CASE 1: 46Y♀VOMITING 新光吳火獅紀念醫院 VS 許瓅文 103.09.09
46Y♀vomiting
• Chief complaint •Past Hx – Abdominal pain, vomiting and no appetite for 2 – Ectopic pregnancy s/p OP 20yrs ago days – Pregnancy: denied • Present illness •PE – Intermittent abdominal pain – Abdomen: – Abdominal distention(+) diffuse tender(+) – Vomitus: yellowish/ greenish fluid no rebound pain – No flatus bowel sound: hypoactive – Similar episode before percussion: tympanic
Impression?/ Order KUB (EIA: negative)
• CBD/DC/Plt Hx • Standing abdomen • Panel Ⅰ/ T-bil/ Lipase Site of tender • PT/aPTT OP? •KUB (待EIA) Anticoagulant use? • Urine EIA •NPO • D5S run 60mL/hr Adhesion ileus Order Clinical feature
•2nd KUB: ileus improved •2nd KUB: fixed bowel loop • Flatus(+), abdominal • Fever(+) • Promeran 1amp iv q6h & st Severe distension pain and distension vomiting • Persisted abd.pain • On NG with decompression improved • Rebound pain(+) • D5S run 120mL/hr Try water and soft diet Fluid resuscitation • NG decompression: 量多， • 排GI床/ 待轉EC Dry mouth/ UOP No discomfort greenish AKI? Prerenal azotemia? • f/u KUB 8hrs later MBD =>what’s next?
Order Ileus
• Abdominal CT with/without contrast • Abd OP Hx + ileus ≒ adhesion ileus =>empiric • B/C xⅡ Tx Bowel obstruction: • Be ware of mechanical bowel obstruction!!! • Cefmetazole 1g iv q8h & st bezoar => OP => CT indication/ OP indicated • Be ware of medication ↓ bowel motility for Abd OP Hx Pt
Terminal ileitis
78y♂ Abdominal pain
• Chief complaint – Abdominal pain since 6 hrs ago • Present illness – 看護：一陣一陣喊肚子痛 – Vomiting once, food content CASE 2: 78Y♂ ABDOMINAL PAIN – Diarrhea for 2 times, watery, brownish/ yellowish – No fever •Past Hx – Old CVA with bed-ridden/ DM/ HTN/ CAD Hx Impression?/ Order
– Abd OP Hx: nil •NPO • PE: • D5S run 60mL/hr – Chest: clear BS, IRHB • CBD/DC/Plt – Abdomen: soft, no tender point •F/S DKA? no rebound pain • VBG G6 檢查項目避免重複開立 – Ext: warm, no pitting edema • Cr, AST, lipase, T-bil •KUB •ECG Previous ECG: Af OPD drug: warfarin 3mg qd • PT/aPTT
Lab data/ Image Impression?/ Order
• WBC: 22000/ seg. 80%/ band 5% Enteritis Leukocytosis, other infection source? • INR: 1.65 • ECG: Af • B/C xⅡ • F/S: 206 • Stool culture xⅠ, stool pus cell & OB • VBG • U/A, U/C – pH 7.372 Na 138 K 3.6 •CXR –PO2 61 PCO2 33 • Cravit 500mg iv qd & st – HCO3 18 • 排GI床/ 待轉EC
8 hrs later… Abd CT contrast
看護表示大便為磚紅色，病患呼吸比較喘 SMA thrombosis • Consult GS PE: diffuse tender(+) rebound pain(+) • On critical • ABG G4 • Send Pt to OR on – pH 7.205 call Aorta –PO2 61 PCO2 15 SaO2 91% • PreOP prepare – HCO3 6 • Admit to ICU post – Lactate 85 OP • Abdominal CT with/without contrast •O2 mask 10L/min Ischemic bowel disease
• Great mimic – From enteritis to septic shock, respiratory failure, unknown cause of acidosis 心中有ischemic bowel, 才能抓到ischemic bowel Persisted pain without tender • Risk factor CASE 3: 63Y♂SUDDEN ONSET – > 60 y/o ABDOMINAL PAIN – Af/ hypercoagulopathy/ digoxin use
63y♂sudden onset abd pain
• Chief complaint – No abd OP Hx – 剛剛突然肚子痛，有冒冷汗 • PE: • Present illness – Chest: clear BS, RHB – 坐在警衛哨內吃便當時，突然肚子痛 – Abdomen: soft, no tender point – 快要暈倒的感覺，從來沒這樣過 Vital signs no rebound pain – Tearing pain(+), 胸口也會痛 BT: 37.3℃ – Ext: warm, no pitting edema HR: 78bpm – 現在比較不痛了 RR: 18/ min – Skin: wet and cold •Past Hx BP: 195/ 100 (剛剛冒冷汗) mmHg – 平時都沒有看醫生的習慣 SpO2: 99%
Impression?/ Order AORTA CT with contrast
• On monitor • 四肢BP •ECG NSR, no ST elevation 195/100 195/100 •On IV lock 228/135 185/100 • Morphine 5mg iv st • Aorta CT with/without • CBC/DC/Plt contrast • PT/aPTT Type B aortic dissection 195/100 195/100 不等NPO & Cr • PanelⅠ, CK, CKMB, Tro I 打電話給2134要求急做 228/135 185/100 • CXR (portable) •D-dimer Order Aortic dissection
• On critical HR 82bpm • Tearing/ cutting pain/ severe pain • Consutl CVS BP 195/100 mmHg – Rupture/ tearing/ occlusion Pt 覺得左腳冷冷的 • Labetalol 20mg iv st • Cold sweating – ↑Sympathetic tone • Admit to SICU • With direction • No tender point – visceral pain • Risk factor: HTN, connective tissue disease(Marfan syndrome),
82 Y♂sudden onset flank pain
• Chief complaint – Sudden onset flank pain just now Vital signs • Present illness BT: 37.3℃ HR: 78bpm – 剛下計程車的瞬間開始痛 RR: 18/ min 現在一直很痛 BP: 165/95 mmHg – Not aggravated with motion ♂ SpO2: 99% CASE 4: 82Y SUDDEN ONSET – Abdominal pain: mild FLANK PAIN – Nausea (+) vomiting (-) tenesmus(-) diarrhea(-) – Hematuria (-) – Flank pain(+): 好像右邊比較痛
Impression?/ Order
•Past Hx •U/A Stone四寶 – HTN(+) CAD(+) urolithiasis Hx(+) • Morphine 5mg IM st – OP Hx: s/p appendectomy, trauma s/p OP (腸子破？) •KUB •PE • Bedside echo AAA rupture Tender(+) Right side No rebound flank pain knocking tender Order AORTA CT with contrast
• On critical • ECG, CXR • On monitor • NS 1000mL IV st • On large bore IV x2 • 緊急備血pRBC 6U, 輸 • Abdominal •O2 N/C 4L/min pRBC 4U aneurysm: >3cm • Triage改Ⅰ級 • Consult CVS – ≧5cm rupture risk ↑ • CBC/DC/Plt, PanelⅠ, •NPO PT/aPTT • PreOP prepare • Aorta CT with/ without • Admit to ICU post OP contrast
AAA rupture
• Most important D.D of urolithiasis – Bedside echo=> always check aorta – Life-threatening • Tender point(+) – somatic pain • Risk factor – Old age CASE 5: 45Y♀SUDDEN ONSET – HTN, AAA Hx ABDOMINAL PAIN • Keep BP balance
45Y♀sudden onset abd. pain
• Chief complaint •Past Hx – Abdominal pain since 2hrs ago – Pregnancy: denied LMP: 忘記了，都不規則 • Present illness – Abd OP Hx: denied – Sudden onset epigastric pain, dull pain(+) – PUD (+) – Diffuse abdominal pain now •PE – Radiate to back(+) – Diffuse rebound tender(+) – 騎車來的路上遇到坑洞震動就特別痛 – Bowel sounds: normoactive – Nausea/ vomiting (-) –Pt一直坐在床上不敢動 – Diarrhea(-) Impression?/ Order Lab data & Image
• CBC/DC/Plt • Urine EIA: negative • PanelⅠ, lipase, T-bil • WBC 15000 seg. 78% band 0% • PT/aPTT • Urine EIA • CXR (sitting or standing, 待EIA), KUB •NPO • Bain 5mg iv st • D5S run 60mL/hr
Next order?
Pt表示肚子痛有比較減輕，但一動還是很痛 => PE: diffuse rebound pain(+)
• Abdominal CT with/ without contrast
Hollow organ perforation
What if… 1st CXR
• Ertapenem 1g IV st • Hx + image = hollow • Consult GS Dome sign organ perforation • Send Pt to OR on call => Immediate GS • preOP prepare consultation for OP •ECG • Admit to ward post OP Hollow organ perforation Triangle sign 10 signs of HOP on KUB
• Typical presentation: sudden onset + Falciform Double wall/ ligament sign peritoneal sign 痛到不敢動 Rigler’s sign • Atypical presentation Liver margin sign Transalucent – Duodenal posterior wall: retroperitoneum liver sign – Sealing of perforated wound →delayed ED visit • Diagnostic tool – X ray: CXR, Left decubitus view, KUB –CT Gallbladder sign
Italian style Doge’s cap sign • Doge’s cap sign • Inverted V sign Cupola sign – Air in Morrison – Sacrotuberous ligament pouch (liver & kidney)
Doge’s cap sign
不識總督， 看不出來… Football sign
DIFFERENTIAL DIAGNOSIS Extra-abdominal cause Red flag signs
• Thoracic • Pain →vomit – Pneumonia/ myocardial infarction/ pulmonary embolism • Peritoneal sign • Abdominal wall • Sudden onset – Herpes zoster/ muscle spasm – Vessel/ occlusion •GU • No tender point + old age – Testicular torsion • Syncope/ cold sweating • Systemic Conscious change – DKA/ AKA/ uremia/ porphyria/ SLE/ vasculitis Unexplained shock or acidosis => Late stage of sever intraabdominal infection
Thank you for your attention!!!