#MiniTeach: Another Surgical Abdomen
"An 84-year-old lady presents with a four-day history of abdominal pain. She has vomited today and not opened her bowels in several days."
She has a past medical history of diabetes, high blood pressure, peptic ulcer disease and hiatus hernia. On examination, her observations are within normal range her abdomen is distended and she has tenderness over both upper quadrants. Bowel sounds are present.
1. What steps should be taken from a nurse assessment point of view in the assessment bay?
Do a complete set of observations including a BM and a pain score.
Make sure the patient has been weighed.
Ensure that the patient is put into a gown, with trousers removed if she is wearing them. (This is because the groin needs to be examined in patients with abdominal pain to look for hernias and check pulses and this is very difficult if the patient is wearing trousers).
Obtain IV access and request FBC, U+E, LFT, Amylase, Bone (hypercalcaemia can cause abdominal pain and constipation), Venous blood gas (especially to look for lactate) and a group and save.
Advise the patient to remain nil by mouth.
Obtain a medical stat from an ANP or doctor, who can then prescribe IV fluids and order an abdominal X-ray (one of the very few times in ED when ordering an AXR can be useful).
Ensure analgesia given.
Check AMT 4 and ISAR (if time allows).
2. What else would you want to know from the history and examination?
History:
What is the pain like? (SQITAS): Site, quality, intensity, timing, aggravating and relieving factors, symptoms associated.
Does it go through to the back?
Has she ever had this pain before?
Has she been passing flatus?
What is the vomiting like? (any blood, bile, coffee grounds)
Has she ever had any surgery on her abdomen?
Any altered bowel habit or weight-loss?
Any previous endoscopies?
What medication is she on? (She might need a CT scan so ask if she’s on Metformin now)
Any drug allergies?
Alcohol and smoking status.
Physiological baseline – (what can she do for herself when she’s well on a day to day basis).
Examination:
General examination – look at obs, level of hydration, colour, hands.
Focused abdominal examination:
Any scars, distension, tenderness, rebound/guarding
Bowel sounds
Feel for organs/masses/aorta
Rectal examination
DON’T FORGET TO EXAMINE THE PATIENT’S GROIN!
3. What does the X-ray show?
The X-ray is inadequate as it misses off the lower abdomen, but there are dilated small bowel loops.
Given the clinical presentation, this is consistent with small bowel obstruction.
4. How should this patient be managed?
‘Drip and suck’ is the classic initial management of small bowel obstruction.
Ensure that you have reviewed the blood results above.
Make sure her potassium and electrolytes are OK.
Close observation – start an Obs chart.
IV fluids.
Insert an NG tube on free drainage.
Keep nil by mouth.
Monitor urine output – this may need a catheter, but urine output can be monitored without one, depending on compliance of both patient and staff.
Monitor the effects of the analgesia.
Refer to the surgical registrar to review the patient in ED – a CT scan is usually indicated.
5. What are the potential underlying causes of this condition?
Adhesions, Groin Hernia (the diagnosis in this patient), Tumour, other hernias, Inflammatory bowel disease, volvulus, foreign body.
6. How sensitive and specific is plain radiography for diagnosing this condition?
Only a couple of papers reporting on this, but a sensitivity of 69-75% has been reported and a specificity of 53-57% (small numbers in both studies).
