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abdopain

the patient with acute abdominal pain in the ED

Initial Mx of the haemodynamically unstable patient in ED with abdominal pain

  • examples include:
    • the patient with a rigid abdomen
    • abdominal pain with referred shoulder tip pain - suggests free fluid in abdomen such as ruptured ectopic pregnancy
    • abdominal pain with increasing unexplained tachycardia with HR > 120 (in adult) or hypotension
    • possible abdominal aortic aneurysm (AAA) - epigastric pain radiating to back in the elderly
    • abdominal pain with diabetic ketoacidosis (DKA) (the abdominal pain is usually due to DKA but occasionally a surgical abdomen can be the cause of the DKA)
    • abdominal pain with raised serum lactate level (suggests ischaemic gut)
  • move patient to a resuscitation cubicle if available
  • iv access
  • iv N Saline as indicated
  • supplemental oxygen
  • iv analgesia (eg. morphine)
  • notify surgical registrar ASAP
  • consider bladder scan to exclude acute urinary retention
  • send bloods for:
    • FBE, U&E, glucose, LFT's, lipase, INR, group and hold
    • HCG if female in fertile age range
    • lactate and ABG if risk of ischaemic bowel (eg. AF or unexplained increasing tachycardia with minimal abdominal signs)
    • troponin if chest pain or upper abdominal pain - particularly if diabetic
  • ECG
  • erect CXR (to detect free air as a sign of perforated viscus) and supine AXR if NOT pregnant
  • consider bedside abdominal US to help exclude AAA and to look for free fluid which may suggest ruptured ectopic
  • consider NGT if persistent vomiting
  • consider IDC if critically ill and need to monitor urine output
  • urinalysis
  • if febrile or possibly septic, and still unstable:
  • if diagnosis is unclear and the patient continues to be very unwell:
    • a CT chest and abdo/pelvis should be considered, preferably with contrast if eGFR and time allows, otherwise as a non-contrast CT to avoid delay in diagnosis of an occult life threatening condition.

general Mx of abdominal pain in the ED:

  • abdominal pain is a clinical risk RED FLAG condition:
    • abdominal pain is a major clinical risk area as it is common and has a multitude of relatively common potential life-threatening conditions which can easily be missed leading to delay in diagnosis and increased morbidity & sometimes mortality. 
  • important points to assist in Mx of this often perplexing presentation:
  • ask about the pattern of pain, in particular:
  • could the patient be pregnant?
    • this is extremely important as not only does one need to exclude ectopic pregnancy, etc but one should make sure patient is not pregnant BEFORE ordering Xrays.
  • could there be an extra-abdominal cause?
  • are there risk factors for certain conditions?
  • is the problem really faecal soiling or incontinence?
  • remember to get early senior consult:
    • especially if patient is unwell or elderly as these patients are particularly at risk of increased morbidity with delay in diagnosis and are often the most difficult patients to assess.
    • junior staff should discuss all patients with abdominal pain who are over 65 years age with a surgical registrar or a senior ED doctor.
  • always check inguinal region & scrotum:
    • exclude herniae & testicular torsion, patients may be too embarrassed to tell you!
  • don't just put the diagnosis as “constipation” or “gastro” until you have excluded other major causes, and in particular, if the patient is febrile or has a raised WCC, do not attribute these to “constipation”
  • remember atypical presentations:
    • pelvic appendicitis presents with minimal abdo. signs but often with fever, diarrhoea
    • appendicitis in children under 5yrs or the elderly can be especially difficult to diagnose
    • ischaemic colitis often has severe pain but minimal abdominal signs
    • diverticulitis may be right-sided
    • many non-urological conditions can cause dysuria & frequency such as appendicitis, diverticulitis, endometriosis, PID
    • although inflammatory bowel disease (IBD) is most commonly seen in pts under 30yrs, a 2nd peak of onset occurs in the 50's.
    • biliary conditions commonly present with R pain radiating to back, but uncommonly may present with left lateral chest pain but RUQ tenderness!
    • pyelonephritis can often present as RUQ tenderness - check the urinalysis!
  • remember some things may be red herrings or confuse the picture:
    • gallstones are common incidental findings - 20% females & 8% males over age 40yrs have them
    • renal calculi does not necessarily mean renal colic, it could be drug seeking behaviour, or another cause
    • air-fluid levels on AXR may represent paralytic ileus rather than bowel obstruction
    • pleural effusions may be secondary to pancreatitis, cholecystitis, etc.
    • a normal WCC, LFT's or ultrasound does not exclude cholecystitis or appendicitis
    • a normal lipase or amylase does not exclude pancreatitis - it may be too early in the course, or it may be chronic.
    • a negative urine pregnancy test or recent menses does not exclude ectopic pregnancy - one should do a serum HCG for more confidence.
  • a few paediatric points:
    • acute testicular pain should have paed. consultant notification within minutes - do not arrange an US!
    • avoid abdominal Xrays or CT where possible as even a plain AXR has radiation dose equivalent to some 15-20 CXR's
    • blood tests are usually unhelpful unless the patient is very unwell with generalised peritonitis and likely to need substantial fluid Rx
    • remember intussusception, malrotation, Meckel's diverticulum, and, in girls over 8yrs, torsion of ovary
abdopain.txt · Last modified: 2019/10/30 15:42 (external edit)