ABDOMINAL PAIN

Mihael Klašnja
Introduction:

 Abdominal pain accounts for up 10% of emergency visits

 Most abdominal pain is non-emergent and self-limited in nature

 Three important factors to consider are age, gender, and co-morbidities

 Most diagnoses can be made by history alone

 History: Physical examination:

 Careful attention must be paid to:  General characteristics:

 Time/mode of onset  Overall appearance
 Duration  Vital signs
 Location  Body posture
 Character/progression  Inspection (scars, distension…)
 Medical history  Auscultation (bowel sounds)
 Percussion (organomegaly, dullness)
 Palpation (tenderness, guarding,
reffered pain)
Acute appendicitis

 Abdominal pain is the primary presenting complaint

 Colicky central abdominal pain  24h  migration of the pain to the right
iliac fossa, becomes constant and sharp

 Ussually anorexia, nausea, +/- low grade fever

 US and CT can make definitive Dx

 Ruptured abdominal aoritc aneurism
(AAA)
 More comon in males, >65 yo

 Typical presentation: epigastric or periumbilical pain radiating to back

 May present as back or groin pain

 +/- shock

 US/CT

 Immediate surgical repair

Ectopic pregnancy

 ‘Females of childbearing age with abdominal pain have an ectopic

pregnancy until proven otherwise’

 ~ 7 weeks after the last normal menstrual period

 Symptoms similar to those of other GU and GI disorders

 Sharp/dull/crampy unilateral lower abdominal pain, worsened by palpation

Timothy Barnett, MD

 Graduated from Boston University School of Medicine 1994

 Residency at Boston University Hospital, General surgery 1999

 Associate Professor of Surgery, Harvard Medical School

 Fields of interest: laparoscopic surgery, colorectal cancer, cancer genetics

Laparoscopic appendicectomy is superior
to open surgery for
complicated appendicitis
David J. Stott, M.B., Ch.B., M.D.,
Timothy Barnett M.D.
Patricia M. Kearney, M.D., Ph.D.

N Engl J Med 2017; 376:2534-2544

 Background:

 Over the last three decades, laparoscopic appendicectomy (LA) has become the
routine treatment for uncomplicated acute appendicitis.
 The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or
perforated) remains controversial due to concerns of an increased incidence of
post-operative intra-abdominal abscesses (IAA) in LA compared to open
appendicectomy (OA)

 Aim: to compare the outcomes of LA versus OA for complicated appendicitis

 Materials and methods:

 systematic literature search following PRISMA guidelines

 MEDLINE, EMBASE, PubMed and Cochrane Database for 3 randomised

controlled trials (RCT) and 30 case-control studies (CCS) that compared LA with
OA for complicated appendicitis
 Results:

 There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%;
OR = 1.02, 95% CI = 0.71-1.47, p = 0.91).

 LA for complicated appendicitis has decreased overall post-operative morbidity

(LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31-0.59, p < 0.0001), wound
infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19-0.36, p < 0.001),
respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13-0.49,
p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%;
OR = 0.65, 95% CI: 0.42-1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%;
OR = 0.15, 95% CI: 0.04-0.61, p = 0.008).

 LA has a significantly shorter hospital stay (6.4 days vs. 8.9 days, p = 0.02) and
earlier resumption of solid food (2.7 days vs. 3.7 days, p = 0.03)
 Conclusion:

 LA for complicated appendicitis has the same incidence of IAA but a

significantly reduced morbidity, mortality and length of hospital stay compared
with OA