Abdo Pain in ED

Abdo Pain in the EDClinical Cases

Miss A

7 F

Unwell for 3 days with abdominal pain

Generalised

Afebrile

Normal bowel habits

1x vomit

Miss A

Further history

Nil medical problems

Immunised

Nil unwell contacts/travel

Generally unwell for past 3 weeks- easily fatigued, decreased school performance

Miss A

Examination

Weight 22kg

Looks unwell

HR 150

RR 50

Afebrile

BP 90/-

Clutching abdomen- Not distended- Nil peritonism- BS present

What next?

RCH Age Corrected Observations

Miss A

Investigations

- Urine dip

Leuks 0

Nitrites 0

SG 1.005

Urobilinogen 3.2

Ketone 16

Bilirubin 0

Protein trace

Glucose >1000

What is the next test?

Miss A

BSL

‘hi’

Ketones

7.4

Diagnosis?

Miss A

Diabetic Ketoacidosis

Diagnostic criteria

- Glucose >11mmol/K

- Venous pH <7.3 OR bicarbonate <15mmol/L

- Presence of ketonaemia OR ketonuria

Treatment of DKA differs in children

Involve the paeds unit early with first presentation DKA but DO NOT delay management

Fluid resuscitation is the first priority, HOWEVER

Children are prone to cerebral oedema with rapid or over- volume resus

- Symptoms include new/increasing headache, confusion, drowsiness, seizures

Miss A

Management Steps

� Obtain the child’s weight

� ABC

� Assess extent of

dehydration

� 2x IV access

� Venous gas, bloods

� Consider septic workup

� First presentation DKA� Insulin antibodies� GAD antibodies� ZnT8 antibodies� Coeliac screen� TSH, T4

Degree of dehydration Clinical signs

Assessment Percentage

Mild <4% No clinical signs

Moderate 4-7% Easily detectable dehydration –decreased tissue turgor, poor central capillary return

Severe >7% Shock - Poor perfusion, rapid pulse, hypotension

Miss A

Management Steps

� Hourly blood glucose, ketones

� 2-4 hourly VBG, UEC, CMP

Goals of Therapy

- Correct dehydration

- Reverse ketosis, correct acidosis

and glucose

- Monitor for complications- Hypokalaemia- Hypoglycaemia- Cerebral oedema

- Identify and treat cause (if present)

Blood Gas ValuespH 7.01pCO2 15pO2 45HCO3- 9BE -10

Na 136K 3.4

Glu 37Lac 3.2

Miss A

Management Steps

� 10-20ml/kg nsaline bolus

� Keep child nil by mouth

� Follow the RCH DKA guideline and check fluid orders carefully with nursing staff

� Admit to paeds

� Consider tf if� <2 yrs old� Coma/cardiovascular compromise� Suggestion of cerebral oedema� Severe acidosis ph <7.1 or HCO3 <5

Medical Causes of Abdominal Pain

1. DKA

2. Porphyria

3. Addisons disease

Miss B

18 F

3/7 increasing RIF pain

Very severe this AMà presented to ED

Nil vomiting, diarrhoea, LUTS

Nil travel or unwell contacts

Phx endometriosis, nil reg meds

Miss B

Further History

Insidious onset

Non migratory

Associated lower back pain

Eating and drinking as normal

Miss B

Examination

HR 92

BP 120/80

Afebrile

Abdo: tender RIF to palpation, nil rebound, not cross tender, psoas sign –ve

What next?

- Bloods?

- USS?

- Analgesia, home?

Miss B

Bloods

- FBE 99/12.1/379

- CRP 40

USS

Booked for 3pm

Send her home?

Miss B

Urine dip

- N.. Aside from

- +ve HCG

So what next?

• Approximate gestational age• Quantitative HCG• G&H + Ab• Bedside USS

Miss B

� Bedside USS

� Which is which?� Normal pelvic USS� Positive fast� Yolk sac� Positive fast

Miss B

Progress

- LMP 6 weeks ago

- Bedside fast –ve, nil intrauterine contents seen

- Quan HCG 3000

- Formal USS 3pm: Code blue!

- What’s the diagnosis?

Miss B

Diagnosis

- Ruptured ectopic pregnancy

Miss B

Management of ruptured ectopic pregnancy

- ABC

- Large bore dual IV access

- Call O&G urgently

- Cross match 4 units

- Permissive hypotension

- Get to theatre

Mr C

87 M

7 days of constipation

Seen in ED 5 days ago

AXR demonstrating constipation

Sent home with PO aperients, + microlax enema

Passed 1x small stool since, now vomiting

Further History

Not usually constipated, nil phx of same

Phx IHD, dyslipidaemia, GORD

Associated abdominal discomfort and LoA

Nil LoW, nil night sweats

Tolerating fluids, though intermittently vomiting for 24/24

Mr C

Examination

Obs WNL

Abdomen distended

Nil bowel sounds

Tympanic percussion note

Generally tender without peritonism

Mr C

Investigations

What is relevant?

What is the provisional diagnosis?

Mr C

Investigations in Abdominal Pain

A good history will guide you best

“Abdominal Bloods”

Consider VBG

Urine dip

CTAP

Mr C

Interpretations of CT Abdomen

Have a process

Do a scroll through first and look for obvious abnormalities

Always look at the scan you have ordered

A CT KUB can be a good tool for patients with poor renal function, non-bowel pathology, or other contraindications to contrast

Mr C

Constipation in the Elderly

- A red flag diagnosis

- Its not constipation until the CT says it is

- Consider the aetiology- Why a change in bowel habits?- Does the patient need an IP or OP scope?- Which patients are appropriate for SSOU vs expectant mx at home?

Mr C

Conclusion

- Hemicolectomy

- Complicated be anastamotic leak, return to theatre, breakdown of lapatotomy woundà stoma formation

- Nil mets or local invasion

Mr C

Mrs O

77 F

From home

Presenting with high fever and RUQ pain, increasing over past 48/24

Differentials?

Mrs O

Further History

Intermittent RUQ pain for months

Usually spont resolves after a few hours

Nil previous investigation

Onset of constant RUQ pain 48/24 ago

Last 24/24 fevers, rigors, 2x vomits

Phx

TIA, pancreatitis, peripheral vascular disease, recurrent UTI

Mrs O

Examination

GCS 14- mildly confused

HR 105

T 38. 6

BP 75/50

RR 28

Scleral icterus

Jaundiced

RUQ peritonism

Mrs O

What is the diagnosis?

What is the next step?

How should this patient be

managed?

Mrs O

Differentials in RUQ Pain

- Which is which?- Cholelithiasis- Cholecystitis- Choledocholithiasis- Cholangitis

Mrs O

Relevant Investigations for Mrs O

WCC 24, Neuts 18

CRP 260

ALP 230

GGT 211

Bili 84

AST 74

ALT 99

What is the Diagnosis?

Mrs O

Ascending Cholangitis

Charcot’s Triad

1. Jaundice

2. Fever

3. RUQ pain

Reynolds Pentad

1. Jaundice

2. Fever

3. RUQ pain

4. Shock

5. Confusion

Mrs O

Management of Ascending Cholangitis

- ABC

- Blood cultures

- Tazocin 4.5g IV OR 2g IV ceftriaxone + 500mg IV metronidazole

- Haemodynamic support if required

- Early AGSU referral

- CTAP +/- MRCP, then ERCP

- ICU/HDU if unstable

Resources

RCH DKA guideline

https://www.rch.org.au/clinicalguide/guideline_index/Diabetic_Ketoacidosis/

Radiopaedia

LIFTL

eTG