Abdo Pain, Swelling, Mass & Constipation

“Abdominal pain presentations can be extremely varied and the differential diagnosis may include conditions managed by different specialities.”

EM Curriculum: (click to view)

Background

Patients with acute abdominal pain are a common reason for attendance at the Emergency Department (ED) and account for approximately 10% of all attendances [1]. Yet, some 40% of all abdominal pain presenting to secondary care will never receive a formal diagnosis and will be classified as ‘non-specific abdominal pain’.

Abdominal pain is the most common surgical presenting complaint, with acute appendicitis being the most common surgical emergency accounting for approximately 20% of all abdominal pains (Gallagher 2000).

Abdominal pain presentations can be extremely varied and the differential diagnosis may include conditions managed by different specialities.

Due to this, a systematic approach to abdominal pain is crucial to the accurate assessment and management of a range of potentially life threatening conditions. A sound knowledge of the relative anatomy of the abdomen is a good place to start. However understanding referred pain and how this may present is also vital.

Remember:

  • All women of childbearing age with abdominal pain must have a pregnancy test.

  • Flank/back pain – think AAA.

  • Don't forget external genitalia and hernial orifices.

References:

  1. Fairclough PD. Gastrointestinal disease. In: Kumar P, Clark ML, eds. Clinical Medicine. 5th edn. New York: Elsevier, 2005.

Learning Outcomes from completing the tasks

  • Explain the presentation, management and ongoing surgical care of patient's presenting with appendicitis.

  • Describe the spectrum of pathologies seen in gall bladder disease and explain their management in the ED.

  • Recall the definition of constipation and its management as relevant to the ED.

  • Describe the presentation and management of renal colic and review the various investigation options available.

Learning Outcome from face-to-face teaching

  • Review all the ED presentations of abdominal pain not included above.

  • Distinguish between surgical and medical causes of abdominal pain.

  • Define the indications and contraindications for various investigations in abdominal pain and be able to interpret gross pathology seen in them.

  • Explain the different causes of abdominal mass and describe the investigations appropriate to distinguish between them.

  • Recognise and treat obstruction and constipation appropriately.

Tasks

Complete the following before the face to face session:

Task 1: Appendicitis

Duration: 72 mins

This in depth podcast looks at several controversies surrounding appendicitis including:

  • how it presents,
  • some pearls/pitfalls for assessment,
  • scoring systems...

The show notes are also worth reading and are available at the EM Cases Website

Task 2: Gall Bladder Disease

Duration: 60 mins

This e-learning module explores in depth the biliary causes of abdominal pain. It also revisits the key topics of anatomy and physiology. The module is an excellent insight into the module into how surgeons approach this patient group and what key information they look for in the ED clerking and management.

Task 3: Constipation

Duration: 20 mins

This video from the RCEM Learning (formerly RCEM FOAMed network) covers constipation which, whilst not the most glamorous of medical topics, is relatively common and referenced by name in the RCEM curriculum.

It includes the definition of constipation, common causes, and some management tips.

Task 4: Beware of Diagnosing Renal Colic

Duration: 20 mins

This short blog entry is inspired by a case that is quite easy to imagine presenting to our ED, it covers some of the presenting features of renal colic and mentions the role of urine dipstick. However most importantly it is a reminder to think twice when things are not adding up.

Task 5: The Geriatric Abdomen - How To Get It Right

Duration: 6 mins

This short video from #GEMCON16 covers some pearls for managing older patients with abdominal pain. It also talks about why it is important that patients are referred appropriately from the ED.

#EM3 Content

Lightning Learning

Simblog

EMERGENCY PROTOCOLS

You should familiarise yourself with relevant Local Guidelines, but for East Midlands Trainees we are aiming to host these on the website shortly (although this may password protected).

In the meantime please review your local guidelines relevant to abdominal pain.

CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

“Mrs H. is a 40 year old woman who presents to the ED with acute abdominal pain. The pain is of a colicky nature and central.”
“You are in Resus and a gentleman has been brought in from assessment looking jaundiced and febrile at 38.6°C.”

ADDITIONAL RESOURCEs

Abdominal Pain in the Elderly:

An american case, discussing some of the pitfalls in assessing abdominal pain in the elderly. It is a good reminder that often significant pathology may have little in the way of clinical findings.

"Best Case Ever":

A short podcast from Canada discussing five cases where it is necessary to think outside the box to address abdominal pain.

Abdominal X-ray interpretation:

COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form:

Updated: 4th January 2017