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Abdominal Lecture 4/29/2019 The Acute Abdomen: What the NP Needs to Know When Examining Complaints of Abdominal Pain NPA NYS NP Conference May 4, 2019 New York, NY Dr. Bruce S. Zitkus EdD, ARNP, ANP-BC, FNP-BC, CDE Family Nurse Practitioner, CDE Northport, NY Copyright Zitkus 2019 1 DISCLOSURE I have no current affiliation or financial arrangement with any grantor or commercial interests that might have direct interest in the subject matter of this CE Program. Bruce S. Zitkus May 2019 Copyright Zitkus 2019 2 DISCLAIMER Although every effort has been made to provide complete and accurate information, the information within this presentation is not guaranteed to be complete. The treatment and management regimens as well as diagnostic guidelines often change in the field of medicine. Similar to any printed materials, the information can become out of date. Every healthcare provider has a personal responsibility to keep up to date with changes in medicine including new guidelines affecting diagnosis, treatments and management. Thus, please know that changes may occur to the information originally presented in this workshop. Bruce S. Zitkus May 2019 Copyright Zitkus 2019 3 1 4/29/2019 Objectives 1. Differentiate the characteristics of the various types & causes of abdominal pain 2. Discuss the top common causes of a potential acute surgical abdomen in primary care 3. Develop appropriate history questions to ask individuals with abdominal pain 4. Review evidence-based guidelines for diagnosis, treatment & management of an acute abdomen Copyright Zitkus 2019 4 Definitions • Acute Abdominal Pain – Arises suddenly – Individuals present to PCP within 48 hours • Signs & Symptoms usually occur within 7 days – Pain lasting ≥ 6 hrs • ? Disorder of surgical significance De Dombal FT: Diagnosis of Acute Abdominal Pain, 2nd ed. Churchill Livingstone, London, 1991. Silen, W: Cope’s Early Diagnosis of the Acute Abdomen, 20th ed. Oxford University Press, New York, 2000. Copyright Zitkus 2019 5 Definitions • Chronic Abdominal Pain – May appear as acute pain initially – Persists or progresses over weeks or months – Initially chronic abdominal pain is considered “acute” until work-up reveals otherwise De Dombal FT: Diagnosis of Acute Abdominal Pain, 2nd ed. Churchill Livingstone, London, 1991. Silen, W: Cope’s Early Diagnosis of the Acute Abdomen, 20th ed. Oxford University Press, New York, 2000. Copyright Zitkus 2019 6 2 4/29/2019 ICD-10 Diagnosis Billable Codes Specific Diagnoses ICD- 10 Code Abdominal Aortic Aneurysm I71.XX Appendicitis K35.XX, K36, K37 Bleeding from Esophageal Varices I85.XX Cholecystitis K81.XX Diverticulitis K57.XX Ectopic Pregnancy O00.XX Incarcerated Inguinal Hernia K40.XX Intestinal Obstruction K56.XX Mesenteric Ischemia K55.XX Perforated Viscus K25.xx, K26.XX, K28.XX Obtained from ICD10Data.com @ http://www.icd10data.com/ICD10CM/Codes Copyright Zitkus 2019 7 ICD-10 Diagnosis Billable Codes General Diagnoses ICD- 10 Code Abdomen Pain / Tenderness R10.XX • Unspecified Tenderness R10.81 • Left lower quadrant tenderness R10.814 • Unspecified pain R10.9 • Upper abdomen pain unspecified R10.10 Abdominal Rigidity R19.XX • RUQ rigidity R19.31 • LUQ rigidity R19.32 • RLQ rigidity R19.33 • LLQ rigidity R19.34 Abdominal Distension (gaseous) R14.XX Obtained from ICD10Data.com @ http://www.icd10data.com/ICD10CM/Codes Copyright Zitkus 2019 8 . e1.jpg&oldid=218867637. Wikimediamedia Commons, the free repository File:Mystere1.jpg. (2016, November24). File:Mystere1.jpg. (2016, 27,2018 Retrieved01:23, February from https://commons.wikimedia.org/w/index.php?title=File:Myster 9 © Dr Michel Royon / Wikimedia Commons Copyright Zitkus 2019 3 4/29/2019 Circatrices after shot perforation of the abdomen ices_ Wikimedia Commons, the free media . Retrieved 01:26, February 27,2018 February Retrieved 01:26, . By USG [Public domain], via Wikimedia Commons File:Cicatricesvolperforation abdomenMSHWR partII shot pag 2 29). (2016,November 81.png. repository from https://commons.wikimedia.org/w/index.php?title=File:Cicatr shot_perforation_abdomen_MSHWR_part_II_vol_2_pag_81.png&oldid =224285163. 10 Copyright Zitkus 2019 Being successful in diagnosing an acute abdomen requires knowing….. 1. How to develop your differential diagnoses 2. Understanding the difference between textbook presentations versus real-time presentations 3. Using evidence-based guidelines 4. Determining the final diagnosis Copyright Zitkus 2019 11 The diagnostic problem of today Has greatly changed – the change has come to stay; We all have to confess, though with a sigh, On complicated tests we much rely And use to little hand and ear and eye. Sir Zachary Cope (1881-1974) Abdomen in Rhyme, 1947 Zeta (1947). The Diagnosis of the Acute Abdomen in Rhyme. London: H.K. Lewis & Co Ltd. Copyright Zitkus 2019 12 4 4/29/2019 How to determine your diagnosis? Pathophysiology of Abdominal Pain A Review Copyright Zitkus 2019 13 Pain Pathophysiology Neuropathic Pain 9- • Damage to the nerve causes typical pain symptoms Nociceptive Pain Wikimedia Commons, the free media • Nociceptors in tissues send pain signals to the central nervous system • Nociceptors “A delta” . Retrieved 01:31, February Retrieved27,2018 February 01:31,. “C fibers” File:Gray839-gl.png. (2017, July File:Gray839-gl.png. (2017,July 9). repository from https://commons.wikimedia.org/w/index.php?title=File:Gray83 gl.png&oldid=250835529. LoStrangolatore Commons /Wikimedia /Public Domain Copyright Zitkus 2019 14 Pain Pathophysiology Nature Visceral Pathway Somatic (Parietal) Pathway rsity and mage ID 3251. Spinal • Afferent “C” fibers innervate walls • Somatic “A-delta” fibers of hollow organs & capsules of solid organs • Innervates parietal peritoneum, – “C” nerve fibers also found in skeletal muscles, & skin muscle, periosteum, mesentery, peritoneum and viscera • May be associated with autonomic activation – Sweating, nausea or vomiting, tachycardia – Bradycardia with ’d BP, skin pallor, & hyperesthesia Copyright Zitkus 2019 15 PUBLIC DOMAIN: National Institute of General Medical SciencesI Nerve Cells – Lawrence Marnett and colleagues / Vanderbilt Unive Chemical Biology. 5 4/29/2019 Somatic Pain (Parietal = think A-delta) • Mylenated nerve: fast, acute pain –Intense, sharp, severe, localized to the site of inflammation, & often muscle rigidity (guarding) • Interior stimuli: – Sensitive to inflamed viscus itself and/or chemical stimulus such as infectious pus, blood, gastric acid, or bile – May cause involuntary muscle contraction or “involuntary guarding” at area area of inflammation • External stimuli: – Sensitive to mechanical stimulus (stretching, pinch, palpation or pinprick), heat, and/or electric shock. Copyright Zitkus 2019 16 Visceral Pain (Splanchnic = think C fibers) • Poorly localized and referred to areas corresponding to the embryonic origin of the affected structure 7, December 21, 2018 7,December21,2018 ter%27s_principles_of_human 174).jpg. (2015, October 174).jpg.(2015, Foregut Midgut Hindgut - Esophagus -3rd & 4th part of - Distal 1/3rd of - Spleen Duodenum transverse colon -Stomach - Jejunum - Descending colon -Liver - Ileum - Sigmoid colon - Gall bladder - Appendix -Rectum - Pancreas - Ascending colon - Upper anal canal -1st & 2nd part of - Cecum - Urogenital sinus Duodenum - Proximal 2/3rd of transverse colon Copyright Zitkus 2019 17 File:Carpenter's principleshumanphysiology (1881) (14779392 of 6).Retrieved20:5repository. Wikimedia Commons,thefreemedia from https://commons.wikimedia.org/w/index.php?title=File:Carpen _physiology_(1881)_(14779392174).jpg&oldid=174682076. Visceral Pain (Splanchnic) • Unmylenated nerve: slow, chronic pain –Insidious –Difficult to localize • Interior stimuli: –Sensitive to distension, ischemia, squeezing, and torsion • Usually caused by distension of hollow organs or capsular stretching of solid organs –Insensitive to heat, cutting, or electrical shock • Associated with motor / autonomic reflexes –Nausea, vomiting, tachycardia, bradycardia, diarrhea, hypotension, muscle rigidity Copyright Zitkus 2019 18 6 4/29/2019 Colicky Pain • Visceral organs associated with peristalsis & obstruction of the hollow viscera - Pain described sharp or dull • Ureters • Bowel NOTE: Gallbladder & bile duct do not have peristaltic movement/motion – biliary colic is not truly colic! Copyright Zitkus 2019 19 Referred Pain (Think both A-delta & C fibers) • Pain felt at a site distant from the origin of pain, i.e., diseased organ • Neurophysiology: – Convergence of visceral afferent neurons (C fibers) with somatic (parietal) afferent neurons (A-delta) from different anatomic regions. Copyright Zitkus 2019 20 a Commons, the free //commons.wikimedia. 69875303. File:1506 File:1506 Referred Pain Chart.jpg. (2017, November 29). Wikimedi media Retrieved repository. 21:48, December 21, from2018 https: org/w/index.php?title=File:1506_Referred_Pain_Chart.jpg&oldid=2 Copyright Zitkus 2019 21 7 4/29/2019 Sensory Innervation of Viscera Embryonic Organ Site of Pain Sensory Sensory Segment Esophagus T5-T6 Retrosternal – Epigastrium Stomach T6-T10 Epigastrium Spleen T6-T10 Left Hypochondrium Pancreas T6-T10 Epigastrium Liver & Gallbladder T7-T9 Epigastrium / Right Hypochondrium Suprarenal T8-L1 Posterior Lumbar Small Intestine T9-T10 Umbilical Kidney T10-L1 Posterior Lumbar Gonads T10-L1 Lumbar to Groin Large Intestine T11-L1 Umbilical 2009). Visceral pain: the neurophysiological mechanism. Visceral pain: the neurophysiological In 2009). Urinary Bladder T11-L2 Hypogastrium (pp. 31-74). Springer Springer Berlin Heidelberg. 31-74). (pp.
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