Approach to abdominal pain

Why is this important?

 Abdominal pain is one of the most common reasons for
outpatient and ER visits

 A lot can happen in the abdomen and you need an

organized approach

 Timely identification of acute abdomen is key

Epidimiology
 5% of all ER admissions
 Varied presentations

Acute exacerbations of chronic problems (e.g peptic disease,

pancreatitis, IBD)
Acute surgical abdomens (e.g, appendicitis, perforation,
volvulus)
 10% of abdominal pain turn to be a surgical abdomen
 Nonsurgical abdominal emergencies(e,g, gastritis, billiary
colic)
 Differential is extensive
 Differential Diagnosis of abdominal pain
Right Upper Quadrant Left Upper Quadrant
•Biliary colic •Gastric ulcer
•Cholangitis •Gastritis
•Cholecystitis •Herpes Zoster
•Fitz-Hugh-Curtis Syndrome •Myocardial ischemia
•Hepatitis •Pancreatitis
•Hepatic abscess •Pneumonia (LLL)
•Hepatic congestion •Pulmonary embolism
•Herpes zoster •Splenic rupture/distension
•Mesenteric ischemia •Pyelonephritis/nephrolithiasis
•Perforated duodenal ulcer
•Pneumonia (RLL)
•Pulmonary embolism
•Pyelonephritis/nephrolithiasis
Right Lower Quadrant Left Lower Quadrant
•Aortic aneurysm •Aortic aneurysm
•Appendicitis •Diverticulitis
•Crohn disease •Ectopic pregnancy
•Diverticulitis •Endometriosis
•Ectopic pregnancy •Epiploic appendagitis
•Endometriosis •Herpes zoster
•Epiploic appendagitis •Inguinal hernia
•Herpes zoster •Ischemic colitis
•Inguinal hernia •Meckel diverticulum
•Ischemic colitis •Mittelschmerz
•Meckel diverticulum •Ovarian cyst
•Mittelschmerz •Ovarian torsion
•Ovarian cyst •Pelvic inflammatory disease
•Ovarian torsion •Psoas abscess
•Pelvic inflammatory disease •Regional enteritis
•Psoas abscess •Testicular torsion
•Regional enteritis •Ureteral calculi
•Testicular torsion
•Ureteral calculi
So how do we organize this ?

 Location
 Onset and pattern
 Acute v. chronic
 Severity and quality
Acute abdominal pain
 Generally present for less than a couple weeks
 Usually days to hours old
 Don’t forget about the chronic pain that has acutely worsened
 More immediate attention is required
 Surgical v. nonsurgical
Understanding the Types of
Abdominal Pain
• Visceral
– Crampy, achy, diffuse
– Poorly localized
• Somatic/parietal
– Sharp, cutting, stabbing
– Well localized
• Referred
– Distant from site of generation
– Symptoms, but no signs
Approach to the patient
 History is THE MOST IMPORTANT part of the
diagnostic process
 HPI  PMH

• Onset • PMHx
• Palliates/provokes • Surgicak Hx
• Quality • Allergies
• Radiation • Meds
• Severity • Social Hx (EtOH)
• Time course
• Undo(what “undo’s” the pain)
History: Age
 Abdominal pain in the elderly is “an M&M waiting to
happen”
• Mortality and misdiagnosis rise exponentially w/each
decade >50
• for those >65, ~ 60-70% get admitted to the OR with a
mortality rate of 10%
Onset

 Abrupt or gradual onset (abrupt is worse)

 Duration (<48H is worse)
 Trend and pattern: constant vs. intermittent
 Timing in relation to other symptoms (e.g, pain that
percedes vomiting)

 Tip:
• Constant pain that began abruptly suggests renal colic,
perforated viscus, ischemia (bowel, MI, testicular or
ovarian torsion) or hemorrhage
Characterizing the pain – location
Ask where the pain and how
it changed
Characterizing the pain – alleviating and
aggravating factors
 Eating, movement, medication
 Tips:
• Worsened by eating often related to pancreas or gall
bladder
• Relieved by eating often peptic disease
Characterizing the pain
 Severity 1-10 scale
• Allows assessment of response to therapy
 Quality, sometimes helpful, some Pts. unable to describe
precisely
• Tip: ask if they had a pain like this before, if yes consider:
peptic disease, billiary, IBD, hepatitis and pancreatitis
Approach to the patient - Physical exam

 Overall appearance (key)

 Level of distress (and response to analgesia)
 Physical exam
 Vitals, general appearance
 A good thorough medical exam
 Abdominal exam
 Inspect for distention, ascites, contusions, incisions
 Auscultate for presence and quality of bowel sounds
 Percuss to determine liver span, tendernes
 Palpate to determine maximal tenderness, abscense of guarging or rebound
tendereness
 Start gently, away from the area of pain, distract the patient then palpate deeply
 Know a few tricks
 DRE

NARROW THE EXTENSIVE DIFFERENTIAL

Approach to the patient
 Labs
 CBC, electrolytes, BUN, Cr, coags
 BG
 Amylase and lipase, LFTs
 UA
 bHCG
 Lactate
 CRP
Approach to the patient
 Imaging
 Plain films (Chest, abdominal X-rays)
 CT
 Ultrasound
 MRI
 Angiography
 Endoscopy
 EGD
 Colonoscopy
 ERCP
Surgical abdomen
 This is the first thing to be considered in acute abdominal
pain
 Early identification is a must as prognosis worsens rapidly with
delay in treatment
 This is a clinical diagnosis
 Essential to rule out the life threatining causes
• AAA
• Perforation
• Obtstruction
• Ischemia
• Ectopic pregnancy
Surgical abdomen
 Presentation is usually bad
 Fever, tachycardia, hypotension
 VERY tender abdomen, possibly rigid
 Presentation can vary with other demographic and
medical factors
 Advanced age
 Immunosuppression
 Diabetes
Surgical abdomen
 Peritonitis
 Often signals an intraabdominal catastrophe
 Perforation, big abscess, severe bleeding, bowel ischemia
 Patient usually appears ill
 Exam findings
 Rebound, rigidity, tender to percussion or light palpation, pain with
shaking bed
Surgical abdomen
 Work-up
 Start with stat labs
 Surgical abdominal series (plain films)
 Consider stat CT if readily available
 Sometimes patients go straight to surgery as initial step
Cases to discuss