Approach to patient with acute abdominal pain

If any patient comes to you with severe Acute appendicitis

abdominal pain you first exclude the surgical Perforation
causes of acute abdomen Intestinal obstruction
Clinically Investigation
Perforation Obliteration liver dullness on percussion Plain x-ray abdomen in erect posture including both
broad like rigidity dome of diaphragm Exclude perforation and
rebound tenderness ( peritonitis ) intestinal obs. Subacute obs.
Intestinal Cramping pain, vomiting, constipation
obstruction or abdominal distension by percussion
Subacute obstruction bowel sound may be absent
Appendicitis Pain in right ilac fossa , HR-USG for appendix
McBurney's point tenderness CBC—leucocytosis
rebound tenderness ( peritonitis ) urine RME—to exclude UTI & xray KUB-Renal stone

Upper abdomen Diffuse Lower abdomen

Acute cholecystitis
Acute pancreatitis
Peptic ulcer disease.
Perforation of hollow viscous
Liver abscess
Hepatitis /
myocardial infarction,
pneumonia
.
Intestinal obstruction
Acute intestinal ischaemia/
infarction or vasculitis
Abdominal aortic aneurysm.
Gastroenteritis.
IBD
Renal colic or renal tract pain
Acute appendicitis
Acute pyelonephritis
Diverticulitis.
Pelvic inflammatory disease.
Torsion of ovarian cyst
Rupture ectopic pregnancy

Next step to exclude 3 important cause C Cholecystitis/ Cholelithiasis / Biliary colic,

upper abdominal pain --CRP R Renal colic or renal tract pain/
P Acute pancreatitis
Pyelonephritis
Peptic ulcer disease
Pelvic pain PID
Torsion of ovarian cyst
Rupture Ectopic pregnancy

Clinical clue Investigation clue

Cholecystitis Pain in the right hypochrondium USG of abdomen can exclude it
Murphy sign positive
Renal colic Severe cramping pain not relief by ordinary Xray –KUB-- renal stone
treatment USG—renal stone / ureteric stone
May have typical loin to groin pain Urine –RBC
Pancreatitis Severe epigastric pain with /out tenderness USG—
which radiates to the back S.lipase
Pain not relief by ordinary treatment

Dr shamol 1
 May associated with shock , oligouria,
discoloration in flank / umbilicus
Pyelonephritis High fever with chill and rigor CBC—leucocytosis
Abdominal pain Urine –RME-pus cell (+/-), WBC cast (+/-)
Renal angle tender USG
PUD If above this are excluded in severe upper Dx of exclusion by
abdominal pain it more possibility to be PUD X-ray abdomen
If Fever present than less liked to be PUD USG
CBCand urine
S.lipase
Endoscopy of upper PUD
Pl . do and ECG to exclude atypical presentation
MI inform of epigastric pain in middle and elderly

Lower abdominal pain in adult male Cystitis

Lower abdominal pain in female Cystitis /UTI
PID
Dysmenorrhoea
Torsion /infection or haemorrhage in ovarian and adenexal cyst
Rupture ectopic pregnancy

Clinical clue Investigation clue

Cystitis /UTI burning sensation micturation /dysuria Urine RME – pus cell > 5
suprapubic tenderness USG
Urgency , frequency Xray –KUB and RBS
PID Lower abdominal pain Urine RME
Vaginal discharge –itchy(+/-) , foul-smelling USG—pelvic collection
Dyspareunia , history recent abortion /STI CBC/RBS/Creatinine
Rupture ectopic HO amenorrhea US
pregnancy Lower abdominal pain and tender pregnancy test
Shock / anaemia
Torsion adenexal Lower severe lower abdominal pain USG
cyst HO Adenexal cyst

Other atypical causes Diverticulitis.

IBD
Acute intestinal ischaemia / vasculitis
Never forget nor abdominal causes MI—inferior MI
Lower lobe pneumonia
PLID / radiculopathy

Dr shamol 2
Acute abdomen Pain is moderate moderate
Treatment on admission Diet : normal
Bed rest Any one of the following
NPO  Inj.pantoprazole 40 mg (pantonix )
NG suction 2 hrly (if abdominal distension ) 1 vial iv stat and daily
Fluid :  Inj.Esomeprazole 40mg (maxpro/esonix)
Inj. Normal saline 1000 ml 1 vial iv stat and daily
+  Inj.Oemprazole 40 mg (losectil/ seclo )
Inj. Hartman 1000 ml 1 vial iv stat and daily
…………………………………………… Anti spasmodic
I V @ v 20 drop / min  Inj. Tiemonium 5mg ( Algin / norvis)
Antibiotic 2 amp iv stat and 8 hrly if ( clamping pain )
Any one of following NPO—in case of severe upper abdominal pain
 Inj. Ciprofloxacin (ciprocin/ciprox)100 ml NG suction and enema  in following case
1 bag iv bd Intestinal obstruction / sub acute obstruction
 Inj. ceftriaxone 2g(ceftron /exephine) If abdomen is distend
I vial IV daily Anti –biotics : indication
 Inj. Cefuroxime 750 mg (furocef /kilbac)  In all cases except PUD
I vial IV 8 hrly
Add following antibiotic in special case Metronidazole should be given in following
 Inj . metronidazole 500mg  If Peritonitis present
1 bag iv stat and 8 hrly  Appendicitis / where the pathology in pelvic
PPI region or pain bellow the umbilicus
Any one of the following
 Inj.pantoprazole 40 mg (pantonix ) Red flag sign :
1 vial iv stat and daily  Fever
 Inj.Esomeprazole 40mg (maxpro/esonix)  Rebound tenderness
1 vial iv stat and daily  Obliteration of liver dullness
 Inj.Oemprazole 40 mg (losectil/ seclo )  Persistent vomiting
1 vial iv stat and daily  ↓Urine out put
Analgesic any one of the following  BP/ Shock
 Inj. Tramadol 100mg (Anadol)  Not responding to ordinary treatment
1 amp IM stat and 8 hrly or hrly
 Inj. Ketorolac 30/60mg (Torax/ Rolac )
1 amp IM stat and 8 hrly or 12hrly
 Inj.Nulbuphine 2omg (nalbun-2/)
1 amp IM stat and SOS
Anti spasmodic
 Inj. Tiemonium 5mg ( Algin / norvis)
2 amp iv stat and 8 hrly if ( clamping pain )
Anti-emetic (if vomiting or nulbuphine /tramadol given )
 Inj. ondensatron (Emistat)
1 amp IV BD
Enema (intestinal obstruction / abdominal dist)
Enema simplex /fleet enema

Dr shamol 3
Investigation
1st line Must do Plain x–ray abdomen in Perforation
erect posture Acute /subacute intestinal obstruction
USG of whole Acute cholecystitis
abdomen Acute pancreatitis
Acute appendicitis
Acute pyelonephritis
Pelvic inflammatory disease.
Rupture ectopic pregnancy
Torsion of ovarian cyst
Should CBC
do RBS & s.creatinin
Urine RME
s.lipase

Second line SGPT

CRP
S.Calcium
Xray-KUB
Endoscopy and colonoscopy

Dr shamol 4
Approach to patient with dyspepsia
What is dyspepsia Upper abdominal pain and discomfort is called dyspepsia
the Rome III criteria of dyspepsia is defined as one or Postprandial fullness
dyspepsia more of the following symptoms Early satiation
Epigastric pain or burning
Clinical feature Upper abdominal discomfort / pain
Early satiety
Fullness,
Bloating and nausea usually after meal
NON-ULCER DYSPEPSIA This is defined as chronic dyspepsia (pain or upper abdominal discomfort) in the absence of
organic disease.

Causes
Upper Peptic ulcer disease Drugs Non-steroidal antiinflmmatory drugs (NSAIDs)
gastrointestinal Acute gastritis Corticosteroids
disorders Oesophageal spasm Iron and potassium supplements
Non-ulcer dyspepsia Digoxin
Irritable bowel syndrome Colonic Colonic carcinoma
Hepato-biliary Gallstones Alcohol
and pancreatic Pancreatic chronic pancreatitis Systemic Hypercalcaemia
disease Pancreatic cancer disease Renal failure
Hepatic hepatitis Psychological anxiety
disease metastases depression

First you look for We Weight loss If present have Must Do endoscopy
any alarm H Haematemesis and/or melaena to exclude the
symptom present A Anaemia malignancy
or not V Vomiting
We HAV MD-55 M Palpable abdominal mass Malignancy is Endoscopy is not
D Dysphagia unlikely mandatory
55 Age >55

Investigation
1st line USG of whole abdomen
CBC
RBS
S. Creatinin
ECG
Endoscopy of upper GIT –first line if alarm symptoms
Second line Endoscopy of upper GIT
s.calcium
Test for healicobacter pylori
TSH

Dr shamol 5
Drug group Generic name Trade name Dose
PPI Cap .Omeprazole 20/ 40 mg Seclo /losectil/ Xeldrin 1+0+1 ½ hr before meal
Tab/Cap. Esomeprazole 20/ 40mg Maxpro / esonix 1+0+1 ½ hr before meal
Tab.Pantoprazole 20/ 40mg Pantonix,pantobex 1+0+1 ½ hr before meal
Tab. Rabiprazole 20/ 40mg Paricel / finix 1+0+1 ½ hr before meal
Prokinetic agent Tab Domperidon10 mg Domin / Don-A 1+1+1 ½ hr before meal
Acid neutralizing Syp.Antacid Entacyd plus 2 tsf TDS
Syp Magaldrate and semithicon Digecid plus 2 tsf TDS
Anti-reflux Potassium bicarbonate and sodium Algicid / 2 tsf TDS
alginate
BISMUTH Pink bismol 2 tsf TDS
TRIPPLE therapy lansoprazole 30 mg +amoxicillin 1 g Pylotrip 1+o+1…..7 to 14 day
+ clarithromycin500mg
Esomeprazole 20+amoxicillin 1 g + Maxpro-HP
clarithromycin500mg

DYSPEPSIA GERD
Diet: Life style modification:
Explanation and reassurance  Weight reduction,
smoking cessation  Not to go bed after eating
small & regular meals  Avoid ingesting large quantities of fluids with meals
Avoid: Hot drinks, alcohol, citrus fruits, spicy foods, cofee,  Sleeping with the head of the bed elevated by about
tea, chocolate 4–6 in.
Fat And milk restriction may help in some people  Stop smoking
Any one of the PPI  Avoid consuming fatty foods, coffee, chocolate,
 Cap .Omeprazole 20/ 40 mg (Seclo /losectil/ Xeldrin)  Alcohol, mint, orange juice, and
1+0+1 ½ hr before meal  Avoid some medications such as
 Tab/Cap. Esomeprazole 20/ 40mg(Maxpro / esonix )  Anticholinergic drugs,
1+0+1 ½ hr before meal  Calcium channel blockers,
 Tab.Pantoprazole 20/ 40mg(Pantonix,pantobex)  Other smooth-muscle relaxants
1+0+1 ½ hr before meal PPI
 Tab. Rabiprazole 20 mg (Paricel / finix)  Tab/Cap. Esomeprazole 40mg(Maxpro / esonix )
1+0+1 after meal 1+0+1 ½ hr before meal
Prokinetic agent Prokinetic agent
 Tab Domperidon10mg(Domin/ Don-A/omidon)  Tab Domperidon10mg(Domin/ Don-A/omidon)
1+1+1 ½ hr before meal 1+1+1 ½ hr before meal
Any one of the following Anti-reflux
Acid neutralizing  Syp.sodium alginate (Algicid/viscocid)
 Syp. Antacid(Entacyd plus) 2 tsf TDS
2 tsf TDS ……………………………………………………………………………………….
 Syp Magaldrate and semithicon (Digecid plus) In Refractory GERD & NUD
2 tsf TDS A course of triple therapy for 7 to 14 day followed by PPI
Anti-reflux for 2 months along with prokinetic and acid neutralizer /
 Syp.sodium alginate (Algicid/viscocid) anti-reflux syp.
2 tsf TDS
Syp. Bismuth (Pink bismol)
2 tsf TDS

Dr shamol 6
If the patient has endoscopy proven ulcer /gastritis triple therapy
Diet:
 Explanation and reassurance
 smoking cessation
 small & regular meals
 Avoid: Hot drinks, alcohol, citrus fruits, spicy foods,
cofee, tea, chocolate
 Fat And milk restriction may help in some people
Triple therapy
Tab Pylotrip/ Maxpro-HC
1+o+1…..7 to 14 day
Prokinetic agent (for one month)
 Tab Domperidon10mg(Domin/ Don-A/omidon)
1+1+1 ½ hr before meal
Any one of the following (for 15 days )
a)Acid neutralizing
 Syp. Antacid(Entacyd plus)
2 tsf TDS
 Syp Magaldrate and semithicon (Digecid plus)
3 tsf TDS
b)Anti-reflux
 Syp.sodium alginate (Algicid/viscosid)
2 tsf TDS
c)Syp. Bismuth (Pink bismol)
2 tsf TDS
After completing the triple therapy pl continue at least two
month Any one of the PPI
 Cap .Omeprazole 20/ 40 mg (Seclo /losectil/ Xeldrin)
1+0+1 ½ hr before meal
 Tab/Cap. Esomeprazole 20/ 40mg(Maxpro / esonix )
1+0+1 ½ hr before meal
 Tab.Pantoprazole 20/ 40mg(Pantonix,pantobex)
1+0+1 ½ hr before meal
 Tab. Rabiprazole 20 mg (Paricel / finix)
1+0+1 after meal

Dr shamol 7
Triple therapy Cap. Amoxicillin 500mg (moxacil/tycil)2+0+2
Duration 7 to 14
Tab. Clarithromycin 500 mg (clarin) 1+0+1
Pylotrip Any one of this drug Cap .Omeprazole 20 (Seclo /losectil/ Xeldrin )
Helicon kit
Maxpro HP
Tab/Cap. Esomeprazole 20 (Maxpro / esonix )
Tab.Pantoprazole 20 (Pantonix,pantobex )
Tab. Rabiprazole 20 (Paricel / finix)
Tab. Lansoprazole 30 (Lanso )
Quadruple therapy Bismuth 525 mg four times daily
10 to 14 days metronidazole 250 mg four times daily
tetracycline 500 mg four times daily
Any one of this drug Cap .Omeprazole 20 (Seclo /losectil/ Xeldrin )
Tab/Cap. Esomeprazole 20 (Maxpro / esonix )
Tab.Pantoprazole 20 (Pantonix,pantobex )
Tab. Rabiprazole 20 (Paricel / finix)
Tab. Lansoprazole 30 (Lanso )

Sequential therapy
Clarithromycin First five day Cap. Omeprazole 20 mg 1+0+1
sequential therapy Cap. Amoxicillin 500mg (moxacil/tycil)2+0+2
Next five day Cap. Omeprazole 20 mg 1+0+1
Clarithromycin 500 mg (clarin) 1+0+1
Levofloxacin -250 First five day Cap. Omeprazole 20 mg 1+0+1
sequential therapy Cap. Amoxicillin 500mg(moxacil/tycil) 2+0+2
Next five day Cap. Omeprazole 20 mg 1+0+1
Tab. levofloxacin 250 mg (Evo/Trevox) 1+0+1
Tab.tinidazole500 mg (protogyn)1+0+1
Levofloxacin -500 First five day Cap. Omeprazole 20 mg 1+0+1
sequential therapy Cap. Amoxicillin 500mg (moxacil/tycil) 2+0+2
Next five day Cap. Omeprazole 20 mg 1+0+1
Tab. levofloxacin 500 mg (Evo/Trevox) 1+0+1
Tab.tinidazole 500 mg (protogyn)1+0+1

Indication of  Peptic ulcer Side effect of  Diarrhoea: 30–50%

triple therapy  H. pylori-positive dyspepsia Triple  Nausea, vomiting
 Long-term NSAID or low-dose aspirin users therapy  Abdominal cramps
 Chronic ( > 1 yr) PPI users  Headache
 Extranodal marginal-zone lymphomas of MALT  Rash
type  Flushing and vomiting
 Family history of gastric cancer Previous when taken with alcohol
resection for gastric cancer (metronidazole)
 Extragastric disorders:
 Unexplained vitamin B12 defiiency*
 Idiopathic thrombocytopenic purpura*
 Iron defiiency anaemia

Dr shamol 8
Treatment of chronic pancreatitis
Diet: surgical or endoscopic pancreatic therapy
Avoid fatty food  Coeliac plexus neurolysis
Alcohol  minimally invasive thoracoscopic
Pain relief any one or both splanchnicectomy
(In sever case injectable form / suppository may need )  Total pancreatectomy
NSAID
 Tab. Ketorolac 10 mg (rolac/torax)
o 1+1+1/1+0+1
 Inj . Ketorolac 30 /60mg (rolac/torax)
o 1 Amp IM bd
 OPIATE
 Cap. Tramadol 50mg (Anadol)
o 1+1+1/1+0+1
 Inj. Tramadol 100mg (Anadol)/ suppository
o 1 Amp IM bd

month Any one of the PPI

 Cap .Omeprazole 20/ 40 mg (Seclo /losectil/ Xeldrin)
1+0+1 ½ hr before meal
 Tab/Cap. Esomeprazole 20/ 40mg(Maxpro / esonix )
1+0+1 ½ hr before meal
 Tab.Pantoprazole 20/ 40mg(Pantonix,pantobex)
1+0+1 ½ hr before meal
 Tab. Rabiprazole 20 mg (Paricel / finix)
1+0+1 after meal
Pancreatic enzyme
 Tab.pancreatin 325 mg(zymet / azyme )
o 2+2+2—with meal –contiued

chronic pancreatitis Presentation recurrent ‘acute pancreatitis'—50% / acute on chronic

Progressive chronic pain 35%
Pain epigastric pain,
which may radiate posteriorly
Post-prandial pain
Pain relieved by leaning forwards or by drinking alcohol
Others Alcoholic men
Gall stone
Malabsorption and/or steatorrhoea when > 90% exocrine tissue destroyed)
Diabetes--30%, 70% in case of chronic calcific pancreatitis
thin, malnourished patient
epigastric tenderness
Skin pigmentation over the abdomen and back is common(erythema ab igne).
Deficiency of fat soluble vitamin

Dr shamol 9
Investigation to establish the Ultrasound
diagnosis Abdominal X-ray (may show calcification)
CT (may show atrophy, calcification or ductal dilatation)
MRCP
Endoscopic ultrasound
Tests of pancreatic Faecal pancreatic elastase
function Pancreolauryl or PABA test
(not done clinically ) Collection of pure pancreatic juice after secretin injection (gold
standard but invasive and seldom used)
Others RBS
S.creatin
s.calcium

Causes of chronic T- Toxic–metabolic Alcohol

pancreatitis Tobacco
Hypercalcaemia
Chronic renal failure
I Idiopathic
G Genetic Hereditary pancreatitis
Cystic fibrosis
A Autoimmune
R Recurrent and severe acute pancreatitis
O Obstructive Ductal adenocarcinoma
Intraductal papillary mucinous neoplasia
Pancreas divisum
Sphincter of Oddi stenosis
Others FCPD-fibro cystic pancreatic diseases

Dr shamol 10
Acute pancreatitis
Treatment on admission  NG suction is only required if paralytic ileus is present.
Bed rest  If patient tolerate the enteric feeding if should be
NPO started as early as possible to reduced endotoxeamia
NG suction 2 hrly (if abdominal distension )  Prophylaxis of thromboembolism with subcutaneous
Fluid : low-molecular-weight heparin
Inj. Normal saline 1000 ml Intervention
+ urgent ERCP
Inj. Hartman 1000 ml  to diagnose and treat choledocholithiasis
…………………………………………… Cholecystectomy
I V @ v 20 drop / min  within 2 weeks following resolution of pancreatitis
Antibiotic  necrotising pancreatitis or pancreatic abscess
Any one of following urgent endoscopic or surgical necrosectomy to
 Inj. Meropenem 1g (meropen/carbanem) débride all cavities of necrotic material
I vial iv 8 hrly Pancreatic pseudocysts
 Inj. ceftriaxone 2g(ceftron /exephine)  drain into the stomach, duodenum or jejunum
I vial IV daily (Roux en Y)
 Inj. Cefuroxime 750 mg (furocef /kilbac)  usually performed after 6 weeks,
I vial IV 8 hrly
PPI
Any one of the following
 Inj.pantoprazole 40 mg (pantonix ) Clinical feature
1 vial iv stat and daily  abdominal pain
 Inj.Esomeprazole 40mg (maxpro/esonix) o Severe, constant upper abdomen
1 vial iv stat and daily o radiates to the back( 65%)
 Inj.Oemprazole 40 mg (losectil/ seclo )  Nausea and vomiting
1 vial iv stat and daily  marked epigastric tenderness—early stage absent
Analgesic any one of the following  if paralytic ileus develops
 Inj.Nulbuphine 2omg (nalbun-2/) o Bowel sounds quiet or absent
1 amp IM stat and SOS  hypoxic
 Inj. Tramadol 100mg (Anadol)  hypovolaemic shock with oliguria
1 amp IM stat and 8 hrly or hrly  Grey Turner's sign(Discoloration of the flanks)
 Inj. Ketorolac 30/60mg (Torax/ Rolac )  Cullen's sign (Discoloration of the the periumbilical
1 amp IM stat and 8 hrly or 12hrly region)
Anti-emetic (if vomiting or nulbuphine /tramadol given )
 Inj. ondensatron (Emistat)
1 amp IV BD

investigation CBC with ESR

serum lipase (more accurate )
USG or CT
Plain xray abdomen
C-reactive protein (CRP)
RBS
s. creatin
CRP > 210 mg/L in the first 4 days predicts severe acute
S.calcium

Dr shamol 11
 SIRS N—Necrosis
systemic Hyperglycaemia A—Abscess
Hypoxia Pancreatic P—Pseudocyst
Hypocalcaemia A--Pancreatic ascites or pleural effusion
Hypo albumia The
Gastrointestinal V..Variceal haemorrhage pseudocyst matures over a 6-week period
VUDEO U-Upper gastrointestinal bleeding 6 cm—needed surgical intervention
D..Duodenal obstruction CF—
abdominal pain
E---Erosion into colon  compress or erode surrounding
structures-pseudoaneurism
O--- Obstructive jaundice

Dr shamol 12