Diagnosis and Management of Abdominal Pain (non-trauma)

Ema Dianita Agil Wijaya Sharanraj

Klasifikasi Abdominal Pain :

- Durasi : acute ; chronic - Pathophys : visceral, parietal, reffered - Location : upper, low, right, left, epigastrial, umbilical;

Acute abdominal pain (AAP):

Presentation of previously undiagnosed abdominal pain lasting 1 week or less
NSAP (34%) Acute appendicitis (28%) Acute chlecystitis (10%) SBO (4%) Perforated PU (3%) Pancreatitis (3%) Diverticular disease (2%)

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1De

Dombal FT. Diagnosis of acute abdominal pain. New York: Churchill Livingstone; 1991.

Chronic Abdominal Pain

Irritable bowel syndrome Chronic pancreatitis Diverticulosis Gastroesophageal reflux disease (GERD) Inflammatory bowel disease Duodenal ulcer Gastric ulcer

Classification on Abdominal Pain

Three main categories of abdominal pain:
1. Intra-abdominal (arising from within the abd cavity / retroperitoneum) involves:
GI (Appendicitis, Diverticulitis, etc, etc, etc) GU (Renal Colic, etc, etc, etc) Gyn (Acute PID, Pregnancy, etc) Vascular systems (AAA, Mesenteric Ischemia, etc)
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Classification on Abdominal Pain

2. Extra-abdominal (less common) involves:
Cardiopulmonary (AMI, etc) Abdominal wall (Hernia, Zoster etc) Toxic-metabolic (DKA, OD, lead, etc) Neurogenic pain (Zoster, etc) Psychic (Anxiety, Depression, etc)

3. Nonspecific Abd pain not well explained or described.

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Pathophysiology
Visceral pain Distention, inflammation or ischaemia in hollow viscous & solid organs Localisation depends on the embryologic origin of the organ: Forgut to epigastrium Midgut to umbilicus Hindgut to the hypogastric region Parietal pain is localised to the dermatome above the site of the stimulus. Referred pain produces symptoms, not signs e.g. tenderness

Generalized AP
Perforation Acute pancreatitis Bilateral pleurisy Generalized peritonitis Acute Pancreatitis Sickle Cell Crisis Mesenteric Thrombosis Gastroenteritis Metabolic disturbances Dissecting or Rupturing Aneurysm Intestinal Obstruction Psychogenic illness

Central AP
Early appendicitis SBO (small bowl obs) Acute gastritis Acute pancreatitis Ruptured AAA Mesenteric thrombosis

Epigastric pain
DU / GU Oesophagitis Acute pancreatitis AAA

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RUQ pain
Gallbladder disease DU Acute pancreatitis Pneumonia Subphrenic abscess

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LUQ pain
GU Pneumonia Acute pancreatitis Spontaneous splenic rupture Acute perinephritis Subphrenic abscess

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Suprapubic pain
Acute urinary retention UTIs Cystitis PID Ectopic pregnancy Diverticulitis

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LRQ pain
Acute appendicitis Mesenteric adenitis (young) Perf DU Diverticulitis PID Salpingitis Ureteric colic Meckels diverticulum Ectopic pregnancy Crohns disease Biliary colic (low-lying gall bladder)

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Loin pain
Muscle strain UTIs Renal stones Pyelonephritis

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LLQ pain
Diverticulitis Constipation IBS PID Rectal Ca UC Ectopic pregnancy

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Abdominal pain yang sering mengancam jiwa

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Key points on history

Onset Duration Site, reffered Nature & character Intensity Precipitating & relieving factors Associated symptoms

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Associated symptoms
Fever Genitourinary Gynaecological Vascular

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Physical examination
OBS are important Observation
Bending Forward: Chronic Pancreatitis Jaundiced: CBD obstruction Dehydrated: Peritonitis, Small Bowel obstruction

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Systemic Examination
Abdomen: Inspection
- Scaphoid or flat in peptic ulcer - Distended in ascites or intestinal obstruction - Visible peristalsis in a thin or malnourished patient (with obstruction)

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Physical examination
Auscultation
BS > 2min to confirm absent High pitched, hyperactive or tinkling Bruit in epigastrium

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Systemic Examination
Palpation Check for Hernia sites Tenderness Rebound tenderness Guarding- involuntary spasm of muscles during palpation Rigidity- when abdominal muscles are tense & board-like. Indicates peritonitis.

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Systemic Examination
Local Right Iliac Fossa tenderness:
Acute appendicitis Acute Salpingitis in females

Low grade, poorly localized tenderness:

Intestinal Obstruction

Tenderness out of proportion to examination:

Mesenteric Ischemia Acute Pancreatitis

Flank Tenderness:
Perinephric Abscess Retrocaecal Appendicitis
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Important Signs in Patients with Abdominal Pain

Sign Finding
Bluish periumbilical discoloration

Association
Retroperitoneal haemorrhage

Cullen's sign

Kehr's sign McBurney's sign Murphy's sign Iliopsoas sign Obturator's sign Grey-Turner's sign Chandelier sign Rovsing's sign

Severe left shoulder pain Tenderness located 2/3 distance from anterior iliac spine to umbilicus on right side

Splenic rupture Ectopic pregnancy rupture Appendicitis

Abrupt interruption of inspiration on palpation of right upper quadrant Hyperextension of right hip causing abdominal pain Internal rotation of flexed right hip causing abdominal pain Discoloration of the flank

Acute cholecystitis

Appendicitis Appendicitis

Retroperitoneal haemorrhage

Manipulation of cervix causes patient to lift buttocks off table Right lower quadrant pain with palpation of the left lower quadrant

Pelvic inflammatory disease

Appendicitis

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Systemic Examination
PR Examination: - tenderness - induration - mass - frank blood

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Systemic Examination
PV Examination - Bleeding - Discharge - Cervical motion tenderness - Adnexal masses or tenderness - Uterine Size or Contour
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Initial management
1st 20 sec there are only 3 diagnoses:
Very ill:
Going to die? ask for help & resus

ill:
stable for couple h? Urgent investigations, initial diagnosis & management

Reasonably well:
Investigate as appropriate formulate diagnosis.

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Initial management
ABCDE Resuscitation & analgesia (NSAID, antispasme,opioid IV) Full monitoring (including Urine Output) Low threshold in seeking senior help

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Management
Hemodinamic unstable :
Managemen in critical care area Monitoring ABC (airway, oksigenasi, EKG dll) IV line ( fluid chalange 1 L kristaloin if no IMA susp) Lab Antibiotic IV if sepsis X ray (thorax, abdmenKUB) ECG NMB (nill by mouth) Cateter consult
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Management
Hemodinamic stable :
Managemen in intermediate care area IV line Lab berdasar klinis Antibiotic IV if sepsis X ray (thorax, abdmenKUB) ECG NMB (nill by mouth)

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Investigations
CBC (Hb & WCC) Amylase (Pancreatitis) U&Es, LFTs Clotting (acute pancreatitis, sepsis, DIC, liver disease) Glucose GxM ABG ECG Cardiac enzymes (if appropriate)
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Investigations
Attention to the WCC as a screening test only if substantially elevated.
25% of patients with elevated WCC do not have different outcomes from those with a normal WCC8

CBC has a limited clinical utility

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Investigations
Urinalysis
Cheap Simple & readily available test High yield when results fit with the clinical scenario

Pregnancy test

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Investigations
Radiology
PA CXR 3 positions AXR USG IVU (renal/ureteric colic)

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Investigations
Plain X-rays have limited utility in the evaluation of AAP
Low diagnostic yield High incidence of misleading incidental findings Lack of impact on management Exception: Bowel obstruction or perforation
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CT scanning
No significant advantage in DD of AAP Delay of necessary treatment Routine use not justified Hx taking & physical examination are the basis of correct diagnosis
8Keeman

Hx, physical examination & lab investigations are often non-specific CT is now 1st-line imaging modality in pts with APP. MDCT is now faster with thinner slices High diagnostic accuracy
9Leschka

JN, New diagnostic imaging technology offten offers no advantage in the differential diagnosis of acute abdomen. Ned Tijdschr Geneeskd. 1999. Nov. 6:143(45):2225-9

et al,Multi-detector computer tomography of acute 37 abdomen. Eur Radiol. Dec;15(12):2435-47. 2005

Laparoscopy
Early diagnostic laparoscopy may result in:
accurate, prompt, efficient management of AAP

Reduces the rate of unnecessary laparotomy Increases the diagnostic accuracy May be a key to solving the diagnostic dilemma of NSAP.
10Golash

and Willson. Early laparoscopy as a routine procedure in the management of acute abdominal pain: a review of 1320 patients. Surg Endosc. 2005 Jul;19(7):882-5 11Keller et al. Diagnostic laparoscopy in acute abdomen. Chirurg. 2006 Nov;77(11):981-5 38

Suggestions
Audit of all patients referred with AAP to assess:
Initial diagnosis Choice & diagnostic efficacy of investigations Treatment Timing (length of stay) Cost effectiveness
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Thank you

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