Abdominal Pain

Consider these in all patients with ABD Pn

AAA

Cardiac Ischemia

Mesenteric Ischemia

DKA

Hernia

Testicular Torsion/Ovarian Torsion

Nephrolithiasis

Porphyria

pain during first few days of menstrual cycle=endometriosis or endometrioma

Analgesics for Abdominal Pain

Surgeons review the literature (Am J Surg 185:291, April 2003)

1st Study: Ann R Coll Surg Engl 1986;68:209-210

2nd Study: BMJ 1992;305:554-6

3rd Study: Acad Emerg Med 1996;3:1086-92

4th Study: J Emerg Med 1997;15:775-9.

Not mentioned is: J Am Coll Surg. 2003 Jan;196(1):18-31, a prospective, double blind with 74 patients.

and Am J Emerg Med 18(7):753, November 2000, another small prospective randomized trial

largest trial to date shows ok to give (ann emerg med 2006;48:150)

rational clinical exam series (JAMA 2006;296(14):1764)

opiate admin had no signif. negative effects

Special Considerations

The Elderly

With each decade of life, mortality increases and diagnostic accuracy decreases. The risk of surgical pathology is much, much higher. (Scand J Gastroent 1988:144:35-42)

HIV

In addition to normal pathology, can also have bacterial enterocolitis, drug induced pancreatitis, or AIDS-related cholangiopathy.

Women of Child Bearing Age

Urinary vs. Gastrointestinal vs. Pelvic etiologies.

If women is pregnant, diff. becomes much wider. In 3rd trimester, the appendix will be in the extreme upper right quadrant.

High Yield Questions

Which came first, the pain or the vomiting?
How long have you had the pain (>48hrs is more reassuring.)
Prior surgeries?
Could you jump up and down right now?
Are you taking any antibiotics or steroids?
Do you have a history of hypertension, vascular problems, or A. Fib?

Abdominal Exam

Abdominal Contour should always be assessed

Carnett’s sign-increased tenderness to palpation when abdominal muscles are contracted (have pt raise their head or lift his legs)

Most appendices are inferior and medial to McBurney’s point. 20% of appies will have no RLQ pain or tenderness. Use cough test or heel drop (pt drops from standing on toes on to heels) or simply bang the heels to test for peritoneal signs.

Murphy’s Sign Sensitivity ~97% hold palpation of RUQ, have take deep breath. Place L hand with the index finger on the lowest rib with the thumb in the midclavicular line. Press thumb into the belly and have the patient take a deep breath. Repeat with placebo by doing the same with the thumb just touching the skin.

McBurney’s Point 1 1/2 – 2 inches from anterior spinous process of ilium on a straight line from that process to umbilicus

Psoas Sign specificity 95% flex thigh against resistance

Obdurator sign-rotate flexed thigh internally and externally

Rovsing sign-pain in RLQ with palpation of LLQ

Make pt take deep breath to differentiate between voluntary and involuntary guarding

All women with undifferentiated ABD pain should have a pelvic, PID can present as RUQ pain b/c of Fitz-Hugh-Curtis)

Pelvic Exam has very little sensitivity or specificity in females with abdominal pain if they are not pregnant (Canadian Journal of EM 5:2, March 2003)

Antibiotics

ABX: Amp or amp/gent. Unasyn 1.5 g proph or 3g

Rx If allergic: clinda/gent

or cipro/flagyl

Pneumoperitoneum

Pneumoperitoneum should resolve 2-3 days post-op on X-ray

Tension Pneumoperitoneum is a consequence of colonoscopy c perf. Relieve c 14 G just like paracentesis

Non-Abdominal causes of Abdominal Pain

Heme: Sickle Cell,

Metabolic

Porphyria

Increased production of porphobilinogen

“Port wine” urine

Precipitated by decreased heme production

Severe abdominal pain, very benign exam

Similar episodes in past

Asssociated with CNS changes

Categories to consider

Hematologic sickle cell, thrombocytosis, coagulopathies, leukemia, lymphoma

Metabolic – above

Infectious RMSF, TB, Varicella, meningococcemia, lyme disease

Inflammatory HSP, polyarteritis nodosa, vasculitis, SLE, eosinphilic enteritis

Toxin – black widow, heavy metal

Psychogenic somatization, munchhausen, malingering

Clues to suggest a systemic cause:

Diffuse pain

Pain out of proportion to exam

Patient sick, exam benign

Constitutional symptoms

Immunocompromised, Elderly

Multiple return visits

Test for porphyria

A fresh urine sample protected from light has been sent for Watson-Schwartz test [

H.L. Bonkowsky and G.F. Barnard, Diagnosis of porphyric syndromes: a practical approach in the era of molecular biology, Semin. Liver Dis. 18 (1998), pp. 5765.

Derivation of CPR (American Journal of Emergency Medicine (2005) 23, 709717)

showed that Non-contrast CT should be done on all pts as hist and phys is specific but not at all sensitive

Spontaneous Hemoperitineum

Spontaneous Hemoperitoneum (Emerg Radiol 2007;14:65)

ruptured ovarian cyst, ectopic, spont rupture of liver or hepatic mass, tumor, inflammation, endometriosis,

Abdominal Layers

The New EMedHome Clinical Pearl is: Chilaiditis Sign

Chilaiditis Sign

Chilaiditis sign (pronounced “Ky-La-Ditty”) refers to the usually asymptomatic interposition of the bowel (typically the hepatic flexure of the colon) between the liver and the (right) hemidiaphragm. The importance of this sign is that it can mimic the radiographic appearance of pneumoperitoneum.

Chilaiditi’s syndrome refers to this radiographic finding plus symptomatology. The “syndrome” may involve nausea, vomiting, abdominal pain, anorexia, constipation or respiratory distress. The clinical presentation of Chilaiditis syndrome may simulate pneumoperitoneum, even though it is a benign entity.

Identifying haustral folds between the liver and diaphragm can distinguish pneumoperitoneum from Chilaiditi syndrome. Furthermore, the radiographic findings of Chilaiditi’s sign on plain radiographs will not move with change in position, unlike pneumoperitoneum; a left lateral decubitus abdominal film may help in this distinction. If the distinction is still unclear, CT scan can be used to make the final diagnosis.

Click Here for a radiographic example of Chilaiditis sign.

References: (1) Lo BM. Radiographic Look-alikes: Distinguishing between Pneumoperitoneum and Pseudopneumoperitoneum. J Emerg Med. 2008; Aug 30 [Epub ahead of print]. (2) Sanyal K, Sabanathan K. Air below the right diaphragm: Chilaiditi sign. Emerg Med J. 2008;25: 300.

Spontaneous Retroperitoneal Hemorrhage

Retroperitoneal Hemorrhage from EMEDHome

Spontaneous retroperitoneal bleeding can present in the absence of specific underlying pathology or trauma and is commonly seen in association with anticoagulation therapy. Given the frequency of patients presenting to the ED on triple anticoagulant therapy (warfarin, aspirin, and clopidogrel), emergency physicians need to be aware that the presentation is varied and may be vague and that retroperitoneal hematomas can present as an acute femoral neuropathy. Early identification is crucial to improving patient morbidity and mortality.

Retroperitoneal hematomas can result in femoral neuropathy at 2 different locations along the femoral nerve’s course. The first is the iliopsoas gutter due to the rigid surrounding fascia. The second is at the inguinal ligament overlying the femoral canal, which contains the femoral nerve.

Femoral neuropathy caused by retroperitoneal hematoma may present with sudden onset severe pain in the affected groin and hip, with radiation to the anterior thigh and the lumbar region. Femoral neuropathy can result in quadriceps muscle weakness and the sensation of the knee buckling. Later on, pain and paresthesia in the anterior thigh is characteristic.

References:
(1) Krause, ML, et al. Mayo Clin Proc 2011; 86: e21-e24.
(2) Parmer SS, et al. Ann Vasc Surg 2006;20: 536-540.
(3) Sasson Z, et al. Can J Cardiol 1996; 12: 490-4.

| | |