abdopain_central
central / periumbilical abdominal pain in the ED
periumbilical pain:
differential diagnosis:
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bowel conditions:
see bowel obstruction
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aetiology:
adhesions (40-60%)
inguinal herniae (10-40%)
neoplasms (7-20%) & rare causes eg. gallstones, FB, diverticulitis
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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
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initial Mx in ED:
FBE, U&E, LFT's, amylase, lipase, RBG
IV fluids as indicated, keep nil orally
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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
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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
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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:
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
abdopain_central.txt · Last modified: 2018/08/11 00:47 (external edit)