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Acute Abdomen in the Emergency Department IAJPS 2018, 05 (11), 11847-11852 Muhanad Khalid Kondarji et al ISSN 2349-7750 CODEN [USA]: IAJPBB ISSN: 2349-7750 INDO AMERICAN JOURNAL OF PHARMACEUTICAL SCIENCES Available online at: http://www.iajps.com Review Article ACUTE ABDOMEN IN THE EMERGENCY DEPARTMENT Muhanad Khalid Kondarji1, Mohammed Khalid Kondarji2, Abdullah Mohammed Alzahrani1, Hussa Ali Alrashid2, Turki Ghaleb Al Ahmadi1, Faisal Mohammed Hinkish3, Fisal Amjed Abdulaziz4, Hamoud Marzuq Alrougi1, Rayan Tareq Alrefai1, Hassan Ibrahim Alasmari1 1 King Fahd Hospital, Jeddah 2 King Abdulaziz University 3 Althaghr Hospital 4 Taibah University Abstract: Introduction: 7% of the patients come to the emergency department with the chief complain of acute abdominal pain. They can have minor causes, but also be due to very serious causes, which requires urgency in care and serious diagnosis and management. Acute abdominal emergencies are a big contributor to morbidity and mortality. Aim of the work: In this study, we aim to understand the standard way to approach a case of acute abdominal pain in the emergency department. Methodology: we conducted this review using a comprehensive search of MEDLINE, PubMed and EMBASE from January 1970 to March 2017. The following search terms were used: acute abdomen, abdominal pain management, clinical evaluation of abdominal pain, management acute abdomen Conclusion: Acute abdomen is an extremely common presentation in the emergency department. However, it is not easy to assess, diagnose, and manage. Rate of misdiagnoses and fatalities are high; therefore, physicians should always consider all possible and start with more serious etiologies. Proper assessment and management of acute abdomen can lead to significant improvement of morbidity and mortality. Keywords: acute abdomen, gastro intestinal emergencies, emergency evaluation Corresponding author: Muhanad Khalid Kondarji, QR code King Fahd Hospital, Jeddah [email protected] +966 55 530 0784 Please cite this article in press Muhanad Khalid Kondarji et al., Acute Abdomen in the Emergency Department., Indo Am. J. P. Sci, 2018; 05(11). www.iajps.com Page 11847 IAJPS 2018, 05 (11), 11847-11852 Muhanad Khalid Kondarji et al ISSN 2349-7750 INTRODUCTION: perforated ulcer, ischemia of the mesenteries, torsion, In the emergency department, one of the most etc. All these mentioned causes could occur without common patients’ presentations is pain in the the presence of a prior warning or relevant history. abdominal area. In fact, it has been estimated that of An important example of this is that less than half 119 million patients who present to the emergency elderly patients who presented with a perforated ulcer department annually, about 7% present with had reported the presence of an acute abdominal pain. abdominal pain. Therefore, it is essential that Other examples of this are vascular diseases of the healthcare providers get proper and sufficient training sigmoid colon (like volvulus and ischemia) that could to become able to assess and manage abdominal pain also present with gradual (rather than acute) pain. On cases. Despite being that common, the management the other hand, infectious and inflammatory of acute abdomen should be done seriously, as etiologies are usually expected to have gradual course abdominal pain could sometimes be a reflection of a of pain [3]. Generally, any patient who suffers from serious, or even fatal, underlying condition [1]. an abdominal pain that awakens him from sleep Moreover, abdominal pain in many cases can have could be managed and assessed seriously until medicolegal issues, and poor management could lead serious causes are ruled out. By determining the onset to bad consequences on physicians in the emergency of pain, the clinician will be able to know the department. Sometimes, it is difficult to detect acute duration of pain and assess the case accordingly. abdominal pain in patients. This is due to the presence of other factors that could obscure the pain, Location leading to a significant delay in reaching a diagnosis. The embryological origin of visceral organs are the This will eventually lead to severe adverse events. determinants of the exact site of pain. Generally, Therefore, it is essential for physicians to consider visceral organs are sensitive to stretch, distension, serious causes when they are approaching such contraction, and ischemia. A pain in the epigastric patients. This approach can have significant effects region usually reflects pain originating from on improving morbidity and mortality. Although structures of the foregut, which include the stomach, diagnostic modalities have been becoming more proximal duodenum, liver, biliary system, and advanced and sophisticated, with the continuous pancreas. On the other hand, pain in the periumbilical emerging of newer imaging modalities, rates of region reflects pain originating from the midgut, misdiagnosis of acute appendicitis have been which include the distal duodenum, jejunum, ilium, increasing [2]. the appendix, and the proximal third of the colon. Finally, pain in the suprapubic regions reflects pain METHODOLOGY: originating from the structures of hindgut, which • Data Sources and Search terms include the remaining parts of the colon, the bladder, We conducted this review using a comprehensive along with pelvic genitourinary organs. When pain search of MEDLINE, PubMed and EMBASE, from originates from the kidneys, aorta, or any other January 1970 to March 2017. The following search retroperitoneal structure, it usually radiates to the terms were used: acute abdomen, abdominal pain back [2]. management, clinical evaluation of abdominal pain, management acute abdomen Intensity • Data Extraction Usually, severe pain is a reflection of a severe Two reviewers have independently reviewed the etiology. However, this is not always a reliable studies, abstracted data and disagreements were measure, as sometimes serious etiologies can present resolved by consensus. Studies were evaluated for with relatively mild pain. This occurs mainly in quality and a review protocol was followed elderly patients [2]. throughout. This study was done after approval of ethical board Radiation and referral of pain of King Abdulaziz University. A classic example of neural pathways that give predicted radiation of pain is Kehr’ sign. Kehr’s sign Assessment of Pain is the presence of radiated shoulder pain that results Onset from diaphragmatic irritation (from the accumulation It is essential for physicians to seriously consider any of free blood in the intra peritoneum, inflammation or case that presents with a severe abdominal pain that from other probable causes). Another famous started acutely. Focused attention should be present example is the feeling of pain in the right scapula on vascular etiologies like the presence of an which reflects the presence of a biliary disease. The underlying aortic dissection or aortic aneurysm. importance of radiation of pain also extends to reflect Other less serious etiologies may include volvulus, disease progression. Examples of this include the www.iajps.com Page 11848 IAJPS 2018, 05 (11), 11847-11852 Muhanad Khalid Kondarji et al ISSN 2349-7750 continuous passage of stones in the ureter, and of abdominal pain, this must not justify ruling out ongoing aortic dissection. However, it is important to serious diseases. An example of a serious disease that keep in mind that deep structures of the can present with diarrhea is mesenteric ischemia. musculoskeletal system are also innervated of the Appendicitis could also sometimes present with exact same sensory fivers of the abdominal visceral diarrhea. A study on 1000 patients in the emergency organs, making it necessary to carefully assess the department who presented with abdominal pain musculoskeletal system of patients before a diagnosis found that about 18% of them had diarrhea at is made [4]. presentation. Moreover, they found that younger patients who had diarrhea were found to have benign Associated symptoms causes of their pain. On the other hand, another study It is essential to assess associated symptoms other has reported that up to twenty percent of patients who than the abdominal pain, with putting all gathered have large intestinal obstruction can have diarrhea information in context. Examples of important [8]. associated signs and symptoms include: Constipation and the absence of flatus can also be 1. Anorexia considered important signs in diagnosing obstruction. There is a common belief that anorexia is almost The presence of blood in stool with severe abdominal always present in patients who present with pain is an indicator of the possible presence of abdominal pain due to appendicitis. However, recent ischemia. The presence of melena can indicate studies have suggested that only 68% of appendicitis bleeding from the upper gastrointestinal tract, while cases can report anorexia. Moreover, when dealing fresh blood can indicate the presence of bleeding with older patients, the prevalence of anorexia among from the lower gastrointestinal tract [9]. appendicitis patients can decrease to 20% [5]. 4. Other symptoms: 2. Vomiting: Abdominal pain can be the main symptom of many Vomiting is one of the most common symptoms diseases of the genitourinary tract. Therefore, dysuria associated with abdominal case and occur in virtually and pyuria are common symptoms that can be all cases of acute abdomen. Generally, in surgical associated with abdominal pain. An adult male with conditions, pain usually occurs before
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