Presentasi Abdominal Pain Non Trauma

7/28/2019 Presentasi Abdominal Pain Non Trauma

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Diagnosis and Management ofAbdominal Pain (non-trauma)

Ema Dianita

Agil Wijaya

Sharanraj

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- Durasi : acute ; chronic- Pathophys : visceral, parietal, reffered

- Location : upper, low, right, left, epigastrial, umbilical;

Klasifikasi Abdominal Pain :

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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%)

1De Dombal FT. Diagnosis of acute abdominal pain. New York: Churchill Livingstone; 1991.

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Chronic Abdominal Pain

Irritable bowel syndrome

Chronic pancreatitis

Diverticulosis

Gastroesophageal reflux disease (GERD)

Inflammatory bowel disease

Duodenal ulcer

Gastric ulcer

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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

Pain2. 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 theembryologic origin of the

organ: Forgut to epigastrium

Midgut to umbilicus

Hindgut to thehypogastric region

Parietal pain

is localised to thedermatome above the siteof the stimulus.

Referred pain

produces symptoms, notsigns e.g. tenderness

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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

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Central AP

Early appendicitis

SBO (small bowl obs)

Acute gastritis

Acute pancreatitis Ruptured AAA

Mesenteric

thrombosis

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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 gallbladder)

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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 malnourishedpatient (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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Palpation

Check for Hernia sites

Tenderness

Rebound tenderness

Guarding- involuntary spasm of musclesduring palpation

Rigidity- when abdominal muscles are tense& board-like. Indicates peritonitis.

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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


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Important Signs in Patients with Abdominal Pain

Sign Finding Association

Cullen's sign Bluish periumbilicaldiscoloration

Retroperitoneal 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 ofthe left lower quadrant

Appendicitis

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PR Examination:

- tenderness

- induration

- mass

- frank blood

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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 nothave 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 significantadvantage in DD of

AAP

Delay of necessarytreatment

Routine use notjustified

Hx taking & physical

examination are thebasis of correctdiagnosis

Hx, physicalexamination & labinvestigations areoften non-specific

CT is now 1st-lineimaging modality inpts with APP.

MDCT is now fasterwith thinner slices

High diagnosticaccuracy

8Keeman JN, New diagnostic imaging technology offten

offers no advantage in the differential diagnosis of acuteabdomen. Ned Tijdschr Geneeskd. 1999. Nov.

6:143(45):2225-9

9Leschka et al,Multi-detector computer tomography of acute

abdomen. Eur Radiol. Dec;15(12):2435-47. 2005 37


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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 diagnosticdilemma 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):882-511Keller et al. Diagnostic laparoscopy in acute abdomen. Chirurg. 2006 Nov;77(11):981-5

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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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Presentasi Abdominal Pain Non Trauma

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