ABDOMINAL PAIN:
Few areas of the body present us with the challenge we face when assessing the acute abdomen. The Stomach, Small intestine, Large intestine, Liver, Gallbladder, Pancreas, Appendix, Spleen, peritoneum, mesentery, and abdominal blood vessels (Aorta and SVC), are all housed here. In addition to the organs themselves, we also have abdominal muscles to complicate things. With such a variety of tissues that can be the origin of a patient's problem, we have to become familiar with not only common presentations of various illnesses, but also with the characteristics of abdominal pain itself.
Visceral pain: In general, visceral pain is dull, poorly localized, and may be described as a ache or “crampy” feeling. Visceral pain originates from the walls of hollow organs, and is caused by inflammation, distension, or ischemia.
Somatic pain: Originates in solid organs and tissues such as those of abdominal wall muscles. It is described as sharp, and is generally well localized.
Referred pain: This is pain that may take on a variety of characteristics, and is felt at a site other than it's origin. An example would be the pain felt in early appendicitis, that is felt in the periumbilical region, rather than in the RLQ where it originates.
When a patient presents with acute abdominal pain, we want to perform the same pain assessment we would use in any body system. Gather NOPQRST-ASPN, PMHx, Meds, Allergies, and determine if the patient has had any changes to their diet/appetite.
Specific questions we want to know are:
Has the patient had any blood in the urine or stool?
Has there been a change in bowel habits?
Any burning with urination?
Any recent fever or chills?
If the patient identifies pain in the epigastric region, we really need to consider potential cardiac causes. In this case we also want to ask about any shortness of breath, any nausea, any weakness, and observe for obvious pallor or diaphoresis.
The differential of consequence for acute abdominal pain includes:
AAA
Appendicitis
Cholecystitis
Mesenteric ischemia
Bowel obstruction
Ectopic pregnancy
Following a history, you need to do a physical assessment of all 4 quadrants of the abdomen. Note any tenderness, rigidity, guarding, masses, or pulsations (If you feel a pulsatile mass STOP palpating). We want to look for tenderness in particular areas to rule out specific conditions.
Murphy's Sign: Perform deep palpation on the RUQ while having the patient take a deep breath. If sudden pain causes the patient to stop breathing, the test is positive. This indicates cholecystitis.
RLQ Tenderness: This generally suggests appendicitis. To confirm, have the patient lie flat and attempt to lift their right leg against resistance. If this elicits pain, ou can be fairly confident that the appendix is the source of the problem.
Rebound tenderness: Pain that increases when palpation pressure is released. This is a common feature of peritonitis, which is seen in conditions such as ruptured appendix, perforated bowel, ruptured ectopic pregnancy, ect.
Common presentations:
AAA:
Sharp periumbilical pain that may radiate through to the lumbar region, and may also be felt in the sacral region.
Sudden onset.
May present with sudden weakness in the lower extremities.
May present with diminished or absent distal pulses.
A pulsatile mass may be noted.
The patient usually has cardiovascular risk factors. HTN, DM, CAD, dyslipidemia, and may have a family history of aneurysm or connective tissue disorders such as Marfan Syndrome.
Appendicitis:
Visceral periumbilical pain that gradually migrates to the RLQ and may become sharp in nature.
Bloating or distension
Fever is typically present.
Gradual onset over several hours is common.
Nausea and vomiting.
RLQ tenderness on palpation
Anorexia
Cholecystitis:
visceral pain located in the RQU and epigastric regions.
Generally the pain develops following ingestion of a large or fatty meal.
The patient usually vomits biliary emesis.
Fever, diaphoresis, and potentially right shoulder tip pain.
Positive Murphy's sign
Mesenteric ischemia:
Generally presents with diffuse visceral pain that develops gradually, much like that of ACS.
The pain is typically out of proportion to a relatively normal physical examination.
The patient usually has cardiovascular risk factors.
Bowel obstruction:
Visceral “colicky” pain that develops gradually and comes in waves. Not relieved by position changes.
The patient usually reports constipation, or passage of only watery stools for several days.
Distension and tenderness may be present.
The patient may vomit fecal matter, and may have fecalent odour on their breath.
The patient may be on medications that cause constipation, have a history of IBS, Crohn's/Colitis, Diverticular disease, or Cancer. History of abdominal surgery is also a risk factor.
Ectopic pregnancy:
Should be considered in all females of child bearing age.
May present with sharp pain localized to either side of the lower abdomen.
If rupture occurs, vaginal bleeding may occur, or the bleeding may be internal, presenting with discolouration of the flanks.
Tachycardia and hypotension should be concerning for possible rupture.
The patient may report missing regular menstruation, weight change, breast tenderness, and morning sickness.
Many causes of abdominal pain require further testing in the ED, and treatments are often surgical. In the pre-hospital setting, supportive care, management of hypotension, and analgesia are the primary interventions. In any patient with pain above the umbilicus, a 12-lead ECG is warranted to rule out atypical cardiac presentation.
Comments