How to approach a patient with acute abdominal

How to approach a patient with acute abdominal pain Andrew Mc. Govern Brighton and Sussex Medical School

Introduction Plan 1. Common causes 2. History and examination 3. Investigations 4. Case example Epidemiology Abdominal pain present in 10% of hospital admissions. 1/3 of these require surgical intervention.

Diffuse Causes Acute pancreatitis DKA Gastroenteritis Intestinal obstruction Peritonitis Mesenteric ischaemia RUQ/LUQ Acute pancreatitis Lower lobe pneumonia Myocardial ischaemia RUQ LUQ Cholecystitis Biliary colic Hepatitis Hepatic abscess Gastritis Splenic rupture/abscess RLQ LLQ Appendicitis Caecal diverticulitis Meckel’s diverticulitis Sigmoid diverticulitis RLQ/LLQ IBD Renal stones Cystitis Endometriosis Ruptured ectopic pregnancy Incarcerated hernias Psoas abscess

Pain History SOCRATES Site – has the pain moved? Character – visceral, somatic, colic Radiation - pain in retroperitoneal structures radiates to the back - Loin to groin in ureteric colic Associated symptoms -GI symptoms: nausea, vomiting bleeding - also GU symptoms and cardiopulmonary symptoms Severity – elderly patients have threshold/reduced visceral sensation. increased pain

Other history Fever Recent travel Past surgical and medical history Psychiatric disorders Menstrual and gynaecological history

Examination Vitals – HR, RR, BP, Temperature General appearance – jaundiced, anaemia, nutritional status Check for signs of dehydration Cardiorespiratory examination Abdominal examination Inspection – scars, distension Palpation - hernial orifices Percussion Auscultation – high pitched tinkling bowel sounds

Examination Special signs Murphy’s sign – cholecystitis Cullen’s Sign – pancreatitis Grey-Turner’s sign – pancreatitis, ruptured AAA, RTA Rectal and pelvic examination

Investigations General investigations FBC, ESR – ↓Hb in peptic ulcer disease, malignancy. ↑WCC in infective/inflammatory disease. U&E – ↑urea/creatinine in renal conditions. Electrolyte disturbance in D&V. LFTs – abnormal in cholangitis and hepatitis. Amylase – ↑↑ in acute pancreatitis. ↑ in perforated peptic ulcer or infarcted bowel. MSU CXR – Gas under diaphragm in perforation. Pneumonia. AXR – Dilated bowel – IBD, obstruction. Sentinel loop – pancreatitis, appendicitis. Renal stones, etc. USS

Case History Mr G: 62 year old male with gradual onset of severe epigastric pain. Examination BP 132/79 Sa. O 2 98% on air HR 78/min Patient comfortable at rest. Heart sounds normal: I + II + O Chest clear Abdomen soft – tender in RUQ, Murphy’s +ve no palpable masses, no organomegally, BS present

Case Investigations Bloods – CRP 28 [NR <5] AXR – normal USS – thickened GB wall, stones and pericholecystic fluid. Diagnosis Acute cholecystitis Treatment NBM, pain relief, antibiotics, cholecystectomy within 72 h.