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Approach to Acute Abdominal Pain (in emergency ward)
1. Department of Emergency Medicine
H o w t o a p p r o a c h a c a s e o f
i n e m e r g e n c y ?
Niraj Phoju (94)Dhruba Chhetri (93)
2. Objectives:
To assess a patient complaining of acute abdomen.
To formulate the differential diagnosis for acute abdomen.
To initiate basic initial therapy for a patient in acute abdomen.
To consult the patient to medicine or surgical ward.
3. 26 yrs male presented to the ED of KISTMCTH at 11 am with the
complain of left lower abdomen pain for 1 hr. The vitals was stable
at the time of presentation and later on USG bilateral nephrolithiasis
with mild hydronephrosis on left kidney was found. The pain
subsided after IV analgesic and the patient left on LAMA.
43yrs male presented to ED of KISTMCTH at 9 am with the complain
of Pain in right lower region for 1 day. The vitals was stable at the
time of presentation and later on USG the diagnosis of Acute
appendicitis was made. Later after surgical consultation, emergency
open appendectomy was planned.
4. Definition
Acute abdomen is a term used to include a spectrum
of surgical, medical and gynecological conditions,
ranging from trivial to life threatening, which require
hospital admission, investigation and treatment.
5. •Nature and quality of pain is difficult for patient to
explain
•Location and severity of pain may change over time
•Atypical and variable presentations common
•Abdominal pain in women
•Extra-abdominal cause of abdominal pain
•Referred pain
Challenges
6. A n a t o m y
Regions of abdomen
Development
Nerve supply
7. A n a t o m y
Regions of abdomen
Development
Nerve supply
9. A n a t o m y
Regions of abdomen
Development
Nerve supply
10. A n a t o m y
Regions of abdomen
Development
Nerve supply
Abdominal wall and
Parietal peritonium
Somatic nerves
Abdominal organs and
visceral peritonium
Autonomic nerves
19. History :
SOCRATES
Site: where do you fell the pain most?
Onset: can you remember how it started? Did it come over a few mins,
hrs or days?
Character: how would you describe the pain? Is it always there or does
it come and go?
Radiation: does it always stay there or does it move?
Associated symptoms: do you have any other symptoms?
Time: how long have you had the pain?
Exacerbating factors: do you think is it getting better or worse? Does
anything makes it better or worse?
Severity: (Subjective) Score pain from 1-10
21. History :
SOCRATES
Site: where do you fell the pain most?
Onset: can you remember how it started? Did it come over a few mins,
hrs or days?
Character: how would you describe the pain? Is it always there or does
it come and go?
Radiation: does it always stay there or does it move?
Associated symptoms: do you have any other symptoms?
Time: how long have you had the pain?
Exacerbating factors: do you think is it getting better or worse? Does
anything makes it better or worse?
Severity: (Subjective) Score pain from 1-10
22. History :
SOCRATES
Site: where do you fell the pain most?
Onset: can you remember how it started? Did it come over a few mins,
hrs or days?
Character: how would you describe the pain? Is it always there or does
it come and go?
Radiation: does it always stay there or does it move?
Associated symptoms: do you have any other symptoms?
Time: how long have you had the pain?
Exacerbating factors: do you think is it getting better or worse? Does
anything makes it better or worse?
Severity: (Subjective) Score pain from 1-10
23. History: Onset and Character
• How would you describe the pain? Is it always there or does it come
and go?
• Dull/ Sharp/ Burning/ Steady/ Intermittent/ Throbbing
24. History :
SOCRATES
Site: where do you fell the pain most?
Onset: can you remember how it started? Did it come over a few mins,
hrs or days?
Character: how would you describe the pain? Is it always there or does
it come and go?
Radiation: does it always stay there or does it move?
Associated symptoms: do you have any other symptoms?
Time: how long have you had the pain?
Exacerbating factors: do you think is it getting better or worse? Does
anything makes it better or worse?
Severity: (Subjective) Score pain from 1-10
25. History :
SOCRATES
Site: where do you fell the pain most?
Onset: can you remember how it started? Did it come over a few mins,
hrs or days?
Character: how would you describe the pain? Is it always there or does
it come and go?
Radiation: does it always stay there or does it move?
Associated symptoms: do you have any other symptoms?
Time: how long have you had the pain?
Exacerbating factors: do you think is it getting better or worse? Does
anything makes it better or worse?
Severity: (Subjective) Score pain from 1-10
26. Associated symptoms
• Diarrhea, constipation, bleeding, distension
GI:
• Jaundice
Hepatobiliary:
• Dysuria, oliguria
Urological:
• LMP, timing of symptoms with menstrual cycle
Gynecological:
Pyrexia , Malaise, Nausea, Vomiting
Malignancy: weight loss, fatigue and loss of appetite
27. History :
SOCRATES
Site: where do you fell the pain most?
Onset: can you remember how it started? Did it come over a few mins,
hrs or days?
Character: how would you describe the pain? Is it always there or does
it come and go?
Radiation: does it always stay there or does it move?
Associated symptoms: do you have any other symptoms?
Time: how long have you had the pain?
Exacerbating factors: do you think is it getting better or worse? Does
anything makes it better or worse?
Severity: (Subjective) Score pain from 1-10
28. History :
SOCRATES
Site: where do you fell the pain most?
Onset: can you remember how it started? Did it come over a few mins,
hrs or days?
Character: how would you describe the pain? Is it always there or does
it come and go?
Radiation: does it always stay there or does it move?
Associated symptoms: do you have any other symptoms?
Time: how long have you had the pain?
Exacerbating/Relieving factors: do you think is it getting better or
worse? Does anything makes it better or worse?
Severity: (Subjective) Score pain from 1-10
30. History :
SOCRATES
Site: where do you fell the pain most?
Onset: can you remember how it started? Did it come over a few mins,
hrs or days?
Character: how would you describe the pain? Is it always there or does
it come and go?
Radiation: does it always stay there or does it move?
Associated symptoms: do you have any other symptoms?
Time: how long have you had the pain?
Exacerbating factors: do you think is it getting better or worse? Does
anything makes it better or worse?
Severity: (Subjective) Score pain from 1-10
31. Other History
Past medical and surgical history
Drug use
Social history: alcohol, smoking, blood transfusion, tattoos, IV drug
abuse, foreign travel
Family history: IBD, Peptic ulcers, Colorectal carcinoma
Last meal
39. Clinical featuresConditions History Examination
Acute appendicitis Nausea, vomiting, central
abdominal pain which later
shifts
to the right iliac fossa
Fever, tenderness,palpable
mass in the right iliac fossa.
Acute pancreatitis Anorexia, nausea, vomiting,
constant severe epigastric
pain,
previous alcohol
abuse/cholelithiasis
Fever, periumbilical or loin
bruising,
epigastric tenderness, variable
guarding,
reduced or absent bowel
sounds
Acute diverticulitis Lower abdominal pain,nausea
dairrhoea or constipation and
may be blood in stool.
Fever, tenderness.
Acute cholecystitis Pain in right hypochondrium
that may radiate to shoulder or
scapula,nausea & vomiting
Fever, tenderness, murphy’s
sign
40. Pelvic inflammatory
disease
Sexually active young female,STD
history,recent gynaecological
procedure,pregnancy or use of intruterine
contraceptive device,lower abdominal
pain,irregular mensturation.
Fever, vaginal discharge, pelvic peritonitis
causing tenderness on rectal examination,
right upper quadrant tenderness,
pain/tenderness on vaginal
examination (cervical excitation), swelling/
fullness in the fornix on vaginal
examination
41. Peptic ulcer vomiting at onset associated with severe acute
onset
abdominal pain, previous history of dyspepsia,
ulcer disease,
NSAIDs or corticosteroid therapy
Shallow breathing with minimal abdominal
wall movement, abdominal tenderness and
guarding, board-like rigidity, abdominal
distention and absent bowel sound.
Ruptured ectopic
pregnancy
premenopausal; delayed or missed menstrual
period,
hypotension, unilateral iliac fossa pain, pleuritic
shoulder tip
pain, ‘prune juice’-like vaginal discharge
Suprapubic,tenderness,periumbilical bruising,
pain and tenderness on vaginal
examination (cervical excitation), swelling/
fullness in the fornix on vaginal
examination
Ruptured aortic
aneurysm
Sudden onset of severe, tearing
back/loin/abdominal pain,
hypotension and past history of vascular disease
and/or high
blood pressure
Shock and hypotension, pulsatile, tender,
abdominal mass, asymmetrical femoral
pulses
42. Intestinal obstruction Colicky central abdominal pain, nausea,
vomiting and constipation
Surgical scars, hernias, mass, distension,
visible peristalsis, increased bowel sounds
Ureteric colic Flank pain(colicky) that may radiate to
hypochondrium.
Tenderness,
43. Diabetic ketoacidosis Nausea and vomiting,abdominal pain,excessive thrist
and urine production,diabetis history usually.
Tenderness,dry mouth,ketotic odor is
present
Acute intermittent
porphyria
Severe and poorly localized abdominal pain.urinary
symptoms(painful urination, urinary retention).
High blood pressure,↑heart rate
,proximal muscle weakness.
46. Management:
•The main therapeutic goals in managing
acute abdominal pain are physiologic
stabilization, mitigation of symptoms
(e.g, nausea and pain), and expeditious
diagnosis, with consultation if required.
Immediate Management
47.
48. Disposition from ED:
• Clinical findings : Subsided
• Vitals : Normal or near normal
• Abdominal examinations : No abnormal findings
• Able to take fluids by mouth
Consider followings before discharge:
Clear instruction for Follow-up.
52. References:
Rosen’s Emergency Medicine Concepts and Clinical Practice, 9th
Tintinallis Emergency Medicine A Comprehensive Study Guide, 8th
Davidson's Principles and practice of medicine, 22nd Edition
Principles and Practice of Surgery 7th Edition 2017
Bailey and Love’s Short Practice of Surgery, 26th Edition
Notes de l'éditeur
Severe abdominal pain
Sudden onset or gradual
Less than 24 hr duration
Unclear etiology
Symptom of many diseases
Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like;
1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia
2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis
3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like;
1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia
2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis
3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like;
1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia
2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis
3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like;
1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia
2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis
3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like;
1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia
2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis
3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like;
1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia
2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis
3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like;
1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia
2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis
3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like;
1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia
2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis
3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
Severity and descriptive nature of pain is usually subjective, but few descriptions may be classic like;
1. “pain out of proportion to examination” (ie, severe pain that is not readily reproduced with palpation) observed in patients with mesenteric ischemia
2. radiation of pain from the epigastrium straight through to the midback, almost invariably accompanied by nausea and vomiting associated with acute pancreatitis
3. onset of pain associated with syncope seen in ruptured aortic aneurysm or ruptured ectopic pregnancy
h/o immunosuppersive therapy may indicate infection.
h/o NSAID/ anti-coagulants may indicate GI bleeding.
h/o chronic opoid therapy may indicate constipation or even bowel obstruction.
h/o previous surgery may indicate adhesion thus intestinal obstruction.
Significant tachycardia and hypotension are indicators that hypovolemia or sepsis may be present.
Elevated temperature is associated with intra-abdominal infections.
Vital signs may be misleading and should be interpreted in the context of the entire presentation.
Abdominal examination requires properly positioning the patient supine and exposing the abdomen.
For female patients, abdominal evaluation should include a pelvic examination when there is pain or tenderness below the umbilicus.
Examine each quadrant.
Culprit quadrant at last.
Rectal examination usually has limited use in case of acute abdomen except when there is suspicion of GI hemorrhage, prostatitis or peri-rectal diseases.
Main use of digital rectal examination is in the detection of
1. melena or heme-positive stool,
2. anal fissure or fistulae,
3. stool impaction, or
4. the empty vault associated with bowel obstruction.
Urogenital examination is important.
Testicular torsion
Inguinal hernia (risk of srtangulation)
In view of the evolving nature of abdominal pain, repetitive examinations are useful.(esp. in case of suspected Appendicitis)
