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Ix & Mx Abdominal pain

Ix & Mx
Abdominal pain
General Investigations
• Blood tests: FBC, electrolytes, renal profile, clotting studies, group
and cross match, blood glucose level, LFTs, lipase
• Urinalysis
• Urine pregnancy test
Imaging tests to consider
• FAST scan
• Abdominal Ultrasound
• Abdominal X-ray
• CT Abdomen
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?
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
• 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
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
• 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
• 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
• If severe add Vancomycin to cover for Enterococcus
• Referral to surgical department for ERCP, ideally performed within 2448hrs
Thank you
• 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