Surgery

“Patients with acute abdominal pain are a common reason for attendance at the Emergency Department (ED) and account for approximately 10% of all attendances. (Fairclough 2005)

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”

BACKGROUND

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 can include a multitude of different specialities. Due to this variance, a systematic approach to abdominal pain is crucial to the accurate assessment and management of a range of potentially life threatening conditions.

Back Pain

Back pain affects up to a third of the adult population of the UK. It is the second most common cause of long term absence from work in the UK after stress (European Back Pain Society Guidelines, 2004).

The vast majority of acute back pain is self limiting and of a "non-specific" character. However, approximately 3-5% of all back pain presentations represent serious pathologies including spinal cord compression and cauda equina syndrome (Bigos, 1994).

NICE and the European back society has produced several guidelines into the assessment and management of acute back pain including red and yellow flag symptoms. It is crucial to know these as a missed diagnosis of cauda equina syndrome can lead to severe permanent disability.

This level of disability is most commonly caused by delay in either diagnosis or referral to surgical teams.

When assessing abdominal pain and back pain, have these top diagnoses in your mind:

  • Appendicitis

  • Ruptured abdominal aortic aneurysm

  • Gall Stone Disease

  • Cauda Equina/Spinal Cord Compression

  • Renal Colic

  • Ectopic pregnancy

  • DKA

  • Perforated DU

  • Pancreatitis

  • Testicular / Ovarian torsion

  • Intestinal Obstruction

Problems in Pregnancy

Many women will experience symptoms of bleeding and pain in early pregnancy. Potential pathological causes for these symptoms include miscarriage, ectopic pregnancy and gestational trophoblastic disease.

Recurrent miscarriage affects 1% of couples (Stirrat, 1990) and is defined as the loss of three or more pregnancies.

Ectopic pregnancy occurs when the fertilised egg implants outside the uterine cavity. It is a common complication with an incidence of 1 in 100 conceptions. Women may present with shoulder pain due to blood irritating the diaphragm, fainting due to blood loss or occasionally with shock due to extensive intra-abdominal bleeding.

Remember:
  • All females of child-bearing age presenting with abdominal pain must have a pregnancy test to exclude an ectopic pregnancy.
  • All males with lower abdominal pain should have a testicular examination for torsion.
  • You should examine for hernias in patients with possible obstruction.

LEARNING OUTCOMES FROM COMPLETING THE TASKS

  • Choose the most appropriate analgesia for an adult or child presenting with pain

  • Compose a broad differential diagnosis for abdominal pain presenting to the Emergency Department

  • Propose the appropriate investigations required for acute gynaecological emergencies

  • Formulate a management plan for back pain and gynaecological emergencies presenting to the Emergency Department

  • Apply local Emergency Department protocols and evaluate the evidence behind them

Tasks

Complete the following before the face-to-face session:

Task 1: Management of Pain

Duration: 20 mins

Pain in a common presenting symptom to the Emergency Department and it is important that you are able to assess it and manage it well. Click on the links below and read the RCEM guidelines on pain management for adults and children: Please note that codeine is now not recommended in children under 12 years. Both these documents will download as a .pdf file.

Task 2: Differential Diagnosis of Abdo Pain

Duration: 15 mins

This video is produced by a surgical registrar and is designed to provide you with a useful mnemonic for building a differential diagnosis of abdominal pain. While the video does labour to make it’s point, the overall mnemonic is helpful.

Task 3: Abdo Pain Without Shock

Duration: 45 mins

Another great module very specific to the Emergency Department to help diagnose and differentiate between the differential diagnosis of abdominal pain. Please click on the screenshot or link below. The new RCEM Learning website contains loads of content mapped to the RCEM curriculums, if it is your first visit there take the time to look around at the other content.

Task 3a: The geriatric abdomen

Duration: 5 mins

This short video from #GEMcon16 in Leicester gives some good tips for how to manage abdominal pain in older patients.

Task 4: Acute Lower Back Pain

Duration: 45 mins

This RCEM Learning module is good for making you think about the acute presentations of back pain. It covers the simple all the way through to the emergency presentations, and provides useful tools to help you single out the serious pathologies. Click on the screenshot or link below.

Task 5: Problems of Early Pregnancy

Duration: 30 mins

This module covers the emergency presentations of early pregnancy problems, and goes into detail about the specialist management and follow up of these patients. Click on the screenshot or link below.

#EM3 Content

Lightning Learning:

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:

“A 61 year old gentleman presents to the Emergency Department with acute lower back pain. The pain began suddenly 1 day ago with no history of trauma, lifting or strain to the back...”
“A 72 year old man presents to the Emergency Department with left sided abdominal pain. The pain came on suddenly at night and is located around the left flank...”

ADDITIONAL RESOURCES

Here are some extra resources that offer further insight into some surgical problems:

Emergency Medicine Cases:

Part of their "Best Case Ever" series and available via their website.

LIFE IN THE FAST LANE:

A nice summary of the indications for and possible findings on AXR, includes some examples of small and large bowel obstruction (click here).

NICE GUIDELINES:

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: 5th January 2017