[CPX] 급성복통 Acute abdominal pain

Approach to the patient with acute abdominal pain (★★★)

 

 

Approach to the patients

1. History taking

2. Physical examination

3. Laboratory examination

4. Radiologic examination

5. Endoscopy / Laparoscopy

 

 

1. History taking

(1) Onset : Acute vs chronic

(2) Vector : spontaneous or with some events

(3) Nature : Location, Quality, Severity, Radiation

(4) Duration (course)

(5) Factors : Agg' or All'

(6) Associated Sxs :  Warning symptoms

(7) Medication

(8) Past Hx, SHx, FHx

 

(1) Onset : acute abdominal pain

- Sudden (immediately) : perforated viscus, mesenteric infarction, ruptured aneurysm, etc.

- Rapid (several minutes) : acute cholecystitis, pancreatitis, etc.

- Gradual (several hours) : appendicitis, diverticulitis, intestinal obstruction, ureteral stone, gastroenteritis,

peptic ulcer, Crhon's disease, PID, etc.

 

(2) Vector

 

(3) Nature

a) Location of pain

- 복통의 위치에 따라 어떤 질환이 있을 수 있는지 기억할 것!

- However, the chronological sequence of events in the patient's history is often more important than emphasis on the location of pain.

         

 

b) Quality : Visceral pain / somatoperietal pain / referred pain

*  Visceral pain (내장성 통증)

Dull & poorly localized

- midline epigastrium, periumbilical region, or lower midabdomen
- 어디가 아프십니까? 손바닥으로 배부위를 애매하게 가리킴.

Cramping(경련성), burning(작열감), or gnawing(쏘는)

Sweating, restlessness, nausea, vomiting, perspiration, pallor

Move about in an effort to relieve discomfort

* Somatoparietal pain (체성 통증 혹은 벽측 통증)

More localized and intense

- 환자가 통증의 위치를 더 정확하게 손가락으로 가리킴
- Acute appendicitis: vague periumbilical pain (visceral pain)

➜ localized pain at McBurney's point (somatoparietal pain)

Aggravated by movement or coughing

* Referred pain (연관통)

Perceived in areas remote from diseased organ

Convergence of visceral afferent neurons with somatic afferent neurons in the spinal cord

- 담도질환 ➜ 오른쪽 어깨 혹은 등쪽으로

- 횡격막 상부 질환 ➜ C4 distribution에 있는 목 혹은 어깨쪽

- 콩팥결석 ➜ 샅굴부위 혹은 샅부위 통증 

c) Severity : 통증이 시작부터 극심, 갑자기 호전

 

(4) Duration : Patterns of acute abdominal pain

 

(5) Factors

- 식사

 

(6) Associated symptoms

- Warning symptoms and sign

Sudden, diffuse, tearing pain

Fever : low fever ➜ diverticulum, appendicitis, acute cholecystitis

     high fever ➜ pneumonia, UTI, septic cholangitis, gynecologic infection

Nausea/vomiting ➜ Acute cholecystitis, gastritis, pancreatitis, ileus

Appendicitis : pain & anorexia before vomiting

Gastroenteritis : vomiting before abdominal pain

Small bowel obstruction : proximal > distal

Melena, hematochetzia, hematemesis

Jaundice

 

(7) Medication

- High dose narcotics ➜ constipation, spasm of sphincter of  Oddi
- Corticosteroids ➜ Gastroduodenal ulceration & perforation
    * Pts have taken steroids for long periods ➜ Perioperative steroid supplementation
- Diuretics ➜ Evaluation of their fluid and electrolyte status
- Anticoagulants ➜ Intra-abdominal, intestinal, mesenteric bleeding
- NSAID ➜ GI perforation
- Cocaine ➜ Can cause abdominal pain

 

(8) Past History / FHx / SHx

- 과거 수술력

- 전신 질환 및 심장, 폐질환 배제

 

(9) Menstrual Hx

- 여성 환자의 경우 꼭 물어봐야 함

- Ovulation, undiagnosed pregnancy, ectopic pregnancy

 

• Narcotics or analgesics should not be withheld until a definite diagnosis or definite plan has been formulated;

   obfuscation of the diagnosis by adequate analgesia is unlikely.

 

 

2. Physical examination (I-A-P-P-P)

 

(1) Inspection : Face, position in bed, respiratory activity, Distension, scar, hernia, bowel movements

- Mechanical Obstruction ➜ hyperperistalsis

- severe pancreatitis ➜ Cullen's sign (umbilicus 주위), Grey-Turner's sign (flank 출혈반)

- Knee-chest position ➜ acute cholecystitis

(2) Auscultation : Bowel sounds - increased vs decreased/abscent

- Hyperactive bowel sounds ➜ GE

- paralytic ileus ➜ no sound (최소한 2~3분간)

- mechanical ileus ➜ metallic sound

(3) Percussion : Tympanic vs dullness

- ascites ➜ shifting dullness (500cc 이상이 될 때)

(4) Palpation : Tenderness, rebound tenderness

- acute cholecystitis ➜ Murphy sign

- peritonitis ➜ RT (손가락을 빨리 뗐을 때 통증 심해짐 - 복막이 빠르게 움직이기 때문)

- mass ➜ 복부의 근육에 힘을 주었을 때 종괴가 만져지면 복벽내 종괴, 만져지지 않으면 복강내 종괴

(5) Pelvic and rectal examination : Perforated appendicitis, diverticulitis, twisted ovarian cyst

 

 

3. Laboratory examination

- Leukocytosis > 20,000/μL ➜ perforation of viscus, pancreatitis, acute cholecystitis, PID, intestinal infarction

* A differential count may disclose a marked left shift Can be more significant than finding of elevated WBC
* Increased WBC : but not always true

- BUN, glucose, bilirubin, AST, ALT, GGT, ALP ➜ obstructive jaundice or acute hepatitis
- Serum amylase, lipase ➜ pancreatitis, perforated ulcer, strangulating intestinal obstruction, acute cholecystitis

* Help in the evaluation of upper abdominal pain by giving evidence of pancreatitis

- Urinalysis ➜ Urinary tract infection, hematuria, proteinuria

- b-hCG

 

4. Radiologic examination

- Plain abdomen x-ray : upright, supine

* small bowel obstruction ➜ multiple air-fluid level

- Chest x-ray : PA, lateral, decubitus

* Chest PA로 pneumoperitoneum 꼭 확인할 것!

* Chest PA 찍을 수 없는 경우엔 abdomen x-ray를 Lt. decubitus position으로 찍을 것!

- Barium or water-soluble contrast study

- Ultrasound

- CT

- Angiography

- Radioisotope scans

 

5. Endoscopic / Laparoscopic examination

 

 

Findings Associated With Surgical Disease

Abdominal compartment pressures >30 mm Hg
Worsening distention after gastric decompression
Involuntary guarding or rebound tenderness
Gastrointestinal hemorrhage requiring >4 U of blood without stabilization
Unexplained systemic sepsis
Signs of hypoperfusion (e.g., acidosis, pain out of proportion to examination findings, increasing LFT results)

Radiographic Findings

Massive dilation of intestine
Progressive dilation of stationary loop of intestine (sentinel loop)
Pneumoperitoneum
Extravasation of contrast from bowel lumen
Vascular occlusion on angiography
Fat stranding, thickened bowel wall with systemic sepsis

Diagnostic Peritoneal Lavage (1000 mL)

>250 white blood cells/mL
>300,000 red blood cells/mL
Bilirubin level higher than plasma level (bile leak)
Particulate matter (stool)
Creatinine level higher than plasma level (urine leak)

 

급성 복통 환자를 대할 때 유의할 점

1. 흉부의 급성 질환이 복부의 일차질환과 매우 유사 할 수 있다.

2. 급성 복통이 발생한 첫 12시간 동안에는 충수염을 완전히 배제할 수 없다.

3. 혈청 아밀라제치가 (>1,000 IU/L)가 아니더라도 급성 췌장염은 그 가능성을 염두에 두어야 할 질환이다.

4. 급성 신우신염이 종종 배뇨곤란에 비해 심한 복통을 일으켜 급성 충수염, 담낭염, 장폐쇄로 혼동될 수 있다.

5. 천공성 소화성 25% 정도에서 발병이 급작스럽지 않거나 복강 내 유리가스가 없는 등 비전형적인 소견을

나타낼 수 있다.

6. 급성 장간막 경색은 수술적 치료가 효과적일 수 있는 초기에 진단을 내리기가 매우 어렵다.

7. 내장성 통증으로 발현하며 장폐쇄의 징후가 없고 복부 종괴나 국소적인 압통이 없는 외과적 상태는 위장염과

 기타 다른 비특이적 원인의 통증과 임상적 양상이 동일하기 때문에 조기에 진단을 내리기가 어렵다.

8. 임상 소견으로 장폐쇄에 감돈이 합병되었는지를 확실하게 알 수는 없다.

9. 복강내 출혈로 인한 통증 및 저혈량성 쇼크에 대비하여야 한다.

10. 구토에 의한 식도파열의 경우 대부분의 환자는 주증상으로 흉통이 아니라 복통을 호소한다.

11. 가임기여성이라면 반드시 마지막 월경 날짜를 물어보아야 한다.