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Abdominal Pain

Melissa Kerg MDHoward 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

· Mortality doubles with incorrect diagnosis

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Introduction

· 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· Useful to tract progress of treatment

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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

· Abdominal pain may be associated with disease processes not in the abdomen

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Abdominal Pain

· 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)

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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 Painwithin the Chest

· Angina/MI· Pleuritic irritation· Great vessels

· Aortic dissection· Aortic aneurysm

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Causes of Abdominal Pain Abdomen/Pelvic Organs

· 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)

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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

· The “typical appendicitis” occurs in only 33% of cases

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But with that being said….

· 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

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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· onset/chronology· aggrevating/alleviating factors· associated symptoms: anorexia,

nausea, vomiting, bowel changes, urinary sx, vaginal sx

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History

Location of the pain major factor in developing a differential diagnosis

History

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History

History

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History

History

· O onset

· P palliation/provocation

· Q quality

· R radiation

· S severity

· T time

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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

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History

· 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· Recreational drugs

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Abdominal Pain

· There are 2 types of abdominal pain

Abdominal Pain

· VisceralForegut, midgut, hindgut

· Autonomic nerves· Innervates involuntary

muscles, heart and glands

· Poorly localized· Achy/colicky· Intermittent· Felt in the abdominal

wall in the area of embryonic origin of the pain

· Somatic· Typical pain and

temperature fibers that innervate the skin

· Irritation of the parietal peritoneum or mesenteric root

· Intense and well localized· Sharp· Felt directly over area of

inflammation

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Abdominal Pain

· 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 periumbilicalpain 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

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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)

· Medications· Respiratory Rate· Vital signs do not correlate well with patients level

of pain

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Physical Examination

· 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

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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

· Guarding· Voluntary· Involuntary

· Unilateral always involuntary· 25% of patients with rebound tenderness do not have surgical

pathology

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Physical Examination

· 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

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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· Strangulated hernia· Ectopic pregnancy

· Need to go to OR!

· Gallbladder disease· Pancreatitis· Bowel obstruction· PID· Torsions

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The Rest

· 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)

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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

· Consider a Chest x-ray on young children

· Consider glucose testing (DKA)

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Blood

· 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· Type and screen vs type and cross

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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 increase sensitivity

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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

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Radiology

· CT scan· Know what you are looking for

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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· Intussusception

· Typical: male, 5-10 months old, involves ileocecal valve

· Colicy pain, bloody stool or mucus within several hours

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The Most Common Causes of Children Presenting with Acute

Abdominal Pain· 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· Appendicitis malpractice issue

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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· identify clear follow-up for each patient· list the signs and symptoms for which the

patient should immediately return for evaluation

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Cases

· 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

· Disposition of patient?

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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?· Differential diagnosis?

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Case 2

· 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

· Disposition?

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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?

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Case 3

· 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.

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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?· X-rays?

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Case 4

· 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

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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?· X-rays?

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Case 5

· 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· give clear discharge instructions