Transcript Clinical Framework Abdominal Pain

Abdominal Pain
Barry D. Mann, M.D.
Professor of Surgery
Drexel University College of Medicine
Philip Wolfson, M.D.
Mrs. Jones
• Your patient in the ER is a 62 year-old female
with a three day history of LLQ abdominal
pain, constipation and fever.
History
What other points of the history
do you want to know?
History, Mrs. Jones
Consider the Following
• Characterization of
symptoms
• Temporal sequence
• Alleviating /
Exacerbating factors:
• Pertinent PMH, ROS,
MEDS.
• Associated signs and
symptoms
• Relevant family hx.
History, Mrs. Jones
Characterization of pain:
initially crampy, now steady,
increasingly severe in left
lower quadrant
Temporal sequence:
has become more pronounced
in last 24 hrs
Alleviating / Exacerbating
factors:
worse with movement and
eating, partly alleviated by
lying still and drawing legs
upward
Associated sign/symptoms
nausea x 2 days, no vomiting,
tendency toward constipation
over the years, no blood in
stools
PMH
Diabetes Mellitus
Cholecystectomy 15 years ago
Physical Examination
What would you look for?
Physical Examination
Mrs. Jones
 Vital Signs: T= 101.2 P= 100 R= 22 BP= 126/80
 General : Well nourished, slightly obese, in moderate distress
 Abdomen :
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Inspection – mild distention, symmetric, shallow breathing
Auscultation – bowel sounds present but diminished
Percussion – tympanitic; elicits tenderness in LLQ
Palpation - generally soft, but + LLQ tenderness, guarding and rebound directly
and referred
 Rectal: Guaiac neg. scant stool, no mass or tenderness
 Pelvic: no discharge, no-cervical motion tenderness, uterus non-tender, no
adnexal masses but tender to palpation on LLQ bimanual
Remaining exam non-contributory
What is your Differential Diagnosis?
Laboratory
What would you obtain?
Labs ordered, Mrs. Jones
• CBC
 Hb
 Hematocrit
 WBC
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Electrolytes
LFTs
Amylase
Lipase
PT/PTT
Urinalysis
Lab Results, Mrs. Jones
• CBC
 Hb
 Hematocrit
 WBC
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12.4
35.2
16.4
Electrolytes
134/101/3.5/23
LFTs Bili = 1.1, AST=45, ALT=47, Alk Phos= 104
Amylase 89
(nl=80-100)
Lipase
44
(nl=30-90)
PT/PTT - pending
U/A – 5 RBCs/hpf
15 WBCs/hpf
What do you think of her Labs?
Lab Results, Mrs. Jones
The leukocytosis is consistent with a bacterial infection.
The serum electrolytes are normal but the BUN is
elevated, suggesting isotonic dehydration. The LFT’s,
amylase and lipase are fairly normal indicating that this
patient probably does not have significant hepatic or
pancreatic disease. The urine is not completely clear,
which may be typical of an uncatheterized specimen in
the elderly or reflect inflammation contiguous to the
urinary tract.
Interventions at this point?
Interventions at this point?
• Start IV with Ringers Lactate or similar
isotonic crystalloid solution
• Administer broad spectrum antibiotics
Studies
What further studies would you want
at this time?
Studies, Mrs. Jones
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Obstruction Series?
Acute Abdominal Series
Flat and Upright Abdomen
Studies – obstruction series
• The Obstruction Series shows that there is some
small bowel dilatation consistent with ileus;
otherwise a non-specific gas pattern. No free air,
no air fluid levels.
What is the Differential Diagnosis
at this point?
Differential Diagnosis
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Diverticulitis
Diverticulitis with Abscess
Appendicitis
Tumor +/- perforation
Colonic ischemia / infarction
Inflammatory bowel disease
UTI
What next?
What next?
CT Scan?
What next?
CT Scan – Acute diverticulitis is the leading diagnosis,
and a CT scan is indicated to confirm it and assess its
severity (whether there is an abscess, extraluminal air,
or extravasated contrast medium).
A barium enema and lower endoscopy are
contraindicated in acute diverticulitis because they
may rupture a sealed area and cause free perforation.
CT Scan
Can you describe the CT findings
suggestive of Diverticulitis?
Consider the following
• Thickened bowel wall
• Involved segment containing diverticuli (may
see contained air/fluid)
• Fat stranding to suggest local inflammation
• Localized Peri-colonic fluid or air
Complicated Sigmoid Diverticulitis
CT findings in complicated Diverticulitis
• May see free air or free fluid
• May see a localized abscess
• May see perforation into adjacent viscera such
as bladder, vagina
• May see a phlegmon or abscess involving the
abdominal wall or retroperitoneum
CT Mrs. Jones
CT Scan
CT Scan shows diverticular abscess. No free
air, no free fluid
What next?
Management
Percutaneous drainage under ultrasonic or CT
guidance is indicated due to the presence of an
abscess
Management
Following the drainage of purulent material the
patient’s condition improves markedly over the
next several days.
What should be done next?
Management
Following clearing of the acute infection, the
patient should be scheduled for semi-elective
surgery, with resection of the sigmoid colon and
a primary anastomosis.
Discussion
Diverticular disease has become extremely common in middle aged
and elderly individuals in industrialized areas where there is a low dietary
intake of fiber. Increased pressure in the colon leads to herniations of the
mucosa through sites of least resistance, such as where nutrient vessels
enter the colonic wall between the teniae. These resulting “false” (because
they do not contain all the layers of the bowel wall) diverticula are most
common in the left, and especially the sigmoid colon, where the
intraluminal pressure is highest.
Acute inflammation, or diverticulitis, is a common complication of
diverticular disease. The inflamed diverticulum may then perforate, which
can either be contained or cause free peritonitis. Symptoms of diverticulitis
are typically left lower quadrant pain, fever, and chills. Patients often have
a history of chronic constipation. Findings include diminished or absent
bowel sounds due to the resulting paralytic ileus, left lower quadrant
tenderness, and variable signs of peritonitis, including guarding and
rebound. If there is a localized abscess, a mass may be palpable.
Discussion
A CT scan is most useful to confirm the diagnosis of
diverticulitis and determine the extent of the disease, which will
affect treatment. Most cases of uncomplicated inflammation will
respond to intravenous antibiotics, which should be active against
anaerobes and gram negative aerobes. The presence of an abscess,
as in the current patient, mandates percutaneous drainage; once the
infection is controlled, resection of the involved segment of colon
should be performed. If there is free perforation with peritonitis,
emergency laparotomy is warranted with resection of the affected
segment of intestine; a temporary colostomy is necessary in the
presence of a purulent infection due to the high incidence of
anastomotic breakdown under these conditions.
In the case of uncomplicated diverticulitis that responds to
antibiotics, elective surgical resection is usually recommended after
the second attack requiring hospitalization.
QUESTIONS ??????