Abdominal pain cases - Semmelweis Egyetem · • Chronic cholecystitis • Hydrops • Surgical...

Abdominal

Cases

The obligatory ancient Greek

Qualities of pain

• S: Site

• O: Onset (How?)

• C: Character

• R: Radiation• R: Radiation

• A: Association

• T: Timing

• E: Exacerbation or alleviating factors

• S: Strenght

Locations

Assessment of the strenght pain

Mechanisms behind the pain

• Mucosal injuries

• Smooth muscle spasm

• Capsular dystension

• Peritoneal inflammation• Peritoneal inflammation

• Direct splanchnic nerve stimulation

How to find the cause?

Algorithm ComplaintComplaint

History

• GI illnesses

History

• GI illnesses

Physical findingsPhysical findings

Laboratory testsLaboratory tests

Imaging findingsImaging findings

Solved?Solved?

Case #1

• 35 yrs old female

• 5 days ago pain in the right lower

quadrant.

• Became better, but the pain returned.

ComplaintComplaint

History

•GI illnesses

History

•GI illnesses

Physical Physical

• Became better, but the pain returned.Physical findingsPhysical findings



Solved?Solved?

Qualities of pain

• S: Epigastrial, then umbilical, then LRQ

• O: Sudden, then gone, then returned: recurring

• C: Sharp, burning

• R: Not typical• R: Not typical

• A: Nausea, vomitting, subfebrility

• T: For hours

• E: Independent from meals or bowel movements

• S: Strong

Case #1

• Cholecystectomy

• Pyelonephritis

• Helminthiasis (no further info)

ComplaintComplaint

History

•GI illnesses

History

•GI illnesses

Physical Physical

• Hepatitis infectiosaPhysical findingsPhysical findings



Solved?Solved?

Laboratory findings

Hematology Kidney Liver/ Pancreas Inflammation

WBC: 16.8 Na: 133 Bi: 7.0 CRP: 4.23

Hgb: 144 K: 4.0 GOT: 36

Plt: 234 CN: 4.0 ALP: 70

Kreat: 54 LDH: 171

Amylase 27

Ultrasound

Dg

• Appendicitis acuta

• Surgical consultant suggested operation

• Phlegmonosus appendix was removed

Differential dg

• Enterocolitis

• Lymphadenitis mesenterica virosa

• Extrauterinal gravidity

• Ileocolitis – M. Crohn• Ileocolitis – M. Crohn

Case #2


• Epigastrial pain for more than a week

ComplaintComplaint

History

•GI illnesses

History

•GI illnesses

Physical Physical Physical findingsPhysical findings



Solved?Solved?

Qualities of pain

• S: Epigastrial, then RUQ, hypochondrial

• O: Slowly

• C: blunt, cramps

• R: To the back• R: To the back

• A: Nausea, vomitting, fever

• T: For days

• E: Worse after meals, Nospa, Algoflex make it better

• S: 5/10

Case #2

• Curettage

• GP evaluated her for similar

complaints. Ultrasound found

gallbladder stones.

ComplaintComplaint

History

•GI illnesses

History

•GI illnesses

Physical Physical gallbladder stones.Physical findingsPhysical findings



Solved?Solved?

Laboratory findings


WBC 9.02 Na 143 Bi: 30/5 CRP: 26.5

Hgb 127 K 3.8 GOT: 17

Plt 196 CN 3.4 ALP: 131

Creat 62 LDH: 136

Amylase 15

Ultrasound

Dg

• Chronic cholecystitis

• Hydrops

• Surgical consultant: delayed (a froid)

operationoperation

• Antibiotics excreted through bile (e.g.

ceftriaxon)

Differential dg

• Acute cholecytitis

• Pancreatitis

• Duodenal ulcer

Case #3

• 77 yrs old male

• For 7-8 days pain in the left lower

quadrant.

ComplaintComplaint

History

•GI illnesses

History

•GI illnesses




Solved?Solved?

Qualities of pain

• S: LLQ

• O: Sudden, recurring

• C: Sharp, stabbing, colicky

• R: inguinal, downwards• R: inguinal, downwards

• A: diarrhoea, faint pink, blood on paper

• T: For half an hours

• E: After meals or bowel movements

• S: 5-6/10

Case #3

• Childhood asthma bronchiale

• Appendectomy

• In 2011 STEMI, PCI

ComplaintComplaint

History

•GI illnesses

History

•GI illnesses

Physical Physical

• BPH

• Atrial fibrillation, OAC

• Colonoscopy: diverticuli




Solved?Solved?

Laboratory findings


WBC 6.0 Na 141 Bi 16.0 CRP 3.57

Hgb 147 K 4.2 GOT 26

Plt 280 LDH 210

Creat 113 ALP 81

Ultrasound

Dg

• Diverticulitis

• Antibiotics (ciprofloxacin + metronidazol)

• Surgery can be considered

Differential Dg

• Cancer

• Complications of diverticulitis

• Inflammatory bowel disease

• Irritable bowel syndrome• Irritable bowel syndrome

• Ischemic colitis

• Helminthiasis

Case #4


• For 6 months epigastric pain

• GP refers as gastritis

ComplaintComplaint

History

•GI illnesses

History

•GI illnesses




Solved?Solved?

Qualities of pain

• S: Epigastric

• O: Slowly progressing

• C: Blunt

• R: To the back of the patients• R: To the back of the patients

• A: This morning vomiting, but it is not typical

• T: For hours

• E: After meals worse, if she lies on her side and pull up her knees or bends forward it is better

• S: 7-8/10

Case #4

• Deafness after childhood meningitis

• Cholecystectomy

• T2DM (OAD)

• For similar complaints she was evaluated

ComplaintComplaint

History

•GI illnesses

History

•GI illnesses

Physical Physical • For similar complaints she was evaluated two months ago, imaging a labs were negative

• One month ago endoscopy: gastritis and diverticuli

• She has lost 10 kg




Solved?Solved?

Laboratory findings


WBC 7.24 Na 135 Bi 7.5 CRP 14.55

Hgb 115 K 3.8 GOT 21

Plt 244 CN 7.2 ALP 89

Creat 65 LDH 180

Amylase 66

Ultrasound

Dg

• CA19-9: 1936

• Pancreas head carcinoma

• FNAB: adenocc

• Palliative chemotherapy• Palliative chemotherapy

Differential Dg

• Cholecystitis

• Peptic ulcer

• Pancreatitis

• A. mesenterica sup. obstruction, intestinal • A. mesenterica sup. obstruction, intestinal

ischemia

• Diabetic neuropathy

Case #5


• For 2 weeks diffuse pain

ComplaintComplaint

History

•GI illnesses

History

•GI illnesses




Solved?Solved?

Qualities of pain

• S: LLQ, diffuse, spreading out

• O: slow

• C: Colicky, cramps, dystension

• R: To the pelvis• R: To the pelvis

• A: Constant nausea, loss of appetite, constipation for two days fever, chills

• T: For hours

• E: Watery bowel movements helps

• S: 7-8/10

Case #4

• Relapsing atrial fibrillation

• Bradycardy VVI PM

• T2DM

• Sideropenic anemia

ComplaintComplaint

History

•GI illnesses

History

•GI illnesses

Physical Physical • Sideropenic anemia

• Colonoscopy two months ago showed polyposis coli, endoscope could not be passed beyond this point

• Histology: adenocc.

• She has lost 10 kg




Solved?Solved?

Laboratory findings


WBC 13.96 Na 137 Bi 23.1 CRP 1.38

Hgb 159 K 3.1 GOT 24

Plt 247 CN 7.0 ALP 93

Creat 96 LDH: 255

Amylase 28

Abdominal X-Ray

Dg

• Ileus

• Emergency surgery

Summary

Typical illnesses associated with the

locations

Useful points

• Identify the anatomical location precisely

• Character can reveal the mechanism

• Gather as many anamnestic details as possible

• Laboratory panel should be chosen carefully• Laboratory panel should be chosen carefully

• Imaging until you see clearly

• Consider extra-gastrointestinal causes

• Repeat if needed, as the disease progression itself can be meaningful

Abdominal pain cases - Semmelweis Egyetem · • Chronic cholecystitis • Hydrops • Surgical...

Documents

Transcript of Abdominal pain cases - Semmelweis Egyetem · • Chronic cholecystitis • Hydrops • Surgical...