EVALUATION AND MANAGEMENT OF ABDOMINAL PAIN BY DR OJIH.
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Transcript of EVALUATION AND MANAGEMENT OF ABDOMINAL PAIN BY DR OJIH.
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EVALUATION AND MANAGEMENT OF ABDOMINAL PAIN
BYDR OJIH
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OUTLINE
• INTR0DUCTION• CAUSES• MECHANISM OF PAIN ORIGINATING FROM
THE ABDOMEN• HISTORY• EXAMINATION• INVESTIGATION• TREATMENT
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INTRODUCTION• One of the most common causes of presentation at the accident and
emergency• Diagnosis is difficult because numerous causes exist -NSAP 34% -Acute appendicitis 28% -Acute cholecystitis 10% -small bowel obstruction 4% -perforated PU 3% -pancreatitis 3% -Diverticular disease 2% -0thers 13%• 20-40% admission rates• 50-65% inaccurate initial diagnosis
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CAUSESPAIN ORIGINATING IN THE ABDOMEN
• PARIETAL PERITONEAL INFLAMMATION -Bacterial contamination -perforated appendix or other viscus -PID -Chemical irritation -pancreatitis
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CAUSES CONTINUED
• MECHANICAL OBSTRUCTION OF HOLLOW VISCERA
-Obstruction of the small or large intestine -Obstruction of the biliary tree -Obstruction of the ureter
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• VASCULAR DISTURBANCES -Embolism or thrombosis -vascular rupture -pressure or torsional occlusion -sickle cell anaemia
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• Abdominal wall -distortion or traction of the mesentry -trauma or infection of muscles• DISTENSION OF VISCERAL SURFACES-e.g by
haemorrhage -hepatic or renal capsule• INFLAMMATION OF A VISCUS -appendicitis -typhoid fever -typhilitis
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PAIN REFERRED FROM EXTRAABDOMINAL SOURCE
• CARDIOTHORACIC -acute myocardial infarction -myocarditis ,endocarditis, pericarditis -Congestive cardiac failure -pneumonia -Pulmonary embolism -Pleurodynia -Pneumothorax -Empyema -Esophageal disease,spasm,rupture,inflammation• GENITALIA -Torsion of testis
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METABOLIC CAUSES OF ABDOMINAL PAIN
• DM• Uremia• Hyperlipidaemia• Hyperparathyroidism• Acute adrenal insufficiency• Familial Mediterranean fever• Porphyria• C’1 esterase inhibitor deficiency( angioneurotic
oedema)
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NEUROLOGIC /PSYCHIATRIC CAUSES
• Herpes zoster• Tabes dorsalis• Causalgia• Radiculitis from infection or arthritis• Spinal cord or nerve root compression• Functional disorders• Psychiatric disorders
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TOXIC CAUSES
• Lead poisoning• Insect or animal envenomation• Black widow spiders• Snake bites
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UNCERTAIN MECHANISM
• Narcotic withdrawal• Heat stroke
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MECHANISM OF PAIN ORIGINATING IN THE ABDOMEN
• VISCERAL PAIN -afferent impulses from visceral organs poorly localized -pain generally felt in the midline - pain localization depends on the embryologic origin of
the organ Foregut structures------epigastrium midgut structures-------periumbilical region hindgut structures---------suprapubic region -visceral nociceptors are stimulated by distention, Stretch, vigorous contraction, ischaemia and
inflammation
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• SOMATIC PAIN -usually from inflammation or chemical
irritants (gastric content) -localized to the dermatome above the site of
stimulus -transmitted by spinal nerve supplying the
parietal peritoneum or mesodermal structures
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• REFERRED PAIN • Could be from the thorax, spine or genitalia• Produces symptoms not signs
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HISTORY
• Generally the cornerstone of accurate diagnosis• Complete description of the patient’s pain and
associated symptoms• Key points in the history include -P positional, palliating and provoking factors -Q quality -R region, radiation, referral -S severity -T temporal factors ( time and mode of onset,
progression, previous episodes)
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LOCATIONwhere do you feel the pain
• Can be generalized or localized• visceral pain -foregut structures------epigastrium - midgut structures -----periumbilical - hindgut structures-----suprapubic• Somatic pain -localised above the dermatome producing
the stimulus
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CHARACTERwhat kind of pain is it
• VISCERAL PAIN -dull, poorly localised, aching, colicky, or
gnawing.• SOMATIC PAIN -sharp, steady aching, more defined and well
localised
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ONSEThow did it start
• Could be acute or gradual• Tells the duration of pain• Helps to interpret current findings and making
diagnosis
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RADIATIONwhere else do you feel the pain
• Any inflammatory process / organ contiguous to the diaphragm can cause referred shoulder pain
• Acute gall bladder distension gives ipsilateral scapular pain
• abdominal pain radiating to the sacral region , flank, or genitalia may raise suspicion of rupturing abdominal aortic aneurysm
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PROVOCATIVE AND PALLIATNG FACTORSwhat worsens or relieves the pain
• Somatic pain- worsened by pressure or changes in tension of the peritoneum
(palpation, coughing , sneezing)• Pancreatitis – pain is worsened by bending
forward and relieved by upright position• Gastric ulcer – pain is aggravated by food• Duodenal ulcer - relieved by food• Ask about analgesics and NSAIDS
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Associated symptoms
• Fever• Anorexia• nausea• Vomiting• Diarrhoea• Cough• Amenorrhoea• Dysuria etc
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PAST MEDICAL & SURGICAL HX, CURRENT MEDICATIONS
• Previous surgery– adhesions• DM---DKA• CKD– uraemia• SCD– vasocclusive crises• Steroids and NSAIDS
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SOCIAL HX
• Substance abuse e.g cocaine• Alcohol• Domestic violence ( trauma )
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PHYSICAL EXAMINATION
• Inspection -Bending forward : chronic pancreatitis -lying still, avoiding movt: peritonitis -Restless: visceral pain -Jaundiced : common bile duct obstruction -Dehydrated: peritonitis, small bowel
obstruction.
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SYSTEMIC EXAMINATIONABDOMEN
• Inspection -scaphoid or flat in peptic ulcer -distended in ascities or intestinal obstruction -visible peristalsis in a thin or malnourished
patient (with obstruction) -surgical scar (adhesions) -caput medusa in chronic liver disease
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SYSTEMIC EXAMINATION
• Palpation -check the hernia sites -tenderness -rebound tenderness - guarding(involuntary spasm of muscles during
palpations) -rigidity (when abd. muscle are tense and board
like) indicates peritonitis
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SYSTEMIC EXAMINATION
• Epigastric tenderness -DU/GU -acute pancreatitis -esophagitis• Local right iliac fossa tenderness -acute appendicitis -acute salpingitis in females -crohns disease
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SYSTEMIC EXAMINATION
• Periumbilical tenderness -early appendicitis -SBO -acute gastritis -mesenteric thrombosis-ruptured AAA
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• Right upper quadrant tenderness -gall bladder disease -acute pancreatitis -Pneumonia -Subphrenic abscess - DU• Suprapubic tenderness -acute urinary retension -PID -cystitis
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Important Signs in Patients with Abdominal Pain
Sign Finding Association
Cullen's sign Bluish periumbilicaldiscoloration
intraperitoneal haemorrhage
Kehr's sign Severe left shoulder pain Splenic ruptureEctopic pregnancy rupture
McBurney's sign Tenderness located 2/3 distance fromanterior iliac spine to umbilicus on right side
Appendicitis
Murphy's sign Abrupt interruption of inspiration on palpationof right upper quadrant
Acute cholecystitis
Iliopsoas sign Hyperextension of right hip causing abdominal pain Appendicitis
Obturator's sign Internal rotation of flexed right hip causingabdominal pain
Appendicitis
Grey-Turner's sign
Discoloration of the flank Retroperitoneal haemorrhage
Chandelier sign Manipulation of cervix causes patient to liftbuttocks off table
Pelvic inflammatory disease
Rovsing's sign Right lower quadrant pain with palpation of the left lower quadrant
Appendicitis
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PHYSICAL EXAMINATION
• Percussion-differentiates between ascities ( shifting
dullness ) and large bowel obstruction ( drum-like tympany)
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Physical examination
• Auscultation – Has limited diagnostic utility– > 2min to confirm absent ( ileus)– High pitched in early SBO– Bruit in aortic, renal or mesenteric stenosis
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Systemic Examination
• Digital Rectal Examination: - tenderness - indurations - mass - frank blood
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Systemic Examination
• Vaginal Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour
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Investigations
• FBC (Hb & WCC) • Amylase (Pancreatitis) • U&Es, LFTs • Clotting (acute pancreatitis, sepsis, DIC, liver disease) • FBS/RBS• G&S (X-match if necessary) • ABG • ECG • Cardiac enzymes (if appropriate)
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Investigations
• Urinalysis• Pregnancy test• RADIOLOGICAL INVESTIGATIONS -CXR(PA) -Abd XR( erect and supine) -IVU -CT Scan—gold standard for diagnosis of
appendidcitis• Laparoscopy
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TREATMENT• DEPENDS ON THE CAUSE• May need resuscitation (ABCD)• IV fluid if there’s dehydration• Analgesic (iv opiods)• H2 receptor antagonists and proton pump
inhibitors( PUD )• Antibiotics if there’s evidence of infection• Antispasmodic (hyoscine)• Surgery
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REFERENCES
• Harrisons principle of internal medicine 18th edition
• Christopher R.M and Robert M.M,2012, International journal of internal medicine
• Dimitri R and Alec E, diagnosis and management of abdominal pain
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Thank you