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 · Mortality doubles with incorrect diagnosis 1 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 2 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 3 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 lifethreatening 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) 4 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 · Aortic dissection · Aortic aneurysm 5 Causes of Abdominal Pain Abdomen/Pelvic Organs · Stomach · Intestines Gastritis, PUD, gastroenteritis · Pancreas · Liver · Vessels · · · · Ureters · Uterus · Ovaries and fallopian tubes · Appendicitis, SBO, diverticulitis, incarcerated hernia, ischemic gut, IBD · · · Pancreatitis, pseudocyst Acute hepatitis, biliary tract disease AAA, Renal/splenic aneurysm Spleen: Splenic rupture · Colic, stones, UTI PID, fibroids (ruptured) ectopic, ovarian cyst, Mittelschmerz, torsion · Prostate · Testicles and associated structures · · Prostatitis Torsion, hydrocele, Retroperitoneal · Kidneys · Pyelonephritis, infarction · Great Vessels · AAA · Muscles (psoas) 6 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 7 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 8 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 9 History Location of the pain major factor in developing a differential diagnosis History 10 History History 11 History History · · · · · · O P Q R S T onset palliation/provocation quality radiation severity time 12 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 13 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 14 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 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 15 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 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 16 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 17 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 18 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 19 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 20 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 · · · · · Gallbladder disease Pancreatitis Bowel obstruction PID Torsions · Need to go to OR! 21 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) 22 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 nonspecific symptoms in their coronary years · Consider a Chest x-ray on young children · Consider glucose testing (DKA) 23 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 24 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 25 26 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 27 Radiology · CT scan · Know what you are looking for 28 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 29 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 30 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 31 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? 32 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? 33 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? 34 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? 35 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. 36 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? 37 Case 4 · After pain meds and antiemetics…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 38 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? 39 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 lifethreatening (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 40