes of an acute abdomen?
6 Major Causes of an Acute Abdomen
- Acute appendicitis
- Acute pancreatitis
- Acute cholecystitis
- Small bowel obstruction
- Small bowel infarction
- Perforated viscus
A 36 yr old F presents to the ER with sever RLQ pain. The pain started 36 hours ago and at that time was just a dull pain around her umbilicus. Since then, the pain has progressed in severity and she notes that on the car ride over, every bump on the road caused her excruciating pain. The pain is now quite focal in her RLQ, sharp and 10/10. She has been prev. healthy, no prior surgeries. She denies any urinary frequency or urgency. Her last mentstrual period was 3 weeks ago. She takes the birth control pill.
What is at the top of your differential diagnosis?
Appendicitis
Clinical Features
- Most reliable feature is progression of signs and symptoms
- Low grade fever (38 C), rises if perforated
- Abdominal pain then anorexia
- Classic pattern: pain initially periumbilical; constant, dull, poorly localized, then well localized pain over McBurney’s point
- Due to progression of disease from visceral irritation (causing referred pain from structures of the embryonic midgut, including the appendix) to irritation of parietal structures
- McBurney’s sign
- Signs
- Inferior appendix: McBurney’s sign, Rovsing’s sign
- Retrocecal appendix: Psoas sign
- Pelvic appendix: Obturator sign
- Complications: perforation, abscess
A 55 yr old female presents to the ER complaining of 3 days of RUQ and epigastric pain. The patient describes a crescendo of pain that then subsides and returns as a crescendo again. Upon physical exam you note a positive Murphy’s sign. Temp 38 C.
Bloodwork:
- Elevated WBC with a left shift
- Mildly elevated bilirubin, AST, ALT and ALP
What is at the top of your differential diagnosis?
Acute cholecystitis
Clinical Features
- Often have history of biliary colic
- Severe constant (hours to days) epigastric or RUQ pain, anorexia, low grade fever (38.5)
- Focal peritoneal findings: Murphy’s sign, palpable, tender gallbladder (in 33%)
- Boas’ sign: right subscapular pain
A 52 yr old, overweight F presents to the ER with epigastric pain that radiates to her back. She also complains of nausea. She has Crohn’s disease that is maintained with Azathioprine and a family history of gall stone disease. She is tachycardic, T 38.5 C. Abdomen is tender on exam.
What investigation is most likley to reveal the diagnosis?
Serum Lipase
This pt. likely has acute pancreatitis. Acute pancreatitis is most often caused by gall stones or alcohol. This pt. has a FHx of gall stones. Acute pancreatitis can also be drug induced. Azathioprine is a common drug that precipitates pancreatitis.
Acute Pancreatitis Clinical Features
- Pain (epigastric pain radiating to back), N/V, ileus, peritoneal signs, jaundice, fever
- Inglefinger’s sign: pain worse when supine, better when sitting forward
- Rarely may have coexistent cholangitis or pancreatic necrosis
- Ranson’s criteria for determining prognosis of acute pancreatitis
- PE: tachypnea, tachycardica, hypotension, abdominal distension and tenderness, Cullen’s sign, Grey Turner’s sign
A 35 yr old male presents to the ER with severe nausea and vomiting. He describes colicky abdominal pain and has not had a BM in three days. On exam, abdomen is distended. Air fluid levels are present on x-ray.
What is your differential diagnosis?
- Bowel obstruction/infarction
What are the peritoneal signs?
Peritoneal Signs
- Shake tenderness
- Percussion tenderness
- Rebound tenderness
- Gaurding/rigid abdomen
- Murphy’s sign (Cholecystitis)
- Rovsing’s sign (Appendicitis)
- Psoas sign (Appendicitis)
- Obturator sign (Appendicitis)
List the essential ER investigations for someone with an acute abdomen.
Acute Abdomen Investigations
For diagnosis:
- ALP, ALT, AST, bilirubin
- Lipase, amylase
- Beta-hCG (pregnancy test)
- Urinalysis (genitourinary cause)
- Troponins (cardiac cause, ECG)
- Lactate
For OR preparation:
- CBC, electrolytes, BUN, creatinine, glucose
- CXR, ECG
- INR/PTT
Compare and contrast visceral and somatic pain.
Visceral Abdominal Pain
- Derived from visceral peritoneum
- Autonomic Nervous System; vagus n.
- Sensitive to stretching, pulling, contraction
- Poorly localized, dull, crampy
- Made worse with movement
- May come and go in waves
- Examples: intenstinal colic, renal colic, biliary
Somatic Pain
- Derived from parietal peritoneum
- Mediated by somatic nerves: transmitted via spinal nerves from parietal peritoneum or mesoderm of abdominal wall
- Sensitive to cutting, burning, inflammation
- Often caused by peritonitis or somatically innvervated structures
- Typically sharp, well-localized, severe, persistent
- Patient lies still
- Example: peritonitis, appendicitis, diverticulutis
What is the pathophysiology of appendicitis?
Pathophysiology of Appendicitis
- Obstruction of appendiceal lumen (fecalith, fibrosis, neoplasia, foreign bodies, lymph nodes)
- Increased lumenal pressure and spasm (visceral pain)
- Imparied circulation to wall of appendix (ischemia)
- Bacterial invasion (mucosal invasion) of wall with inflammation and necrosis (somatic pain - localization of pain to RLQ)
- Perforation with peritonitis of abscess
What is the management for an acute pancreatitis patient?
Acute Pancreatitis Management
Supportive Care
- Aggressive fluid and electrolyte replacement, NPO
- Monitoring: Vitals, urine output, O2 sat, pain
- Analgesia, anti-emetics
- Other treatments: acid suppression, antibiotics, NG tube, nutritional support, urgent ERCP, ICU, transfer to high volume centre
What are the potential complications of acute pancreatitis?
Acute Pancreatitis Complications
Local
- Fluid collections (Pseudocyts)
- Necrosis
- Infection
- Ascites
- Erosion into adjacent structures
- GI obstruction
- Hemorrhage
Systemic
- Pulmonary (pulmonary edema)
- Renal
- CNS
- Multiorgan failure
Metabolic
- Hypocalcemia
- Hyperglycemia
