Acute Abdominal Pain

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Acute Abdominal PainUNC Emergency MedicineMedical Student Lecture SeriesCase #124 yo healthy M with one day hx of abdominal pain. Pain was generalized at first, now worse…
Acute Abdominal PainUNC Emergency MedicineMedical Student Lecture SeriesCase #1
  • 24 yo healthy M with one day hx of abdominal pain. Pain was generalized at first, now worse in right lower abd & radiates to his right groin. He has vomited twice today. Denies any diarrhea, fevers, dysuria or other complaints. No appetite today. ROS otherwise negative.
  • PMHx: negative
  • PSurgHx: negative
  • Meds: none
  • NKDA
  • Social hx: no alcohol, tobacco or drug use
  • Family hx: non-contributory
  • Abdominal pain
  • What else do you want to know?
  • What is on your differential diagnosis so far?
  • (healthy male with RLQ abd pain….)
  • How do you approach the complaint of abdominal pain in general?
  • Let’s review in this lecture:
  • Types of pain
  • History and physical examination
  • Labs and imaging
  • Abdominal pain in special populations (Elderly, HIV)
  • Clinical pearls to help you in the ED
  • “Tell me more about your pain….”
  • Location
  • Quality
  • Severity
  • Onset
  • Duration
  • Modifying factors
  • Change over time
  • What kind of pain is it?
  • Visceral
  • Involves hollow or solid organs; midline pain due to bilateral innvervation
  • Steady ache or vague discomfort to excruciating or colicky pain
  • Poorly localized
  • Epigastric region: stomach, duodenum, biliary tract
  • Periumbilical: small bowel, appendix, cecum
  • Suprapubic: colon, sigmoid, GU tract
  • Parietal
  • Involves parietal peritoneum
  • Localized pain
  • Causes tenderness and guarding which progress to rigidity and rebound as peritonitis develops
  • Referred
  • Produces symptoms not signs
  • Based on developmental embryology
  • Ureteral obstruction → testicular pain
  • Subdiaphragmatic irritation → ipsilateral shoulder or supraclavicular pain
  • Gynecologic pathology → back or proximal lower extremity
  • Biliary disease → right infrascapular pain
  • MI → epigastric, neck, jaw or upper extremity pain
  • Ask about relevant ROS
  • GI symptoms
  • Nausea, vomiting, hematemesis, anorexia, diarrhea, constipation, bloody stools, melena stools
  • GU symptoms
  • Dysuria, frequency, urgency, hematuria, incontinence
  • Gyn symptoms
  • Vaginal discharge, vaginal bleeding
  • General
  • Fever, lightheadedness
  • And don’t forget the history
  • GI
  • Past abdominal surgeries, h/o GB disease, ulcers; FamHx IBD
  • GU
  • Past surgeries, h/o kidney stones, pyelonephritis, UTI
  • Gyn
  • Last menses, sexual activity, contraception, h/o PID or STDs, h/o ovarian cysts, past gynecological surgeries, pregnancies
  • Vascular
  • h/o MI, heart disease, a-fib, anticoagulation, CHF, PVD, Fam Hx of AAA
  • Other medical history
  • DM, organ transplant, HIV/AIDS, cancer
  • Social
  • Tobacco, drugs – Especially cocaine, alcohol
  • Medications
  • NSAIDs, H2 blockers, PPIs, immunosuppression, coumadin
  • Moving on to the Physical Exam
  • General
  • Pallor, diaphoresis, general appearance, level of distress or discomfort, is the patient lying still or moving around in the bed
  • Vital Signs
  • Orthostatic VS when volume depletion is suspected
  • Cardiac
  • Arrhythmias
  • Lungs
  • Pneumonia
  • Abdomen
  • Look for distention, scars, masses
  • Auscultate – hyperactive or obstructive BS increase likelihood of SBO fivefold – otherwise not very helpful
  • Palpate for tenderness, masses, aortic aneurysm, organomegaly, rebound, guarding, rigidity
  • Percuss for tympany
  • Look for hernias!
  • rectal exam
  • Back
  • CVA tenderness
  • Pelvic exam
  • CMT
  • Vaginal discharge – Culture
  • Adenexal mass or fullness
  • Abdominal Findings
  • Guarding
  • Voluntary
  • Contraction of abdominal musculature in anticipation of palpation
  • Diminish by having patient flex knees
  • Involuntary
  • Reflex spasm of abdominal muscles
  • aka: rigidity
  • Suggests peritoneal irritation
  • Rebound
  • Present in 1 of 4 patients without peritonitis
  • Pain referred to the point of maximum tenderness when palpating an adjacent quadrant is suggestive of peritonitis
  • Rovsing’s sign in appendicitis
  • Rectal exam
  • Little evidence that tenderness adds any useful information beyond abdominal examination
  • Gross blood or melena indicates a GIB
  • Differential Diagnosis
  • It’s Huge!
  • Use history and physical exam to narrow it down
  • Rule out life-threatening pathology
  • Half the time you will send the patient home with a diagnosis of nonspecific abdominal pain (NSAP or Abdominal Pain – NOS)
  • 90% will be better or asymptomatic at 2-3 weeks
  • Gastritis, ileitis, colitis, esophagitisUlcers: gastric, peptic, esophagealBiliary disease: cholelithiasis, cholecystitisHepatitis, pancreatitis, CholangitisSplenic infarct, Splenic rupturePancreatic psuedocystHollow viscous perforationBowel obstruction, volvulusDiverticulitisAppendicitisOvarian cystOvarian torsionHernias: incarcerated, strangulatedKidney stonesPyelonephritis HydronephrosisInflammatory bowel disease: crohns, UCGastroenteritis, enterocolitispseudomembranous colitis, ischemia colitisTumors: carcinomas, lipomasMeckels diverticulumTesticular torsionEpididymitis, prostatitis, orchitis, cystitisConstipation Abdominal aortic aneurysm, ruptures aneurysmAortic dissectionMesenteric ischemiaOrganomegalyHemilith infestationPorphyriasACSPneumoniaAbdominal wall syndromes: muscle strain, hematomas, trauma, Neuropathic causes: radicular painNon-specific abdominal painGroup A beta-hemolytic streptococcal pharyngitisRocky Mountain Spotted FeverToxic Shock Syndrome Black widow envenomationDrugs: cocaine induced-ischemia, erythromycin, tetracyclines, NSAIDsMercury saltsAcute inorganic lead poisoningElectrical injuryOpioid withdrawalMushroom toxicityAGA: DKA, AKAAdrenal crisisThyroid stormHypo- and hypercalcemiaSickle cell crisisVasculitisIrritable bowel syndromeEctopic pregnancyPIDUrinary retentionIleus, Ogilvie syndromeDifferential DiagnosisMost Common Causes in the ED
  • Non-specific abd pain 34%
  • Appendicitis 28%
  • Biliary tract dz 10%
  • SBO 4%
  • Gyn disease 4%
  • Pancreatitis 3%
  • Renal colic 3%
  • Perforated ulcer 3%
  • Cancer 2%
  • Diverticular dz 2%
  • Other 6%
  • Depends what you are looking for!Abdominal series3 views: upright chest, flat view of abdomen, upright view of abdomenLimited utility: restrict use to patients with suspected obstruction or free airUltrasoundGood for diagnosing AAA but not ruptured AAAGood for pelvic pathologyCT abdomen/pelvisNoncontrast for free air, renal colic, ruptured AAA, (bowel obstruction)Contrast study for abscess, infection, inflammation, unknown causeMRIMost often used when unable to obtain CT due to contrast issueLabsCBC: “What’s the white count?”Chemistries Liver function tests, Lipase Coagulation studiesUrinalysis, urine cultureGC/Chlamydia swabsLactate What kind of tests should you order?Disposition
  • Depends on the source
  • Non-specific abdominal pain
  • No source is identified
  • Vital signs are normal
  • Non specific abdominal exam, no evidence of peritonitis or severe pain
  • Patient improves during ED visit
  • Patient able to take fluids
  • Have patient return to ED in 12-24 hours for re-examination if not better or if they develop new symptoms
  • Back to Case #1….24 yo with RLQ pain
  • Physical exam:
  • T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat: 100% room air
  • Uncomfortable appearing, slightly pale
  • Abdomen: soft, non-distended, tender to palpation in RLQ with mild guarding; hypoactive bowel sounds
  • Genital exam: normal
  • What is your differential diagnosis and what do you do next?
  • Classic presentationPeriumbilical painAnorexia, nausea, vomitingPain localizes to RLQOccurs only in ½ to 2/3 of patients26% of appendices are retrocecal and cause pain in the flank; 4% are in the RUQA pelvic appendix can cause suprapubic pain, dysuriaMales may have pain in the testiclesFindingsDepends on duration of symptomsRebound, voluntary guarding, rigidity, tenderness on rectal examPsoas signObturator signFever (a late finding)Urinalysis abnormal in 19-40%CBC is not sensitive or specificAbdominal xrays Appendiceal fecalith or gas, localized ileus, blurred right psoas muscle, free airCT scanPericecal inflammation, abscess, periappendiceal phlegmon, fluid collection, localized fat strandingAppendicitis Appendicitis: Psoas SignAppendicitis: Psoas SignAppendicitis: Obturator SignPassively flexright hip and kneethen internally rotate the hipAppendicitis: CT findingsCecum Abscess, fat strandingDiagnosisWBCClinical appendicitis – call your surgeonMaybe appendicitis - CT scanNot likely appendicitis – observe for 6-12 hours or re-examination in 12 hoursTreatmentNPOIVFsPreoperative antibiotics – decrease the incidence of postoperative wound infectionsCover anaerobes, gram-negative and enterococciZosyn 3.375 grams IV or Unasyn 3 grams IVAnalgesiaAppendicitis Case #2
  • 68 yo F with 2 days of LLQ abd pain, diarrhea, fevers/chills, nausea; vomited once at home.
  • PMHx: HTN, diverticulosis
  • PSurgHx: negative
  • Meds: HCTZ
  • NKDA
  • Social hx: no alcohol, tobacco or drug use
  • Family hx: non-contributory22
  • Case #2 Exam
  • T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99% room air
  • Gen: uncomfortable appearing, slightly pale
  • CV/Pulmonary: normal heart and lung exam, no LE edema, normal pulses
  • Abd: soft, moderately TTP LLQ
  • Rectal: normal tone, guiac neg brown stool
  • What is your differential diagnosis & what next?
  • Risk factorsDiverticulaIncreasing ageClinical featuresSteady, deep discomfort in LLQChange in bowel habitsUrinary symptomsTenesmusParalytic ileusSBOPhysical ExamLow-grade feverLocalized tendernessRebound and guardingLeft-sided pain on rectal examOccult bloodPeritoneal signsSuggest perforation or abscess ruptureDiverticulitisDiagnosisCT scan (IV and oral contrast)Pericolic fat strandingDiverticulaThickened bowel wallPeridiverticular abscessLeukocytosis present in only 36% of patientsTreatment FluidsCorrect electrolyte abnormalitiesNPOAbx: gentamicin AND metronidazole OR clindamycin OR levaquin/flagylFor outpatients (non-toxic)liquid diet x 48 hourscipro and flagylDiverticulitis Case #3
  • 46 yo M with hx of alcohol abuse with 3 days of severe upper abd pain, vomiting, subjective fevers.
  • Med Hx: negative
  • Surg Hx: negative
  • Meds: none; Allergies: NKDA
  • Social hx: homeless, heavy alcohol use, smokes 2ppd, no drug use
  • Case #3 Exam Vital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat: 95% room air
  • General: ill-appearing, appears in pain
  • CV: tachycardic, normal heart sounds, pulses normal
  • Lungs: clear
  • Abdomen: mildly distended, moderately TTP epigastric, +voluntary guarding
  • Rectal: heme neg stool
  • What is your differential diagnosis & what next?
  • Risk Factors AlcoholGallstonesDrugsAmiodarone, antivirals, diuretics, NSAIDs, antibiotics, more…..Severe hyperlipidemiaIdiopathic Clinical FeaturesEpigastric painConstant, boring painRadiates to backSevereN/VbloatingPhysical FindingsLow-grade feversTachycardia, hypotensionRespiratory symptomsAtelectasisPleural effusionPeritonitis – a late findingIleusCullen sign*Bluish discoloration around the umbilicusGrey Turner sign*Bluish discoloration of the flanksPancreatitis *Signs of hemorrhagic pancreatitisDiagnosis LipaseElevated more than 2 times normalSensitivity and specificity >90%AmylaseNonspecificDon’t bother…RUQ US if etiology unknownCT scan Insensitive in early or mild diseaseNOT necessary to diagnose pancreatitisUseful to evaluate for complicationsTreatmentNPOIV fluid resuscitationMaintain urine output of 100 mL/hrNGT if severe, persistent nauseaNo antibiotics unless severe diseaseE coli, Klebsiella, enterococci, staphylococci, pseudomonasImipenem or cipro with metronidazoleMild disease, tolerating oral fluids Discharge on liquid dietFollow up in 24-48 hoursAll others, admitPancreatitis Case #4
  • 72 yo M with hx of CAD on aspirin and Plavix with several days of dull upper abd pain and now with worsening pain “in entire abdomen” today. Some relief with food until today, now worse after eating lunch.
  • Med Hx: CAD, HTN, CHF
  • Surg Hx: appendectomy
  • Meds: Aspirin, Plavix, Metoprolol, Lasix
  • Social hx: smokes 1ppd, denies alcohol or drug use, lives alone
  • Case #4 Exam
  • T: 99.1, HR: 70, BP: 90/45, R: 22, O2sat: 96% room air
  • General: elderly, thin male, ill-appearing
  • CV: normal
  • Lungs: clear
  • Abd: mildly distended and diffusely tender to palpation, +rebound and guarding
  • Rectal: blood-streaked heme + brown stool
  • What is your differential diagnosis & what next?
  • Risk FactorsH. pyloriNSAIDsSmokingHereditaryClinical FeaturesBurning epigastric painSharp, dull, achy, or “empty” or “hungry” feelingRelieved by milk, food, or antacidsAwakens the patient at nightNausea, retrosternal pain and belching are NOT related to PUDAtypical presentations in the elderlyPhysical FindingsEpigastric tendernessSevere, generalized pain may indicate perforation with peritonitisOccult or gross blood per rectum or NGT if bleedingPeptic Ulcer DiseaseDiagnosis Rectal exam for occult bloodCBC Anemia from chronic blood lossLFTsEvaluate for GB, liver and pancreatic diseaseDefinitive diagnosis is by EGD or upper GI barium studyTreatment Empiric treatmentAvoid tobacco, NSAIDs, aspirinPPI or H2 blockerImmediate referral to GI if:>45 years Weight lossLong h/o symptomsAnemiaPersistent anorexia or vomitingEarly satietyGIBPeptic Ulcer DiseaseHere is your patient’s x-ray….Perforated Peptic Ulcer
  • Abrupt onset of severe epigastric pain followed by peritonitis
  • IV, oxygen, monitor
  • CBC, T&C, Lipase
  • Acute abdominal x-ray series
  • Lack of free air does NOT rule out perforation
  • Broad-spectrum antibiotics
  • Surgical consultation
  • Case #5
  • 35 yo healthy F to ED c/o nausea and vomiting since yesterday along with generalized abdominal pain. No fevers/chills, +anorexia. Last stool 2 days ago.
  • Med Hx: negative
  • Surg Hx: s/p hysterectomy (for fibroids)
  • Meds: none, Allergies: NKDA
  • Social Hx: denies alcohol, tobacco or drug use
  • Family Hx: non-contributory
  • Case #5 Exam
  • T: 36.9, HR: 100, BP: 130/85, R: 22, O2 sat: 97% room air
  • General: mildly obese female, vomiting
  • CV: normal
  • Lungs: clear
  • Abd: moderately distended, mild TTP diffusely, hypoactive bowel sounds, no rebound or guarding
  • What is your differential and what next?
  • Upright abd x-rayMechanical or nonmechanical causes#1 - Adhesions from previous surgery#2 - Groin hernia incarcerationClinical FeaturesCrampy, intermittent painPeriumbilical or diffuseInability to have BM or flatusN/VAbdominal bloatingSensation of fullness, anorexiaPhysical FindingsDistention TympanyAbsent, high pitched or tinkling bowel sound or “rushes”Abdominal tenderness: diffuse, localized, or minimalBowel ObstructionDiagnosis CBC and electrolyteselectrolyte abnormalitiesWBC >20,000 suggests bowel necrosis, abscess or peritonitisAbdominal x-ray seriesFlat, upright, and chest x-rayAir-fluid levels, dilated loops of bowelLack of gas in distal bowel and rectumCT scanIdentify cause of obstructionDelineate partial from complete obstructionTreatment Fluid resuscitationNGTAnalgesia Surgical consultHospital observation for ileusOR for complete obstructionPeri-operative antibioticsZosyn or unasynBowel ObstructionCase #6
  • 48 yo obese F with one day hx of upper abd pain after eating, does not radiate, is intermittent cramping pain, +N/V, no diarrhea, subjective fevers. No prior similar symptoms.
  • Med hx: denies
  • Surg hx: denies
  • No meds or allergies
  • Social hx: no alcohol, tobacco or drug use
  • Case #6 Exam
  • T: 100.4, HR: 96, BP: 135/76, R: 18, O2 sat: 100% room air
  • General: moderately obese, no acute distress
  • CV: normal
  • Lungs: clear
  • Abd: moderately TTP RUQ, +Murphy’s sign, non-distended, normal bowel sounds
  • What is your differential and what next?
  • Clinical FeaturesRUQ or epigastric painRadiation to the back or shouldersDull and achy → sharp and localizedPain lasting longer than 6 hoursN/V/anorexiaFever, chillsPhysical FindingsEpigastric or RUQ painMurphy’s signPatient appears illPeritoneal signs suggest perforationCholecystitis DiagnosisCBC, LFTs, LipaseElevated alkaline phosphataseElevated lipase suggests gallstone pancreatitisRUQ USThicken gallbladder wallPericholecystic fluidGallstones or sludgeSonographic murphy signHIDA scan more sensitive & specific than USH&P and laboratory findings have a poor predictive value – if you suspect it, get the USTreatment Surgical consultIV fluidsCorrect electrolyte abnormalitiesAnalgesia AntibioticsCeftriaxone 1 gram IVIf septic, broaden coverage to zosyn, unasyn, imipenem or add anaerobic coverage to ceftriaxoneNGT if intractable vomitingCholecystitis Case #7
  • 34 yo healthy M with 4 hour hx of sudden onset left flank pain, +nausea/vomiting; no prior hx of similar symptoms; no fevers/chills. +difficulty urinating, no hematuria. Feels like has to urinate but cannot.
  • PMHx: neg
  • Surg Hx: neg
  • Meds: none, Allergies: NKDA
  • Social hx: occasional alcohol, denies tobacco or drug use
  • Family hx: non-contributory
  • Case #7 Exam
  • T: 98.9, HR: 110, BP: 150/90, R: 20, O2 sat: 99% room air
  • General: writhing around on stretcher in pain, +diaphoretic
  • CV: tachycardic, heart sounds normal
  • Lungs: clear
  • Abd: soft; non-tender
  • Back: mild left CVA tenderness
  • Genital exam: normal
  • Neuro exam: normal
  • What is your differential diagnosis and what next?
  • Clinical FeaturesAcute onset of severe, dull, achy visceral painFlank painRadiates to abdomen or groin including testiclesN/V and sometimes diaphoresisFever is unusualWaxing and waning symptomsPhysical Findingsnon tender or mild tenderness to palpationAnxious, pacing, writhing in bed – unable to sit stillRenal ColicDiagnosisUrinalysisRBCs WBCs suggest infection or other etiology for pain (ie appendicitis)CBCIf infection suspectedBUN/CreatinineIn older patientsIf patient has single kidneyIf severe obstruction is suspected CT scanIn older patients or patients with comorbidities (DM, SCD)Not necessary in young patients or patients with h/o stones that pass spontaneouslyTreatmentIV fluid bolusesAnalgesiaNarcoticsNSAIDSIf no renal insufficiencyStrain all urineFollow up with urology in 1-2 weeksIf stone > 5mm, consider admission and urology consultIf toxic appearing or infection foundIV antibioticsUrologic consultRenal Colic Just a few more to go….hang in there
  • Ovarian torsion
  • Testicular torsion
  • GI bleeding
  • Abd pain in the Elderly
  • Acute onset severe pelvic pain May wax and wanePossible hx of ovarian cystsMenstrual cycle: midcycle also possibly in pregnancyCan have variable exam:acute, rigid abdomen, peritonitisFeverTachycardiaDecreased bowel soundsMay look just like AppendicitisObtain ultrasoundLabsCBC, beta-hCG, electrolytes, T&SIV fluidsNPOPain medicationsGYN consultOvarian TorsionSudden onset of severe testicular painIf torsion is repaired within 6 hours of the initial insult, salvage rates of 80-100% are typical. These rates decline to nearly 0% at 24 hours.Approximately 5-10% of torsed testes spontaneously detorse, but the risk of retorsion at
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