Abdominal Pain
Melissa Kerg MD Howard Werman MDAbdominal Pain
· Can be a challenge to diagnose
· Personal biases
· Presumptive diagnosis hastily made
· Inefficient use of time and tests · Delay in making actual diagnosis
· 10% of all undifferentiated patients
presenting to ED have abdominal pain as a major complaint
· missed appendicitis and missed
abdominal aortic aneurysm are among the leading causes of malpractice actions
Abdominal Pain
· Pain
· Subjective
· No objective measures of pain
· Vital signs without sensitivity or specificity
· Pain Scales
· Ask the patient
Treat the Pain
· Goal is pain control not pain relief, there is a difference!
· Patients are very receptive to being told that we want to lessen the pain and make it tolerable but that its not realistic to remove it completely.
Abdominal Pain
· It can be anything from the nipples to the pelvis
· Abdominal pain may not be associated with disease processes in the abdomen
· At least 5-10% of ED visits
· Up to 50% remain undiagnosed at discharge
· 5-10% of these have significant disease
· Small % of admitted patients are misdiagnosed
· Delays treatment
· Added morbidity and mortality
Goals
· to identify any immediate
life-threatening causes of abdominal pain
· 15-30% of patients require immediate surgery
· to make an educated guess as to underlying medical condition
· most common dx: nonspecific abdominal pain (40-60% patients)
General Approach
· Rule out surgical pathology
· Look for non-surgical causes
· Referred pain · Systemic illness
· Gut feelings are important and develop over a career
Causes of Abdominal Pain
within the Chest
· Angina/MI
· Pleuritic irritation
· Great vessels
· Stomach
Gastritis, PUD, gastroenteritis
· Intestines
· Appendicitis, SBO, diverticulitis, incarcerated hernia, ischemic gut, IBD
· Pancreas
· Pancreatitis, pseudocyst
· Liver
· Acute hepatitis, biliary tract disease
· Vessels
· AAA, Renal/splenic aneurysm
· Spleen: Splenic rupture
· Ureters
· Colic, stones, UTI
· Uterus
· PID, fibroids
· Ovaries and fallopian tubes · (ruptured) ectopic, ovarian
cyst, Mittelschmerz, torsion
· Prostate · Prostatitis
· Testicles and associated structures · Torsion, hydrocele,
Retroperitoneal
· Kidneys · Pyelonephritis, infarction · Great Vessels · AAA · Muscles (psoas)Miscellaneous
· Abdominal Wall · Shingles · Hernias · Spontaneous Bacterial Peritonitis · Acute Intermitent Porphyria· Strep Throat (think pediatrics)
· Diabetes (DKA)
· Acute narrow angle glaucoma
· Black Widow Spider Bite
History
· Many symptoms are neither sensitive or specific
· Few disease processes in abdomen have pathognomonic historical features
· Inadequate history most common feature of leading to a misdiagnosis
History
· In assessing the patient with abdominal pain, a careful history will lead to a reasonable diagnosis in more than 80% of cases
History
· Suggestive of a surgical cause??
· Sudden onset
· Lasting 1-2 days
· Subsequent peritoneal signs
· Anorexia
History
· location: major factor in developing a differential diagnosis
· character
· radiation
Location of the pain major factor in developing a differential diagnosis
History
History
·
O
onset·
P
palliation/provocation·
Q
quality·
R
radiation·
S
severity·
T
timeHow Fast Did It Start
· Sudden onset
· Perforated ulcer, mesenteric infarction, ruptured AAA,
ruptured ectopic pregnancy, ovarian torsion, ruptured ovarian cyst, PE, AMI, testicular torsion
· Rapid onset (minutes to hours to max)
· Strangulated hernia, volvulus, intussuception, acute
pancreatitis, biliary colic, diverticulitis, ureteral colic
How Fast Did It Start
· Gradual Onset
· Appendicitis, chronic pancreatitis, PUD, inflammatory bowel diseases, mesenteric adenititis, uti, urinary retention, salpingitis, prostatitis
· Where did it start?
· Migratory?
· Where is it at?
· What makes it worse or better?
· Movement, bumps, cough · Eating
· How soon after
· Position
· Associated symptoms
History
· PMH
· Have you ever had this before??
· SH
· Alcohol · Tobacco
Abdominal Pain
·
There are 2 types of abdominal
pain
Abdominal Pain
· Visceral
Foregut, midgut, hindgut
· Autonomic nerves
· Innervates involuntary muscles, heart and glands
· Poorly localized · Achy/colicky
· Somatic
· Typical pain and temperature fibers that innervate the skin · Irritation of the parietal
peritoneum or mesenteric root
· A 20 yo female OSU student presents with sharp RLQ abdominal pain. The patient reports that the pain began approximately 6 hours previously as a dull periumbilical pain which suddenly became localized 30 minutes ago. Can you explain?
Abdominal Pain
· Referred pain: pain felt at a site distant from the involved abdominal organ due to a shared cutaneous sensory nerve
Abdominal Pain
Vital Signs
· Vital signs· Orthostatics---when would they not be useful? · Fever
· When is it unreliable?
· Heart Rate
· Intra-peritoneal blood may be associated with a relative bradycardia (ectopics)
· General Appearance
· May the most useful
· HEENT
· Cardiac
· Pulmonary
· Abdominal
· Rectal
· What will cause black, but heme negative stools?
· GU
· Check for hernias, especially in the pediatric population
Physical Examination
· Observation
· “What do I see?” Look as you enter.
· Level of comfort · Position · Still vs active · Diaphoresis · Breathing pattern · Distention · Icterus
Physical Examination
· Auscultation-prior to palpation
· Bowel sounds
· Poor predictor of peritonitis
· People with peritonitis do have bowel sounds!!
· Listen for minutes-not practical in the ER
· rushes
· Bruits
Physical Examination
· Palpation· Masses, organomegaly
· If you don’t think to check for it you will not find it
· Tenderness
· Abdominal pain with coughing or heal strike more sensitive than palpation or Rovsing’s
· Hernia
· Ventral, inguinal, femoral, umbilical
· Rectal
· Pelvic
· Carnett’s Test
· Straight leg raise or have patient lift head and tightened abdominal muscles and palpate
· If the pain increases - abdominal wall
Rectal Examination
· Only useful to check guaiac or for local phenomena (perirectal abscess)
· Will not/can not help with the diagnosis of appendicitis/diverticulitis
Signs
· Carnett’s· Murphy’s
· 50% specific (less in elderly)
· Presence or absence should not preclude diagnosis
· Ultrasonic (radiographic) murphy’s sign
· Psoas
· Not specific but sensitive
· Obturators and Rovsing’s
· Not predictive of anything good or bad
What are we trying to
diagnosis?
· Bad stuff!! · Ruptured viscus’ · AAA · Ischemic bowel · Appendicitis · Gallbladder disease · Pancreatitis · Bowel obstruction · PID · Torsions· Could be the early presentation of more serious disease
· Usually nonspecific self limiting diseases
· Follow up is going to be important
Diagnostic Approach
· Prior to ordering any tests you should have a reasonably short differential to act on
· In a significant minority of patients with abdominal pain, no tests are needed other than a u/a (and pregnancy test in females)
The Tests
· What is needed?
· We over-utilize every test we can
· CBC, AAS, Amylase, LFT’s
· Pregnancy Tests may be under-utilized
But….
· Always consider an ECG on patients with upper abdominal pain or non-specific symptoms in their coronary years
· WBC
· Not sensitive, not specific, not predictive
· Can be misleading
· Amylase
· Not specific, > 3 times upper level of normal
· Lipase
· More specific and sensitive
· Rises as quickly as the amylase but stays elevated 2x longer
Blood
· LFT’s· Abnormal in only 50% of acute cholecytitis
· Just a ALT and urine bilirubin to screen for hepatitis
· Full battery if patient icteric
· Chem 7
· Why??? Only needed for protracted vomiting or dehydration. BUN/Creatinine is needed prior to IV contrast
· Lactate-late finding
Urinalysis
· Up to 33% of patients with appendicitis have blood or WBC’s in the urine
· 50% with ruptured appy have wbc’s
· 33-67% of AAA have blood in their urine
· Urine pregnancy
Radiology
· AAS
· No role in undifferentiated abd pain · Obstruction, perforation, or foreign body
· The patient needs to be upright for 10 minutes to
Radiology
· Ultrasound
· Not useful in undifferentiated abd pain
· Wonderful for directed exams
· Screening exam for most diagnoses by EP · Sensitive for AAA but not for dissection
· CT scan
Special Considerations
· Elderly
· Higher prevalence of disease
· Up to 40% require surgery · Majority have co-morbid illnesses · Longer delay to presentations (2X) · Less likely to have a fever
· Higher morbidity and mortality · Higher atypical cholecystitis incidence
Special Considerations
· Steroids· Blunt inflammatory response · No peritonitis possible
· Children
· Transfer to a higher level of care if you are not comfortable with children, especially the infants
· URI/OM 18.6% · Pharyngitis 16.6% · Viral Syndrome 16% · Abdominal Pain ? Etiology 15.6% · Gastroenteritis 10.9%
· Acute Febrile Illness 7.8% · Bronchitis/Asthma 2.6% · Pneumonia 2.3% · Constipation 2.0% · UTI 1.6% · Appendicitis 0.9%
Gastroenteritis
· Vomiting (Gastro) and diarrhea (enteritis)
· Frequently used as diagnosis
It’s not simple
· Frustrating to patient, family, staff and you at times
· Don’t forget repeat exams
· If ever in doubt, obtain second opinion
· CLEAR discharge instructions
· Problem could not be identified
· Repeat evaluation in 8 - 12 hours
· Precautions
Discharge Instructions
· write all discharge instructions in language
understandable to the patient · avoid medical abbreviations
· carefully describe any therapies prescribed
· 35 y/o female with upper abdominal pain
· Vitals: Temp 97.5, BP 122/70, HR 92, RR 18
· Hx: Pain, some nausea, no vomiting. Radiates to back
· PHx: S/P cesarean 6 weeks ago, known gallstones
· PE: RUQ tenderness, soft elsewhere
· Test? · Labs? · Medications?
Continued
· WBC 14.5, LFTs normal · Ultrasound shows:· Gallstones, gallbladder wall is not thick, no pericholic edema. Common bile duct is 1.5cm diameter
Case 2
· 79 y/o female from ECF with Abdominal pain
· Vitals: Temp 99.4, BP 110/66, HR 60, RR 20
· Hx: Little ostomy output today, urinated once today,
feels bloated
· PHx: Colon Ca 1999 s/p partial colectomy, SBO, UTI,
Mild dementia, Renal insufficiency, HTN
· PE: Diffuse tenderness, worse in the RLQ, mild
distention. Rectal: no stool. Thin liquid in ostomy bag
Case 2
· Labs?
· X-rays?
· Medications?
· WBC 19.9
· BUN 43, Creatinine 2.7 (baseline 1.6)
· AAS: Mildly dilated small bowel, possible ileus vs. PSBO
· What is the next step?
Case 2
· CT without IV contrast:
· Diverticulitis of the right colon
Case 3
· 82 y/o male with left side pain
· Vitals: Temp 98.5, BP 188/110, HR 105, RR 22
· Hx: Intermittent sharp pain, hurts to the back, no pain
now
· PHx: Mass in the abdomen, told to keep a watch on it
(this was 5 years ago), kidney stone >40ys ago, HTN, CAD
· PE: RRR, CTA, Abd soft, NT, pulsatile mass midline,
pulses equal
Case 3
· Differential Diagnosis? · Labs? · Medications? · X-rays?· WBC nl, Hgb 10.8
· PT/PTT nl
· UA: 1+ blood
· BUN and Creatinine of 30 and 3.0
· Diagnostic dilemma?
· Disposition?
Case 3
· Follow up: Pt was admitted with BP control.
· Surgical repair of 7cm AAA performed, however pt died of post-op complications.
Case 4
· 13 y/o girl arrives 6:30Am with RLQ pain
· Mom talks 99% fo the time
· Vitals: All normal
· Hx: Similar pains in the past, never lasting more than 1 hour at a time. This time non-stop since 8PM. Sharp pain, sudden onset. Now has N/V
· PHs: Menarche 11 y/o, never regular; never had a pelvic before.
· Soc: Never sexually active, Started OCPs 4 days ago by PMD to help regulate her cycle and stop the pains.
· PE: Flat abd, slender, keeps knees and hips flexed. Severely tender in RLQ and suprapubic areas (pelvic deferred until pain meds)
Case 4
· Differential Diagnosis?
· Labs?
· Medications?
· After pain meds and
anti-emetics…pelvic reveals pain and fullness of the right adnexa
· Pregnancy test is negative, WBC 17
· Differential diagnosis further narrowed?
Case 4
Ultrasound: right ovarian torsion
· Pt went to surgery and the ovary was saved · Pt had numerous cysts
Case 5
· 44 y/o male complains of abd pain
· Vitals: Temp 99.2, BP 90/66, HR 120, RR 28
· Hx: Sharp, constant pain epigastic area, some N/V
· PHx: Similar pain in the past, never this intense, told of
elevated BR in the past
· Soc: Drinks significant ETOH whenever possible,
homeless
· PE: Dry mouth, tachy, CTA, scaphoid abdomen, tender
in the epigastric area
Case 5
· Differential diagnosis?
· Labs?
· Meds?
· Rectal: little stool, heme positive
· AAS: no free air
· WBC 14, Hgb 9
· Lipase 120
· LFTs: AST and Alk Phos are elevated
· Why are these elevated?
· NG: positive for dark blood….>200cc
· Management?
Summary/Conclusions
· abdominal pain is a common presenting complaint
· goal is to identify immediately
life-threatening (surgical) problems and make an educated guess as to other causes
· identify the ‘toxic’ patient
· the history is most important is establishing the diagnosis