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Abdominal Pain Defying Diagnosis
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Helen F. Brown MS, APRN -BC, ACNP, FNP Doctors Emergency Services, PA
Emergency Department Anne Arundel Medical Center Clinical Instructor
Georgetown University School of Nursing and Health Studies
Washington, DC
Develop a differential diagnosis for a patient with abdominal pain, including extra -abdominal causes.
Recognize warning signs and symptoms of potential abdominal catastrophes.
Identify high risk patient populations for potentially lethal intra -abdominal disease.
List the pitfalls commonly encountered in the evaluation of abdominal pain .
The Mysterious
Box
Abdominal pain is a frequent chief complaint
OR
A component of a constellation of symptoms
unexpectedmake the difference between life and death.
Clinical manifestations range from simple to complex .
The challenge is recognizing and differentiating
the serious
from the benign.
Facts
75% of abdominal pain is non-surgical
10 % patients seen in the ED have life threatening cause for the abdominal pain and require surgery.
The accuracy of initial impression is ~ 50-65% when compared to the final diagnosis.
Kamin, R., Nowicki, T., Courtney, D., Powers, R. (2003).
Acute Abdomen in ICU
Potential complication in acute/critically ill population
Absent or atypical presentation
Delay in diagnosis and treatment
Increase in morbidity and mortality
Those at greatest risk
Admission with a primary diagnosis other than abdominal pain
Frustrations
Large spectrum of diseases with varying acuity.
The presentation of acute life threatening and benign processes overlap.
Need to consider extra-abdominal causes of pain.
Even common cause of abdominal pain
Evaluation consumes time and resources.
Frequently remains undiagnosed.
Where do we start?
Acutely ill? Toxic appearing? Severe pain acute surgical abdomen?
Peritonitis, obstruction, perforation, mesenteric ischemia
Vital Signs
Febrile, tachycardia, hypo or hypertensive, orthostatic
Lab Data
Leukocytosis, metabolic acidosis, azotemia
Acute Care Management resuscitation, pain management and continue gathering data.
The History.
Assess the pain
Quality
Visceral dull, aching or colicky, poorly localized.
Parietal - sharp, stabbing, well localized.
Referred aching, perceived near body surface.
Abdominal Pain
Acute Surgical Abdomen
Early Surgical
consultation
Non Surgical Intra-abdominal Process
Uncommon presentation
of a common problem
Common presentation of
an uncommon problem
Referred Pain from Extra abdominal cause
Manifestation of a systemic illness
High Risk Population
Older Adult
Immunocompromised
Bariatric Surgery
Post Procedure
Pregnancy
Female Male
Younger Younger
Location
Timing
Symptom Cluster
HCG + or -
Most diagnoses are made in the ED
Not in the inpatient setting or operating room
Advance made in radiographic imaging
Increase options for management
Non invasive surgical procedures
Interventional radiology
The Case of 2 Cases
Different Ages
Different Gender
Similar Clinical Presentations
Similar Differentials
Similar Diagnoses
Let the FUN Begin
67% of Elders with abdominal pain are admitted vs. 7.5% of Younger adults with abdominal pain
7% of Elders with abdominal pain admitted ICU vs..
1% of Younger adults with abdominal pain
33% EMS transport AGING vs. 8% others ELDER = 50% more dx tests
ELDER = 20% longer LOS
The AGING abdomen with pain will have a higher rate of incorrect diagnosis and higher mortality rate than the younger abdomen
Marco, C, Schoenfeld,, C., & Keey, J. (2000)
http://images.google.com/imgres?imgurl=http://dailypics.blogfodder.net/rumsfield.jpg&imgrefurl=http://dailypics.blogfodder.net/archives/2001_10.html&h=322&w=450&sz=16&tbnid=2Cn_DuJkuZV_1M:&tbnh=88&tbnw=124&hl=en&start=3&prev=/images%3Fq%3DRumsfield%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26sa%3DGThe YOUNGER ABD
Straight forward
Clinical presentation usually stronger & very specific
Usually seek STAT care
Usually able to provide accurate hx
Minimal or no
co-morbidities
Usually no risk for serious health outcomes
The OLDER ABD
An atypical presentation
Clinical presentation usually milder & less specific
Usually delay in seeking care
Accurate hx can be difficult to obtain
Co-morbidities
Increased risk for serious outcomes
Common Etiology of the Abdominal Pain in ELDERS
21% = Biliary Disease
16% = Indeterminate
12% = Bowel Obstruction
7% = Perforated Viscus
7% = Pancreatitis
6% = Diverticulitis
4% = Appendicitis
4% = Incarcerated Hernia
4% = Renal Colic
2% = Vascular
Common etiology of abdominal pain YOUNGER adults
40% = Undifferentiated abdominal pain (UDAP) 32% = Appendicitis 6% = Biliary disease 4% = Gynecologic 2% = Bowel obstruction 2% = Pancreatitis 12% = Urinary tract
http://images.google.com/imgres?imgurl=http://www.fpch.org/Images/Black%2520Man%2520Smiling.gif&imgrefurl=http://www.fpch.org/becom_4.htm&h=225&w=193&sz=17&tbnid=gitDbgIh_R09eM:&tbnh=102&tbnw=87&hl=en&start=4&prev=/images%3Fq%3Dpicture%2Bof%2Ba%2Bblack%2Bman%26svnum%3D10%26hl%3Den%26lr%3D%26ie%3DUTF-8%26sa%3DGCase #1 Lily, a 72 yr old w/f, presented to the
ER 4 days ago for LLQ pain radiating to L flank She returns today because of continued pain
described as severe when her pain med wears off
Prior evaluation consisted of CBC, Chem 7,
urinalysis, and non-contrast CT of abdomen/pelvis
to exclude renal calculi or AAA
All studies were negative except urine
+ RBC 8-10
D/C diagnosis = Suspected Renal Calculi
Plan = Fluids, Strain Urine, Rest, Percocet 1 every 6
hrs PRN Pain, and FU with PCP if needed
Case #1: Physical Exam
WD, WN older female appears uncomfortable VS: 97.5, 98, 18, 164/95, 96% RA,
8/10 for pain scale ABD: ND, no visible pulsations/hernias,
NABS, no bruits, tender LLQ, + CVAT, no rebound or guarding
Pelvic: deferred
Rectal: tone intact, no masses, heme -
Biliary Disease
PUD
Bowel Obstruction
Pancreatitis
Appendicitis
Diverticular Dz
Mesenteric Ischemia
Still Renal Calculi? What NEXT Diagnostic Steps?
CV Dz
Aortic Dissection
Aortic Aneurysm
MI
Urogenital Dz
Renal Calculi, BPH
UTI, Pyelonephritis
Non-Abdominal Dz
DKA, Hypercalcemia, Pneumonia, PE, Shingles