Emergency Medicine:

Avoiding the Pitfalls and

Improving the Outcomes

yopi

Evaluation and Management of the

Patient with Abdominal Pain
Pathology on one side of the diaphragm can cause
symptoms
on the opposite side. The most crucial example of this
is acute coronary syndrome (ACS) masquerading as an
intra-abdominal process. It has long been recognized that a
large percentage of patients with ACS will present without
chest pain. Atypical presentations are more common in
women, diabetics, and elderly patients [3, 4]. Canto et al.
examined elderly patients presenting with unstable angina
and found that 45% had no chest pain; 8% of patients
presented with epigastric pain, 38% with nausea, and 11%
with vomiting [5]. A

it is well-reported in the literature that some

intra-abdominal conditions can mimic myocardial
infarction,
most notably pancreatitis, but also acute cholecystitis
(AC).
The literature is replete with cases of acute pancreatitis
(AP)
in which an electrocardiogram shows changes of
myocardial
ischemia, including ST-segment elevation [69]. In several
of these cases, the patients have been mistakenly
administered thrombolytics [10, 11].

Thrombolytic therapy should be

withheld if there is any concern that
the patients symptoms may actually
represent
pancreatitis, peptic ulcer disease
(PUD), or aortic dissection

Acute mesenteric ischemia

The incidence of mesenteric ischemia
is low, approximately 1 in 1000
hospital admissions; however, it
accounts for 1 out
of every 100 admissions for abdominal
pain [12].

Table 3.1 Risk factors for mesenteric ischemia.

Type of mesenteric ischemia Risk factors Special notes
SMA embolus Cardiac disease One-third have a history of a previous
embolic event
Atrial fibrillation or other arrhythmia
Valvular disease
Ventricular aneurysm
Cardiomyopathy
SMA thrombosis Vascular disease risks Acute event may be preceded
by period of
Hypertension intestinal angina and prolonged period of
Hypercholesterolemia significant weight loss
Diabetes mellitus
Smoking
Mesenteric venous thrombosis Hypercoaguable state One-half have
personal or family history of DVT/PE
Inherited (factor V Leiden Subacute presentation
mutation, etc.) Women men
Acquired (malignancy, oral contraceptives, etc.)

NOMI Low-flow states Often ICU patients

Sepsis
Heart failure
Volume depletion
Hemodialysis
Drugs
Digitalis
Ergot derivatives
Cocaine
Norepinephrine
Post-surgery
(DVT: deep venous thrombosis; PE: pulmonary embolus; NOMI:
non-occlusive mesenteric ischemia; ICU: intensive care unit)

Key fact
Mortality from mesenteric
ischemia is
nearly 80% With immediate
angiography, the mortality rate
could be reduced to 54%.

Dr. Alfredo Alvarado established a practical score known as

MANTRELS to assist with the early diagnosis of appendicitis
(see Table 3.2). The score is based on typical signs, symptoms,
and laboratory values often seen in acute appendicitis,
namely:
Migration of pain, Anorexia (or ketonuria), Nausea and
vomiting,
Tenderness in the right lower quadrant, Rebound tenderness,
Elevated temperature (100.4F, 38C), Leukocytosis
(white blood cell (WBC) count 10,400 cells/ml), and Shift to
the left (75% neutrophils).
A point is assigned to each, with right lower quadrant
tenderness and leukocytosis receiving 2 points, for a total of
10 possible points. A score of 5 or 6 indicates possible
appendicitis, 7 or 8 probable appendicitis, and 9
or 10 is very probable appendicitis [36].

This scoring system

has been found to be useful as a diagnostic tool
in assisting clinicians.
Depending on the practice setting, especially when
abdominal CT is not readily available for diagnostic
purposes,
the score can be used to risk stratify patients for
discharge with early follow-up, observation, or
emergent consultation., the findings that
encompass it are thought to be highly
representative of appendicitis

Key fact
Only 20% of elderly patients will
have the
classic findings of fever, anorexia,
right lower quadrant pain, and
leukocytosis

Symptoms

Migration
Anorexia

1
Signs

Nausea/vomiting
Tenderness in right lower quadrant
Rebound
1

Elevated temperature (100.4F, 38.0C)

Leukocytosis (WBC 10,400 cells/ml) 2

Shift to the left

(75% neutrophils on differential)
Total 10
Score: 56: possible appendicitis; 78: probable
appendicitis; 910: very probable appendicitis.

Peptic ulcer disease

Painless ulcers were found in 35% of patients
older than 60 years with endoscopically
proven PUD, compared with only 8% in those
below the age of 60 years [44]. One-half of all
ulcers in the geriatric population will have a
complication as their presenting symptom
[45]. Complications include hemorrhage,
obstruction, or perforation/penetration.

Emphysematous
cholecystitis !
DD/ acute mesenteric ischaemia

Emphysematous cholecystitis is an infection of the

gallbladder
wall by gas-forming organisms. The incidence rises
with age, and it is associated with diabetes and peripheral
vascular disease. It is the only biliary tract disease that is
more common in men. Patients are typically toxic appearing.
Diagnosis is made by visualizing air in the wall of the
gallbladder on plain radiographs or CT (see Figure 3.4), or
by the demonstration of effervescent bile on ultrasound.
Surgery is the mainstay of therapy.

KEY FACT
One-half of elderly patients with
AC will be
afebrile leukocytosis is absent
in one-third and liver function
tests are all normal in a significant
percentage !

Ascending cholangitis is seen more commonly in elderly

patients, presumably due to the increased incidence of
choledocholithiasis. Elderly patients often present in septic
shock, with no prodrome of biliary colic-type symptoms.
While conservative therapy with broad-spectrum antibiotics
induces a response in 7080% of cases, severely ill patients
require emergent decompression. This may be open,
percutaneous or via endoscopic retrograde
cholangiopancreatography (ERCP).
Gallbladder empyema is a complication of AC where the
gallbladder fills with pus due to complete obstruction. It also
is more common in the elderly, and carries a mortality rate
of 25% [53]. In addition to antibiotics, urgent surgical
decompression is required.

KEY FACT
One-third of all cases of
pancreatitis occur
in the elderly with mortality
rates approaching 40%.

AP is an inflammatory process where the pancreatic enzymes

autodigest the gland. It ranges from a disease of mild severity
to a life-threatening entity with hemorrhage or frank necrosis
of the organ. It remains the most common non-surgical
abdominal condition in the elderly population. The incidence
of AP increases 200-fold among those aged 65 years and
older [54]. One-third of all cases of pancreatitis occur in the
elderly, and they tend to have a more severe course with
mortality rates approaching 40% [55].
The clinical presentation in the elderly is quite varied. It
may demonstrate the classic boring epigastric pain radiating
to the back, or it may exhibit a hypermetabolic state
resembling
systemic inflammatory response syndrome. Unfortunately, in
10% of case of AP in the elderly, it merely presents with
altered mental status and shock [45].

The risk of necrotizing pancreatitis is higher,

especially as the patients age approaches 80 years
[56]. These patients are at high risk for rapid
deterioration.
As such, a low threshold for CT scanning in the
elderly
should be maintained, particularly if there are signs
of impending sepsis. If CT scanning shows
necrotizing pancreatitis and bacterial infection is
established (usually through percutaneous
aspiration), surgical intervention has been shown to
be beneficial [57].

Pearls for Improving Patient

Outcomes
Always consider myocardial infarction as a cause of
abdominal pain, especially in patients with traditional cardiac
risk factors.
Maintain a high index of suspicion for mesenteric ischemia
in elderly patients and pursue early diagnostic imaging
based on clinical suspicion alone.
Do not assume that visualization of an IUP on ultrasound
definitively rules out ectopic pregnancy in women
undergoing
ART. These patients are at high risk for heterotopic
pregnancy.

- The MANTRELS scoring system is useful in selected patient

populations, especially at both ends of the scoring spectrum.
It should be used with caution (if at all) in elderly patients
and
women. Low MANTRELS scores in elderly patients should not
preclude imaging with CT scan. High MANTRELS scores in
women (especially of child-bearing age) should not
reflexively
trigger surgery, as they may still have other pelvic pathology
not requiring operative treatment.
Elderly patients often present with atypical signs and
symptoms of common disease entities. A broad diagnostic
net should be cast in these cases, and a period of
observation with early follow-up should be routine, even if
the patient appears well.

Pitfalls Tambahan !
Tidak adanya urine pada pasien
khususnya TRAUMA atau insiden
AKUT umumnya BUKAN GANGGUAN
GINJAL AKUT !...justru tanda SYOK !!!
Tidak adanya URINE mewajibkan
untuk loading cairan 2000 cc ( pd
dewasa BB 50 kg atau lebih ATAU
hingga URINE keluar )

 Pada kasus PERITONITIS dan ILEUS

OBSTRUKTIF biasanya disertai
dehidrasi berat atau SYOK ! Sehingga
wajib segera di pasang 2 IV line dan
di loading segera DENGAN
monitoring rehidrasi via KATETER
URIN

 Hilangnya cairan tubuh karena

perdarahan akut, akan menyebabkan
asidosis metabolik yang akan terlihat
pada pemeriksaan laboratorik DAN
TIDAK BOLEH DI TERAPI DENGAN
BICNAT !!! Satu 2x nya obat adalah
segera REHIDRASI ( loading )

 Penggunaan ANALGETIKA di
waspadai ! Karena hilangnya RASA
SAKIT tidak lantas menghilangkan
proses patologik yang sedang
terjadi ! Malah sering mengkaburkan
GEJALA dan mendorong pasien untuk
discharge

 Tidak semua defense muscular

ADALAH peritonitis yg membutuhkan
SURGICAL....
INGAT ! Peritonitis TBC dan Peritonitis
primer