นพ.ประสิทธิ์ วุฒิเมธาวี

1. Acute abdomen for EP
Prasit Wuthisuthimethawee
Department of Emergency Medicine
Prince of Songkla University

2. Male 34 years old
No underlying dis.
Check up at GP
During took blood examination
 abd pain & syncope

3. Objectives
Abdominal pain pathway
Critical points for assessing abdominal pain

4. Epidemiology
4-10 % of all emergency department visit
50 % have clearly diagnosis
15-30% require surgical procedure esp. elderly
Acute appendicitis is the most common

5. Epidemiology
Unique in Pediatric and Elderly

6. Acute abdominal pain among elderly patients
3 years, 831 cases
Non-specific 22-24%
Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%)
less peritoneal signs
Laurell H, Hansson LE, Gunnarsson U.
Gerontology. 2006;52(6): 339-44

7. Emergency department diagnosis of acute abdominal
pain in elderly patients
1 year retrospective review, 378 cases
Non-specific (35.2%), acute gastritis/gastroenteritis
(10.6%), and biliary tract dis. (8.2%)
Othong R, Wuthisuthimethawee P, Vasinanukorn P
Songkla Med J vol. 28 No 1 Jan-Feb 2010
Non-specific; 90% dissolved, 5.4% Sx.

8. Predictor for an intensive care or specific treatment in
the elderly patients with acute abdominal pain
1 year retrospective review, 386 cases
Dyspepsia (21.8%), non-specific (17.6%) and
acute gastroenteritis (8.8%)
Worapraatya P, Wuthisuthimethawee P, Vasinanukorn P
Male, BT < 38, PR >90, abnormal abd contour, and
Localize tenderness or guarding

9. Pain pathway

10. Abdominal pain pathway
3 type; visceral, somatic, and referred pain

11. Abdominal pain pathway
Visceral pain
Wall or capsule of solid organs/bowel
Midline, dull, archy and cramping pain
Autonomic; pallor, diaphoresis, nausea, and vomiting

13. Abdominal pain pathway
Somatic pain
Parietal peritoneum
Sharp, discrete, and localized
Tenderness, guarding, and rebound

14. Abdominal pain pathway
Somatic pain

15. Abdominal pain pathway
Referred pain
Cutaneous site distant from the diseased organ
Diaphragm  C3-5: neck and shoulder pain

16. Abdominal pain pathway
Referred pain

17. Critical points for assessing abdominal pain

18. Life threatening conditions
Vascular disease
Acute myocardial infarction
Ruptured ectopic pregnancy
Perforated visceral organs

19. Life threatening conditions
Intestinal obstruction
Acute hemorrhagic pancreatitis
Esophageal rupture

20. Aim
Surgical or Non-surgical

21. Physical examination
Accuracy 55-65% with final diagnosis
Reexamination and observation
Technique !

22. Physical examination
Bowel sound
Little diagnostic value

23. Physical examination
Do not forget PR

24. Physical examination
Analgesic ?

25. Analgesia on abdominal examination
Analgesia is safe in abdominal pain
Br J Surg. 2003 Jan;90(1):5-9
Effect on diagnostic efficiency of analgesia for
undifferentiated abdominal pain

26. Analgesia on abdominal examination
Reexam in 60 minutes
Prospective, double-blind clinical trial
No differences with respect to changes in physical
examination or diagnostic accuracy
J Am Coll Surg. 2003 Jan;196(1):18-31
Effects of morphine analgesia on diagnostic accuracy in
Emergency Department patients with abdominal pain:
a prospective, randomized trial

27. Analgesia on abdominal examination
Opioid improve patients comfort and
does not retard decision to treat
Cochrane Database Syst Rev. 2007 Jul 18;(3): CD005660
Analgesia in patients with acute abdominal pain

28. Analgesia on abdominal examination
8-18 years old, 90 patients
Randomized double-blind placebo-controlled trial
Morphine did not delay surgical decision,
not more effective than placebo to diminishing pain
Ann Emerg Med. 2007 Oct;50(4):371-8.
Epub 2007 Jun 27
Efficacy and impact of intravenous morphine before surgical
consultation in children with right lower quadrant pain
suggestive of appendicitis: a randomized controlled trial

29. Buscopan ?
Medication on abdominal examination

30. Clinical assessment
Reassessment

31. Clinical assessment
Patient’s quantification of pain
is unreliable

32. Clinical assessment
Corticosteroids and
immunosuppressants

33. Clinical assessment
Chronic dis.: CRF

34. Clinical assessment
Fever ?

35. Clinical assessment
Prior abdominal surgery

36. Clinical assessment
Hernia
Genitalia

37. Clinical assessment
Peripheral pulse

38. Clinical assessment
Menstrual history
Urine pregnancy test

39. Clinical assessment
WBC 30% in abdominal
pain of unknown etiology

40. Clinical assessment
20% of pancreatitis
have normal amylase

41. Clinical assessment
20% of pancreatitis
have normal amylase

42. Clinical assessment
Lactase and mesenteric ischemia
100% sensitive and 42% specific

43. Clinical assessment
Film acute abdomen
10-38% confirm diagnosis

45. Gallstone Ileus

46. Portal vein gas

47. Clinical assessment
USG and CT scan
Angiogram
Tech99m RBC scan

48. Clinical assessment
Myocardial infarction, pneumonia,
or pulmonary embolus can present
as abdominal pain

49. Clinical assessment
Psychiatric disorder
The last diagnosis

50. Mamagement
Bowel rest +/- decompression
IV resuscitation with correct electrolyte
Antiemesis ? Analgesia ? Antibiotic ?
Pre-op in surgical case

51. Uncertain Diagnosis
Observation
Review the cause
Consultation

52. Uncertain Diagnosis
When in doubt, don’t send them out!
Cope’s Early Diagnosis of the Acute
Abdomen, 20th ed.. New York, Oxford
University Press, 2000.

54. Case 1
Male 34 years old
No underlying dis.
Check up at GP
During took blood examination
 abd pain & syncope

55. Case 1
At ER
Sweating, looked pale
V/S BP 95/60 P 112 RR 26
Abd: tenderness at RLQ, guarding ?

56. What is diagnosis ?

58. Case 2
Female 53 years old
LLQ abdominal pain for 1 day
V/S BP 140/80 P 90 RR 24
Underlying HT

59. Case 2
Abd: LLQ pain, guarding ?
CVA: tenderness Lt.
Diclofenac  improved
Recurrent 2 times in 3 days
UA: microscopic hematuria

60. What is diagnosis ?

61. Hematuria may be seen in
abdominal aortic aneurysm (30%)

62. Case 3
Female 47 years old
RLQ abdominal pain for 1 day
V/S BP 130/80 P 82 RR 22
No known underlying dis.

63. Case 3
Abd: RLQ pain, guarding ?,
CVA: not tender
CBC: leukocytosis
UA: WNL

64. What is diagnosis ?

65. ?

66. Clinical assessment

67. ขอบคุณครับ

68. Special sign
Iliopsoas and Obturator
< 10% in appendicitis

69. Special sign
Fist Percussion

70. Special sign
Rovsing’s Sign
Only 5% of patients

71. High-Yield historical questions
How old are you ?
Which came first-pain or vomiting ?
How long have you had the pain ?
Have you ever had abdominal surgery ?

72. High-Yield historical questions
Is the pain constant or intermittent ?
Have you ever had this before ?
Do you have a history of cancer diverticulosis ?
Do you have HIV ?

73. High-Yield historical questions
How much alcohol do you drink per day ?
Are you pregnant ?
Are you taking antibiotic or steroid ?
Did the pain start centrally and migrate ?
Do you have a history of CAD, HT, AF ?

77. Etiology and clinical course of abdominal pain
In senior patients; a prospective, multicenter study
3 years, 831 cases
Non-specific 22-24%
Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%)
less peritoneal signs
Lewis LM, Banet GA, Blenda M, et al.
J Gerontol A Biol Sci Med Sci. 2005