Ix & Mx Abdominal pain sjr1 General Investigations • Blood tests: FBC, electrolytes, renal profile, clotting studies, group and cross match, blood glucose level, LFTs, lipase • Urinalysis • Urine pregnancy test • ECG Imaging tests to consider • FAST scan • Abdominal Ultrasound • Abdominal X-ray • CT Abdomen Resuscitation 1. 2. 3. 4. Cardiac monitoring Oxygen (2 to 4 L/min via nasal cannula or mask) Large-bore IV access + isotonic fluid bolus adjusted for age Blood samples drawn at IV insertion Order cross-matched blood if hemorrhage is suspected or if urgent transfusion anticipated 5. Perform bedside US to identify abdominal aortic aneurysm and perform FAST if intra-abdominal hemorrhage is suspected What about our patient? Clinically Charcot’s Triad • Right Upper Quadrant Pain • Fever • Jaundice Reynold’s Pentad • Right Upper Quadrant Pain • Fever • Jaundice • Shock • Altered Mental Status So why test any further? • Charcot’s classic triad carries a specificity of 85%, but has a sensitivity of only approximately 25%. • Reynold’s pentad is seen in only 5%–7% of cases, but typically represent more severe disease when present What do we test for? Whatever causes cholangitis • Gallstones are estimated to be responsible for approximately 65% of cholangitis cases • 24% as a result of malignant stenosis • 4% caused by benign stenosis • 3% a result of sclerosing cholangitis • 1% caused by other or unknown factors Lab investigations • As previously mentioned • Add on blood cultures may not confirm dx but will assist with antibiotic choice Imaging Ultrasound • Transabdominal US is approximately 25%–60% sensitive for the detection of common bile duct stones • US can identify dilated intrahepatic ducts, as well as a dilated common bile duct to indicate common bile duct stone or other distal obstruction Computed tomography (CT) • Is the initial imaging study of choice to confirm biliary obstruction and identify its source. • Can identify dilated intrahepatic and common bile ducts and may also identify a nearby mass causing external compression on the biliary structures • Multidetector CT with i.v. contrast demonstrates a sensitivity of 85%– 97% and specificity of 88%–96% in the identification of common bile duct stones Treatment • Fluid resus as previously mentioned • IV antibiotics carbapenem, fluoroquinolone, penicillin with beta-lactamase inhibitor, or fourth-generation cephalosporin • Metronidazole should be added when an anaerobic organism is suspected • If severe add Vancomycin to cover for Enterococcus • Referral to surgical department for ERCP, ideally performed within 2448hrs Thank you References: • Tintinalli's Emergency Medicine: A Comprehensive Study Guide • https://www.jem-journal.com/article/S0736-4679(17)30615-7/pdf • All images belong to the author of “The Awkward Yeti” Nick Seluk
