abdominal pain

ABDOMINAL PAINDR IAN TURNER

peritonitis

renal calculus

shingles

obstruction pancreatitis

trauma

diverticular disease

PUD

cholecystitis

foreign bodiesUTI

neoplasmappendicitis

AAA

hernia

cholangitis

ischaemia

blood loss

NON-SPECIFICABDOMINALPAIN35% OF PRESENTATIONS

PAIN TYPES

• somatic

• localised

• skin, muscle, peritoneum

PAIN TYPES

• visceral

• diffuse

• organs

• autonomic

PAIN TYPES

• referred

• not felt at origin

HISTORY

relievers

migration

escalating steady

exposures

location

aggravators

gradual

de-escalating

sudden

risk factors associations

blood loss

GEOGRAPHY

• Elderly

• Children

• Sudden through to back

• Pregnancy

• ALOC

• Shock signs

THE ELDERLY

• 10% of older patients with abdo pain will die from that abdo pain

• Misdiagnosis increases mortality 2-fold

• Masking – cognitive, polypharmacy, physiology

THE YOUNG

• Poorly localised

• Poorly vocalised

HOW GOOD ARE THEY?

• Bowel obstructionAXR: sens 50-60%; spec 50%CT: sens 80-100%; spec 70%

• AppendicitisUS: sens 75-90%; spec 80-100%CT: sens 75-100%; spec 83-97%

• Renal calculusUS: sens 10-50%; spec 90%CT: sens 97%; spec 98%

HOW GOOD ARE THEY?

• CholelithiasisUS: sens 95%; spec 95%CT: sens 67%; spec 100%

• CholecystitsUS: sens 81-100%; spec 60-100%CT: sens 90-95%; spec 90-95%

• PancreatitisUS: sens 67%; spec 100%CT: sens 92%; spec 100%

• Active lower GI bleedCTA: sens 85%; spec 92%NM: sens 93%; spec 95%

CAN THE IMAGE BE BETTER?

• Patient size

• Contrast agents

• When to give oral

• When to give IV

CASE 1

• 59 FUnwell 1/52, generalised abdo pain, chills, altered bowel habitLap band, chronic pain, femoral hernia37.3C, 105/80, HR 100, RR 22, SaO2 96%Generalised abdo tenderness

• Differentials? Immediate treatment? Tests?

CASE 1

• WCC 18

• CRP 382

• Cr 296, Ur 12.2

• Na 126

• ALP 221

• GGT 288

CASE 2

• 101 M BIBA with 2 hours of lower back painOtherwise wellInitial vitals normal

• Whilst waiting to be seen becomes unresponsive

CASE 2

• Patient now alert with ongoing pain

• What are your care goals?

CASE 3

• 67 M 1/52 mild postural dizziness, 3/7 diarrhoea, 1/7 upper abdo pain37.6C, 167/62, HR 65, RR 20, SaO2 100%, tender RUQ ++

CASE 3

• FBE

• UEC NAD

• LFT – bili 59, ALP 286, GGT 411, ALT 312, lipase 2800

• Imaging?

CASE 4

• 83 M 1/7 mild abdo pain and new red PR bleedingFrom LLC. Known diverticular disease. On clopidogrel.37C, HR 95, 110/50, RR 18, SaO2 100%, soft abdo, red blood mixed with stool on PR

CASE 4

• Hb 98, FBE otherwise NAD

• UEC, LFT NAD

• Imaging?

CASE 4

• How to stop the bleeding?

• When to stop the bleeding?

CASE 5

• 81 F chest/epigastric pain for 24/24. Nil else on systems reviewWell on arrival

• Episode of diaphoresis and transient hypotension36.2C, HR 90, 80/60, RR 20, SaO2 95%

• Mild epigastric tenderness

• Other info?

CASE 5

• FBE: 86 / 11.5 / 141

• UEC: Ur 20.4 otherwise NAD

• Next steps?

CASE 6

• 80 F from home presents with 5/7 abdo pain and decreased stool frequencyOverweight, pale, 37.8C, HR 130, BP 140/80, RR 17, SaO2 96%Large abdo with generalised tenderness

CASE 7

• A distressed mother brings her child 18 month old to the ED after seeing him putting something in his mouth at a caféThe child is well