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Case Based Learning Abdominal Pain Introduction CASE BASED LEARNING ABDOMINAL PAIN INTRODUCTION Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia ABDOMEN- QUADRANTS ABDOMEN- ORGANS ABDOMINAL PAIN- CAUSES ABDOMINAL PAIN- CAUSES Inflammation of a viscus Perforation of a viscus Obstruction of a viscus Infarction of a viscus Intra-abdominal hemorrhage or retroperitoneal hemorrhage Extra-abdominal or medical causes for acute abdominal pain like lower lobe pneumonia and inferior wall MI ABDOMINAL PAIN- HISTORY SOCRATES = Nemonic S - site “S” stands for “site”. Which region/quadrant? Is O - onset it a general sense of overall discomfort? The site C - characteristics of pain helps you fine tune your subsequent R - radiation physical exam and diagnostic decision making. A – associated symptoms & “O” stands for “onset”. When did the pain start? signs Acute or insidious? T - timing “C” stands for “characteristics”. The pain may E - exacerbating/ be sharp, dull, heavy, etc. or a combination of alleviating descriptions. S - severity ABDOMINAL PAIN- HISTORY SOCRATES = Nemonic “R”, which represents “radiation”. Ask if the pain stays at the site they are describing or if it S - site travels somewhere else in the body. Ex:Ureteric O - onset colic C - characteristics A” stands for associated symptoms. What other R - radiation symptoms are present and associated with the A – associated symptoms & pain? Ask do they also have nausea and/or signs vomiting? T - timing "T" stands for timing. When does the pain E - exacerbating/ occur? Does it happen at specific times of the alleviating day, or is it constant? S - severity ABDOMINAL PAIN- HISTORY SOCRATES = Nemonic “E” represents “exacerbating” factors; grouped S - site within this is also alleviating factors. The O - onset patient should be probed as to what makes their C - characteristics pain better or worse. Certain physical positions, R - radiation medications, etc. These factors can all provide A – associated symptoms & historical clues about the root cause. signs “S” stands for “severity”. In most hospitals this T - timing is formulated on a 1 to 10 scale with 10 being E - exacerbating/ the most severe pain they’ve ever experienced. alleviating S - severity ABDOMINAL PAIN Somatic pain: Visceral pain: Originate from internal organs Originate from abdominal wall and visceral peritoneum and parietal peritoneum Achy and crampy Sharper and more distinct Variable localization and Better localized sensation Sensitive to cutting,tearing, Not sensitive to cutting, tearing, burning and crushing burning or crushing Sensitive to stretching of walls of hollow organs and capsule of solid organs ABDOMINAL PAIN Shifting pain: Ex: Periumbilical pain shifting to RLQ in Ac.appendicitis Radiating pain: Ex: Pain radiating from loin to groin in ureteric colic Reffered pain: Ex: Pain felt at Lt shoulder in case of splenic rupture ABDOMINAL PAIN- GRADING It is done by comparing a10cm line numbered 0 to 10 and this is called Visual Analogue Scale- VAS Minimum 0 means no pain 2 is mild pain 4 is discomforting pain 6 is distressing pain 8 is intense pain CASE BASED LEARNING ABDOMINAL PAIN RLQ PAIN Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia ABDOMINAL PAIN- RLQ PAIN A 28-year-old female presents with a 2-day hx of vague periumbilical pain. Today the patient has lower abdominal pain (right greater than left), which is associated with new onset of urinary frequency. She also vomited twice today. She is sexually active and her menstrual cycle tends to be irregular. Her last menstrual period was 6 weeks ago (2 weeks late). VS: T = 100.2, HR = 90, BP = 110/68. Labs: H/H = 12.0/36.3, WBC = 11,300, U/A: 5 RBCs, 10–15 WBCs Physical examination: RLQ tenderness, guarding, and rebound. Pelvic examination without cervical motion tenderness What would be your differential dx and plan for further evaluation? RLQ PAIN- Differential Diagnosis D/D in Adult males RLQ PAIN- Differential Diagnosis D/D in Females D/D in Children ABDOMINAL PAIN- RLQ PAIN This patient has the characteristic prodrome for appendicitis with periumbilical pain migrating to the RLQ and associated with localized peritoneal findings. Check the β-hCG before proceeding with appendectomy particularly in light of the patient’s delayed menstrual period. Ectopic pregnancy must be r/o. The abnormal U/A result may relate to bladder irritation from an inflamed appendix or represent the additional problem of a UTI. Though the clinical picture is most consistent with appendicitis, preoperative USG/CT Abd should be done if the β-hCG is normal. Diagnostic Priorities: Ac Appendicitis, R/O UTI and ectopic pregnancy. RLQ PAIN- Ac. Appendicitis History- Symptoms • Anorexia (hamburger sign), nausea, vomiting • Vague periumbilical pain that shifts to the RLQ- “ Murphy’s Triad” Physical Exam- Signs • McBurney’s point tenderness and rebound tenderness • Cutaneous hyperesthesia, Rovsing’s, psoas, and obturator signs Laboratory • Elevated WBC with left shift • C-reactive protein • Pregnancy test • Urinalysis: sterile pyuria RLQ PAIN- Ac. Appendicitis Diagnosis • Oftentimes is a clinical diagnosis Pathophysiology • Closed-loop obstruction • Fecolith in adults, lymphoid hyperplasia in children Imaging • None needed with classic H&P and leukocytosis • US: women and children • Avoid CT in children (increased risk of malignancy) and pregnancy (risk to fetus) • CT: if diagnosis is equivocal in men and nonpregnant women • MRI: pregnant women Management • Appendectomy (open or laparoscopic) RLQ PAIN- Ac. Appendicitis USG Abdomen: Tubular structure More than 6mm in diameter Non compressible CT Abdomen: Thickened appendix Fecolith Fat stranding ALVARADO SCORING Ac. Appendicitis- Algorithm CASE BASED LEARNING ABDOMINAL PAIN RUQ PAIN- 1 Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia ABDOMINAL PAIN- RUQ PAIN HISTORY: A 40-year-old moderately obese female presents to the emergency department with a 1-day history of constant epigastric and right upper quadrant (RUQ) pain. She describes the severity of the pain as a 7 out of 10. The pain began after eating fried pork. She reports that the pain also seems to affect the right side of her back near her scapula. She feels nauseated and has vomited twice. She has had similar pain, but of lesser severity, about once a month for the past year. The pain comes on after eating fried or spicy foods, but previously it has resolved after an hour. She is gravida six and para six. ABDOMINAL PAIN- RUQ PAIN On physical examination, her temperature is 100 °F, heart rate is 110/min, and her blood pressure is 120/80 mmHg. She has marked tenderness in the RUQ of the abdomen to palpation. When the RUQ is palpated while she is taking a deep breath, she abruptly ceases inspiration secondary to pain Murphy’s Sign+ve Laboratory values are significant for WBC count of 14 × 10 3 /μL (normal 4.1–10.9 × 10 3 /μL), Total Bilirubin 1.0 mg/dL (0.1–1.2 mg/dl), Alkaline phosphatase70 units/L (33–131 u/L), Amylase 60 units/L (30–110 u/L), and Lipase 30 units/L (7–60 u/L). What would be your differential dx and plan for further evaluation? RUQ PAIN- Differential Diagnosis ABDOMINAL PAIN- RUQ PAIN With her current history of severe persistent abdominal pain following ingestion of fatty foods, nausea and vomiting, and associated right upper quadrant tenderness to palpation, the etiology is most likely of biliary origin. The patient’s prior history is consistent with symptomatic cholelithiasis With a positive Murphy’s sign, fever, tachycardia, and elevated WBC count, the most likely current diagnosis is acute cholecystitis. With a normal total bilirubin and alkaline phosphatase, choledocholithiasis and acute cholangitis are less likely. Similarly, a normal amylase and lipase rule out gallstone pancreatitis. RUQ PAIN- Ac. Cholecystitis History • RUQ pain in obese, multiparous female Physical Exam • Murphy’s sign for acute cholecystitis Pathology/Pathophysiology • Acute cholecystitis triggered by persistent cystic duct obstruction by gallstone Diagnosis • RUQ US: gallstones, pericholecystic fluid, thickened gallbladder wall, and sonographic Murphy’s sign • HIDA scan if RUQ ultrasound is nondiagnostic • KUB not helpful: only 10 % of gallstones are radio-opaque RUQ PAIN- Ac. Cholecystitis Manifestations of Gall Stones RUQ PAIN- Ac. Cholecystitis Biliary Colic Vs Ac Cholecystitis RUQ PAIN- Ac. Cholecystitis Management • Asymptomatic gallstones: cholecystectomy not indicated • Symptomatic cholelithiasis (biliary colic): elective lap cholecystectomy • Acute cholecystitis: urgent (within 48 h) lap cholecystectomy • Acute acalculous cholecystitis: cholecystostomy tube if critically ill • Emphysematous cholecystitis: emergent cholecystectomy • Gallstone ileus: remove large impacted gallstone from terminal ileum (leave gallbladder alone) Postoperative • If a patient presents within the first week after cholecystectomy with abdominal pain, distention, and anorexia, consider a biloma (cystic duct stump leak, CBD injury) • Cystic duct stump leak readily treated with ERCP and stenting of the sphincter of Oddi • CBD injury may require hepaticojejunostomy/choledochojejunostomy RUQ PAIN- Ac. Cholecystitis Additional Important Facts • Ursodeoxycholic acid could be employed as conservative management for patients with cholelithiasis • Calcified gallbladder (porcelain): increased risk of malignancy, perform cholecystectomy
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