FRCEM FINAL SBA eBook 1(Preview)

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6 <strong>FRCEM</strong> Final 2) Imaging Tests Tests Reason • This is of limited value, often shows Abdominal XRAY non-specific findings and only useful if obstruction clinically suspected. • No role in standard assessment of patients with RUQ/RIF pain. Erect CXR • May show free gas under the diaphragm if perforated viscus (sensitivity around 80% so cannot rule out). Useful to exclude certain medical causes if suspected. Erect & • These are not necessary and expose Supine the patient to significant CXR or A- unnecessary radiation. Xray USS • Useful to assess RUQ and RIF CT Scan • Investigation of choice, although not always readily available, is costly and exposes patient to radiation, 12-Lead • General workup, particularly in the ECG elderly, or to rule out medical causes. 3) Special/Later Tests Tests Reason Bloods • Further blood tests and imaging are normally performed outside the ED Contrast • Barium enema are occasionally studies performed as part of an on-going surgical investigation of patient. Endoscopy • Colonoscopy, upper GI endoscopy may be performed if bleeding or PUD suspected Angiogram • Angiography is occasionally performed, particularly to investigate the vascular tree in patients with suspected angiodysplasia or ischaemic bowel disease. • Therapeutic procedures such as embolisation can be done at the same time. MRI • MRI is performed more rarely but can be used to delineate the biliary tree. 7. ED MANAGEMENT OF ABDOMINAL PAIN • Resuscitate if signs of sepsis or haemodynamic instability are shown, furthermore if there are any concerns or patient is unwell, discuss with ED senior. • Morphine IV titrated to effect: There is no evidence that opiates mask the signs of peritonism or lead to a delay in diagnosis. Analgesia should never be withheld until the patient has seen the surgeon. o o Tramadol is sometimes prescribed for patients with abdominal pain. However, it is difficult to titrate and morphine remains the analgesic of choice There is no evidence for antispasmodics like Buscopan in the management of acute pain. • IV anti-Emetic: Metoclopramide theoretically increases gastric emptying so cyclizine has been favoured in the past although there is little evidence to support this. • Anti-pyretic (IV paracetamol if necessary). • Nasogastric tube if a bowel obstruction is present. • Urinary catheter if the patient is unwell or peritonitis is suspected. • Broad spectrum IV antibiotics if there are signs of sepsis or peritonitis (local policies vary but normally a 2 nd generation Cephalosporin +/- Metronidazole). • Keep nil by mouth and give IV fluids (normal saline) and Refer to surgical team. ADMIT/DISCHARGE DECISION MAKING • If there is no evidence of a significant surgical pathology, the patient is pain free and has a normal examination then it is reasonable to discharge the patient home with clear advice to return to the department if their pain recurs or they have any concerns. • It may also be appropriate to arrange a review 12-24 hours later. • Patients with suspected biliary colic who have pain that settles can often undergo USS followed by discharge or be brought back the next day for an USS. • Elderly patients and those with significant co-morbidity should be admitted as they are at much higher risk of significant pathology. • It is not uncommon to reassess a patient who initially required morphine for pain to find them pain free with a soft abdomen. Remember these patients have had IV opiates and their pain may recur once this wears off. • In general, they need to be admitted for observation and possible further investigations Acute & Major Presentations Moussa Issa Bookstore
Section I: Major and Acute Presentations 7 II. APPENDICITIS 1. INTRODUCTION • Appendicitis, an inflammation of the vestigial vermiform appendix, is one of the most common causes of the acute abdomen and one of the most frequent indications for an emergent abdominal surgical procedure worldwide. 6 2. CLINICAL ASSESSMENT: History • Abdominal pain is the most common symptom and is reported in nearly all confirmed cases of appendicitis. • The clinical presentation of acute appendicitis is described as a constellation of the following classic symptoms: o Right lower quadrant (right anterior iliac fossa) abdominal pain o Anorexia o Nausea and vomiting • In the classic presentation, the patient describes the onset of abdominal pain as the first symptom. The pain is typically periumbilical in nature with subsequent migration to the right lower quadrant as the inflammation progresses. • Although considered a classic symptom, migratory pain occurs only in 50 to 60 percent of patients with appendicitis. Nausea and vomiting, if they occur, usually follow the onset of pain. Fever-related symptoms generally occur later in the course of illness. • In many patients, initial features are atypical or nonspecific and can include: o Indigestion o Flatulence o Bowel irregularity o Diarrhea o Generalized malaise • Because the early symptoms of appendicitis are often subtle, patients and clinicians may minimize their importance. The symptoms of appendicitis vary depending upon the location of the tip of the appendix. • For example, an inflamed anterior appendix produces marked, localized pain in the right lower quadrant, while a retrocecal appendix may cause a dull abdominal ache. • The location of the pain may also be atypical in patients who have the tip of the appendix located in the pelvis, which can cause tenderness below McBurney's point. 6 Williams GR. Presidential Address: a history of appendicitis. With anecdotes illustrating its importance. Ann Surg 1983; 197:495. Physical examination • The early signs of appendicitis are often subtle. Lowgrade fever reaching 38.3°C may be present. The physical examination may be unrevealing in the very early stages of appendicitis since the visceral organs are not innervated with somatic pain fibers. • However, as the inflammation progresses, involvement of the overlying parietal peritoneum causes localized tenderness in the right lower quadrant and can be detected on the abdominal examination. • Rectal examination, although often advocated, has not been shown to provide additional diagnostic information in cases of appendicitis. In women, right adnexal area tenderness may be present on pelvic examination, and differentiating between tenderness of pelvic origin versus that of appendicitis may be challenging. • High-grade fever 38.3°C occurs as inflammation progresses. • Patients with a retrocecal appendix may not exhibit marked localized tenderness in the right lower quadrant since the appendix does not come into contact with the anterior parietal peritoneum 7 . • The rectal and/or pelvic examination is more likely to elicit positive signs than the abdominal examination. Tenderness may be more prominent on pelvic examination and may be mistaken for adnexal tenderness. • Several findings on physical examination have been described to facilitate diagnosis, but these findings predated definitive imaging for appendicitis, and the wide variation in their sensitivity and specificity suggests that they be used with caution to broaden, or narrow, a differential diagnosis. • There are no physical findings, taken alone or in concert, that definitively confirm a diagnosis of appendicitis. Commonly described physical signs include: • McBurney's point tenderness is described as maximal tenderness at 1.5 to 2 inches from the anterior superior iliac spine (ASIS) on a straight line from the ASIS to the umbilicus. • Rovsing's sign refers to pain in the right lower quadrant with palpation of the left lower quadrant. This sign is also called indirect tenderness and is indicative of right-sided local peritoneal irritation. • The psoas sign is associated with a retrocecal appendix. 7 Guidry SP, Poole GV. The anatomy of appendicitis. Am Surg 1994; 60:68. Acute & Major Presentations Moussa Issa Bookstore
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