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Approach to Patients

with Abdominal Pain:


Trauma vs NonTrauma
Valensia Hanafi
BIMC - 2007

ANATOMY

SURFACE ANATOMY
* Ant-or Abd : lin intermammaria, lig Poupart + pubic,
Lin
Axil. Ant-or
* Flank Area : Lin.Axil Ant-or - Post-or, 6th ICS, Illiac Crist.
* Post-or Abd (Back) : Post-or to LAP, Inf Angle of
Scapula, Illiac Crist

INTERNAL ANATOMY
* Peritoneal Cavity (Treitz Lig.)
> Upper : diaphragm, gaster, H/L, Colon Trans.
> Lower : Jej/Illeum, Duodenum Desc, Colon sigmoid,
Female Reprod Organs
* Retroperitoneal Cavity : Duodenum-other, pancreas,
ren - ureter, ColonAsc/Desc, vessels.
* Pelvic Cavity: Rectum, Female internal reprod organs,
VU,
illiaca vessels

Blunt Trauma

TRAUMA
Penetrating Trauma

Abd cavity may collect blood up to 4 Ltrs

Blunt Trauma

Air bag protect the abd?


Commonest affected organs :
- Spleen (40-55%)
- Intestine (5-10%)
- Liver (35-45%)
- Retroperitoneal organs (15%)

Penetrating Trauma

Commonest affected organs :

Liver (40%), intestine (30%), diaphragm (20%), colon (15%)

In gun-shot cases :
- always find bullet way out
- predict the bullet pathway within patients body
- commonest affected organs:
intestine (50%), colon (40%), liver (30%), blood vessels (25%)

Primary Survey
A-irway
B-reathing
stabilize step by step.
C-irculation*
D-isability level of consciousness
E-xposure front and back side, log-roll
technique
* Plus bleeding control, predict class of hemorrhage, apply 2
i.v line w/the largest bore catheter crystaloid 2 L

[Adult blood volume : 7% BW; children 8-9%]

Class of hemorrhage
Class I

Class II

Class III

Class IV

Blood loss < 750


% blood
<15%
loss

750-1500
15-30%

1500-2000 >2000
30-40%
>40%

Pulse
BP
Pulse
Press.

<100
N
N/

100-120
N

120-140

>140

RR
Diuresis
LoC
Fluid th/

14-20
>30
CM
Crystaloid

20-30
20-30
Anxiety
Crystaloid

30-40
5-15
Confused
Crystaloid+
Blood

>35
Least
Lethargic
Crystaloid
+Blood

History Taking

Biomechanism of trauma

Motor vehicle crash, ask:


Speed
Type of collision (frontal, lateral, sideswipe,
rear impact, and rollover)
Vehicle intrusion into compartment
Types of restraint
Pt position in vehicle
Status of pt
Air bag (?)

History Taking (2)


Penetrating trauma, ask:
Time of injury
Type of weapon
Distance (shotgun wound: major visceral
injuries decrease > 7 foot range)
Number of stab / shots
Amount of external bleeding at the scene
Ask pt (if possible): pain scale & location of
pain, any referral pain to the shoulder

Physical Examination
INSPECTION

Ideally: fully undressed


Inspect the whole abd+lower part f the
chest+perineum+pregnacy state
Log-roll

Auscultation

Bowel sound?
Blood retroperitoneum/GIT BS (-)
BS (-) not diagnostic for intraabd trauma

Physical Examination (2)


Percussion

To provoke peritoneal sign, any free air or dullness

Palpation

Guarding sign, rebound tenderness sign of


peritonitis

Evaluation of Penetrating Wound

Most cases end up w/laparotomy, esp w/unstable


CV state

Physical Examination (3)


Assess Pelvic Stability

Manually on SIAS, Crista Illiaca


Should be very careful

Assess Other Areas (Penis,


Perineum, Rectum, Vagina,
Gluteal)

Urethral rupture?

Additional maneuvers
Gastric Tube

Goal : overcome acute gastric dilatation,


decompression, prevent aspiration

Urine Catheter

Goal: overcome urine retention, bladder


decompression, monitoring urine output
Pay attn to C/I

Urine+Blood sample
X-ray

Routine in trauma: C-lateral, Thorax AP, Pelvis


AP
Abd Trauma: Abd 3 Pos

Diagnostic Procedures Abd


Trauma
DPL
FAST
CT-Scan

DPL

98% sensitive Intraperitoneal hemorrhage


I/: hemodynamically unstable w/multiple blunt
injuries, esp w/:
Change in sensorium (Head Injury, ET-OH
intoxication, drug abuse)
Change in sensation (Injury to Spinal Cord)
Injury to adjacent structures (Lower ribs,
Pelvis, Lumbar spine)
Equivocal physical examination
Prolonged loss of contact with patient
anticipated (GA for extraabdominal injuries,
long x-ray studies eg. angiography)
Also : hemodynamically stable but no CT or USG
available

DPL (2)
Consider (+) if
WBC > 500/mmc
RBC > 100,000/mmc
Gram staining (+) for bacterias

FAST

To detect hemoperitoneum
Operator dependent
4 locations:
- Pericard sac
- Hepatorenal fossa
- Splenorenal fossa
- Douglas Cave
Obtain a control scan 30 after the 1st one; what
for?

FAST Probe Position


Pos. for RUQ

Pos for LUQ

FAST Probe Position (2)


Pos for Pelvic/Douglas Sac

Pos for Pericard Sac

Pericard Sac

Morisons Pouch

LUQ

Suprapubic / Douglas
Pouch

CT-Scan

Only for STABLE CV-State, w/o I/laparotomy

May miss some injuries: TGI, pancreas,


diaphragm.

If sign of liver/spleen injuries (-), but intraabd.


free fluid(+) suggest intraabd. trauma

Laparotomy
I/:

Abd blunt trauma + Low BP + clinically suggestion


of intraabd hemorrhage
Abd blunt trauma + DPL/FAST (+)
Abd penetrating trauma + Low BP
Gunshot wound traversing peritoneal cavity
Evisceration omentum/intestine
Bleeding (gaster, rectum, GUT) stab wound
Peritonitis
Free air, retroperitoneal air, diaphragm rupture
CT-Scan (+) for GIT organs rupture

Surface Anatomy - again

Whats Inside?

GIT
Abd. Cavity

Urinary Tr
Female Internal Genital Organs

Today Focus : GIT

Embriology

Understanding abd pain-embriology is important.


Why? Same history almost same location

Part of Fetal
Gut

Organs

Blood
Supply

Region of Abd
Pain

Foregut

Esop, Gaster, 1-2 part


of duodenum, hepar,
lien, pancreas

a.Coeliac

Epigastric

Midgut

Remainder of
duodenum, jej, ill, asc
colon, 2/3 proc colon
trans

a.Mesenterica Sup-or

Umbilical

Hindgut

Remainder of colon
trans, colon desc,
rectum

a.Mesenterica Inf

Suprapubic/Hypogastric

History Taking

Seven Attributes / O-P-Q-R-S-T


Fundamental Four
Visc. Pain

Abd Pain

+ Referred Pain
Parietal/Somatic Pain

Visceral Pain

Origin : visc organs, solid or hollow ones.


* Solid stretched capsule
* Hollow Distended, Stretched, Obstructed
Difficult to localize
Typically, not necessarily, near the midline
Q : gnawing, burning, cramping, aching

Parietal Pain

Origin : parietal peritoneum


E/ Inflammation
Steady aching pain, more severe (compared to
visc)
More precisely located
Usually aggravated by movement/IAP

Referred pain

Def: pain-more distant sites-innervated at


approx the same spinal nerves
Tends to develop later
Usually well localized
May provide clues :
* diapghragm supraclavicular area
* hepatobilliary right shoulder
* spleen left shoulder
* pancreas/duodenum midback
* prox urinary tr. flank area
* distal urinary tr. & genital groin , inner thigh
*

Physical Examination

Empty bladder, pls


Comfortable supine pos, the pts back flat to ur
examining table
Warm ur hands & steth.
PE order : I Au Pe- Pa
* I : skin, umbilicus, abd contour, peristalsis,
pulsations
* Au : BS (N=5-34, click & gurgles)
* Pe : tympani / dullness distribution
* Pa : light & deep palpation

Physical Examination (2)

Also : Abd-al organs examinaton


* Liver : liver spans at midclav & midline
* Kidney : CVA
Mass intraabd / abd wall?
Karnets Test : tighten abd wall

Some Common Cause of


Abd Pain
Problem

Peptic Ulcer,
Dyspepsia

AcutePancreatitis

Process

Due to ulcer, H.pylori

Acute imflam.
pancreas

Location

Epigastric to midback Epigastric to


midback; poorly
localized

Quality

Aching, burning,
boring, hunger-like

Usually steady

Timing

Intermittent
(prominent in ulcer)

Acute onset; persistent

Aggravator

Variable

Lying supine

Reliever

Foods, antacids

Leaning forward;
flexed trunk

Associated
symptoms&Settin

Nause-vomit, bloating,
heartburn

Nausea-vomit, abd
distention, fever

Some Common Cause of Abd


Pain (2)
Problem

Biliary Colic

Acute Cholecystitis

Process

Sudden obstruction
biliary tree

Inflammation
gallbladder

Location

Epigastric / RUQ ; right


scapula/shoulder

RUQ/Epigastric; right
scapula/shoulder

Quality

Steady, aching,NOT
colicky

Steady, aching

Timing

Rapid onset-several
hours-subsides
gradually

Gradual onset, course


onger to bill. colic

Aggravator

Jarring, deep breathing

Reliever

Associated
symptoms&Settin

Nausea,vomit,
restlessness

Anorexia, nausea,
vomit, fever

Some Common Cause of Abd


Pain (2)
Problem

Acute App

Mesenteric Ischemia

Process

Inflamm. app

Blood supply,
bowel/mesentericblocked; hypoperfusion

Location

Periumbilical-RLQ

1st:periumbilical, then
diffuse

Quality

Mild increasing cramp


steady, severe
1st : 4-6 hrs, next
depend on intervention

1st:cramping. Then
steady

Timing
Aggravator

Movement, cough

Reliever

Lying still. (if subsides


temporarily rupture?)

Associated
symptoms&Settin

Anorexia, nausea,
vomit, low fever

Abrupt in onset, then


persistent

Vomit,
diarrhea/constipation,
shock

Important Signs in Patients with Abdominal Pain


Sign

Finding

Cullen's sign

Bluish periumbilical discoloration

Kehr's sign

Severe left shoulder pain

McBurney's sign

Tenderness 2/3 distance from


SIAS to umbilicus-right side
Abrupt interruption of
inspiration on palpation-RUQ
Hyperextension of right hip
causing abdominal pain
Internal rotation of flexed right
hip abdominal pain
Discoloration of the flank

Murphy's sign
Iliopsoas sign
Obturator's sign
Grey-Turner's
Chandelier sign
Rovsing's sign

Manipulation of cervix
patient to lift buttocks off table
RLQ pain with palpation of
LLQ

Association
Retroperitoneal hemorrhage
(hemorrhagic pancreatitis,
AAA rupture)
Splenic rupture, Ectopic pregnancy
rupture
Appendicitis
Acute cholecystitis
Appendicitis
Appendicitis
Retroperitoneal hemorrhage
(hemorrhagic pancreatitis, AAArupture)
Pelvic inflammatory disease
Appendicitis

DD/ Chronic Abdominal


Pain

DD/ Acute Abdominal Pain

The 9 Regions & the Organs


Inside
Right Hypochondriac
Due to bile sac/duct, Hep-is, Pn.

Epigastric
Gastritis, Peptic Ulcer, Pancreatitis, Crohns Dis,
Heart Dis

Left Hypochondriac
Splenomegaly, IBS, Pn.

The 9 Regions & the Organs Inside (2)


Right Lumbar
Ureteric colic, Pyelonephritis, Duodenal ulcer

Umbilical
Early App, Small bowel obstruction, perforated peptic
ulcer, AAA ruptured, mesenteric artery occlusion,
Crohns Dis., Meckels Diverticulitis

Left Lumbar
Ureteric colic, Pyelonephritis, IBS, Diverticulitis

The 9 Regions & the Organs


Inside (3)
Right Iliac

App, Ureteric colic, mesenteric adenitis, diverticulitis,


hernia, unruptured ectopic pregnancy, salpingitis,
ovarian cysts, testicular torsion

Hypogastric

Cystitis, large bowel obstruction, ruptured ectopic


pregnancy, uterine cramps, endometriosis, PID

Left Iliac

GE, Ca Colon, diverticulitis, constipation, hernia,


ulcerative colitis, ureteric colic, salpingitis, ovarian
cysts, unruptured ectopic pregnancy, testicular
torsion

Most common causes

GEA
App
Mittelschmerz / Dysmenorrhoea
IBS

Serious Disorders (not to be


missed)
CV : AMI, AAA-ruptured, AAA-dissecting, a.Mesenterica
occlusion
Neoplasia : L/S Bowel
Severe Infx : Acute salpingitis, Asc. Cholangitis,
Peritonitis, Intra-abd abscess
Others :

Ectopic pregnancy

(Sigmoid) volvulus

Perforated ulcer

Often missed

App
Myofascial tear
Pulmonary origin
Fecal impaction
HZ
Rare: porphyria, lead poisoning,
hemochromatosis, tabes dorsalis, sickle cell
anemia

Thank You

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