Among surgical patients presenting to the ED, abdominal pain is the most common complaint, comprising 10% of ED visits. Evaluation of such patients in the ED is often challenging for a variety of reasons, such as the variability in the description of the perception of pain in individual patients, variable and changing physical findings with time, and life-threatening conditions presenting as seemingly benign symptoms. I always advise inexperienced doctors working in the ED to bear in mind seven time bombs that may be ‘sitting inside’ every adult patient’s abdomen who presents with abdominal pain. Patients who are discharged, but in whom one of these diagnoses was missed, will be blue-lighted back to the department dead. Therefore, before discharging a patient presenting with acute abdomen pain, all such conditions as listed below must be excluded beyond reasonable doubt. These conditions are: • Ruptured AAA • Hollow viscus perforation • Mesenteric ischaemia • Ruptured ectopic pregnancy • Acute pancreatitis • Intestinal obstruction • Acute myocardial infarction. Acute (inferior) myocardial infarction may present as upper abdominal pain and cannot afford to be missed. Patients >50 years presenting with abdominal pain must have an ECG in the ED, not only for detecting acute myocardial infarction, but for other associated cardiac problems precipitating an abdominal catastrophe. Elderly patients are more likely to have life-threatening conditions such as a ruptured AAA, mesenteric ischaemia, peptic perforation, and diverticulitis. Atypical presentations and rapid progression of these diseases, coupled with decreased diagnostic accuracy, may increase the risk of mortality in elderly patients. The only way to avoid the above is, as importantly as in other parts of medicine, by taking an accurate history, performing a thorough full clinical examination, arranging appropriate investigations rapidly, and making the correct decisions as to whether or not urgent surgery is required. Even with advanced imaging techniques, a good understanding of background clinical information is of utmost importance for accurate interpretation of imaging findings. This chapter includes questions on acute abdominal emergencies to give the reader an insight into the latest management strategies for these situations.
A Series of Unfortunate Events: Prinzmetal Angina Culminating in Transmural Infarction in the Setting of Acute Gastrointestinal Hemorrhage
