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abdopain_central

central / periumbilical abdominal pain in the ED

read this first: abdominal pain in ED

periumbilical pain:

differential diagnosis:

  • bowel conditions:
    • see bowel obstruction
      • small bowel obstruction (tends to be more painful early with more vomiting but more poorly localised than LBO)
        • aetiology:
          • adhesions (40-60%)
          • inguinal herniae (10-40%)
          • neoplasms (7-20%) & rare causes eg. gallstones, FB, diverticulitis
      • ischaemic colitis (eg. mesenteric thromboembolism due to AF)
      • other causes of colitis
      • paralytic ileus or pseudo-obstruction:
        • aetiology:
          • abdominal causes such as appendicitis, pancreatitis, perforated PU, pyelonephritis, retroperitoneal h'age;
          • extra-abdominal causes such as pneumonia, AMI, rib or vertebral trauma
          • metabolic causes - usually hypokalaemia but also hyponatraemia, uraemia, DKA, severe anaemia & hypoproteinaemia
          • drugs such as opiates, anticholinergics, phenothiazines, tricyclics & anti-Parkinsonian
          • rare causes such as CT disorders, amyloidosis, myxoedema
      • in young children, remember, intussusception, malrotation!
  • testicular torsion
  • uncommonly, DKA

initial Mx in ED:

  • FBE, U&E, LFT's, amylase, lipase, RBG
  • IV fluids as indicated, keep nil orally
  • consider urgent bedside US if > 50yrs and suspect abdominal aortic aneurysm (AAA)
  • abdominal distension without bowel sounds suggests paralytic ileus but if tenderness is present, this suggests it may be secondary to peritonitis
  • high-pitched tinkling bowel sounds suggests mechanical obstruction
  • localised tenderness may suggest gangrenous or perforated bowel
  • generalised tenderness suggests peritonitis
  • check for organomegaly or masses which may suggest malignancy
  • PR may reveal empty rectum (suggesive of bowel obstruction), faecal impaction, rectal carcinoma, occult blood or stricture
  • FWT urine +/- urine HCG to exclude pregnancy
  • consider erect & supine AXR with erect CXR if not pregnant to exclude bowel obstruction and perforated viscus
  • if sigmoid volvulus on AXR:
    • discuss with surg. registrar ASAP
    • if evidence of bowel ischaemia (eg. fever, tachycardia, peritonism, or air in bowel wall on plain CT abdo), then needs iv antibiotics and urgent surgery
    • if no evidence bowel ischaemia, usually needs urgent rectal tube to decompress and this will usually resolve the volvulus
  • if free gas under the diaphragm on erect CXR:
    • this is a surgical emergency as indicates perforated viscus
    • contact surg. reg. and senior ED doctor ASAP 
  • if bowel obstruction on AXR:
  • if elderly or patient has AF, consider ischaemic colitis:
    • serum lactate, ABG's
    • plain AXR may show thumb printing of involved colonic segment, & in more advanced cases, there may be gas within the bowel wall, or, if perforation has occurred, free gas in the abdomen on erect CXR.
  • if generalised peritonitis:
    • IV fluid resuscitation, FBE, U&E, RBG
    • erect CXR, erect & supine AXR
  • if ascites, suspect spontaneous bacterial peritonitis:
    • paracentesis for culture, WCC, protein, glucose, LDH
      • WCC < 250/cu.mm makes SBP unlikely
      • WCC > 500 is highly specific for SBP
      • WCC > 10,000 or protein > 1g/dL or glucose < 50mg/dL or elevated LDH greatly increase the risk that the peritonitis is from a local cause
    • early empirical antibiotics eg. cefotaxime but still high mortality.
    • urgent surg. consult
    • IV anti's as per surg. consult.
  • if cause is not evident, consider urgent abdo. CT and discuss with surg. reg and radiology oral & iv contrast
    • check renal function and if on metformin before giving iv contrast.
    • CT scan is more sensitive for small bowel obstruction than AXR which is only 45-70% sensitive - the fluid and gas in the bowel may negate need for oral contrast for CT scanning
abdopain_central.txt · Last modified: 2018/08/11 00:47 (external edit)