Systematic Approach to Abdominal PainDr Devinder Singh Bansi BM DM FRCP

Consultant GastroenterologistImperial College Healthcare NHS Trust

What Do They Have?As you go through this presentation, think about each of these cases:An 18 mo old that suddenly became inconsoleable from AP while playingA 20 yo man with 12 hours of diffuse crampy AP that migrated to RLQ that became sharp78 yo woman with h/o chronic steroid use with sudden sharp AP and a rigid exam

Scale of the ProblemGI symptoms in primary care7.1-9.6% of all primary consultations are with regard to GI complaints

Gastric pain: 5.0per 1000/yrRegurgitation:2.0Abdominal pain:6.1Nausea:2.9Diarrhoea:6.7Constipation:8.1

Thompson WG, Gut 2000: 46: 78-82

Scale of the Problem:Abdominal pain in the general populationCommunity prevalence 15-20%75% of these abdominal complaints non-consulting25% consulting23.5% stay in primary care1-2% referred to secondary care

Scale of the Problem:Abdominal pain in general practice578 cases of non-acute abdominal pain presenting to 11 general practicesFollow up 15 monthsFemales predominated in the younger age groups80% visited GP

Scale of the Problem:Prevalence of GI diseasePeptic ulcer:1.9 per 1000/yrOesophagitis:2.9IBD:1.5GI cancer:1.6

Functional dyspepsia:12GORD:5.8 IBS:10.5

80% of chronic GI disease has a functional background

Thompson WG . Gut 2000: 46: 78-82

Scale of the problem;Acute abdominal painAcute abdominal pain is not uncommon.Approximately 5 admissions to the MRI/day with acute abdominal pain from a population base of 500,000. 1 case per GP per month for an average list size of 2,000.

Acute Abdominal PainApproximately 6% of ED visitsAdmission rates vary by population, up to about 65% in high risk elderly populationsMost common diagnosis is NONSPECIFIC (ie, I dunno)Use H+P, risk factors, and directed studies to arrive at diagnosisMUST rule out emergency conditions

Acute Abdominal PainCauses in 10320 patientsAppendicitis28%Cholecystitis10%Small bowel obstruction4%Gynaecological4%Pancreatitis3%Renal colic 3%Peptic ulcer2%Cancer2%No clinical diagnosis34%

De Dombal, Scand J Gastroenterol 1988

Abdominal Pain Across the AgesAges 0-2Colic, GE, viral illness, constipationAges 2-12Functional, appendicitis, GE, toxinsTeens to adultsAddition of genitourinary problemsElderlyBeware of what seems like everything!

Special PopulationsElderly/ nursing home patients

Immunocompromised

Post operative patients

Infants

Abdominal Pain in the ElderlyDiminished sensation of pain in the elderly Comorbid diseasesPolypharmacyCombinations of above result in many more vague, nonspecific presentationsTwice as likely to require surgery with presentation over age 65Social factors

Understanding the Types of Abdominal Pain VisceralStretch fibers in capsules or walls of hollow viscus that enter both sides of spinal cordSomaticFibers dermatomally distributed and enter unilaterally in the spinal cordReferredOverlap of fibers from other locations

Understanding the Types of Abdominal PainVisceralCrampy, achy, diffuse, Poorly localizedSomaticSharp, lancinatingWell localizedReferredDistant from site of generationSymptoms, but no signs

Understanding the Types of Abdominal PainLocation, location, locationOrgans and their corresponding fiber entry to the spinal cordC3-5 liver, spleen, diaphragmT5-9 gallbladder, stomach, pancreas, small intestine T10-11 colon, appendix, pelvic viscerat11-l1 sigmoid, renal capsules, ureters, gonadsS2-4 - bladder

History Taking in Abdominal Pain PresentationsOLD CARS

O- onsetL- locationD- durationC- characterA-alleviating/aggravating factors associated symptomsR- radiationS- severity

History Taking for Abdominal Pain PresentationsPMHSimilar episodes in pastOther medical problems that increase disease likelihood of problems (ex: DM and gastroparesis)PSHAdhesions, hernias, tumorsMEDSAbx, NSAIDS, acid blockers, etcGYN/UROLMP, bleeding, dischargeSocialTob/EtoH/drugs/home situation/agenda

Physical Exam in Abdominal Pain PresentationsGeneral appearanceSick versus not sickMobile versus stillObvious pain or discomfortDoorway impressionVital signsThats why theyre called vital

Physical Exam in Abdominal Pain PresentationsInspectionDistention, scars, bruisesAuscultationPresent, hyper, or absentActually not that helpful!PalpationOften the most helpful part of examTenderness versus painStart away from painful area firstGuarding, rebound, masses

Physical Exam in Abdominal Pain PresentationsSignsIliopsoasMurphysExtra-abdominal examPelvic or scrotal examsLungs, heartRemember its a patient, not a partRectalAdds very little (despite the angst) beyond gross blood or melena

Laboratory Testing Everybody likes a CBC, but

Lacks sensitivity, no specificityLittle to no change in diagnostic probabilitiesShould not dramatically alter approach (tender is still tender)

Laboratory TestingDirected approach to lab studiesThere are no standard belly labsPregnancy test in women of child bearing ageUrine dipsticks

ImagingPlain filmsFree air, obstruction, air-fluid, FBsUltrasoundRapid yes or no ED evaluationsFormal studiesMay add dopplerComputed TomographyRevolutionized acute careOften better than we are!

Common Diagnoses by Quadrant

Management of Abdominal PainAlways right to start with ABCsIV accessFluid administrationAntiemeticsAnalgesicsDirected testing and imagingRe-evaluationsAntibioticsConsultantsSurgeons, OB/GYN, urologists, cardiologists, etc

Now How About Those Cases18 mo old had classic presentation of intussusception, and symptoms may wax and wane; rectal would be to look for current jelly stool. Air enema for diagnosis and reduction. Involve consultants early in the course.

Now How About Those Cases20 year old with classic presentation of appendicitis, which likely does not need CT scan. Most do not present so simply, quite a wide array of presentations. General surgery consultation, pain meds, IVF, and an operation would all be good, but dont be shocked if CT requested.

Now How About Those Cases78 yo has perforated abdomen, with age, multiple problems, and chronic steroids risks for perforation. Rapid resuscitation, plain films to confirm free air, antibiotics, pain medicine, and a surgeon as fast as you can would be good practice.

Pearls, Pitfalls and MythsDo not restrict the diagnosis solely by the location of the pain.Consider appendicitis in all patients with abdominal pain and an appendix, especially in patients with the presumed diagnosis of gastroenteritis, PID or UTI.Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain.The WBC count is of little clinical value in the patient with possible appendicitis.Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative.Pain medications reduce pain and suffering without compromising diagnostic accuracy.

An elderly patient with abdominal pain has a high likelihood of surgical disease.Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain.A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis; they need an operation.The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA.

Simplified rules for the diagnosis of acute abdominal pain.Think in terms of the area of the pain.Common conditions are common.Disease prevalence changes with age.Different patterns of disease between men and women.

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