Abdominal Pain. Abdominal Pain

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Abdominal Pain

Melissa Kerg MD Howard Werman MD

Abdominal Pain

· Can be a challenge to diagnose

· Personal biases

· Presumptive diagnosis hastily made

· Inefficient use of time and tests · Delay in making actual diagnosis

(2)

· 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

(3)

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

(4)

· 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)

(5)

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

(6)

· 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)

(7)

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

(8)

· 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

(9)

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

(10)

Location of the pain major factor in developing a differential diagnosis

(11)

History

(12)

History

·

O

onset

·

P

palliation/provocation

·

Q

quality

·

R

radiation

·

S

severity

·

T

time

(13)

How 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

(14)

· 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

(15)

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

(16)

· 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

(17)

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)

(18)

· 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

(19)

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

(20)

· 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

(21)

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

(22)

· 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)

(23)

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

(24)

· 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

(25)

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

(26)
(27)

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

(28)

· CT scan

(29)

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

(30)

· 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

(31)

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

(32)

· 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

(33)

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?

(34)

· 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

(35)

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?

(36)

· 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.

(37)

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?

(38)

· 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

(39)

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?

(40)

· 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

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