Emergency medicine clinics of North America
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Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. ⋯ Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.
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Vascular emergencies are an uncommon but significant cause of abdominal pain, back pain, hemorrhagic shock, and death in adults. This article reviews abdominal vascular anatomy, risk factors, signs and symptoms, abdominal vascular thrombosis, mesenteric ischemia and infarction, and abdominal vascular emboli and aneurysms.
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The infant or child that presents with abdominal pain must be evaluated with a careful history, physical examination, and selective laboratory studies. There are a few diagnoses that the emergency physician should always consider as "life threatening." In the event of any uncertainty in the diagnosis of conditions like appendicitis, pyloric stenosis, or intussusception, the child or infant should be observed carefully over time with appropriate laboratory/radiologic studies ordered to further delineate pathology. Ultrasound evaluation of children with abdominal pain continues to be one of the most valuable tools to help diagnose different conditions.
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Common and uncommon GI and other intraperitoneal illnesses may present in unusual ways. In addition, many systemic or extraperitoneal disease processes frequently include abdominal pain as a clinical manifestation. ⋯ After initial resuscitation and stabilization have taken place, early evaluation of the need for urgent surgical evaluation and operative management is crucial in the patient with abdominal pain, even when the cause of the symptoms is unclear. A thorough history and careful and complete abdominal and nonabdominal physical examination, paired with appropriate but judicious diagnostic testing, are essential to detecting these unusual causes of abdominal pain and to preventing needless morbidity and mortality.
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Evaluation of the older patient presents a unique challenge to the emergency physician. The increased age of the population, a high incidence of comorbidity, general poverty of history and clinical signs in acute abdominal conditions, poor reliability of diagnostic procedures, and the variable presentations of diseases with significant morbidity and mortality summarize the problems to be encountered with the complaint of abdominal pain in the elderly. The correct diagnosis is often difficult to establish and coexisting complicating diseases influence the patient's condition and the ED management. The emergency physician must maintain a wide differential and have a low threshold for admission and more extensive evaluation in this patient population.