Acute Abdominal Pain Reference A comprehensive study of

Acute Abdominal Pain ( 急性腹痛 ) Reference: A comprehensive study of emergency medicine V 6 Upto date web site

生理病理學 l l l 臟器性疼痛 (Visceral pain) 腹膜性疼痛 (Parietal pain) 轉移性疼痛 (Referred pain)

概念(Conceptual Framework ) l l l 腹腔內(Intra-abdominal): “ 3 G AND 1 V”: GI, GU, GYN and VASCULAR 腹腔外(Extra-abdominal) : 1. Carddiopulmonary 2. Abdominal wall 3. Toxic-Metabolic including infectious origin 4. Neurogenic disorders 非專一性腹痛 Nonspecific abdominal pain (NSAP)

腹部區塊(Abdominal Topograpy I) l l RUQ(right upper quadrant) LUQ(left upper quadrant) RLQ(right lower quadrant) LLQ(left lower quadrant)

腹部區塊(Abdominal Topography II) UHA(upper half of abdomen) v LHA (lower half of abdomen) v CTL(central) v GEN(general) v

臨床症狀分析 – 病史詢問 l 疼痛特徵 (Pain Characters): 1. 位置 (Location) 形式 (Quality) 嚴重度 (Severity) 開始時間及情形 (Onset) 症兆歷行時間 (Duration) 惡化因子 (Aggravation factors) 緩解因子 (Alleviating factors) 2. 3. 4. 5. 6. 7. l l 相關症狀 (Associated Signs and Symptoms)及其發 生之先後順序 過去病史 (Past Medical History)

臨床症狀分析 – 理學檢查 l l l 表情及外觀 生命徵象 視診 (Inspection) 聽診 (Auscultation) 觸診 (Palpation): 2) Patient’s position Peritoneal signs: involuntary muscle guarding; diffused abdominal tenderness; and rebound tenderness. l 肛診 (Rectal examination) 1)

臟器破裂 (Perforated Viscous) l l l l l 消化性潰瘍。 盲腸炎。 發炎性腸症 (Inflammatory bowel disease) 。 憩室炎。 大腸癌。 誤食外物 (Foreign body ingestion) 。 外傷 – jejunum。 輻射性腸炎 (radiation enteritis) 。 醫源性。

臟器破裂 (Perforated Viscous) l l l l Upright CXR --- best demonstrate pneumoperitoneum. Upright for 5 -10 minutes may detect as little as 1 -2 ml of free air Left lateral decubitus films Abdominal CT CBC/DC Electrolytes, BUN/Cr. , glucose Amylase/lipase U/A

急性胰臟炎(Ranson criteria) l 1. 2. 3. 4. 5. On Admission Age > 55 y/o Blood sugar > 200 mg/d. L WBC > 16000/mm 2 AST > 250 IU/L LDH > 350 IU/L l 1. 2. 3. 4. 5. 6. 48 hours Later A drop in Hct > 10% Rise in BUN > 5 mg/d. L Pa O 2 < 60 mm. Hg BE > 4 m. Eq/L Serum Ca 2+ < 8 mg/d. L Fluid sequestration > 6 L

急性胰臟炎(CT severity index) l A. B. C. D. E. Grade of pancreatitis Normal pancrease Pancrease enlargement alone Inflammation compared with peripancreatic fat One peripancreatic fluid collection Two or more fluid collection B. Points 0 1 C. 2 D. 3 E. 4 l A.

子宮外孕 (Ectopic Pregnancy) l l Urine ICON can detect β-h. CG level of 50 m. IU/L β-h. CG level of 25 m. IU/L can be detected in serum For p’ts with no demonstrable IUP--quantitative serum β-h. CG >6500 and no gestational sac seen on echo --- 100% ectopic pregnancy

子宮外孕 (Ectopic Pregnancy) l l l β-h. CG > 6500, gestational sac+ ---94% IUP β-h. CG <2000 --- too little to have sac β-h. CG <6500 and >2000 should have IUP sac; suspect ectopic pregnancy if IUP is absent Transvaginal echo--- sac 5 wks, HB 6. 5 wks Transabdominal echo--- sac 6 wks, HB 8 wks

腹壁 (Abdominal wall) l l l 疼痛特質類似臟器疼痛。 Sit-up test (Carnett’s sign) 。 疝氣 (Hernia) 。 腹直肌血腫 (Rectus sheath hematomas) – 抗凝 血劑。 外傷。

神經性病變 (Neurogenic) l l l 感覺異常(Dysesthetic sensation)，特別是對輕 觸感。 “Hover” sign。 Herpes Zoster -- dermatome。 糖尿病神經病變 -- dermatome。 Incisional entrapment syndrome。

LIFE THREATENING ABD. PAIN l l l l AAA rupture Appendicitis Bowel obstruction DKA Ectopic pregnancy Incarcerated hernia Intussusception Ischemial bowel l l l l AMI Pulmonary emboli Ovarian torsion Perforated bowel Solid organ rupture Testicular torsion Volvulus Adrenal crisis Sickle cell crisis

THANKS FOR YOUR ATTENTION