abdominal pain cases -...
TRANSCRIPT
Abdominal
Cases
The obligatory ancient Greek
Qualities of pain
• S: Site
• O: Onset (How?)
• C: Character
• R: Radiation• R: Radiation
• A: Association
• T: Timing
• E: Exacerbation or alleviating factors
• S: Strenght
Locations
Assessment of the strenght pain
Mechanisms behind the pain
• Mucosal injuries
• Smooth muscle spasm
• Capsular dystension
• Peritoneal inflammation• Peritoneal inflammation
• Direct splanchnic nerve stimulation
How to find the cause?
Algorithm ComplaintComplaint
History
• GI illnesses
History
• GI illnesses
Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
Case #1
• 35 yrs old female
• 5 days ago pain in the right lower
quadrant.
• Became better, but the pain returned.
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical
• Became better, but the pain returned.Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
Qualities of pain
• S: Epigastrial, then umbilical, then LRQ
• O: Sudden, then gone, then returned: recurring
• C: Sharp, burning
• R: Not typical• R: Not typical
• A: Nausea, vomitting, subfebrility
• T: For hours
• E: Independent from meals or bowel movements
• S: Strong
Case #1
• Cholecystectomy
• Pyelonephritis
• Helminthiasis (no further info)
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical
• Hepatitis infectiosaPhysical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
Laboratory findings
Hematology Kidney Liver/ Pancreas Inflammation
WBC: 16.8 Na: 133 Bi: 7.0 CRP: 4.23
Hgb: 144 K: 4.0 GOT: 36
Plt: 234 CN: 4.0 ALP: 70
Kreat: 54 LDH: 171
Amylase 27
Ultrasound
Dg
• Appendicitis acuta
• Surgical consultant suggested operation
• Phlegmonosus appendix was removed
Differential dg
• Enterocolitis
• Lymphadenitis mesenterica virosa
• Extrauterinal gravidity
• Ileocolitis – M. Crohn• Ileocolitis – M. Crohn
Case #2
• 44 yrs old female
• Epigastrial pain for more than a week
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
Qualities of pain
• S: Epigastrial, then RUQ, hypochondrial
• O: Slowly
• C: blunt, cramps
• R: To the back• R: To the back
• A: Nausea, vomitting, fever
• T: For days
• E: Worse after meals, Nospa, Algoflex make it better
• S: 5/10
Case #2
• Curettage
• GP evaluated her for similar
complaints. Ultrasound found
gallbladder stones.
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical gallbladder stones.Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
Laboratory findings
Hematology Kidney Liver/ Pancreas Inflammation
WBC 9.02 Na 143 Bi: 30/5 CRP: 26.5
Hgb 127 K 3.8 GOT: 17
Plt 196 CN 3.4 ALP: 131
Creat 62 LDH: 136
Amylase 15
Ultrasound
Dg
• Chronic cholecystitis
• Hydrops
• Surgical consultant: delayed (a froid)
operationoperation
• Antibiotics excreted through bile (e.g.
ceftriaxon)
Differential dg
• Acute cholecytitis
• Pancreatitis
• Duodenal ulcer
Case #3
• 77 yrs old male
• For 7-8 days pain in the left lower
quadrant.
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
Qualities of pain
• S: LLQ
• O: Sudden, recurring
• C: Sharp, stabbing, colicky
• R: inguinal, downwards• R: inguinal, downwards
• A: diarrhoea, faint pink, blood on paper
• T: For half an hours
• E: After meals or bowel movements
• S: 5-6/10
Case #3
• Childhood asthma bronchiale
• Appendectomy
• In 2011 STEMI, PCI
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical
• BPH
• Atrial fibrillation, OAC
• Colonoscopy: diverticuli
Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
Laboratory findings
Hematology Kidney Liver/ Pancreas Inflammation
WBC 6.0 Na 141 Bi 16.0 CRP 3.57
Hgb 147 K 4.2 GOT 26
Plt 280 LDH 210
Creat 113 ALP 81
Ultrasound
Dg
• Diverticulitis
• Antibiotics (ciprofloxacin + metronidazol)
• Surgery can be considered
Differential Dg
• Cancer
• Complications of diverticulitis
• Inflammatory bowel disease
• Irritable bowel syndrome• Irritable bowel syndrome
• Ischemic colitis
• Helminthiasis
Case #4
• 72 yrs old female
• For 6 months epigastric pain
• GP refers as gastritis
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
Qualities of pain
• S: Epigastric
• O: Slowly progressing
• C: Blunt
• R: To the back of the patients• R: To the back of the patients
• A: This morning vomiting, but it is not typical
• T: For hours
• E: After meals worse, if she lies on her side and pull up her knees or bends forward it is better
• S: 7-8/10
Case #4
• Deafness after childhood meningitis
• Cholecystectomy
• T2DM (OAD)
• For similar complaints she was evaluated
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical • For similar complaints she was evaluated two months ago, imaging a labs were negative
• One month ago endoscopy: gastritis and diverticuli
• She has lost 10 kg
Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
Laboratory findings
Hematology Kidney Liver/ Pancreas Inflammation
WBC 7.24 Na 135 Bi 7.5 CRP 14.55
Hgb 115 K 3.8 GOT 21
Plt 244 CN 7.2 ALP 89
Creat 65 LDH 180
Amylase 66
Ultrasound
CT
Dg
• CA19-9: 1936
• Pancreas head carcinoma
• FNAB: adenocc
• Palliative chemotherapy• Palliative chemotherapy
Differential Dg
• Cholecystitis
• Peptic ulcer
• Pancreatitis
• A. mesenterica sup. obstruction, intestinal • A. mesenterica sup. obstruction, intestinal
ischemia
• Diabetic neuropathy
Case #5
• 86 yrs old female
• For 2 weeks diffuse pain
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
Qualities of pain
• S: LLQ, diffuse, spreading out
• O: slow
• C: Colicky, cramps, dystension
• R: To the pelvis• R: To the pelvis
• A: Constant nausea, loss of appetite, constipation for two days fever, chills
• T: For hours
• E: Watery bowel movements helps
• S: 7-8/10
Case #4
• Relapsing atrial fibrillation
• Bradycardy VVI PM
• T2DM
• Sideropenic anemia
ComplaintComplaint
History
•GI illnesses
History
•GI illnesses
Physical Physical • Sideropenic anemia
• Colonoscopy two months ago showed polyposis coli, endoscope could not be passed beyond this point
• Histology: adenocc.
• She has lost 10 kg
Physical findingsPhysical findings
Laboratory testsLaboratory tests
Imaging findingsImaging findings
Solved?Solved?
Laboratory findings
Hematology Kidney Liver/ Pancreas Inflammation
WBC 13.96 Na 137 Bi 23.1 CRP 1.38
Hgb 159 K 3.1 GOT 24
Plt 247 CN 7.0 ALP 93
Creat 96 LDH: 255
Amylase 28
Abdominal X-Ray
Dg
• Ileus
• Emergency surgery
Summary
Typical illnesses associated with the
locations
Useful points
• Identify the anatomical location precisely
• Character can reveal the mechanism
• Gather as many anamnestic details as possible
• Laboratory panel should be chosen carefully• Laboratory panel should be chosen carefully
• Imaging until you see clearly
• Consider extra-gastrointestinal causes
• Repeat if needed, as the disease progression itself can be meaningful