4. Epidemiology
4-10 % of all emergency department visit
50 % have clearly diagnosis
15-30% require surgical procedure esp. elderly
Acute appendicitis is the most common
6. Acute abdominal pain among elderly patients
3 years, 831 cases
Non-specific 22-24%
Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%)
less peritoneal signs
Laurell H, Hansson LE, Gunnarsson U.
Gerontology. 2006;52(6): 339-44
7. Emergency department diagnosis of acute abdominal
pain in elderly patients
1 year retrospective review, 378 cases
Non-specific (35.2%), acute gastritis/gastroenteritis
(10.6%), and biliary tract dis. (8.2%)
Non-specific; 90% dissolved, 5.4% Sx.
Othong R, Wuthisuthimethawee P, Vasinanukorn P
Songkla Med J vol. 28 No 1 Jan-Feb 2010
8. Predictor for an intensive care or specific treatment in
the elderly patients with acute abdominal pain
1 year retrospective review, 386 cases
Dyspepsia (21.8%), non-specific (17.6%) and
acute gastroenteritis (8.8%)
Male, BT < 38, PR >90, abnormal abd contour, and
Localize tenderness or guarding
Worapraatya P, Wuthisuthimethawee P, Vasinanukorn P
25. Analgesia on abdominal examination
Effect on diagnostic efficiency of analgesia for
undifferentiated abdominal pain
Analgesia is safe in abdominal pain
Br J Surg. 2003 Jan;90(1):5-9
26. Analgesia on abdominal examination
Effects of morphine analgesia on diagnostic accuracy in
Emergency Department patients with abdominal pain:
a prospective, randomized trial
Prospective, double-blind clinical trial
Reexam in 60 minutes
No differences with respect to changes in physical
examination or diagnostic accuracy
J Am Coll Surg. 2003 Jan;196(1):18-31
27. Analgesia on abdominal examination
Analgesia in patients with acute abdominal pain
Opioid improve patients comfort and
does not retard decision to treat
Cochrane Database Syst Rev. 2007 Jul 18;(3): CD005660
28. Analgesia on abdominal examination
Efficacy and impact of intravenous morphine before surgical
consultation in children with right lower quadrant pain
suggestive of appendicitis: a randomized controlled trial
Randomized double-blind placebo-controlled trial
8-18 years old, 90 patients
Morphine did not delay surgical decision,
not more effective than placebo to diminishing pain
Ann Emerg Med. 2007 Oct;50(4):371-8.
Epub 2007 Jun 27
52. Uncertain Diagnosis
When in doubt, don’t send them out!
Cope’s Early Diagnosis of the Acute
Abdomen, 20th ed.. New York, Oxford
University Press, 2000.
53.
54. Case 1
Male 34 years old
No underlying dis.
Check up at GP
During took blood examination
abd pain & syncope
55. Case 1
At ER
Sweating, looked pale
V/S BP 95/60 P 112 RR 26
Abd: tenderness at RLQ, guarding ?
71. High-Yield historical questions
How old are you ?
Which came first-pain or vomiting ?
How long have you had the pain ?
Have you ever had abdominal surgery ?
72. High-Yield historical questions
Is the pain constant or intermittent ?
Have you ever had this before ?
Do you have a history of cancer diverticulosis ?
Do you have HIV ?
73. High-Yield historical questions
How much alcohol do you drink per day ?
Are you pregnant ?
Are you taking antibiotic or steroid ?
Did the pain start centrally and migrate ?
Do you have a history of CAD, HT, AF ?
74.
75.
76.
77. Etiology and clinical course of abdominal pain
In senior patients; a prospective, multicenter study
3 years, 831 cases
Non-specific 22-24%
Misdiagnosis (52% VS 45%), high mortality (2.8% VS 0.1%)
less peritoneal signs
Lewis LM, Banet GA, Blenda M, et al.
J Gerontol A Biol Sci Med Sci. 2005
