Management of Patients Management of Patients with Abdominal Pain in with Abdominal Pain in

the Emergency the Emergency Department Department

Abdominal PainAbdominal PainLecture OutlineLecture Outline

Recognition & resuscitation for Recognition & resuscitation for life-threatening causes of abd. life-threatening causes of abd. painpain

Physical exam featuresPhysical exam features Choosing diagnostic testsChoosing diagnostic tests Initial treatmentInitial treatment Differential diagnosisDifferential diagnosis Key points about the most Key points about the most common specific causescommon specific causes

Abdominal Pain : Abdominal Pain : Diagnostic & Treatment Diagnostic & Treatment PrioritiesPriorities

First : recognize presence of shock or First : recognize presence of shock or intraabdominal bleedingintraabdominal bleeding

Second : start resuscitative measures for Second : start resuscitative measures for shock or bleeding (if these are present)shock or bleeding (if these are present)

Third : determine if the abdomen is the source Third : determine if the abdomen is the source of the shock or bleedingof the shock or bleeding

Fourth : determine if emergency laparotomy is Fourth : determine if emergency laparotomy is neededneeded

Fifth : complete the secondary survey (head to Fifth : complete the secondary survey (head to toe exam) ; obtain needed lab or radiographic toe exam) ; obtain needed lab or radiographic studiesstudies

Sixth : Conduct frequent reassessments of the Sixth : Conduct frequent reassessments of the patientpatient

General Approach to the General Approach to the Patient Presenting with Patient Presenting with Abdominal PainAbdominal Pain

Evaluate & treat the ABC's (Airway, Breathing, Evaluate & treat the ABC's (Airway, Breathing, Circulation) first in same sequence as for any Circulation) first in same sequence as for any other emergency patientother emergency patient

Determine if an immediate life-threatening Determine if an immediate life-threatening cause of abd. pain may be present & if there is cause of abd. pain may be present & if there is any history of possible abd. traumaany history of possible abd. trauma

Start resuscitation and emergently consult a Start resuscitation and emergently consult a surgeon if an emergent laparotomy is needed surgeon if an emergent laparotomy is needed

Complete the secondary survey, Complete the secondary survey, treat paintreat pain, , and decide what other diagnostic tests will be and decide what other diagnostic tests will be neededneeded

Immediate Life-Immediate Life-Threatening Causes of Threatening Causes of Abdominal PainAbdominal Pain

These must be recognized from the primary These must be recognized from the primary survey :survey :Ruptured abdominal aortic aneurism (AAA)Ruptured abdominal aortic aneurism (AAA)Rupture of the spleen or liverRupture of the spleen or liverRuptured ectopic pregnancyRuptured ectopic pregnancyBowel infarctionBowel infarctionPerforated viscusPerforated viscusAcute myocardial infarction (MI)Acute myocardial infarction (MI)

Ruptured Abdominal Aortic Ruptured Abdominal Aortic Aneurism (AAA)Aneurism (AAA)

More common in males > 65 years of ageMore common in males > 65 years of ageMay present initially as back or groin painMay present initially as back or groin painTypically would have epigastric or periumbilical pain Typically would have epigastric or periumbilical pain radiating to backradiating to back

May present in shock from intraperitoneal rupture May present in shock from intraperitoneal rupture (retroperitioneal rupture may initially be contained)(retroperitioneal rupture may initially be contained)

Often can feel pulsating supraumbilical mass (if you can Often can feel pulsating supraumbilical mass (if you can feel the aortic pulse width > 4 cm : suspect AAA)feel the aortic pulse width > 4 cm : suspect AAA)

Can sometimes make this Dx from lateral X-ray of abd.Can sometimes make this Dx from lateral X-ray of abd.Bedside ultrasound (U/S) is best Dx test for unstable Bedside ultrasound (U/S) is best Dx test for unstable patientpatient

Abd. CT scan is best Dx test for stable patient (surgeon Abd. CT scan is best Dx test for stable patient (surgeon may also want angiography preop if patient is stable)may also want angiography preop if patient is stable)

Ultrasound showing 7.5 cm AAA with intraluminal clot

CT scan of AAA (L = lumen, T = thrombus)

Emergency Management of Emergency Management of Ruptured AAARuptured AAA

Oxygen & IV fluid resuscitation (normal Oxygen & IV fluid resuscitation (normal saline or lactated Ringer's) if systolic BP < saline or lactated Ringer's) if systolic BP < 100 mm Hg (but do not "overresuscitate" ; 100 mm Hg (but do not "overresuscitate" ; do not increase the BP to over 120 systolic do not increase the BP to over 120 systolic because higher BP may cause increased because higher BP may cause increased bleeding)bleeding)

Type and cross for at least 6 units of bloodType and cross for at least 6 units of bloodInsert foley catheterInsert foley catheterObtain an electrocardiogramObtain an electrocardiogramEmergently consult a surgeonEmergently consult a surgeonNotify the operating roomNotify the operating room

Ruptured Spleen or LiverRuptured Spleen or Liver

Usually due to trauma, but can be Usually due to trauma, but can be spontaneous from malaria, mononucleosis, spontaneous from malaria, mononucleosis, or hematologic diseasesor hematologic diseases

Patient may present with shock ; may also Patient may present with shock ; may also have referred pain to shoulder (Kehr's sign)have referred pain to shoulder (Kehr's sign)

Dx and Rx considerations & sequence same Dx and Rx considerations & sequence same as for ruptured AAA (IV fluid, Type & cross, as for ruptured AAA (IV fluid, Type & cross, U/S or CT, call surgeon, etc.)U/S or CT, call surgeon, etc.)

Ruptured Ectopic Ruptured Ectopic PregnancyPregnancy

Most common cause of pregnancy-related Most common cause of pregnancy-related death in U.S.A.death in U.S.A.

May NOT have missed menstrual periodMay NOT have missed menstrual periodTypically have severe sudden onset lower abd. Typically have severe sudden onset lower abd. pain +/- shockpain +/- shock

Should obtain stat serum or urine HCG test in Should obtain stat serum or urine HCG test in any female of reproductive age with abd. painany female of reproductive age with abd. pain

Pelvic U/S is Dx test of choicePelvic U/S is Dx test of choiceRx : Oxygen, IV fluid (NS or LR), Type & cross Rx : Oxygen, IV fluid (NS or LR), Type & cross at least 2 units, emergently consult surgeon or at least 2 units, emergently consult surgeon or obstetricianobstetrician

Bowel InfarctionBowel Infarction

Due to clot embolus or thrombosis in Due to clot embolus or thrombosis in mesenteric arterymesenteric artery

Most patients have severe coronary artery Most patients have severe coronary artery disease (this can be a post-MI complication)disease (this can be a post-MI complication)

May have "pain out of proportion to May have "pain out of proportion to findings" (may not demonstrate much findings" (may not demonstrate much tenderness)tenderness)

Physical exam may show signs of Physical exam may show signs of peritonitis, hypoactive bowel sounds, blood peritonitis, hypoactive bowel sounds, blood in rectum or guiac positive stoolin rectum or guiac positive stool

Bowel Infarction (cont.)Bowel Infarction (cont.)

Usual lab findings :Usual lab findings :High WBCHigh WBCSevere lactic acidosis (anion gap > 18)Severe lactic acidosis (anion gap > 18)

Plain X-ray film findings :Plain X-ray film findings :Free air, air in portal vein, air in bowel Free air, air in portal vein, air in bowel wall ("pneumatosis intestinalis")wall ("pneumatosis intestinalis")

May need emergent angiography for DxMay need emergent angiography for DxRx : Oxygen, IV fluid resuscitation, IV broad Rx : Oxygen, IV fluid resuscitation, IV broad spectrum antibiotics, consult surgeonspectrum antibiotics, consult surgeon

Angiogram (arrow shows superior mesenteric artery clot) of a 65 year old male with bowel ischemia

Perforated ViscusPerforated Viscus

Causes :Causes :Blunt or penetrating trauma, tumors, Blunt or penetrating trauma, tumors, inflammaory bowel disease, typhoid inflammaory bowel disease, typhoid fever, amebiasis, other parasitesfever, amebiasis, other parasites

Typically see free air under diaphragm on Typically see free air under diaphragm on plain films (Chest X-ray is most sensitive to plain films (Chest X-ray is most sensitive to see small amounts of air)see small amounts of air)

Rx : Oxygen, IV fluids, IV broad spectrum Rx : Oxygen, IV fluids, IV broad spectrum antibiotics (such as cefoxitin & antibiotics (such as cefoxitin & metronidazole), emergently consult metronidazole), emergently consult surgeonsurgeon

Free air under the diaphragm from a perforated peptic ulcer

Chest X-ray showing colonic interposition (NOT free air)

Abdominal film showing the “Rigler double wall sign” of free intraperitoneal air (can see both inside and outside wall of bowel)

Acute Myocardial Infarction Acute Myocardial Infarction (MI) as a Cause of Abdominal (MI) as a Cause of Abdominal PainPain

Suspect in adult patient with upper abd. Suspect in adult patient with upper abd. pain but no or minimal abd. tendernesspain but no or minimal abd. tenderness

Inferior MI commonly presents as Inferior MI commonly presents as "indigestion" ; may also have emesis "indigestion" ; may also have emesis

MI may also secondarily occur from shock MI may also secondarily occur from shock due to an intraabdominal cause (such as due to an intraabdominal cause (such as intraluminal bleed, etc.)intraluminal bleed, etc.)

Dx by EKG +/- enzymes ; need Chest X-ray Dx by EKG +/- enzymes ; need Chest X-ray alsoalso

Rx : Oxygen, IV line, nitrates, aspirin, Rx : Oxygen, IV line, nitrates, aspirin, consider thrombolytics, etc., & admit to consider thrombolytics, etc., & admit to monitor bed unitmonitor bed unit

Now That Immediate Life-Threatening Causes Now That Immediate Life-Threatening Causes of Abd. Pain Have Been Reviewed, Next the of Abd. Pain Have Been Reviewed, Next the Lecture Will Review History and Exam for the Lecture Will Review History and Exam for the Stable PatientStable Patient

History items to ask the patient with abd. pain :History items to ask the patient with abd. pain :Time and rapidity of onsetTime and rapidity of onsetCharacter of pain (burning, cramping, etc.)Character of pain (burning, cramping, etc.)Associated symptomsAssociated symptomsSigns of bleeding (dark vomitus or stool)Signs of bleeding (dark vomitus or stool)Prior surgeries & illnessesPrior surgeries & illnessesLast menstrual periodLast menstrual periodMedications (especially steroids, aspirin, Medications (especially steroids, aspirin, warfarin)warfarin)

Alcohol intakeAlcohol intakeUnusual ingestion or foreign travelUnusual ingestion or foreign travel

Physical Exam for the Physical Exam for the Patient with Abdominal Patient with Abdominal PainPain

Need complete set of vital signsNeed complete set of vital signsLook in nose and mouth for sites of bleeding Look in nose and mouth for sites of bleeding (swallowed blood may mimic an intraluminal (swallowed blood may mimic an intraluminal bleed)bleed)

Look at skin for stigmata of liver disease or Look at skin for stigmata of liver disease or signs of coagulapathysigns of coagulapathy

Careful chest & lung exam (basilar pneumonias Careful chest & lung exam (basilar pneumonias can present as abd. pain)can present as abd. pain)

Palpate and observe the backPalpate and observe the backGenital and rectal exam (& stool guiac) should Genital and rectal exam (& stool guiac) should usually be routineusually be routine

Exam of the Abdomen in Exam of the Abdomen in the Patient with Abdominal the Patient with Abdominal PainPainInspection : Look for :Inspection : Look for :

Scars from prior surgeriesScars from prior surgeriesDistensionDistensionLocalized swelling or massLocalized swelling or massEccymoses or erythemaEccymoses or erythemaVisible peristalsisVisible peristalsis

Auscultation with stethescopeAuscultation with stethescopeListen for bowel sounds & bruitsListen for bowel sounds & bruits

Palpation & percussionPalpation & percussion

Interpretation of Bowel Interpretation of Bowel SoundsSounds(Associated, but not Definite, (Associated, but not Definite, Diagnoses)Diagnoses)

High pitched or "tinkling" : bowel High pitched or "tinkling" : bowel obstructionobstruction

Continuous & hyperactive : acute Continuous & hyperactive : acute gastroenteritisgastroenteritis

Absent : ileus or peritonitis (need to Absent : ileus or peritonitis (need to listen for at least one minute)listen for at least one minute)

Audible without stethescope : Audible without stethescope : "borborygmi""borborygmi"

Percussion of the AbdomenPercussion of the Abdomen

Should tap with 2 fingers on all 4 Should tap with 2 fingers on all 4 quadrantsquadrants

If tympanitic : implies bowel If tympanitic : implies bowel obstructionobstruction

If dull, implies intraabdominal If dull, implies intraabdominal bleding or fluid (such as ascites)bleding or fluid (such as ascites)

If tender, correlate with tender If tender, correlate with tender areas noted on palpationareas noted on palpation

Palpation of the AbdomenPalpation of the Abdomen

Should be done following inspection & Should be done following inspection & auscultationauscultation

Assess for tenderness, guarding, mass, crepitus, Assess for tenderness, guarding, mass, crepitus, referred tendernessreferred tenderness

Differentiate lower rib tenderness from true Differentiate lower rib tenderness from true upper abd. tendernessupper abd. tenderness

Don't need to directly assess rebound ; just Don't need to directly assess rebound ; just wiggle abdomen from the side & check for wiggle abdomen from the side & check for referred tenderness (direct rebound is cruel if referred tenderness (direct rebound is cruel if peritonitis is present)peritonitis is present)

Don't forget leg maneuvers (psoas, obturator, & Don't forget leg maneuvers (psoas, obturator, & heel tap signs)heel tap signs)

Lab Studies for Patients Lab Studies for Patients with Abdominal Painwith Abdominal Pain

Use selectively ; not all are Use selectively ; not all are needed for all patientsneeded for all patients

For example, for young adults For example, for young adults with simple acute viral with simple acute viral gastroenteritis or food poisoning, gastroenteritis or food poisoning, usually no lab studies are needed usually no lab studies are needed (they may just need IV fluids & (they may just need IV fluids & parenteral antiemetics)parenteral antiemetics)

Draw with the initial venipuncture Draw with the initial venipuncture if an IV line is to be establishedif an IV line is to be established

List of Lab Studies to List of Lab Studies to Consider for Patients with Consider for Patients with Abdominal PainAbdominal Pain

Type and Cross (the most important if patient has shock)Type and Cross (the most important if patient has shock)Complete blood count (CBC)Complete blood count (CBC)Urine or serum pregnancy test (HCG)Urine or serum pregnancy test (HCG)Serum amylase, lipase Serum amylase, lipase Urinalysis, urine culture and sensitivityUrinalysis, urine culture and sensitivityLiver function tests (bilirubin, SGOT, SGPT, alk. phos.)Liver function tests (bilirubin, SGOT, SGPT, alk. phos.)Electrolytes, glucose, creatinine, blood urea nitrogen (BUN)Electrolytes, glucose, creatinine, blood urea nitrogen (BUN)Serum alcohol, serum or urine drug screenSerum alcohol, serum or urine drug screenSerum medication levels (such as digoxin)Serum medication levels (such as digoxin)Clotting studies (platelet count, protime, PTT, fibrinogen)Clotting studies (platelet count, protime, PTT, fibrinogen)Cardiac enzymes (if coronary ischemia suspected)Cardiac enzymes (if coronary ischemia suspected)Blood culture (if sepsis or bacteremia suspected)Blood culture (if sepsis or bacteremia suspected)Nonemergent tumor markers (CEA, AFP)Nonemergent tumor markers (CEA, AFP)

Interpretation of Lab Interpretation of Lab Studies for Abdominal PainStudies for Abdominal Pain

WBC typically elevated (+/- "left-shifted") in WBC typically elevated (+/- "left-shifted") in any cause of peritonitis & in bowel any cause of peritonitis & in bowel infarction & in spleen & liver bleedinginfarction & in spleen & liver bleedingHowever often NOT elevated However often NOT elevated appropriately in :appropriately in :ƒ the elderly the elderly ƒ immunocompromised patientsimmunocompromised patientsƒ patients on chronic corticosteroid Rxpatients on chronic corticosteroid Rx

Interpretation of Lab Interpretation of Lab Studies for Abdominal Pain Studies for Abdominal Pain (cont.)(cont.)

Hematocrit may be normal in early stages Hematocrit may be normal in early stages of even severe hemorrhageof even severe hemorrhage

BUN to creatinine ratio of > 20 to 1 may BUN to creatinine ratio of > 20 to 1 may indicate upper gastrointestinal (GI) bleed indicate upper gastrointestinal (GI) bleed with digestion of blood in upper GI tractwith digestion of blood in upper GI tract

Degree of elevation of amylase or lipase Degree of elevation of amylase or lipase does not always correlate with severity of does not always correlate with severity of panceatitis or of pancreatic injurypanceatitis or of pancreatic injuryAmylase may also be chronically Amylase may also be chronically elevated in patients with renal elevated in patients with renal dysfunctiondysfunction

Plain Radiographs for Plain Radiographs for Abdominal PainAbdominal Pain

If needed, usually the 3 view "Acute Abdomen If needed, usually the 3 view "Acute Abdomen Series " is best (upright Chest X-ray, upright and Series " is best (upright Chest X-ray, upright and flat plate of the abd.)flat plate of the abd.)Chest X-ray best shows small amounts of free Chest X-ray best shows small amounts of free airair

Upright abd. film best shows bowel air-fluid Upright abd. film best shows bowel air-fluid levels (indicating bowel obstruction or ileus if levels (indicating bowel obstruction or ileus if multiple)multiple)

Look also for abnormal calcificationsLook also for abnormal calcifications"KUB" film is oriented to include all the pelvis, "KUB" film is oriented to include all the pelvis, whereas "abd. flat plate" is oriented to include whereas "abd. flat plate" is oriented to include the diaphragms (so these two are different for a the diaphragms (so these two are different for a tall patient)tall patient)

Diagnostic Ultrasound for Diagnostic Ultrasound for Abdominal PainAbdominal Pain

Dx test of choice for :Dx test of choice for :Unstable patient in shock & Unstable patient in shock & suspected intraabdominal bleedsuspected intraabdominal bleed

Gallstones (cholecystitis)Gallstones (cholecystitis)Ectopic pregnancyEctopic pregnancyOther complications of pregnancy Other complications of pregnancy (placenta previa, abruptio, etc.)(placenta previa, abruptio, etc.)

Renal or ureteral stones in the Renal or ureteral stones in the pregnant patientpregnant patient

Disadvantages of Disadvantages of Diagnostic UltrasoundDiagnostic Ultrasound

Visualization may be limited by bowel Visualization may be limited by bowel gas or obesitygas or obesity

Good interpretation requires Good interpretation requires experienceexperience

Not good at showing retroperitoneal Not good at showing retroperitoneal conditionsconditions

May not directly visualize solid organ May not directly visualize solid organ lacerationslacerations

Use of Computed Use of Computed Tomography (CT) for Tomography (CT) for Abdominal PainAbdominal Pain

Noncontrast spiral scan is now Noncontrast spiral scan is now method of choice for ureteral calculi method of choice for ureteral calculi (replaces intravenous pyelogram or (replaces intravenous pyelogram or IVP)IVP)

Using both IV and oral (or via Using both IV and oral (or via nasogastric tube) contrast can then nasogastric tube) contrast can then show appendicitis, diverticulitis, etc.show appendicitis, diverticulitis, etc.However even with greater use of However even with greater use of CT for appendicitis, overall accuracy CT for appendicitis, overall accuracy of this Dx in the E.D. has not of this Dx in the E.D. has not improvedimproved

Other Diagnostic Studies Other Diagnostic Studies to Consider for Abdominal to Consider for Abdominal PainPain

If contrast CT not available :If contrast CT not available :Gastrografin Upper GI study for Gastrografin Upper GI study for suspected :suspected :ƒ Stomach or bowel perforationStomach or bowel perforationƒ Diaphragm ruptureDiaphragm ruptureƒ Duodenal hematomaDuodenal hematoma

Never do barium GI study if any Never do barium GI study if any chance of barium leak (causes severe chance of barium leak (causes severe peritonitis)peritonitis)

Intravenous pyelogram (IVP) for Intravenous pyelogram (IVP) for suspected :suspected :ƒ Ureteral stone or injuryUreteral stone or injuryƒ Renal massRenal mass

Other Diagnostic Studies to Other Diagnostic Studies to Consider for Abdominal Pain Consider for Abdominal Pain (cont.)(cont.)

Retrograde urethrogram / cystogram Retrograde urethrogram / cystogram for suspected urethral or bladder for suspected urethral or bladder injuryinjury

Fistulogram for any suspected Fistulogram for any suspected abdominal wall fistulaabdominal wall fistula

Technetium bleeding scan to localize Technetium bleeding scan to localize intraluminal GI bleedintraluminal GI bleed

Angiography for preop planning of Angiography for preop planning of surgery for stable patient with AAA, surgery for stable patient with AAA, or for suspected arterial bleed or or for suspected arterial bleed or mesenteric ischemiamesenteric ischemia

Post-Exam "Procedures" to Post-Exam "Procedures" to Consider for the Patient with Consider for the Patient with Abdominal PainAbdominal Pain

Insertion of foley catheterInsertion of foley catheterIndicated for monitoring of any unstable Indicated for monitoring of any unstable patient or if urinary retention suspectedpatient or if urinary retention suspected

Insertion of nasogastric (NG) tube (see next Insertion of nasogastric (NG) tube (see next slide)slide)

Paracentesis (needle aspirate of abd. fluid)Paracentesis (needle aspirate of abd. fluid)Indicated for :Indicated for :Suspected infected ascites (check cell count Suspected infected ascites (check cell count & culture)& culture)

Relieving tense ascitesRelieving tense ascitesSometimes can make Dx of bowel perforation Sometimes can make Dx of bowel perforation or intraabd. bleedor intraabd. bleed

Usefulness Of NG Tube Suction Usefulness Of NG Tube Suction for the Patient with Abdominal for the Patient with Abdominal PainPain

Allows decompression of stomachAllows decompression of stomachLessens risk of aspirationLessens risk of aspirationCan remove some of residual Can remove some of residual toxins in stomachtoxins in stomach

May demonstrate upper GI May demonstrate upper GI bleedingbleeding

Required before peritoneal lavageRequired before peritoneal lavageContraindicated if nasal or Contraindicated if nasal or midface fractures or severe midface fractures or severe coagulapathy (insert via mouth coagulapathy (insert via mouth instead)instead)

General Mechanisms General Mechanisms Causing Abdominal PainCausing Abdominal Pain

Pain originating in the abdomenPain originating in the abdomenPeritonitisPeritonitisDistension of hollow visceraDistension of hollow visceraIschemiaIschemia

Pain referred to the abdomen Pain referred to the abdomen from another part of the bodyfrom another part of the body

Metabolic disordersMetabolic disordersNeurogenic disordersNeurogenic disorders

Causes of Referred Causes of Referred Abdominal Pain from Chest Abdominal Pain from Chest ConditionsConditions

Acute coronary syndromes (and "angina Acute coronary syndromes (and "angina equivalents")equivalents")

Pneumonia (especially basilar)Pneumonia (especially basilar)Spontaneous pneumothoraxSpontaneous pneumothoraxPulmonary embolus (rare cause)Pulmonary embolus (rare cause)PericarditisPericarditis

Metabolic Causes of Metabolic Causes of Abdominal PainAbdominal Pain

Diabetic ketoacidosisDiabetic ketoacidosisHyperlipidemia (often with Hyperlipidemia (often with pancreatitis)pancreatitis)

Acute prophyriasAcute prophyriasBlack Widow spider bitesBlack Widow spider bitesScorpion bitesScorpion bitesSickle cell crisis (sequestration in Sickle cell crisis (sequestration in spleen or liver, or vaso-occlusive)spleen or liver, or vaso-occlusive)

Neurogenic Causes of Neurogenic Causes of Abdominal PainAbdominal Pain

Herpes zoster (Shingles)Herpes zoster (Shingles)Pain often present several days before Pain often present several days before characteristic dermatomal vesicles characteristic dermatomal vesicles appearappear

Thoracic or lumbar spinal disc disease Thoracic or lumbar spinal disc disease or compressionor compression

Syphilis ("tabetic crisis")Syphilis ("tabetic crisis")

Patient with Herpes Zoster (“Shingles”) of the abdomen

Trauma-Related Causes of Trauma-Related Causes of Abdominal PainAbdominal Pain

May present delayed, or from seemingly May present delayed, or from seemingly minor trauma in the elderly :minor trauma in the elderly :Ruptured spleen or liverRuptured spleen or liverBowel or stomach perforationBowel or stomach perforationPancreatic contusion or transectionPancreatic contusion or transectionRuptured bladderRuptured bladderMesenteric hematomaMesenteric hematomaAbdominal wall hematoma (U/S is good at Abdominal wall hematoma (U/S is good at diagnosing this)diagnosing this)

Pregnancy-Related Causes Pregnancy-Related Causes of Abdominal Painof Abdominal Pain

Ectopic (usually tubal) pregnancyEctopic (usually tubal) pregnancyFalse labor (Braxton-Hicks False labor (Braxton-Hicks contractions)contractions)

Active laborActive laborAbruptio placentae (note that Abruptio placentae (note that placenta previa which can cause placenta previa which can cause severe bleeding is usually severe bleeding is usually painlesspainless))

Septic abortionSeptic abortion

Genitourinary Tract Causes Genitourinary Tract Causes of Abdominal Painof Abdominal Pain

CystitisCystitisPyelonephritisPyelonephritisUreterolithiasisUreterolithiasisPerinephric abscess (may see gas around Perinephric abscess (may see gas around kidney on KUB film)kidney on KUB film)

Renal infarction (as from sickle cell disease)Renal infarction (as from sickle cell disease)Psoas abscessPsoas abscessTesticular torsionTesticular torsionUrinary retention (as from prostatic Urinary retention (as from prostatic hypertrophy)hypertrophy)

Peritonitis Causing Abdominal Peritonitis Causing Abdominal PainPain

Definition : inflammation of the peritoneumDefinition : inflammation of the peritoneumCauses : exposure of peritoneum to gastric acid, bile, Causes : exposure of peritoneum to gastric acid, bile, urine, blood, pancreatic enzymes, bacteria, stool, or urine, blood, pancreatic enzymes, bacteria, stool, or exogenous toxins exogenous toxins

Complications : fluid & electrolyte disorders, "third Complications : fluid & electrolyte disorders, "third spacing" of fluid causing hypovolemia & shock, spacing" of fluid causing hypovolemia & shock, paralytic ileusparalytic ileus

Symptoms and signs : abdominal pain, rebound Symptoms and signs : abdominal pain, rebound tenderness, abdominal muscle guarding or rigidity, tenderness, abdominal muscle guarding or rigidity, fever, emesis, decreased bowel sounds, abdominal fever, emesis, decreased bowel sounds, abdominal distentiondistention

Key Rx : IV fluid resuscitation, IV antibiotics (usually), Key Rx : IV fluid resuscitation, IV antibiotics (usually), EARLY PAIN RELIEF WITH NARCOTICS, try to determine EARLY PAIN RELIEF WITH NARCOTICS, try to determine the most likely cause, emergently consult a surgeonthe most likely cause, emergently consult a surgeon

List of Most Common Causes List of Most Common Causes of Acute Abdominal Pain in of Acute Abdominal Pain in AdultsAdults

Acute gastroenteritisAcute gastroenteritisAcute cholecystitisAcute cholecystitis

Acute cholangitisAcute cholangitisAcute appendicitisAcute appendicitisAcute diverticulitisAcute diverticulitisAcute gastritis or Acute gastritis or peptic ulcerpeptic ulcerAcute esophagitisAcute esophagitis

Acute panceatitisAcute panceatitisBowel obstructionBowel obstructionInflammatory Bowel Inflammatory Bowel DiseaseDisease

Acute salpingitis Acute salpingitis (pelvic inflammatory (pelvic inflammatory disease)disease)

Acute pyelonephritisAcute pyelonephritisAcute cystitisAcute cystitisUreterolithiasisUreterolithiasisUrinary retentionUrinary retentionAcute viral hepatitisAcute viral hepatitisMesenteric ischemiaMesenteric ischemiaOvarian cystsOvarian cystsComplications of Complications of pregnancypregnancy

Caveat About Workup of Caveat About Workup of Abdominal Pain in the E.D.Abdominal Pain in the E.D.

Several large studies show that even Several large studies show that even after complete workup, 60 % of E.D. after complete workup, 60 % of E.D. patients with abdominal pain do not patients with abdominal pain do not have a specific diagnosishave a specific diagnosis

For most of these patients, it is For most of these patients, it is appropriate just to treat their appropriate just to treat their symptoms (pain meds, antispasmodics, symptoms (pain meds, antispasmodics, antiemetics, etc.) and perform further antiemetics, etc.) and perform further diagnostic tests only if their pain does diagnostic tests only if their pain does not resolve in one to 2 days not resolve in one to 2 days

Acute GastroenteritisAcute Gastroenteritis

Present with nausea / emesis / Present with nausea / emesis / diarrheadiarrhea

Usually viral or reaction to foodUsually viral or reaction to foodIf bacterial, usually have abd. If bacterial, usually have abd. tenderness +/- lower GI bleedingtenderness +/- lower GI bleeding

If abd. nontender and diarrhea is If abd. nontender and diarrhea is nonbloody, usually do not need lab nonbloody, usually do not need lab studiesstudies

Rx with IV LR 1 to 5 liters, oral, rectal, Rx with IV LR 1 to 5 liters, oral, rectal, or parenteral antiemetics, +/- or parenteral antiemetics, +/- antidiarrhealsantidiarrheals

Choices for AntiEmetics in the Choices for AntiEmetics in the E.D.E.D.

My favorite : hydroxyzine (Atarax, Vistaril)My favorite : hydroxyzine (Atarax, Vistaril)Antihistamine, also an antianxiety agentAntihistamine, also an antianxiety agentVery low incidence of side effectsVery low incidence of side effects25 to 50 mg IM or PO q 6 hours25 to 50 mg IM or PO q 6 hours

Promethazine (Phenergan)Promethazine (Phenergan)Some risk of dystonic reactions & sedationSome risk of dystonic reactions & sedation25 to 50 mg q 6 hours IV, IM, PO, or PR25 to 50 mg q 6 hours IV, IM, PO, or PR

Prochlorperazine (Compazine)Prochlorperazine (Compazine)40 to 50 % incidence of dystonic reactions40 to 50 % incidence of dystonic reactions10 to 25 mg q 6 hours IV, IM, PO, or PR10 to 25 mg q 6 hours IV, IM, PO, or PR

Metclopromide (Reglan) : 5 to 20 mg q 4 hrs. IV, IM, or Metclopromide (Reglan) : 5 to 20 mg q 4 hrs. IV, IM, or POPO

Choices for AntiDiarrheals Choices for AntiDiarrheals in the E.D.in the E.D.

Do not use these in patients with tender Do not use these in patients with tender abdomen or toxicityabdomen or toxicity

Lomotil (diphenoxylate and atropine)Lomotil (diphenoxylate and atropine)2 tabs PO, then one after each diarrheal 2 tabs PO, then one after each diarrheal stool up to 8 per daystool up to 8 per day

Loperamide (Imodium)Loperamide (Imodium)2 mg tabs, same dosing as Lomotil2 mg tabs, same dosing as Lomotil

Codeine 15 to 60 mg PO q 4 hoursCodeine 15 to 60 mg PO q 4 hoursDonnatal elixir 2 tsp PO q 6 hours Donnatal elixir 2 tsp PO q 6 hours (good (good antispasmodic)antispasmodic)

Acute CholecystitsAcute Cholecystits

Usual clinical profile is obese female > age 40Usual clinical profile is obese female > age 40May cause more complications in diabeticsMay cause more complications in diabeticsUsually RUQ +/- epigastric tenderness and emesisUsually RUQ +/- epigastric tenderness and emesisU/S is best Dx testU/S is best Dx testLFT's usually normal ; lipase & amylase elevated if LFT's usually normal ; lipase & amylase elevated if secondary panceatitis (common duct stone)secondary panceatitis (common duct stone)

If cholangitis (severe RUQ tenderness, fever, emesis, If cholangitis (severe RUQ tenderness, fever, emesis, usually elevated LFT's, +/- air in biliary tree on X-ray) : usually elevated LFT's, +/- air in biliary tree on X-ray) : consult surgery emergentlyconsult surgery emergently

Rx : IV fluids, NPO at first, pain meds, surgery consult Rx : IV fluids, NPO at first, pain meds, surgery consult unless quickly resolvesunless quickly resolves

Emphysematous cholecystitis (arrows show gas around the gallbladder)

Acute AppendicitisAcute Appendicitis

Accuracy of Dx on clinical grounds alone is Accuracy of Dx on clinical grounds alone is not goodnot good

Usually periumbilical pain, then migrates to Usually periumbilical pain, then migrates to RLQRLQ

Usually anorexia, nausea, +/- low grade Usually anorexia, nausea, +/- low grade feverfever

KUB film rarely shows diagnostic KUB film rarely shows diagnostic appendicolith in RLQappendicolith in RLQ

U/S and CT can make definitive DxU/S and CT can make definitive DxConsult surgeon if suspectedConsult surgeon if suspected

Acute DiverticulitisAcute Diverticulitis

More common after age 45More common after age 45Typically pain & tenderness in Typically pain & tenderness in LLQ, but can be diffuseLLQ, but can be diffuse

Can result in inflammatory mass Can result in inflammatory mass in LLQ or perforationin LLQ or perforation

CT with contrast is best Dx testCT with contrast is best Dx testMilder cases can be discharged on Milder cases can be discharged on oral antibioticsoral antibiotics

Acute Gastritis ; Peptic Acute Gastritis ; Peptic UlcerUlcer

Typically epigastric pain & Typically epigastric pain & tendernesstenderness

If perforation or severe bleeding, If perforation or severe bleeding, may require laparotomymay require laparotomy

Definitive Dx by endoscopy Definitive Dx by endoscopy preferred over Upper GI contrast preferred over Upper GI contrast study, but not needed for many study, but not needed for many patientspatients

Rx with H2 blockers such as Rx with H2 blockers such as ranitidine (in addition to IV fluids, ranitidine (in addition to IV fluids, etc. for severe cases)etc. for severe cases)

Acute PancreatitisAcute Pancreatitis

Usually diffuse abd. pain + back pain, Usually diffuse abd. pain + back pain, emesis, elevated amylase & lipaseemesis, elevated amylase & lipase

Often attributed to gallstones or Often attributed to gallstones or alcohol, but many cases idiopathicalcohol, but many cases idiopathic

Can have severe complications :Can have severe complications :Hypovolemia, ARDS, hypocalcemia, Hypovolemia, ARDS, hypocalcemia, retroperitoneal bleeding or abscessretroperitoneal bleeding or abscess

CT is Dx method of choiceCT is Dx method of choice

Bowel ObstructionBowel Obstruction

Can be either large or small bowelCan be either large or small bowelMost common causes :Most common causes : Adhesions from prior surgery, Adhesions from prior surgery, incarcerated hernia, cancer, volvulus, incarcerated hernia, cancer, volvulus, mass of parasites, inflammatory mass of parasites, inflammatory bowel diseasebowel disease

Plain X-ray films are key Dx testPlain X-ray films are key Dx testIf possible associated bowel necrosis If possible associated bowel necrosis (infarction), consult surgeon (infarction), consult surgeon emergentlyemergently

Plain film showing small bowel obstruction from adhesions in a 72 year old male

Upright film showing multiple air-fluid levels from small bowel obstruction

Upright film of sigmoid volvulus in a 67 year old male

Supine film showing sigmoid volvulus in a 67 year old male

Upright film showing cecal volvulus in a 62 year old male

Inflammatory Bowel Inflammatory Bowel DiseaseDisease

Two types :Two types :Ulcerative colitisUlcerative colitisCrohn's DiseaseCrohn's Disease

Ulcerative colitis can sometimes Ulcerative colitis can sometimes have complication of "toxic have complication of "toxic megacolon"megacolon"

Complications of either type may Complications of either type may need Rx with high dose IV need Rx with high dose IV steroids in addition to other usual steroids in addition to other usual Rx'sRx's

Acute Salpingitis (Pelvic Acute Salpingitis (Pelvic Inflammatory Disease)Inflammatory Disease)

Typically present as severe lower abd. Typically present as severe lower abd. pain & vaginal dischargepain & vaginal discharge

Get cervical cultures as part of workupGet cervical cultures as part of workupUsually caused by gonococcus or Usually caused by gonococcus or chlamydia, but can involve other chlamydia, but can involve other bacteriabacteria

Rx : IV antibiotics, pain medsRx : IV antibiotics, pain medsAdmit to hospital if :Admit to hospital if :Toxic, pregnant, immunosuppressed, Toxic, pregnant, immunosuppressed, suspected tubo-ovarian abscesssuspected tubo-ovarian abscess

Acute PyelonephritisAcute Pyelonephritis

Usually have dysuria & back pain Usually have dysuria & back pain & CVA tenderness, but can show & CVA tenderness, but can show projected anterior abd. projected anterior abd. tendernesstenderness

Admit to hospital for IV Admit to hospital for IV antibiotics if :antibiotics if :Toxic, hypotensive, persistent Toxic, hypotensive, persistent emesis, pregnant, emesis, pregnant, immunosuppressed, chronic or immunosuppressed, chronic or structural renal disease, failure of structural renal disease, failure of outpatient Rx, diabetic, age < 2 or outpatient Rx, diabetic, age < 2 or > 60> 60

UreterolithiasisUreterolithiasis

Commonly have sudden back or flank and/or Commonly have sudden back or flank and/or abd. pain +/- groin radiation, but not much abd. pain +/- groin radiation, but not much tendernesstenderness

Need early Rx with pain meds (parenteral Need early Rx with pain meds (parenteral NSAID such as ketorolac 30 mg IV is most NSAID such as ketorolac 30 mg IV is most effective) ; IV morphine if more analgesia effective) ; IV morphine if more analgesia neededneeded

Noncontrast spiral CT is Dx method of choiceNoncontrast spiral CT is Dx method of choiceIVP or U/S are alternativesIVP or U/S are alternatives

Should "cover" with antibiotic (such as Bactrim Should "cover" with antibiotic (such as Bactrim or Cipro) if any bacteria noted on urinalysisor Cipro) if any bacteria noted on urinalysis

Over 90 % of patients can be discharged from Over 90 % of patients can be discharged from E.D.E.D.

Urinary RetentionUrinary Retention

Most common in elderly men with Most common in elderly men with benign prostatic hypertrophybenign prostatic hypertrophy

Can occur also from acute prostatitisCan occur also from acute prostatitisRx with foley catheterRx with foley catheterIf bladder residual > 100 cc, should If bladder residual > 100 cc, should leave foley catheter in at least 24 hours leave foley catheter in at least 24 hours to allow bladder to recover its muscle to allow bladder to recover its muscle tonetone

Routine use of coverage antibiotics Routine use of coverage antibiotics while foley is in is debatedwhile foley is in is debated

Acute Viral HepatitisAcute Viral Hepatitis

Incidence greatly decreased by Incidence greatly decreased by use of Hep B and A vaccinesuse of Hep B and A vaccines

Typically present with nausea, Typically present with nausea, emesis, +/- RUQ pain, +/- jaundiceemesis, +/- RUQ pain, +/- jaundice

Need to check serologies on close Need to check serologies on close contacts of index casecontacts of index case

Admit to hospital if Admit to hospital if encephalopathic, GI bleed, encephalopathic, GI bleed, increased protime, hypoglycemicincreased protime, hypoglycemic

Ovarian Cysts and Ovarian Cysts and Complications of Complications of PregnancyPregnancy

U/S is Dx method of choice for U/S is Dx method of choice for thesethese

Ovarian cysts typically have lower Ovarian cysts typically have lower abd. pain & lateralizing abd. pain & lateralizing tenderness +/- adnexal mass on tenderness +/- adnexal mass on examexam

If large amount of blood in pelvis If large amount of blood in pelvis or suspected ovarian torsion on or suspected ovarian torsion on U/S, emergently consult surgeon U/S, emergently consult surgeon or obstetricianor obstetrician

Some Caveats About Some Caveats About Abdominal PainAbdominal Pain

Don't hesitate to treat the patient's Don't hesitate to treat the patient's abd. pain early, even if consulting a abd. pain early, even if consulting a surgeonsurgeonIt has been definitively shown that pain It has been definitively shown that pain meds make the physical exam of the meds make the physical exam of the abd. pain patient MORE reliableabd. pain patient MORE reliable

Don't forget to consider child abuse or Don't forget to consider child abuse or trauma as a cause for abd. paintrauma as a cause for abd. pain

Repeated physical exams over time Repeated physical exams over time may be needed to clarify the Dxmay be needed to clarify the Dx

"Secondary" Aspects to "Secondary" Aspects to Remember for Abdominal Remember for Abdominal PainPain

Oxygen if any possible major systemic Oxygen if any possible major systemic compromisecompromise

Question patient about prior Question patient about prior anesthetic complications if surgery anesthetic complications if surgery anticipatedanticipated

Additional doses of pain meds as Additional doses of pain meds as neededneeded

Tetanus immunization if associated Tetanus immunization if associated skin injuryskin injury

Antibiotics (+/- cultures if indicated)Antibiotics (+/- cultures if indicated)Tell the patient & family what is going Tell the patient & family what is going onon

Abdominal PainAbdominal PainSummarySummary

Assess the ABC's & provide Assess the ABC's & provide emergent Rx if life-threatening emergent Rx if life-threatening cause suspectedcause suspected

Complete exam prior to deciding Complete exam prior to deciding on other Dx testson other Dx tests

Focus on the most likely Dx's Focus on the most likely Dx's initiallyinitially

Decide early if surgical consult or Decide early if surgical consult or hospital admission neededhospital admission needed

Don't forget "secondary" Don't forget "secondary" treatmentstreatments