Approach to Acute Abdominal Pain Flashcards
Life threatening differentials
- Peritonitis
- AAA
- Ischaemic bowel
- Medical causes - DKA, pneumonia, MI, Addinsonian Crisis
Upper abdo differentials
- Hepatitis
- Cholecystitis
- PUD
- Pancreatitis
Lower abdo differentials
GI
- appendicitis
- IBD
- diverticulitis
Urinary
- UTI
- pyelonephritis
- renal calculi
Gynae
- ectopic
- ovarian torsion
- PID
Focussed hx
SOCRATES
General - malaise, fever
GI - N&V, bowel habit, blood, weight loss
Uro - dysuria, frequency
Gynae - LMP, pregnant? PV discharge, contraception
Focussed exam
Inspect
- movement with respiration
- grey turners / Cullens
- scars
Guarding and rebound tenderness
Murphy’s sign, Roving’s sign
Quickly palpate liver, spleen, kidneys and for AAA
Palpate for hernias
Percussion tenderness
Bowel sounds
Examine external genitalia and perform DRE if indicated
Investigations
Bloods - FBC, U&E, LFT, CRP, amylase, INR, G&S, cap glucose, VBG (lactate)
Orifice - urine dip and bHCG
X-ray / imaging
- erect CXR
- AXR if ?bowel obstruction
- FAST scan (for AAA)
- USS / CT scan
Peritonitis / Perforation
- hx
- exam
- ix
- mx
i.e. peptic ulcer, colonic tumour, diverticulum, gallbladder, appendix, spleen, AAA, ectopic
Hx
- severe generalised abdo pain
Exam
- shock
- no abdo movement with respiration
- guarding
- firm, peritonitic abdomen
- rebound tenderness
- severe pain to light palpation
- percussion tenderness
Ix findings
- erect CXR - air under diaphragm
- CT abdo pelvis - help determine site of perforation
Mx
- urgent surgical repair
- consider patient comorbidities and chance of survival
Ruptured AAA
- hx
- exam
- ix
- mx
Hx
- elderly
- severe generalised abdo pain
- back pain
- reduced GCS / collapse
Exam
- shock
- peritonitis
- expansile mass
Ix
- bedside USS abdomen
- CT angio
Mx
- aim for permissive hypotension (SBP 100)
- activate massive haemorrhage protocol i.e. 10 units
- urgent open repair (or end-vascular aneurysm repair if stable)
Appendicitis
- hx
- exam
- ix
- mx
Hx
- young patient
- periumbilical pain initially
- moves to RIF
- anorexia/nausea
- fever
Exam
- tender RIF - worse at McBurney’s point
- Guarding / local peritonitis
- Roving’s sign +ve
Ix - clinical diagnosis
- USS abdo/pelvis if gynae differentials
- Raised CRP
- bHCG - exclude pregnancy
Mx
- appendicectomy
Gallstones
- hx
- exam
- ix
- mx
Hx + Exam
- Biliary colic - severe intermittent RUQ/epigastric pain exacerbated by fatty food
- Cholecystitis - continuous RUQ/epigastric pain, tender and guarding in RUQ, Murphy’s sign +ve
- CBD stone - jaundice and RUQ pain
- Cholangitis - RUQ pain, jaundice + fever/rigors, hypotension, confusion
Ix
- LFTs - obstructive picture if CBD stones/cholangitis
- Raised CRP in cholecystitis and cholangitis
- Abdo USS (diagnostic)
- CT if percutaneous biliary drainage or cholecystostomy required
Mx
Colic - analgesia, fat free diet, outpatient cholecystectomy
Cholecystitis - abx and cholecystectomy (within 1 week)
CBD stone - continuous IV fluids to prevent renal injury
Cholangitis - IV abx and treat cause (ERCP after 24-48H to relieve obstruction)
Acute pancreatitis
- hx
- exam
- ix
- mx
Hx
- Severe epigastric/central pain radiating to back
- relieved by sitting forwards
- vomiting
- hx of cause - i.e. alcohol, gallstones, trauma, surgery, hypertriglyceridaemia, medications (thiazides, azathioprine, tetracyclines)
Exam
- epigastric tenderness
- tachycardia
- fever
- shock
- jaundice
- grey turners / Cullens signs
Ix - clinical diagnosis
- amylase or lipase raised
- deranged LFTs
- CT abdomen if diagnostic uncertainty
- Apache II / glasgow score (requires Ca and ABG)
- Confirm cause - abdo USS, triglycerides, immunoglobulins
Glasgow score - PANCREAS
- PaO2 <8
- Age >55
- Neutrophils - WCC >15x10^9
- Calcium <2
- Renal - urea >16
- Enzymes - LDH >16
- Albumin <32
- Sugar - glucose >10
Mx
- supportive
- aggressive fluid resuscitation with Hartmann’s i.e. 1L every 4 hours due to 3rd space sequestration - titrate to UO
- NBM until nausea / pain improve (enteric feeding if prolonged)
- No abx unless proven infection, gas on CT or raised procalcitonin
- Treat / withdraw cause
- ICU may be required
Diverticulitis
- hx
- exam
- ix
- mx
Hx
- elderly with LIF pain, pyrexia and diarrhoea
Exam - tender LIF, guarding/local peritonism, PR (malignancy /abscess)
Ix
- raised inflammatory markers
- CT abdo/pelvis (diagnostic)
Mx
- clear fluids only initially, then build up over 2-3 days
- abx
Renal colic
- hx
- exam
- ix
- mx
Hx
- spasms of loin to groin pain, N&V, cannot lie still
Exam
- soft abdomen, renal angle tenderness
Ix
- urine dip - microscopic haematuria
- CT KUB
Mx
- analgesia - diclofenac
- IV fluids
- Abx if infection
- removal
- —- <1cm - smooth muscle relaxants (tamsulosin)
- —- >1cm - ureteroscopy / ESWL
- —- >2cm in renal pelvis - percutaneous nephrolithotomy
- —- if obstruction - ureteric stent / nephrostomy
Bowel obstruction
- hx
- exam
- ix
- mx
Hx
- vomiting (may be faeculant)
- colicky abdo pain
- no bowel motions / flatus
Exam
- distended / tender abdo
- tinkling bowel sounds
Ix
- AXR - distended bowel loops
- CT abdo/pelvis - confirm and look for cause
- Gastrografin study in SBO
Mx
- NBM and IV fluids
- Wide-bore NG tube (free drainage)
- Laparoscopy / laparotomy (if complete or non-resolving partial obstruction)
Acute Mesenteric Ischaemia
- hx
- exam
- ix
- mx
Hx
- severe abdo pain and diarrhoea in over 50
- RF - AF, CVD RF
Exam
- hypovolaemia / shock
- soft abdomen (pain out of proportion to exam)
Ix
- high lactate
- CT abdo/pelvis - ischaemic bowel
- Mesenteric angiography - if required
Mx
- Aggressive IV fluids + NBM + NG decompression
- Abx
- If infarction - bowel resection + post-op heparinisation
- No infarction - revascularisation
