Abdominal Pain

AMY LITTLE, MD ALBANY MEDICAL CENTER 1

GOALS

 Review the anatomy of the abdomen  Quadrants  Peritoneal vs. Retroperitoneal  Solid vs. Hollow organ  Vascular structures  Assessment (History and Physical Exam)  Management  Abdominal trauma  Special situations 2

The Abdomen  Everything between diaphragm and pelvis  Injury and illness can be very difficult to assess because of large variety of structures 3

Abdominal Anatomy  Abdomen divided into four quadrants by body mid-line, horizontal plane through umbilicus  Organs can be located by quadrant 4

Abdominal Anatomy  Right Upper Quadrant  Liver  Gall Bladder  Right Kidney  Ascending Colon  Transverse Colon 5

Abdominal Anatomy  Left Upper Quadrant  Spleen  Stomach  Pancreas  Left Kidney  Transverse Colon  Descending Colon 6

Abdominal Anatomy  Right Lower Quadrant  Ascending Colon  Appendix  Right Ovary (female)  Right Fallopian Tube (female) 7

Abdominal Anatomy  Left Lower Quadrant  Descending Colon  Sigmoid colon  Left Ovary (female)  Left Fallopian Tube (female) 8

Abdominal Anatomy  Periumbilical area  Located around (peri) the navel (umbilicus)  Small bowel lies in all quadrants in periumbilical area  Suprapubic area  Located just above pubic bone  Urinary bladder, uterus lie in this area 9

Abdominal Cavity  Peritoneum = abdominal cavity lining  Divides abdomen into two spaces  Peritoneal cavity  Retroperitoneal space (retro=behind) 10

Abdominal Anatomy  Peritoneal  Spleen  Liver  Stomach  Gall bladder  Bowel  Retroperitoneal  Pancreas  Kidney  Ureter  Inferior vena cava  Abdominal aorta  Urinary bladder  Reproductive organs

NOTE: Disease or injury of retroperitoneal organs often causes back pain.

11

Abdominal Anatomy  REVIEW: Organs are classified by  Quadrant, periumbilical, or suprapubic  Peritoneal or retroperitoneal  Organs can also be classified as:  Solid  Hollow  Major vascular 12

Solid Organs  Liver  Spleen  Kidney  Pancreas

NOTE: When solid organs are injured, they bleed heavily and cause shock.

13

Solid Organs  Liver  Largest abdominal organ  Most frequently injured  Fractures of ribs 8-12 on right side  Bleeding can be either:  Slow, contained under capsule  Free into peritoneal cavity 14

Solid Organs  Spleen  Frequently injured with trauma ribs 9-11 on left side  Bleeds easily  Capsule around spleen tends to slow development of shock  Rapid shock onset when capsule ruptures 15

Solid Organs  Pancreas  Lies across lumbar spine  Sudden deceleration produces straddle injury  Very little hemorrhage  Leakage of enzymes digests structures in retroperitoneal space, causes volume loss, shock 16

Solid Organs  Kidney  Retroperitoneal  Vulnerable to trauma (blunt & penetrating), infection, obstruction, chronic disease  Tenderness: Lower ribs, upper L-spine, flank  Pain: groin, shoulder, back, flank 17

Hollow Organs  Stomach  Gall bladder  Large, small intestines  Ureters, urinary bladder, urethra

Rupture causes content spillage & inflammation of peritoneum.

18

Hollow Organs  Stomach  Acid, enzymes  Immediate peritonitis  Pain, tenderness, guarding, rigidity 19

Hollow Organs  Colon  Spillage of bacteria  May take 6 hrs to develop peritonitis  Small Bowel  Fewer bacteria  May take 24-48 hours to develop peritonitis 20

Hollow Organs: Urinary System  Ureters  Penetrating injury  Bladder  Blunt injury (seatbelts, pelvic fracture)  Urethra  Straddle injury

Signs and Symptoms

 Abnormal urination

(Urgency, Inability, Dysuria, Hematuria)

 Blood at external meatus  Perineal bruising

(butterfly bruise)

 Scrotal hematoma  Shock  Abdominal distension 21

Major Vascular Structures  Aorta  Inferior vena cava  Major branches Injury can cause severe blood loss; exsanguination (bleeding out).

22

QUESTIONS about Abdominal Anatomy?

23

ASSESSMENT of Abdominal Pain

History LOCATION



Where

do you hurt?

 Know locations of major organs  But realize abdominal pain locations do not always correlate well with source 24

ASSESSMENT of Abdominal Pain QUALITY  What does pain

feel

like?

 Steady pain - inflammatory process  Crampy pain - obstructive process 25

ASSESSMENT of Abdominal Pain ONSET  Was

onset

of pain gradual or sudden?

 Sudden = perforation, hemorrhage, infarct  Gradual = peritoneal irritation, hollow organ distension 26

ASSESSMENT of Abdominal Pain RADIATION  Does pain radiate (travel) anywhere?

 Right shoulder, angle of right scapula = gall bladder  Left shoulder = spleen, stomach  Around flank to groin = kidney, ureter 27

ASSESSMENT of Abdominal Pain  DURATION  > 6 hour duration = ? surgical significance  ASSOCIATED SYMPTOM:  Nausea &/or vomiting? Bloody? “Coffee Grounds”?

Any blood in GI tract = Emergency until proven otherwise

28

ASSESSMENT of Abdominal Pain  Change in urinary habits? Urine appearance?

 Change in bowel habits? Diarrhea? Appearance of bowel movements? Melena?

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss.

29

ASSESSMENT of Abdominal Pain  Females  Last menstrual period?  Abnormal vaginal bleeding?

In females, abdominal pain = Gynecological problem until proven otherwise.

30

PHYSICAL EXAM  General Appearance  Lies perfectly still inflammation = peritonitis  Restless, writhing obstruction  Abdominal distension?

 Ecchymosis around umbilicus, flanks?

31

PHYSICAL EXAM 

Vital signs

 Tachycardia = Early shock &/or pain (more important than BP)  Rapid shallow breathing = peritonitis 32

PHYSICAL EXAM  Palpate each quadrant  Work toward area of pain  Warm hands  Patient on back, knee bent (if possible)  Note tenderness, rigidity, involuntary guarding, voluntary guarding, masses  Bowel sounds (?) 33

Management  Airway  High concentration O 2  Anticipate vomiting  Anticipate hypovolemia  Need PIV, IVF  Nothing by mouth except medications 34

Management  Consider referred cardiac pain:  Adults > 30  Diabetics  History of cardiac problems  In females, consider gynecological problems, especially ruptured ectopic pregnancy (surgical emergency) 35

QUESTIONS about general assessment or management?

36

REVIEW:

GOALS

 Review the anatomy of the abdomen  Quadrants    Peritoneal vs. Retroperitoneal Solid vs. Hollow organ Vascular structures   Assessment (History and Physical Exam) Management NEXT:  Abdominal trauma  Special situations 37

Abdominal Trauma  Most survive to reach hospital  Most common factors leading to death  Failure to adequately evaluate  Delayed

resuscitation

 Inadequate volume replacement  Inadequate/missed diagnosis  Delayed surgery 38

High Index of Suspicion in Trauma  Mechanism  Unexplained hypovolemic shock  Signs of injured abdomen  Management 39

Mechanism  Look for signs of injury  Bruises  Tire marks  Obvious open injuries  Trauma to lower chest, back, flank, buttocks, and perineum  Injury above umbilicus also involves chest until proven otherwise 40

Unexplained Shock  Assess vital signs; skin color, temperature; capillary refill  Tachycardia; restlessness; cool, moist skin  In trauma, signs of shock suggest abdominal injury if no other obvious causes present  Assume any abdominal injury is serious until proven otherwise!

41

Signs of Injured Abdomen  Diffuse tenderness  Pain  Pain referred to shoulder = Organ under diaphragm involved (?spleen)  Pain referred to back = Retroperitoneal organ involved (?kidney) 42

Abdominal Trauma Management  Less important to diagnose exact injury  Treat clinical findings (open wounds, hypotension/tachycardia)  Management same regardless of specific organ(s) injured 43

Abdominal Trauma Management  Airway  C-Spine if mechanism indicates  High flow O 2  Assist ventilations if needed  Give nothing by mouth  (?) MAST may be helpful in slowing intraabdominal bleeding with shock 44

Special situations in Abdominal Pain  Impaled objects  Evisceration  Trauma to the reproductive system  Sexual assault 45

46

Impaled Object  Leave in place  Shorten if necessary for transport  Leave part of object exposed 47

Evisceration  With large laceration abdominal contents may spill out  Do NOT try to replace 48

Evisceration  Cover exposed organs with saline moistened multi-trauma dressing  Do NOT use 4 x 4s  Cover first dressing with second DRY dressing or aluminum foil 49

Reproductive System Trauma  Can occur to both external and internal reproductive systems  External  More common  Pain, extensive bleeding  Internal  Less frequently injured  Treat like blunt or penetrating soft tissue injuries elsewhere on body 50

Male Genitalia Trauma  Usually NOT life-threatening  Very painful  Great source of concern to patient 51

Male Genitalia Trauma  Avulsion of skin of penis, scrotum  Cover with a moist, sterile dressing  Complete amputation of penis  Treat as any amputated part 52

Male Genitalia Trauma  Blunt trauma to penis, scrotum  Apply ice pack  Urethral foreign bodies  Do NOT remove  Penis entrapped in zipper  If 1 or 2 teeth involved, try to unzip  If more involved, cut zipper out of trousers, transport 53

Female Genitalia Trauma  Internal  Rarely injured  External  Can cause pain, extensive bleeding  Usually not life threatening  Treat with compresses, pressure 54

Sexual Assault  Avoid examining genitalia unless obvious bleeding present  Ask patient to NOT wash, douche, urinate, defecate  Ask patient NOT to change clothes  Record history, but avoid extensive questioning about incident 55

SUMMARY: Abdominal Pain  Consider the anatomy  In general abdominal pain, note HISTORY  In trauma, think about mechanism  Management  ANTICIPATE!

 Vomiting=airway  Hypovolemia  resuscitation  Appropriate transport 56

THANK YOU FOR YOUR ATTENTION!

57