Acute Abdominal PainUNC Emergency MedicineMedical Student Lecture Series

Case #124 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: negativePSurgHx: negativeMeds: noneNKDASocial hx: no alcohol, tobacco or drug useFamily hx: non-contributory

Abdominal painWhat 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?Lets review in this lecture:Types of painHistory and physical examinationLabs and imagingAbdominal pain in special populations (Elderly, HIV)Clinical pearls to help you in the ED

Tell me more about your pain. LocationQualitySeverity OnsetDuration Modifying factorsChange over time

What kind of pain is it?VisceralInvolves hollow or solid organs; midline pain due to bilateral innvervationSteady ache or vague discomfort to excruciating or colicky painPoorly localizedEpigastric region: stomach, duodenum, biliary tractPeriumbilical: small bowel, appendix, cecumSuprapubic: colon, sigmoid, GU tractParietalInvolves parietal peritoneumLocalized painCauses tenderness and guarding which progress to rigidity and rebound as peritonitis developsReferred Produces symptoms not signsBased on developmental embryologyUreteral obstruction testicular painSubdiaphragmatic irritation ipsilateral shoulder or supraclavicular painGynecologic pathology back or proximal lower extremityBiliary disease right infrascapular painMI epigastric, neck, jaw or upper extremity pain

Ask about relevant ROSGI symptomsNausea, vomiting, hematemesis, anorexia, diarrhea, constipation, bloody stools, melena stoolsGU symptomsDysuria, frequency, urgency, hematuria, incontinenceGyn symptomsVaginal discharge, vaginal bleedingGeneralFever, lightheadedness

And dont forget the historyGIPast abdominal surgeries, h/o GB disease, ulcers; FamHx IBDGUPast surgeries, h/o kidney stones, pyelonephritis, UTIGynLast menses, sexual activity, contraception, h/o PID or STDs, h/o ovarian cysts, past gynecological surgeries, pregnancies Vascularh/o MI, heart disease, a-fib, anticoagulation, CHF, PVD, Fam Hx of AAAOther medical historyDM, organ transplant, HIV/AIDS, cancerSocial Tobacco, drugs Especially cocaine, alcoholMedications NSAIDs, H2 blockers, PPIs, immunosuppression, coumadin

Moving on to the Physical ExamGeneralPallor, diaphoresis, general appearance, level of distress or discomfort, is the patient lying still or moving around in the bedVital SignsOrthostatic VS when volume depletion is suspectedCardiac ArrhythmiasLungsPneumonia AbdomenLook for distention, scars, massesAuscultate hyperactive or obstructive BS increase likelihood of SBO fivefold otherwise not very helpfulPalpate for tenderness, masses, aortic aneurysm, organomegaly, rebound, guarding, rigidityPercuss for tympanyLook for hernias!rectal examBackCVA tendernessPelvic examCMTVaginal discharge CultureAdenexal mass or fullness

Abdominal FindingsGuardingVoluntaryContraction of abdominal musculature in anticipation of palpationDiminish by having patient flex kneesInvoluntaryReflex spasm of abdominal musclesaka: rigiditySuggests peritoneal irritationReboundPresent in 1 of 4 patients without peritonitisPain referred to the point of maximum tenderness when palpating an adjacent quadrant is suggestive of peritonitisRovsings sign in appendicitisRectal examLittle evidence that tenderness adds any useful information beyond abdominal examinationGross blood or melena indicates a GIB

Differential DiagnosisIts Huge!

Use history and physical exam to narrow it downRule out life-threatening pathologyHalf 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

Differential DiagnosisGastritis, 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 ischemiaOrganomegaly

Hemilith 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 syndrome

Most Common Causes in the EDNon-specific abd pain34%Appendicitis28%Biliary tract dz10%SBO 4%Gyn disease 4%Pancreatitis 3%Renal colic 3%Perforated ulcer 3%Cancer 2%Diverticular dz 2%Other 6%

What kind of tests should you order?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: Whats the white count?Chemistries Liver function tests, Lipase Coagulation studiesUrinalysis, urine cultureGC/Chlamydia swabsLactate

Disposition Depends on the sourceNon-specific abdominal painNo source is identifiedVital signs are normalNon specific abdominal exam, no evidence of peritonitis or severe painPatient improves during ED visitPatient able to take fluidsHave 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 painPhysical exam:T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat: 100% room airUncomfortable appearing, slightly paleAbdomen: soft, non-distended, tender to palpation in RLQ with mild guarding; hypoactive bowel soundsGenital exam: normal

What is your differential diagnosis and what do you do next?

Appendicitis Classic presentationPeriumbilical painAnorexia, nausea, vomitingPain localizes to RLQOccurs only in 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 stranding

Appendicitis: Psoas Sign

Appendicitis: Psoas Sign

Appendicitis: Obturator SignPassively flexright hip and kneethen internally rotate the hip

Appendicitis: CT findingsAbscess, fat strandingCecum

Appendicitis DiagnosisWBCClinical 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 IVAnalgesia

Case #268 yo F with 2 days of LLQ abd pain, diarrhea, fevers/chills, nausea; vomited once at home. PMHx: HTN, diverticulosisPSurgHx: negativeMeds: HCTZNKDASocial hx: no alcohol, tobacco or drug useFamily hx: non-contributory*

Case #2 ExamT: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99% room airGen: uncomfortable appearing, slightly paleCV/Pulmonary: normal heart and lung exam, no LE edema, normal pulsesAbd: soft, moderately TTP LLQRectal: normal tone, guiac neg brown stool

What is your differential diagnosis & what next?

DiverticulitisRisk factorsDiverticulaIncreasing ageClinical featuresSteady, deep discomfort in LLQChange in bowel habitsUrinary symptomsTenesmusParalytic ileusSBO

Physical ExamLow-grade feverLocalized tendernessRebound and guardingLeft-sided pain on rectal examOccult bloodPeritoneal signsSuggest perforation or abscess rupture

Diverticulitis DiagnosisCT 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 flagyl

Case #346 yo M with hx of alcohol abuse with 3 days of severe upper abd pain, vomiting, subjective fevers.Med Hx: negativeSurg Hx: negativeMeds: none; Allergies: NKDASocial hx: homeless, heavy alcohol use, smokes 2ppd, no drug use

Case #3 ExamVital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat: 95% room airGeneral: ill-appearing, appears in painCV: tachycardic, normal heart sounds, pulses normalLungs: clearAbdomen: mildly distended, moderately TTP epigastric, +voluntary guardingRectal: heme neg stool

What is your differential diagnosis & what next?

Pancreatitis Risk Factors AlcoholGallstonesDrugsAmiodarone, antivirals, diuretics, NSAIDs, antibiotics, more..Severe hyperlipidemiaIdiopathic Clinical FeaturesEpigastric painConstant, boring painRadiates to backSevereN/Vbloating

Physical FindingsLow-grade feversTachycardia, hypotensionRespiratory symptomsAtelectasisPleural effusionPeritonitis a late findingIleusCullen sign*Bluish discoloration around the umbilicusGrey Turner sign*Bluish discoloration of the flanks

*Signs of hemorrhagic pancreatitis

Pancreatitis Diagnosis LipaseElevated more than 2 times normalSensitivity and specificity >90%AmylaseNonspecificDont botherRUQ US if etiology unknownCT scanInsensitive 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, admit

Case #472 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, CHFSurg Hx: appendectomyMeds: Aspirin, Plavix, Metoprolol, LasixSocial hx: smokes 1ppd, denies alcohol or drug use, lives alone

Case #4 ExamT: 99.1, HR: 70, BP: 90/45, R: 22, O2sat: 96% room airGeneral: elderly, thin male, ill-appearingCV: normalLungs: clearAbd: mildly distended and diffusely tender to palpation, +rebound and guardingRectal: blood-streaked heme + brown stool

What is your differential diagnosis & what next?

Peptic Ulcer DiseaseRisk 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 elderly

Physical FindingsEpigastric tendernessSevere, generalized pain may indicate perforation with peritonitisOccult or gross blood per rectum or NGT if bleeding

Peptic Ulcer DiseaseDiagnosisRectal exam for occult bloodCBCAnemia from chronic blood lossLFTsEvaluate for GB, liver and pancreatic diseaseDefinitive diagnosis is by EGD or upper GI barium study

Treatment Empiric treatmentAvoid tobacco, NSAIDs, aspirinPPI or H2 blockerImmediate referral to GI if:>45 years Weight lossLong h/o symptomsAnemiaPersistent anorexia or vomitingEarly satietyGIB

Here is your patients x-ray.

Perforated Peptic UlcerAbrupt onset of severe epigastric pain followed by peritonitisIV, oxygen, monitorCBC, T&C, LipaseAcute abdominal x-ray seriesLack of free air does NOT rule out perforationBroad-spectrum antibioticsSurgical consultation

Case #535 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: negativeSurg Hx: s/p hysterectomy (for fibroids)Meds: none, Allergies: NKDASocial Hx: denies alcohol, tobacco or drug useFamily Hx: non-contributory

Case #5 ExamT: 36.9, HR: 100, BP: 130/85, R: 22, O2 sat: 97% room airGeneral: mildly obese female, vomitingCV: normalLungs: clearAbd: moderately distended, mild TTP diffusely, hypoactive bowel sounds, no rebound or guarding

What is your differential and what next?

Upright abd x-ray

Bowel ObstructionMechanical 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, anorexia

Physical FindingsDistention TympanyAbsent, high pitched or tinkling bowel sound or rushesAbdominal tenderness: diffuse, localized, or minimal

Bowel 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 unasyn

Case #648 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: deniesSurg hx: deniesNo meds or allergiesSocial hx: no alcohol, tobacco or drug use

Case #6 ExamT: 100.4, HR: 96, BP: 135/76, R: 18, O2 sat: 100% room airGeneral: moderately obese, no acute distressCV: normalLungs: clearAbd: moderately TTP RUQ, +Murphys sign, non-distended, normal bowel sounds

What is your differential and what next?

Cholecystitis Clinical FeaturesRUQ or epigastric painRadiation to the back or shouldersDull and achy sharp and localizedPain lasting longer than 6 hoursN/V/anorexiaFever, chills

Physical FindingsEpigastric or RUQ painMurphys signPatient appears illPeritoneal signs suggest perforation

Cholecystitis DiagnosisCBC, LFTs, LipaseElevated alkaline phosphataseElevated lipase suggests gallstone pancreatitisRUQ USThicken gallbladder wallPericholecystic fluidGallstones or sludgeSonographic murphy signHIDA scan more sensitive & specific than US

H&P and laboratory findings have a poor predictive value if you suspect it, get the US

Treatment Surgical consultIV fluidsCorrect electrolyte abnormalitiesAnalgesia AntibioticsCeftriaxone 1 gram IVIf septic, broaden coverage to zosyn, unasyn, imipenem or add anaerobic coverage to ceftriaxoneNGT if intractable vomiting

Case #734 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: negSurg Hx: negMeds: none, Allergies: NKDASocial hx: occasional alcohol, denies tobacco or drug useFamily hx: non-contributory

Case #7 ExamT: 98.9, HR: 110, BP: 150/90, R: 20, O2 sat: 99% room airGeneral: writhing around on stretcher in pain, +diaphoreticCV: tachycardic, heart sounds normalLungs: clearAbd: soft; non-tenderBack: mild left CVA tendernessGenital exam: normalNeuro exam: normal

What is your differential diagnosis and what next?

Renal ColicClinical FeaturesAcute onset of severe, dull, achy visceral painFlank painRadiates to abdomen or groin including testiclesN/V and sometimes diaphoresisFever is unusualWaxing and waning symptoms

Physical Findingsnon tender or mild tenderness to palpationAnxious, pacing, writhing in bed unable to sit still

Renal Colic DiagnosisUrinalysisRBCs 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 weeks

If stone > 5mm, consider admission and urology consultIf toxic appearing or infection foundIV antibioticsUrologic consult

Just a few more to go.hang in thereOvarian torsionTesticular torsionGI bleedingAbd pain in the Elderly

Ovarian TorsionAcute 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 Appendicitis

Obtain ultrasoundLabsCBC, beta-hCG, electrolytes, T&SIV fluidsNPOPain medicationsGYN consult

Testicular TorsionSudden onset of severe testicular pain

If 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 a later date remains high. Most occur in males less than 20yrs old but 10% of affected patients are older than 30 years.

DetorsionEmergent urology consultUltrasound with doppler

Abdominal Pain in the ElderlyMortality rate for abdominal pain in the elderly is 11-14%Perception of pain is alteredAltered reporting of pain: stoicism, fear, communication problems

Most common causes:CholecystitisAppendicitisBowel obstructionDiverticulitisPerforated peptic ulcerDont miss these:AAA, ruptured AAAMesenteric ischemiaMyocardial ischemiaAortic dissection

Appendicitis do not exclude it because of prolonged symptoms. Only 20% will have fever, N/V, RLQ pain and WBCAcute cholecystitis most common surgical emergency in the elderly. Perforated peptic ulcer only 50% report a sudden onset of pain. In one series, missed diagnosis of PPU was leading cause of death.Mesenteric ischemia we make the diagnosis only 25% of the time. Early diagnosis improves chances of survival. Overall survival is 30%. Increased frequency of abdominal aortic aneurysmsAAA may look like renal colic in elderly patientsAbdominal Pain in the Elderly

Mesenteric IschemiaConsider this diagnosis in all elderly patients with risk factorsAtrial fibrillation, recent MIAtherosclerosis, CHF, digoxin therapyHypercoagulability, prior DVT, liver diseaseSevere pain, often refractory to analgesicsRelatively normal abdominal examEmbolic source: sudden onset (more gradual if thrombosis)Nausea, vomiting and anorexia are common50% will have diarrheaEventually stools will be guiaic-positiveMetabolic acidosis and extreme leukocytosis when advanced disease is present (bowel necrosis)Diagnosis requires mesenteric angiography or CT angiography

Abdominal Aortic AneurysmRisk increases with age, women >70, men >55Abdominal pain in 70-80% (not back pain!)Back pain in 50%Sudden onset of significant painAtypical locations of pain: hips, inguinal area, external genitaliaSyncope can occurHypotension may be presentPalpation of a tender, enlarged aorta on exam is an important findingMay present with hematuriaSuspect it in any older patient with back, flank or abdominal pain especially with a renal colic presentationUltrasound can reveal the presence of a AAA but is not helpful for rupture. CT abd/pelvis without contrast for stable patients. High suspicion in an unstable patient requires surgical consult and emergent surgery.

GI BleedingUpperProximal to Ligament of TreitzPeptic ulcer disease most commonErosive gastritisEsophagitisEsophageal and gastric varicesMallory-Weiss tearLowerHemorrhoids most commonDiverticulosisAngiodysplasia

Medical History Common Presentation:Hematemesis (source proximal to right colon)Coffee-ground emesisMelenaHematochezia (distal colorectal source)High level of suspicion withHypotensionTachycardiaAnginaSyncopeWeaknessConfusionCardiac arrest

Labs and ImagingType and crossmatch: Most important!Other studies: CBC, BUN, creatinine, electrolyte, coagulation studies, LFTsInitial Hct often will not reflect the actual amount of blood loss Abdominal and chest x-rays of limited value for source of bleedNasogastric (NG) tube Gastric lavageAngiographyBleeding scanEndoscopy/colonoscopy

Management in the EDABCs of ResuscitationAIRWAY: Consider definitive airway to prevent aspiration of bloodBREATHINGSupplemental OxygenContinuous pulse oximetry

Management in EDCirculationCardiac monitoring Volume replacement Crystalloids 2 large-bore intravenous lines (18g or larger)Blood ProductsGeneral guidelines for transfusionActive bleeding Failure to improve perfusion and vital signs after the infusion of 2 L of crystalloid Lower threshold in the elderlyNOT BASED ON INITIAL HEMATOCRIT ALONECoagulation factors replaced as needed Urinary catheter with hypotension to monitor output

ManagementEarly GI consult for severe bleedsTherapeutic Endoscopy: band ligation or injection sclerotherapy Also.electrocoagulation, heater probes, and lasers Drug Therapy: somatostatin, octreotide, vasopressin, PPIsBalloon tamponade: adjunct or temporizing measure Surgery: if all else fails

DispositionADMITCertain patients with lower GI bleeding may be discharged for Outpatient work-upPatients are risk stratified by clinical and endoscopic criteria Independent predictors of adverse outcomes in upper GI bleeding (Corley and colleagues): Initial hematocrit < 30 %Initial SBP < 100 mm HgRed blood in the NG lavageHistory of cirrhosis or ascites on examinationHistory of vomiting red blood

Abdominal Pain Clinical PearlsSignificant abdominal tenderness should never be attributed to gastroenteritisIncidence of gastroenteritis in the elderly is very lowAlways perform genital examinations when lower abdominal pain is present in males and females, in young and oldIn older patients with renal colic symptoms, exclude AAASevere pain should be taken as an indicator of serious diseasePain awakening the patient from sleep should always be considered signficantSudden, severe pain suggests serious diseasePain almost always precedes vomiting in surgical causes; converse is true for most gastroenteritis and NSAPAcute cholecystitis is the most common surgical emergency in the elderlyA lack of free air on a chest xray does NOT rule out perforationSigns and symptoms of PUD, gastritis, reflux and nonspecific dyspepsia have significant overlapIf the pain of biliary colic lasts more than 6 hours, suspect early cholecystitis

Basic cases to go through the most common abd pain complaints we see in the ED*Orthostatic VS are less reliable in the diabetic, elderly, those on beta-blocker. Pulse increase of 30 or presyncope on standing are highly sensitive for loss of 1 L of blood or 3L of fluid. BP changes are less reliable. Patient must be standing at least one minute before measurements are taken.*Heme positive stool 10% of people over the age of 50 sent home with diagnosis of NSAP and heme positive stools were found to have cancer within a year.Heme positive stool in the setting of suspected PUD should elicit more urgent referral for further evaluationFirst: r/o upper GI bleedLower GI bleed: most common hemorrhoidsDiverticulosis has potential for massive bleedingNG tube for all significant bleeds: in 14% of bright red blood or maroon per rectum from upper GI sourceNegative NG aspirate does not r/o upper sourceUse room temp water for lavage and lavage until clearOctreotide is 50 g IV bolus, followed by 50 g 824hSomatostatin is 250500 g IV bolus followed by 250500 g per hProtonix 80mg IV bolus x 1; then 8mg/hr for 72 hours*For free air instill 500cc of air into stomach via NGT and repeat xray or do noncontrast CT scan