key: cord-0035938-wkyai7xx authors: Mehta, Harshil title: Abdominal Pain date: 2016-02-22 journal: Clinical Pathways in Emergency Medicine DOI: 10.1007/978-81-322-2710-6_26 sha: 54fc5dc3ea78805241987e696f83db674d25a699 doc_id: 35938 cord_uid: wkyai7xx Wide range of pathologies may present with abdominal pain. Key to reach proper diagnosis is adequate history and physical examination along with laboratory tests and imaging. Disposition of patients with abdominal pain is as difficult as its diagnosis. Low threshold should be kept for high-risk patients. Life-threatening diseases should not be missed in emergency. • Abdominal pain is one of the most common reasons for emergency department visits. Incidence is around 10-12 % globally. Demographic factors like age, gender, ethnicity and family history affect its presentation. • It is paramount for emergency physicians to have methodical approach in history, physical examination, investigation and treatment. Clinical suspicion of life-threatening diseases in high-risk patients is utmost important. • Wide range of pathologies may present with abdominal pain. • Key to reach proper diagnosis is adequate history and physical examination along with laboratory tests and imaging. • Disposition of patients with abdominal pain is as diffi cult as its diagnosis. • Low threshold should be kept for high-risk patients. • Life-threatening diseases should not be missed in emergency. -Somatic (parietal) pain: It results from irritation of parietal peritoneum caused by infl ammation, infection or chemical reaction. It is supplied by myelinated nerve fi bres. It is localised and constant. As the disease process evolves and irritates parietal peritoneum, we can elicit tenderness, guarding and rigidity. The patient prefers to lie immobile. -Visceral pain: It is caused by stretching of walls of hollow viscera, innervated by unmyelinated fi bres. It is diffuse and intermittent, dull aching and colicky in nature. Patients keep tossing on the bed. It is felt in the abdominal region which correlates to the somatic segment of embryonic region. Foregut, midgut and hindgut structures (Table 26 .1 ) relate to upper, middle and lower abdomen, respectively. Visceral pain can be perceived away from actual disease process, i.e. pain of acute appendicitis is felt around umbilicus initially as it corresponds to T10 somatic distribution. -Referred pain: It is defi ned as a pain that is felt away from the site of origin. Common anatomical origin or same nerve root innervations are primary reasons for such pain ( Fig. 26.1 ). • History: -Age and gender are important history points. Elderly patients with nonspecifi c complaints may have serious pathology. In females, obstetrics and gynaecological causes should be considered. Laboratory evaluation in addition to history and clinical fi ndings aid in diagnosis (Box 26.2 ). Acute intestinal obstruction Viscus perforation Traumatic rupture of the spleen/liver/bowel Acute pancreatitis Mesenteric ischaemia Ruptured abdominal aortic aneurysm Ruptured ectopic pregnancy Myocardial infarction Upright chest and abdomen x-rays: An upright chest x-ray detects 1 ml of air in peritoneal cavity [ 8 ] . Lateral decubitus x-ray shows 5-10 ml of intraperitoneal air (pneumoperitoneum) in bedridden patients. Indications (Fig. 26.2 Computed tomography: It is sensitive and accurate in diagnosing acute appendicitis, bowel wall diseases, solid organs, urinary tract calculi, mesenteric ischaemia and retroperitoneal structures. It is useful in differentiating mechanical vs. paralytic bowel obstruction. CT scan of abdomen has become an imaging modality of choice. Intraperitoneal and extraperitoneal structures can be visualised through CT scan. It helps to reduce morbidity and mortality. Elderly people are more prone to undergo surgery and have higher mortality than young patients. Moreover, history, vital signs and physical examination are not reliable in elderly due to comorbid conditions and medication use [ 10 ] . CT scan is associated with radiation risk. Improved technology and better image resolution have made oral contrast obsolete, and pathologies of solid organ and bowel wall are detected with intravenous contrast only [ 11 ] (Fig. 26.5 ) . Recommended imaging studies based on location of abdominal pain is shown in Table 26 .5 . Electrocardiogram is essential especially in elderly people with risk factors. Therapeutic goals for acute abdominal pain patients are primary stabilisation, mitigation from symptoms, diagnosis and treatment of cause. Haemodynamic instability may be present in patients with following features: Extremes of age Immunocompromised state Abnormal vital signs Signs of dehydration Early resuscitation and identifi cation of primary cause are the mainstay of treatment. This includes (OMIV): O , oxygen; M , cardiac monitor; IV , large bore IV lines; and V , vitals. Blood samples should be collected for routine investigations. Blood transfusion should be anticipated in haemorrhagic conditions (ruptured abdominal aortic aneurysm, massive GI haemorrhage, ruptured ectopic pregnancy, traumatic spleen rupture). Bedside ultrasound helps in identifi cation of undifferentiated shock. These patients require prompt surgical consultation. Early pain management doesn't mask physical fi ndings, delay diagnosis or increase morbidity and mortality. Analgesics in the form of paracetamol, NSAIDs and opioids like fentanyl or morphine are used depending on pain score. Cope's early diagnosis of acute abdomen [ 15 ] favours opioid analgesia in abdominal pain patients. Antacids relieve burning pain due to gastric acid production [ 16 ] . Antiemetics like ondansetron and metoclopramide are useful in remitting nausea and vomiting. NG tube is essential in patients with small bowel obstruction to decompress stomach and provide symptomatic relief. Metoclopramide has extrapyramidal side effects. Administration of antibiotics is useful in cessation of disease process and early recovery. Antibiotics should cover gram-negative anaerobic and aerobics and extended to gram-positive pathogens too. Table 26 .6 shows some commonly used regimens. Decision to discharge is as diffi cult as diagnosis of acute abdominal pain. Various available options are: Admission and surgical/nonsurgical consultation Admission for observation Discharge with follow-up advice Indications for hospitalisation: Elderly and immunocompromised Intractable nausea, vomiting and abdominal pain Appears ill with unclear diagnosis Intolerable oral intake Abnormal physical examination (signs of peritonitis) Poor social support Patients with less severe symptoms without specifi c diagnosis need laboratory/ radiological evaluation and observation for 8-10 h in ED. Follow-up with primary care physician in 12 h is another valid option. Stable asymptomatic patients can be discharged from emergency. Discharge criteria may include: No abnormal clinical features Normal vital signs Tolerate oral intake Adequate social support at home Patients should be given proper diet advice and safety instructions. 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