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Abdominal pain (급경련복통)

The Root of Ambulatory Care (외래 진료 지침서) 전체 목록 보기
KEYWORDS: ..복통은 가정의학 외래에서 가장 흔히 접하는 증상 중의 하나이다. 전체 내원환자의 5-6%를 차지한다. Common cause of abdominal Pain - Adult - 1. Gastritis, duodenitis 2. Peptic ulcer 3. Gastroenteritis (Infectious, noninfectious) 4. FGID 5. Appendicitis 6. Stone (Urolithiasis, chole(docho)lithiasis) ..Epigastric discomfort는 대부분 FGID로 인해 생기며, 그 다음이 소화성궤양에 의해 생긴다. Common cause of abdominal Pain - Child - 1. Infectious diarrhea 2. Recurrent abdominal pain : may be over 90% 3. Constipation 4. Intussusception 5. Mesenteric lymphadenitis ..사실 복통을 일으킬 수 있는 장기는 다양하며, 복강 외 장기인 심장, 폐, 늑막, 근골격계, 비뇨생식기 등에 의해서도 유발될 수도 있다. Abdominpaal in Key Questions ..1차의료인은 복통환자를 볼때 두 가지 중요한 결정을 해야한다. ① 외래에서 경과를 보며 통원치료해도 될 지, 아니면 응급수술이나 입원을 요하는 중증질환인지 여부 ② 복통을 경감시키기 위해 진통제를 투여해도 좋은 지, 투여한다면 어떻게 해야 효과적인지 여부 < The Alvarado scoring system for likelihood of acute appendicitis > Features Score Migratory right iliac fossa pain 1 Nausea/vomiting 1 Anorexia 1 Right iliac fossa tenderness 2 Fever > 37.3℃ 1 Rebound tenderness in right iliac fossa 1 Leukocytosis > 10,000/mm3 2 Neutrophilic shift to the left > 75% 1 Total score 10 ▶ Score < 4 : no appendicitis ▶ Score 5~6 : compatible with acute appendicitis ▶ Score 7~8 : probable acute appendicitis ▶ Score 9~10 : very probable acute appendicitis 1. General questions Location of pain : Epigastric dull diffuse pain (e.g., gastritis, duodenitis, peptic ulcer, gastroenteritis, early appendicitis etc) RUQ/RLQ/LUQ/LLQ : localization caused by peritoneal irritation (e.g., acute cholecystitis/acute appendicitis/spleen rupture/colonic diverticulitis) Onset type : Acute onset 125 The Root of ambulatory care Key tests Abdominapla in (e.g., peptic ulcer perforation, ectopic pregnancy, cholelithiasis, urolithiasis etc) Chronic onset (e.g., inflammation condition, intestinal obstruction etc) Frequency of pain : Intermittent (e.g., acute gastritis, gastroenteritis, intestinal obstruction, cholelithiasis, urolithiasis, intussusception, fecal impaction etc) 2. Medical history Medical : cardiovascular disease, gastrointestinal disorders Surgical : abdominal surgery, pelvic surgery 3. Social history : tobacco/alcohol/substance abuse and sexual history ▶ 복통이 점차 심해지는 경우, 구토나 설사 후에도 복통이 경감되지 않는 경우, 복통으로 인해 잠에서 깨어 한밤중에 응급실로 내원한 경우 등에선 위중한 질환일 가능성이 있으 므로 주의를 요한다. ..Radiation pain of acute MI, pleurisy can be recongnized at upper abdomen. ..복통이 지속적이며 계속 차도가 없거나 오히려 심해진다면 위중한 질환일 가능성이 많아 상급의료기관으로 의뢰하는 것이 좋으나, 간헐적이고 경련성 인 경우는 Abdominal X ray에서 장폐색이나 장천공을 배제하면 대부분 위중 하지 않으므로 외래 통원치료가 가능하다. 1. Abdominal X ray - F&U Chest PA : Chest X ray is useful to visualize pneumoperitoneum and cardiopulmonary pathology. 2. Urinalysis 3. CBC & Blood chemistry : Leukocytosis (WBC > 12,000) seen in appendicitis (sensitivity 91%, specificity 21%), cholecystitis (sensitivity 78%, specificity 11%), diverticulitis, and bowel ischemia. Hypocalcemia and elevations in serum amylase (sensitivity 74%, specificity 50%) and lipase may be seen in pancreatitis. 4. Urine HCG test : Any woman of childbearing age 5. Abdominal sonography : detects gallstones (sensitivity 85~90%), sludge, gallbladder wall thickening ( > 5mm is diagnostic), pericholecystic fluid (in cholecystitis), and intrahepatic or extrahepatic bile duct dilatation, associated with biliary obstruction. Ultrasound can also identify pancreatitis, pseudocysts and tumors, ascites, chronic liver disease (e.g., fatty liver or cirrhosis), gynecologic abnormalities, renal or adrenal pathologic findings, and acute appendicitis (sensitivity 85~90%, specificity 92~96%). 6. Endoscopy, Colon study 7. CT : most sensitive study in evaluating patients with acute abdominal pain, particularly obese patients. ..Recent studies show that pain medication(anti-cholinergics) is helpful in patients with acute abdominal pain and dose not hinder the diagnostic process. 참고 문헌 William Y. Huang : Abdominal Pain, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia,Saunders, 2000, P 390-392 박기흠 : 복통, in 가정의학 임상편. 서울, 계측문화사, 2002, P 871-876 Kalyanakrishnan Ramakrishnan, M.D. : Abdominal Pain, in A Lange clinical manual Family Medicine Ambulatory Care & Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D. (ed). United States of America, The McGrwa-Hill Companies, Inc., 2005, P 1-9 Dan L. Longo, M.D. : Abdominal Pain, in Harrison's Manual of Medicine, 16th ed, Dennis L. Kasper, M.D., M.A., Eugene Braunwald, M.D., M.A., M.D., ScD., Anthony S. Fauci, M.D., ScD., Stephen L. Hauser, M.D., Dan L. Longo, M.D., J. Larry Jameson, M.D., PhD. (ed). United States of America, The McGrwa- Hill Companies, Inc., 2005, P 136-139 127 The Root of ambulatory care