Abdominal Pain William Beaumont Hospital Department of Emergency Medicine.

Abdominal PainAbdominal Pain

William Beaumont HospitalWilliam Beaumont Hospital

Department of Emergency MedicineDepartment of Emergency Medicine

Abdominal PainAbdominal Pain

• One of the most common chief complaints

• Confounders making diagnosis difficult • Age• Corticosteroids• Diabetics• Recent antibiotics

PitfallsPitfalls

• Consider non-GI causes• Acute MI (inferior), ectopic pregnancy, DKA, sickle

cell anemia, porphyria, HSP, acute adrenal insufficiency

• History• Location• Quality• Severity• Onset• Duration• Aggravating and alleviating factors• Prior symptoms

HistoryHistory

• Sudden onset – perforated viscusSudden onset – perforated viscus

• Crushing – esophageal or cardiac diseaseCrushing – esophageal or cardiac disease

• Burning – peptic ulcer diseaseBurning – peptic ulcer disease

• Colicky – biliary or renal diseaseColicky – biliary or renal disease

• Cramping – intestinal pathology Cramping – intestinal pathology

• Ripping – aneurismal ruptureRipping – aneurismal rupture

Physical ExamPhysical Exam

• AbdomenAbdomen• InspectionInspection• Bowel soundsBowel sounds• Tenderness (rebound, guarding)Tenderness (rebound, guarding)

• Extra-abdominal examExtra-abdominal exam• LungLung• CardiacCardiac• PelvicPelvic• GUGU• Rectal Rectal

LabsLabs

• Beta-hCGBeta-hCG

• WBC – poor sensitivity and specificityWBC – poor sensitivity and specificity

• LFTs – hepatobiliaryLFTs – hepatobiliary

• Lipase – pancreaticLipase – pancreatic

• Electrolytes – CO2Electrolytes – CO2

• Lactic acidLactic acid

• Urinalysis – BEWAREUrinalysis – BEWARE

ImagingImaging

• Acute Abdominal Acute Abdominal SeriesSeries• Free airFree air• Bowel gasBowel gas

• KUBKUB• Poor screening testPoor screening test

• UltrasoundUltrasound

• Biliary diseaseBiliary disease• AAAAAA• Free fluid or airFree fluid or air• Pelvic pathologyPelvic pathology

• CTCT• AppendicitisAppendicitis• DiverticulitisDiverticulitis

Case #1Case #1

• 79 yo female presents with aching sharp pain 79 yo female presents with aching sharp pain in the epigastrium and right upper quadrant in the epigastrium and right upper quadrant ½ hour after eating. Pain radiates to the back. ½ hour after eating. Pain radiates to the back. +N, –V+N, –V

• Differential diagnosis?Differential diagnosis?

• Testing?Testing?

Upper Abdominal PainUpper Abdominal Pain

• Biliary disease

• Hepatitis

• Pancreatitis

• PUD/gastritis/esophagitis

• AAA

• Pneumonia (RLL)Pneumonia (RLL)

• PyelonephritisPyelonephritis

• Acute MIAcute MI

• AppendicitisAppendicitis

• Fitz-Hugh CurtisFitz-Hugh Curtis

Gallstone Risk FactorsGallstone Risk Factors

• Female 4:1Female 4:1

• FertileFertile

• FortyForty

• FatFat

• Family historyFamily history

• Others:Others:• Crohns, UC, SCA, thalassemia, rapid Crohns, UC, SCA, thalassemia, rapid

weight loss, starvation, TPN, elevated weight loss, starvation, TPN, elevated TGs, cholesterolTGs, cholesterol

CholelithiasisCholelithiasis

• History: History: • RUQ/epigastric painRUQ/epigastric pain• Nausea/vomiting with fatty mealsNausea/vomiting with fatty meals• Similar episodes in pastSimilar episodes in past

• PE: RUQ tendernessPE: RUQ tenderness

• Labs: may be normalLabs: may be normal

• ECG: consider in older patientsECG: consider in older patients

• Imaging: test of choice = USImaging: test of choice = US

Cholelithiasis: TreatmentCholelithiasis: Treatment

SymptomaticSymptomatic

• Pain control

• Anti-emetics

• Consult general surgery• 90% with recurrent

symptoms

• 50% develop acute cholecystitis

AsymptomaticAsymptomatic

• Incidental findingIncidental finding

• 15-20% become 15-20% become symptomaticsymptomatic

• Outpatient elective Outpatient elective surgery ifsurgery if• Frequent, severe Frequent, severe

attacksattacks

• DiabeticDiabetic

• Large calculiLarge calculi

Acute CholecystitisAcute Cholecystitis

• Sudden gallbladder inflammation

• Bacterial infection in 50-80%• E. coli, Klebsiella, Enterococci

• History/PE:• Fever, tachycardia, RUQ tenderness• Murphy’s sign – low sensitivity

• Labs:• Elevated WBC with left shift• LFTs – large elevation CBD stone

Acute Cholecystitis: Acute Cholecystitis: ImagingImaging

• KUB – stones only seen ~ 10%• Air in biliary tree gangrenous

• CT scan – sensitivity 50%

• Ultrasound – sensitivity 90-95%• Gallstones (absent in biliary stasis)• Thickened gallbladder wall• Pericholecystic fluid

• HIDA scan – negative scan rules out diagnosis• Positive = no visualization of the GB

Acute CholecystitisAcute Cholecystitis

Acute Cholecystits: Acute Cholecystits: TreatmentTreatment

• Admit

• NPO

• IVF

• Pain control

• Anti-emetics

• Antibiotics

• Surgical consult

HepatitisHepatitis

• ViralViral• Hepatitis AHepatitis A• RNA, fecal-oralRNA, fecal-oral

• Hepatitis BHepatitis B• DNA, STD/parenteralDNA, STD/parenteral• Chronic hepatitis Chronic hepatitis

(10%) (10%) • Hepatitis CHepatitis C• RNA, blood borneRNA, blood borne• Chronic hepatitis Chronic hepatitis

(50%), cirrhosis (50%), cirrhosis (20%)(20%)

• Hepatitis DHepatitis D• RNA, co-infects Hep RNA, co-infects Hep

BB

• BacterialBacterial

• AlcoholicAlcoholic

• ImmuneImmune

• MedicationsMedications

Hepatitis: DiagnosisHepatitis: Diagnosis

• History: History: • Malaise, low-grade fever, anorexiaMalaise, low-grade fever, anorexia• Nausea/vomiting, abd pain, diarrheaNausea/vomiting, abd pain, diarrhea• Jaundice (altered MS, liver failure)Jaundice (altered MS, liver failure)

• Labs:Labs:• ALT and AST (10-100x normal)ALT and AST (10-100x normal)

• AST > ALT – alcoholic hepatitisAST > ALT – alcoholic hepatitis• Elevated bilirubinElevated bilirubin• Abnormal PTAbnormal PT• Hepatitis panelHepatitis panel• Tylenol levelTylenol level

Hepatitis: TreatmentHepatitis: Treatment

• Symptomatic – IVF, electrolytes

• Remove toxins – ETOH, acetaminophen

• Admit if altered MS or coagulopathy

PancreatitisPancreatitis

• Autodigestion of pancreatic tissueAutodigestion of pancreatic tissue

• B – BiliaryB – Biliary

• A – AlcoholA – Alcohol

• D – DrugsD – Drugs

• S – Scorpion biteS – Scorpion bite

• H – HyperTG, HyperCaH – HyperTG, HyperCa

• I – Idiopathic, InfectionI – Idiopathic, Infection

• T – TraumaT – Trauma

Pancreatitis: History and Pancreatitis: History and PhysicalPhysical

• History:History:• Boring pain in LUQ or epigastriumBoring pain in LUQ or epigastrium• ConstantConstant• Radiates to mid-backRadiates to mid-back• Nausea, vomitingNausea, vomiting

• PE:PE:• Epigastric or LUQ tendernessEpigastric or LUQ tenderness• Grey-Turner or Cullen signGrey-Turner or Cullen sign

Gray-Turner signGray-Turner sign

• Flank ecchymosisFlank ecchymosis

• Intraperitoneal bleeding Intraperitoneal bleeding

• Hemorrhagic pancreatitisHemorrhagic pancreatitis

• Ruptured abdominal aortaRuptured abdominal aorta

• Ruptured ectopic Ruptured ectopic pregnancy pregnancy

Cullen's SignCullen's Sign

Pancreatitis: DiagnosisPancreatitis: Diagnosis

• Lipase – most specificLipase – most specific

• Ranson’s criteria – predicts outcomeRanson’s criteria – predicts outcome• Acutely: >55 yo, glucose > 200, WBC >16k, ALT Acutely: >55 yo, glucose > 200, WBC >16k, ALT

> 250, LDH > 350> 250, LDH > 350• 48 hrs: HCT decreases > 10%, BUN rises > 5, 48 hrs: HCT decreases > 10%, BUN rises > 5,

Ca < 8, pO2 < 60, base deficit >4, fluid Ca < 8, pO2 < 60, base deficit >4, fluid sequestration > 6Lsequestration > 6L• 3-4 criteria – 15% mortality3-4 criteria – 15% mortality• 5-6 criteria – 40% mortality5-6 criteria – 40% mortality• 7-8 criteria – 100% mortality7-8 criteria – 100% mortality

Pancreatitis: ImagingPancreatitis: Imaging

• Plain films – sentinel loop (local ileus)

• Ultrasound – poor (biliary tree)

• CT scan with contrast

Pancreatitis: TreatmentPancreatitis: Treatment

• NPO

• IVF

• Pain control

• Antiemetics

• Antibiotics if gallstones or septic

• Surgical consult• If gallstones, abscess, hemorrhage or pseudocyst

• ERCP if CBD stone

Gastritis/PUDGastritis/PUD

• Duodenal 80%; gastric 20%

• Etiology: • H pylori, NSAIDS, zollinger-ellison

syndrome, smoking, ETOH, FHx, male, stress

• H pylori – 95% duodenal; 85% gastric

• History: • Epigastric constant, gnawing pain• Food lessens – duodenal• Food worsens – gastric

Peptic Ulcer DiseasePeptic Ulcer Disease

• Workup:Workup:• HemoglobinHemoglobin• PT/PTT – if bleedingPT/PTT – if bleeding• Lipase – rule out pancreatitisLipase – rule out pancreatitis• Hemoccult stool – rule out GI bleedHemoccult stool – rule out GI bleed

• Treatment: Treatment: • Antacids (GI cocktail)Antacids (GI cocktail)• PPIPPI• Outpatient endoscopyOutpatient endoscopy• H. pylori testingH. pylori testing

Perforated ViscusPerforated Viscus

• Rare in small bowel and mid-gutRare in small bowel and mid-gut

• History: abrupt onset painHistory: abrupt onset pain

• Diagnosis: upright CXRDiagnosis: upright CXR

• Treatment: Treatment: • IVFIVF• IV antibioticsIV antibiotics• NG tubeNG tube• OROR

Questions on Questions on Upper Abdominal Pain?Upper Abdominal Pain?

Let’s Move On DownLet’s Move On Down

Case #2Case #2

• History: 35 y/o female c/o 1 day of History: 35 y/o female c/o 1 day of periumbilical aching pain. +N,+V, +D, +F, +C, periumbilical aching pain. +N,+V, +D, +F, +C, +anorexia. Today, she has crampy lower +anorexia. Today, she has crampy lower abdominal pain. No urinary sx. abdominal pain. No urinary sx.

• Exam: afebrile, bilateral lower quadrant Exam: afebrile, bilateral lower quadrant tenderness (R > L), no rebound or guarding. tenderness (R > L), no rebound or guarding.

• Other questions?Other questions?

• Differential diagnosis?Differential diagnosis?

• Testing?Testing?

Lower Abdominal PainLower Abdominal Pain

• AppendicitisAppendicitis

• DiverticulitisDiverticulitis

• UTI/PyleonephritisUTI/Pyleonephritis

• Renal colicRenal colic

• Torsion/TOA/PIDTorsion/TOA/PID

• Ectopic pregnancyEctopic pregnancy

AppendicitisAppendicitis

• Incidence – 6%Incidence – 6%

• Mortality – 0.1%Mortality – 0.1%• Perforation 2-6% (9% elderly)Perforation 2-6% (9% elderly)

• All ages – peak 10 – 30 yoAll ages – peak 10 – 30 yo

• Difficult diagnosis:Difficult diagnosis:• Young and oldYoung and old• Pregnant (RUQ)Pregnant (RUQ)• ImmunocompromisedImmunocompromised

AppendicitisAppendicitis

• Abdominal pain (98%)Abdominal pain (98%)• Periumbilical migrating to RLQ < 48 hrsPeriumbilical migrating to RLQ < 48 hrs

• Anorexia 70%Anorexia 70%

• Nausea, vomiting 67%Nausea, vomiting 67%

• Common misdiagnosis – gastroenteritis, Common misdiagnosis – gastroenteritis, UTIUTI

AppendicitisAppendicitis

•PE: PE: • RLQ tenderness 95%RLQ tenderness 95%• Rovsing: RLQ pain palpating LLQRovsing: RLQ pain palpating LLQ• Psoas: R hip elevation, extension Psoas: R hip elevation, extension • Obturator: flexion, internal rotationObturator: flexion, internal rotation

Appendicitis: DiagnosisAppendicitis: Diagnosis

•Labs: Labs: • WBC > 10k – 75%WBC > 10k – 75%• UA – sterile pyuriaUA – sterile pyuria

• Imaging: Imaging: • UltrasoundUltrasound• CT scanCT scan• MRIMRI

Appendicitis: TreatmentAppendicitis: Treatment

• IV fluidsIV fluids

• NPONPO

• AnalgesiaAnalgesia

• AntibioticsAntibiotics

• Surgery consultSurgery consult

DiverticulitisDiverticulitis

• Inflammation of a diverticulum (herniation of mucosa through defects in bowel wall)

• Sigmoid colon is the most common site

• History: • L > R• 3% under 40• LLQ pain with BMs• N/V/constipation

• PE: LLQ tenderness

• Diagnosis: clinical, CT

Diverticulitis: TreatmentDiverticulitis: Treatment

•Admit if fever, abscess, elderlyAdmit if fever, abscess, elderly• NPONPO• IV fluidsIV fluids• IV antibioticsIV antibiotics

• Ciprofloxacin AND metronidazoleCiprofloxacin AND metronidazole• Surgical consultationSurgical consultation

Case #3Case #3

• History: 80 y/o male c/o nausea and History: 80 y/o male c/o nausea and crampy abdominal pain x 1 day. Emesis crampy abdominal pain x 1 day. Emesis which was bilious and is now malodorous which was bilious and is now malodorous and brown. and brown.

• PE: Diffusely tender, distended, with PE: Diffusely tender, distended, with hyperactive bowel sounds. hyperactive bowel sounds.

• Differential Diagnosis?Differential Diagnosis?

• Workup?Workup?

Differential DiagnosisDifferential Diagnosis

• Small bowel obstructionSmall bowel obstruction

• Large bowel obstructionLarge bowel obstruction

• Sigmoid volvulusSigmoid volvulus

• Cecal volvulusCecal volvulus

• HerniaHernia

• Mesenteric ischemiaMesenteric ischemia

• GI BleedGI Bleed

Small Bowel ObstructionSmall Bowel Obstruction

• Etiology• Adhesions (>50%)• Incarcerated hernia• Neoplasms• Adynamic ileus – non mechanical

• Abd trauma (post op), infection, hypokalemia, opiates, MI, scleroderma, hypothyroidism

• Rare: intusseception, bezoar, Crohn’s disease, abscess, radiation enteritis

Large Bowel ObstructionLarge Bowel Obstruction

• Etiology• Tumor

• Left obstruct• Right bleeding

• Diverticulitis• Volvulus• Fecal impaction• Foreign body

Bowel obstructionBowel obstruction

• Pathophysiology: Pathophysiology: 33rdrd spacing spacing bowel wall bowel wall ischemia ischemia perforates, perforates, peritonitis peritonitis sepsis sepsis shock shock

• History: crampy, colicky diffuse abdominal History: crampy, colicky diffuse abdominal pain, vomiting (feculent), no flatus or BMpain, vomiting (feculent), no flatus or BM

• PE: abdominal distension, high pitched BS, PE: abdominal distension, high pitched BS, diffuse tendernessdiffuse tenderness

• Diagnosis: AAS shows air fluid levels with Diagnosis: AAS shows air fluid levels with dilated boweldilated bowel• SB > 3cm; LB > 10cmSB > 3cm; LB > 10cm

SBO: ImagingSBO: Imaging

SBO: TreatmentSBO: Treatment

• IV fluids!

• Correct electrolyte abnormalities

• NPO

• NG tube

• Broad spectrum antibiotics if peritonitis

• Surgery consult

Sigmoid VolvulusSigmoid Volvulus

• History: History: • Elderly, bedridden, psychiatric ptsElderly, bedridden, psychiatric pts• Crampy lower abdominal pain, vomiting, Crampy lower abdominal pain, vomiting,

dehydration, obstipationdehydration, obstipation• Prior h/o constipationPrior h/o constipation

• PE: PE: • Diffuse abdominal tendernessDiffuse abdominal tenderness• DistensionDistension

Sigmoid VolvulusSigmoid Volvulus

Sigmoid Volvulus: Imaging Sigmoid Volvulus: Imaging and Treatmentand Treatment

• AAS: dilated loop of colon on leftAAS: dilated loop of colon on left

• Barium enema: “bird’s beak” Barium enema: “bird’s beak”

• WBC > 20k: suggests strangulationWBC > 20k: suggests strangulation

• CT scan CT scan

• TreatmentTreatment• IVFIVF• Surgical consultSurgical consult• Antibiotics if suspect perforationAntibiotics if suspect perforation

Cecal volvulusCecal volvulus

• Most common in 25-35 year olds

• No underlying chronic constipation

• History:• Severe, colicky abd pain• Vomiting

• PE:• Diffusely tender abdomen• Distension

Cecal VolvulusCecal Volvulus

• KUB:KUB:• Coffee bean – large Coffee bean – large

dilated loop colon in dilated loop colon in midabdomenmidabdomen

• Empty distal bowelEmpty distal bowel

• Treatment: Treatment: • SurgerySurgery• Mortality –10-15% if Mortality –10-15% if

bowel viable; 30-bowel viable; 30-40% if gangrene40% if gangrene

HerniasHernias

• Inguinal (most common) 75%• Indirect 50% vs. direct 25%• Men > women• High risk incarceration in kids

• Femoral 5% - women > men• Incisional 10%• Umbilical – newborns, women > men

• Incarcerated – unable to reduce• Strangulated – incarcerated with vascular

compromise

HerniasHernias

• Clinical presentations:Clinical presentations:• Most are asymptomaticMost are asymptomatic• Leads to SBO sxsLeads to SBO sxs• Peritonitis and shock – if strangulationPeritonitis and shock – if strangulation

• TreatmentTreatment• Reduce if non-tender – trendelenberg, Reduce if non-tender – trendelenberg,

sedation, warm compressessedation, warm compresses• Do not reduce if possible dead bowelDo not reduce if possible dead bowel• Admit via OR if strangulationAdmit via OR if strangulation

Mesenteric IschemiaMesenteric Ischemia

• EtiologyEtiology• 50% arterial emboli50% arterial emboli• 20% non-occlusive disease (CHF, sepsis, 20% non-occlusive disease (CHF, sepsis,

shock)shock)• 15% arterial thrombi15% arterial thrombi• 5% venous occlusion5% venous occlusion

• Mortality rates 70-90% - delayed Mortality rates 70-90% - delayed diagnosisdiagnosis

Mesenteric IschemiaMesenteric Ischemia

• Pathophysiology: impaired blood supply Pathophysiology: impaired blood supply from SMA, IMA, celiac trunk from SMA, IMA, celiac trunk adynamic adynamic ileus ileus mucosal infarction & 3 mucosal infarction & 3rdrd spacing spacing bacterial invasion bacterial invasion sepsis sepsis shock shock

• History:History:• Acute, severe, colicky, poorly localized painAcute, severe, colicky, poorly localized pain• Postprandial painPostprandial pain• Nausea, vomiting and diarrheaNausea, vomiting and diarrhea

Mesenteric Ischemia: Mesenteric Ischemia: DiagnosisDiagnosis

• Pain out of proportion to exam!

• Heme positive stools (>50%)• May present as LGIB

• Peritonitis and shock• Late findings

• WBC > 15k

• Metabolic acidosis• Lactic acid – high sensitivity, not specific

Mesenteric Ischemia: Mesenteric Ischemia: DiagnosisDiagnosis

• CT scan• Bowel wall edema/gas, +/- mesenteric

thrombus• Normal CT does NOT rule out

• Plain films – late findings• Portal venous gas• Pneumatosis intestinalis

• Treatment: • IVF• NG tube • IV antibiotics• IR consult for angiography• Surgical consult

GI hemorrhage: GI hemorrhage: Upper GIB vs. Lower GIBUpper GIB vs. Lower GIB

• History:History:• Hematemesis seen in 50% UGIBHematemesis seen in 50% UGIB• MelenaMelena

• 70% UGIB70% UGIB• 30% LGIB 30% LGIB

• Hematochezia – LGIB vs. rapid UGIBHematochezia – LGIB vs. rapid UGIB• Ask about:Ask about:

• NSAID, ASA, ETOH, Plavix, warfarinNSAID, ASA, ETOH, Plavix, warfarin• Night sweats, weight loss, bowel changes Night sweats, weight loss, bowel changes

malignancymalignancy• Iron, bismuth – guaiac negative, black stoolsIron, bismuth – guaiac negative, black stools

GI hemorrhageGI hemorrhage

• Consider with chief complaints: • Weakness• SOB• Dizzy• Abdominal pain

• PE: orthostatics, abdomen, rectal• Conjunctival pallor• Cool, clammy skin• Spider angiomata, palmer erythema,

jaundice, bruises liver disease

GIB: DiagnosisGIB: Diagnosis

• Hemoccult – iodide, methylene blue and red meat cause false pos

• Labs:• CBC (Hg < 8)• PT• T & S• Increased BUN (blood, hypovolemia)

• ECG – rule out silent MI (anemia)

• NG tube – rule out UGI bleed

Upper GI Hemorrhage: Upper GI Hemorrhage: EtiologyEtiology

• PUD 60%PUD 60%

• Gastritis/esophagitis 15%Gastritis/esophagitis 15%

• Varices – portal HTN, liver diseaseVarices – portal HTN, liver disease

• Mallory-Weiss Mallory-Weiss

• Aortoenteric fistula – H/o AAA repairAortoenteric fistula – H/o AAA repair

• Other: Stress ulcers, malignancy, AVM, ENT Other: Stress ulcers, malignancy, AVM, ENT bleeds, hemoptysisbleeds, hemoptysis

Lower GI Hemorrhage: Lower GI Hemorrhage: EtiologyEtiology

• Hemorrhoids – most common overallHemorrhoids – most common overall

• Diverticulosis – most common severe cause Diverticulosis – most common severe cause LGIBLGIB

• AngiodysplasiaAngiodysplasia

• Polyps/cancerPolyps/cancer

• Rectal diseaseRectal disease

• IBDIBD

GIB: TreatmentGIB: Treatment

• Unstable:Unstable:• IV x 2, O2, monitorIV x 2, O2, monitor• Blood products – FFP, pRBCs, plateletsBlood products – FFP, pRBCs, platelets• NG tube with lavage if upper GIB suspectedNG tube with lavage if upper GIB suspected

• Upper GI bleed Upper GI bleed GI for endoscopy GI for endoscopy

• Lower GI bleed Lower GI bleed GI and/or surgery GI and/or surgery consultsconsults

• Tagged red blood cell study – need 0.1 Tagged red blood cell study – need 0.1 – 0.2 ml/min of hemorrhage– 0.2 ml/min of hemorrhage

GIB: TreatmentGIB: Treatment

• Colonscopy – ligate or sclerose Colonscopy – ligate or sclerose diverticulosis, AVM bleedsdiverticulosis, AVM bleeds

• EGD – band ligation or sclerose varicesEGD – band ligation or sclerose varices

• Octreotide – varices, PUDOctreotide – varices, PUD

• Vasopressin – varicesVasopressin – varices

• Sengstaken-Blakemore tube – varicesSengstaken-Blakemore tube – varices

GIB: Surgical IndicationsGIB: Surgical Indications

• Hemodynamically unstable

• Unresponsive to endoscopy, IV fluids, and correction of coagulopathy

• Transfused > 5units in 4-6 hrs

• Mortality 23% if emergent surgery

GIB: DispositionGIB: Disposition

• Admit• Any UGIB• Any hemodynamic instability• Significant LGIB

• Observation• LGIB with stable vital signs and HgB

• Discharge home• Hemorrhoid bleed, rectal negative with

normal HgB

Case #4Case #4

• 70 y/o male with HTN, DM c/o acute onset right flank pain. Pain is sharp and crampy, radiates to the groin. He is pale, diaphoretic. Abdomen is soft, diffusely tender, no rebound or guarding.

• What are you thinking and what are you going to do?

Differential DiagnosisDifferential Diagnosis

• Renal colicRenal colic

• Mesenteric ischemiaMesenteric ischemia

• PUD with perforationPUD with perforation

• GI bleedGI bleed

• DiverticulitisDiverticulitis

• CholecystitisCholecystitis

• PancreatitisPancreatitis

• Low back painLow back pain

AAAAAA

• 4 male: 1 female4 male: 1 female

• Peak incidence 70 yoPeak incidence 70 yo

• 98% infrarenal (50% involve iliacs)98% infrarenal (50% involve iliacs)

• 33% of cases initially misdiagnosed33% of cases initially misdiagnosed• Renal colic, low back painRenal colic, low back pain

• Risk factors: HTN*, smoking, COPD, Risk factors: HTN*, smoking, COPD, diabetes, hyperlipidemia, connective diabetes, hyperlipidemia, connective tissue disease (Marfan’s, Ehlers-danlos)tissue disease (Marfan’s, Ehlers-danlos)

AAA: PathophysiologyAAA: Pathophysiology

• Atherosclerosis causes loss of elastin Atherosclerosis causes loss of elastin and collagen in aortic walland collagen in aortic wall

• Normal aorta diameter = 2 cmNormal aorta diameter = 2 cm

• Uncommon to rupture if < 5 cmUncommon to rupture if < 5 cm• Elective repairElective repair• 30% of aneurysms >5 cm rupture within 30% of aneurysms >5 cm rupture within

5 years5 years

AAAAAA

• History: History: • Sudden onset severe constant mid-Sudden onset severe constant mid-

abdomen or back painabdomen or back pain• Pain may radiate to the thigh or testesPain may radiate to the thigh or testes• Back/flank pain – retroperitoneal ureteral Back/flank pain – retroperitoneal ureteral

irritationirritation

• PE:PE:• Pulsatile mass 50-90%Pulsatile mass 50-90%• Abdominal distension due to RP or IP bloodAbdominal distension due to RP or IP blood• Abdominal bruit 3-8%Abdominal bruit 3-8%• Blue toe syndrome 5% due to emboliBlue toe syndrome 5% due to emboli

AAA: DiagnosisAAA: Diagnosis

• ECG

• Plain films• R/o free air or SBO• Calcified aorta

• US• Helpful to

diagnosis• Does not

delineate rupture or leaking aneurysm

• CTCT• Evaluates size, Evaluates size,

leakage and leakage and extentextent

• AngiographyAngiography• May miss AAA if May miss AAA if

mural thrombusmural thrombus

AAAAAA

AAA: TreatmentAAA: Treatment

• Asymptomatic patient• Incidental finding• <4 cm – repeat US Q6 months• >4 cm – elective repair

• Symptomatic patient• CT to confirm diagnosis (if stable)• 2 large bore IVs• T&C• pRBC - ~8 units• Admit via OR (vascular surgery consult)

AAA: MortalityAAA: Mortality

• Elective repair – 4%Elective repair – 4%

• Post rupture – 45%Post rupture – 45%• Normal BP – 20%Normal BP – 20%• Hypotensive, responds to volume – 40%Hypotensive, responds to volume – 40%• Hypotensive, incomplete response 60%Hypotensive, incomplete response 60%• Hypotensive, no urinary output – 80%Hypotensive, no urinary output – 80%

The EndThe EndAny Questions?Any Questions?