Abdominal pain
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Transcript of 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