Acute Nontraumatic Abdominal/Flank Pain in the ED
Epidemiology
- abdominal/flank
pain = 5–10% ของ ED visits
- differential
diagnosis กว้างมาก:
- benign
→ catastrophic
- intra-abdominal
+ extra-abdominal causes
- undifferentiated
abdominal pain:
- ~25%
ของ discharged patients
- 35–41%
ของ admitted patients
High-Risk Groups
ต้องระวัง atypical presentation:
- elderly
- diabetes
- immunocompromised
- females
of childbearing age
Initial Approach
First question:
“Is this abdominal catastrophe?”
Red flags:
- hypotension
- tachycardia
- tachypnea
- altered
mental status
- severe
distress
- peritonitis
→
resuscitation พร้อม evaluation ทันที
History Taking
1. Pain characteristics
Important features
- onset
- severity
at onset
- progression
- location
- radiation
- aggravating/alleviating
factors
- associated
symptoms
Sudden severe pain
คิดถึง:
- AAA
rupture
- aortic
dissection
- mesenteric
ischemia
- nephrolithiasis
- ovarian
torsion/rupture
Gradual pain
คิดถึง:
- inflammatory
disease
- infection
- appendicitis
- diverticulitis
Colicky pain
คิดถึง:
- biliary
colic
- nephrolithiasis
Important clinical pearls
Pain before vomiting
→
surgical cause มากขึ้น
Pain out of proportion to exam
→
mesenteric ischemia จนกว่าจะพิสูจน์ว่าไม่ใช่
Pain location pearls
RUQ
- biliary
disease
- liver
disease
Epigastric
- pancreatitis
- PUD
- ACS
RLQ
- appendicitis
Flank
- nephrolithiasis
- pyelonephritis
- AAA
Diffuse
- SBO
- gastroenteritis
- mesenteric
ischemia
- peritonitis
Referred/Extra-abdominal causes
ต้องไม่ลืม:
- MI
- pneumonia
- PE
- DKA
- hypercalcemia
Aggravating/Relieving Factors
Worse after meals
- biliary
colic
- mesenteric
ischemia
Better sitting forward
- pancreatitis
Worse movement/cough
- peritonitis
Restless patient
- nephrolithiasis
- vascular
catastrophe
Hot shower relief
- cannabis
hyperemesis syndrome
Associated Symptoms
Fever/chills
→
infection/inflammation
Dysuria/hematuria
→ GU
source
Obstipation/distension
→
obstruction
Vaginal bleeding
→
ectopic pregnancy
Chest symptoms
→
pneumonia/PE/ACS
Important History
Prior surgery
↑ risk
SBO from adhesions
Trauma/instrumentation
delayed presentation possible:
- splenic
rupture
- bowel
injury
- abscess
Female patients
ต้องถาม:
- pregnancy
status
- LMP
- menstrual
history
- dyspareunia/dysmenorrhea
Physical Examination
Vital signs
Hypotension
ominous sign →
shock until proven otherwise
Tachycardia
early shock marker
Fever
infection/inflammation
Tachypnea
pain/sepsis/metabolic acidosis
General appearance
Lying still
→
peritonitis
Restless/agitated
→ renal
colic
Pallor/diaphoresis
→
shock/hemorrhage
Abdominal examination
Peritonitis signs
- involuntary
guarding
- rigidity
- rebound
tenderness
Helpful bedside clues
- pain
with cough
- heel
drop pain
- stretcher
bump pain
Specific signs
Murphy sign
acute cholecystitis
Psoas/obturator/Rovsing
appendicitis
Carnett sign
abdominal wall pain
Extra-abdominal exam
CVA tenderness
→
pyelonephritis
Scrotal exam
exclude torsion
Lung exam
exclude pneumonia
Skin exam
look for zoster/rash/jaundice
Point-of-Care Ultrasound (POCUS)
Useful for:
- AAA
- hemoperitoneum
- ectopic
pregnancy
- hydronephrosis
- gallstones/cholecystitis
- urinary
retention
- IVC/fluid
status
Laboratory Evaluation
Common labs
CBC
nonspecific แต่ช่วย support
infection/inflammation
Electrolytes/BUN/Cr
ดู:
- AKI
- DKA
- metabolic
derangement
Lactate
↑ → hypoperfusion/ischemia/sepsis
แต่ normal lactate ไม่ exclude
mesenteric ischemia
LFT/Lipase
upper abdominal pain
Lipase
preferred over amylase
Cholestatic pattern
↑
bilirubin + ALP → biliary
obstruction/cholangitis
Urinalysis
- pyuria/hematuria
→ GU pathology
- but
appendicitis/AAA ก็อาจมี hematuria ได้
Pregnancy test
ต้องทำใน reproductive-age female ทุกคน
ECG
ต้องทำใน:
- elderly
- diabetes
- epigastric
pain
- atypical
ACS risk
Imaging Approach
CT Abdomen/Pelvis
Main imaging modality ใน ED
ดีที่สุดสำหรับ undifferentiated
abdominal pain
IV contrast
improves diagnostic accuracy significantly
Especially:
- vascular
disease
- ischemia
- abscess
- inflammatory
disease
Ultrasound first
เหมาะใน:
- biliary
disease
- pregnancy
- gynecologic
disease
- nephrolithiasis
Plain abdominal x-ray
utility ต่ำ
ใช้เฉพาะ:
- SBO
- perforation
- foreign
body
Abdominal Catastrophes (Must Not Miss)
Vascular
- AAA
rupture
- aortic
dissection
- mesenteric
ischemia
- visceral
artery aneurysm rupture
GI catastrophe
- perforated
viscus
- bowel
strangulation
- bowel
ischemia
- toxic
megacolon
Infection/sepsis
- cholangitis
- necrotizing
pancreatitis
- urinary
sepsis
- SBP
- Fournier
gangrene
OB-GYN
- ectopic
pregnancy
- ruptured
hemorrhagic ovarian cyst
Resuscitation Principles
ABCs
- oxygen
- monitor
- IV
access
- fluids
Broad-spectrum antibiotics
if sepsis/peritonitis suspected
Blood transfusion
if hemorrhage suspected
Early consultation
- surgery
- vascular
- GI
- urology
- gynecology
- IR
Important Diagnostic Pathways
Suspected mesenteric ischemia/aortic pathology
→ CTA
chest/abdomen/pelvis
Suspected SBO
- AXR ±
upright CXR initially
- CT
abdomen/pelvis usually required
RUQ pain
→ RUQ
ultrasound first
Suspected nephrolithiasis
- US
first in low-risk/pregnancy/recurrent stone
- noncontrast
CT in high-risk/older/unclear cases
Key Clinical Pearls
Elderly + abdominal pain
dangerous until proven otherwise
Normal lactate
does NOT exclude mesenteric ischemia
Hematuria
does NOT guarantee nephrolithiasis
(AAA/appendicitis ก็มีได้)
Pain out of proportion
→ think
mesenteric ischemia
Peritonitis signs
ต้อง surgical abdomen จนพิสูจน์ว่าไม่ใช่
Recurrent abdominal pain
CT yield ต่ำลงถ้า prior negative
evaluations หลายครั้ง
Most undifferentiated abdominal pain
improves within 2 weeks แต่ต้องให้ return
precautions ชัดเจน
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