case 12 - abdominal pain Flashcards
what is acute abdomen?
rapid onset of severe symptoms of abdominal pathology
may indicate a potentially life-threatening condition that requires urgent surgical intervention
a common reason for emergency department attendance
what are the clinical features of acute abdomen?
immediate assessment should distinguish patients with true acute abdomen that require urgent surgical intervention from patients who can initially be managed conservatively
access to an experienced surgeon reduces unnecessary admissions
patients with acute surgical pathology may deteriorate rapidly; patients with severe,
unremitting symptoms warrant thorough investigation and close monitoring
how may abdominal pain present?
be located in any quadrant of the abdomen
be intermittent, sharp or dull, achy, or piercing
radiate from a focal site
be accompanied by nausea and vomiting
be absent in older people, children, the immunocompromised, and in the last trimester of
pregnancy
how is a diagnostic work-up carried out for acute abdominal pain?
history, physical examination, imaging, and laboratory results
+ in some patients = digital laparascopy
which analgesic is used for acute abdominal pain?
opioid analgesia does not increase the risk of diagnosis/treatment decision error
what is important to remember about abdominal pain in older people, the immunocompromised and pregnant women?
often presents atypically so = delayed diagnosis of potentially life-threatening pathology
how is abdominal pain managed in older people?
comorbid conditions/medications may affect physiological response
are at higher risk for more severe disease due to decreased immune function
decreased CNS function can restrict an ability to communicate problems
decreased PNS function can alter perception of pain and temperature
how is abdominal pain managed in pregnant women?
many physical and physiological changes
enlarged uterus displaces and compresses intra-abdominal organs
laxity of the abdominal wall makes it difficult to localise pain and can blunt peritoneal signs
may have a mild physiological leukocytosis, so this finding is non-specific in pregnant
women presenting with an acute abdomen
high suspicion for intra-abdominal pathology = further studies are warranted e.g. additional laboratory testing, radiographic testing, serial physical examinations
how is abdominal pain managed in the immunocompromised?
altered inflammatory response
atypical symptoms and signs
abdominal pain is usually non-specific, and physical examination is often inconclusive
susceptible to opportunistic infections, e.g. cytomegalovirus colitis in AIDS patients
acute abdomen may occur as a result of immunosuppressive therapy
a lower threshold for hospital admission and cross-sectional imaging is required
what are some common differentials for abdominal pain?
adhesions
incarcerated/strangulated hernia
cholecystitis
perforated gastric ulcer
appendicitis
ectopic pregnancy
what are some uncommon differentials for abdominal pain?
volvulus
intussusception
perforated duodenal ulcer
ovarian torsion
what are the commonest causes of acute abdomen?
nonspecific abdominal pain
renal colic
biliary colic
cholecystitis
appendicitis
diverticulitis
how does the aetiology of acute abdomen vary according to age?
renal colic and appendicitis are more common in patients <60 years
gallbladder disease and diverticulitis are more common in older patients
what are the upper abdominal pain differential?
organ-based
- heart
- thorax/lungs
- aorta
GI organs
- pancreas
- bile duct, gallbladder
- stomach (peptic ulcers)
- duodenum
systemic
- DKA
- addisonian crisis
- electrolyte abnormalities
- lead poisoning
other
- gastroenteritis
- pregnancy (women)
what is AST?
aspartate aminotransferase
where is AST made?
hepatocytes
why is AST measured?
when hepatocytes are damaged, the AST enzyme is released from the cells and serum AST levels will be elevated
when is AST most likely to be raised?
obstruction of the liver
when is bilirubin most likely to be raised?
when there is an obstruction of the bile duct
biochemical marker of jaundice
released when RBCs breakdown
what is biliary colic?
symptomatic cholelithiasis
what is the term to describe when gallstones that form leave the gallbladder and enter the bile ducts?
choledocholithiasis
what is cholecystitis?
gallbladder inflammation
what is ascending cholangitis?
bile duct inflammation
explain how biliary colic occurs
pain caused by gallbladder muscle spasms against a stone stuck in the cystic duct/neck of the gallbladder
(no inflammatory response)
