Acute Abdominal PainVishal Bhella, MD, CCFP

PGY3, Academic Family Medicine

Review relevant history for abdominal pain presentations

Review differentials for various abdominal pain presentations

Review some common and important presentations

Objectives

Onset – What was the patient doing when the symptoms started? Acute versus Gradual?

Provoking/Palliative factors – Factors that exacerbate or improve symptoms for example food, antacids, exertion, defecation?

Quality – Characteristics of pain/symptoms – Is it sharp or dull? Is it constant or it comes and goes?

History

Region/Radiation – Can you point with one finger where it hurts the most? Does the pain radiate or move anywhere else?

Severity - On a scale of 1 to 10, how would you rate your level of discomfort right now? Using the same scale, how would you rate your discomfort when it first began?

Timing - When did the symptoms first begin? Have you ever experienced these symptoms before? If so, when?

History continued

Associated symptoms: fevers, chills, weight loss/gain, nausea, vomiting, diarrhea, constipation, melena, jaundice, change of colour of urine or stool

Past medical and surgical history Family history Alcohol intake/Smoking Medications including NSAIDS Women: Menstrual history, ?Pregnancy

History continued

The 'surgical abdomen' can be usefully defined as a condition with a rapidly worsening prognosis in the absence of surgical intervention

Two syndromes that constitute urgent surgical referrals are complete obstruction and peritonitis.

Patients with peritonitis tend to lie very still to minimize discomfort

Peritonitis manifests on physical examination as rebound tenderness, or pain upon removal of pressure rather than application of pressure to the abdomen.

Rigidity and tenderness with percussion Often patients will be guarding during physical

examination.

Is this a surgical abdomen?

Obstruction presents as pain with anorexia, bloating, nausea and vomiting along with constipation and obstipation

Patients who have evolved from partial to complete bowel obstruction may present with weeks of vague abdominal pain, followed by a sudden deterioration

Typically in cases of surgical abdomen – pain is severe and it can be associated with unstable vital signs, fever, and dehydration.

Obstruction

Patients with a surgical abdomen – consider the following laboratory measurements:

CBC, Electrolytes, BUN, creatinine, and glucose LFTs: Aminotransferases, alkaline phosphatase, and bilirubin Lipase Urinalysis, Pregnancy test in women of childbearing potential In the presence of fever or unstable vital signs, blood and urine

cultures should be performed. Abdominal radiograph: proximally dilated loops of bowel are the

hallmark of intestinal obstruction, and free intra-peritoneal air can confirm a suspicion of hollow organ perforation

In the case of suspected partial or complete intestinal obstruction, a CT scan of the abdomen is more sensitive than plain abdominal radiographs

Ultrasound a good initial test to assess - ?Appendicitis/Intra-pelvic pathology/Abdominal abscess

Investigations

Mr. D is a 46 year old man complaining of stomach pain◦ Subacute onset of epigastric pain, stable vitals,

mild to moderate discomfort

Case 1

Dyspepsia is a group of symptoms which alerts physicians to consider diseases of the upper gastrointestinal tract including - upper abdominal discomfort, nausea, bloating, fullness and early satiety amongst others

Dyspepsia

Eliminate precipitating agents – NSAIDS, Alcohol

Consider trial of PPI or H2 receptor antagonist for 4 weeks

• H. Pylori treatment - HP-PAC-(lansoprazole, amoxicillin, clarithromycin package)

Timely investigations including endoscopy is indicated for ◦ New onset symptoms over age 50◦ Alarm features◦ Failure to respond to pharmacotherapy

Dyspepsia

Mr. P is a 50 year old man complaining of nausea and vomiting◦ Relatively sudden onset, no appetite, history of

alcohol use

Case 2

Sudden onset epigastric pain associated with nausea, vomiting, anorexia – think pancreatitis

Risk factors for pancreatitis ◦ Gallstones◦ Alcohol use◦ Recent ERCP◦ Trauma

Lab findings: High amylase/lipase Treatment: NPO/hydration/analgesia/antibiotics May need urgent ERCP

Pancreatitis

Biliary: cholecystitis, cholelithiasis, cholangitis

Cardiac: myocardial infarction, pericarditis Gastric: esophagitis, gastritis, peptic ulcer Pancreatic: mass, pancreatitis Vascular: aortic dissection, mesenteric

ischemia

Epigastric pain

Mrs. C is a 40 year old woman complaining of off/on sharp pains after eating◦ Slightly obese lady, severe pain episodes, right

upper quadrant, worse with heavy meals

Case 3

Cholecystitis

The patient with acute cholecystitis usually presents with unremitting and intensifying pain at the right side of the abdomen, often associated with fever and vomiting.

Indicators such as right upper quadrant pain and Murphy’s sign (i.e., inspiratory arrest with palpation of the right upper quadrant) are present in about one half of older patients

Complications include acute ascending cholangitis, gallbladder perforation, emphysematous cholecystitis, bile peritonitis, and gallstone ileus.

Acute ascending cholangitis :Charcot’s triad (i.e., fever, jaundice, and right upper quadrant pain). The majority of patients have an elevated alkaline phosphatase level, 50 percent have positive blood cultures, and approximately 40 percent have hyperbilirubinemia.

Reynold’s pentad (i.e., Charcot’s triad plus shock and mental status changes.

Cholecystitis

Right upper quadrant Biliary: cholecystitis, cholelithiasis,

cholangitis Colonic: colitis, diverticulitis Hepatic: abscess, hepatitis, mass Pulmonary: pneumonia, embolus Renal: nephrolithiasis, pyelonephritis

Right upper quadrant pain

Mrs. P is a 35 year old female with left sided pain, fever, nausea.◦ Pain is worst in left flank, having nausea, with a

couple of episodes of emesis, decreased appetite

Case 4

Typical microorganisms: E.coli, Klebsiella, Proteus, Enterococcus, S. Saprophyticus

Symptoms – Fever, chills, nausea, vomiting, myalgia, malaise, CVA tenderness or exquisite flank pain, lower urinary tract symptoms (urgency, frequency, dysuria)

Tx with 10-14 day course of Septra. Ciprofloxacin x 7 days has activity against Pseudomonas

IV antibiotics in severe cases. Switch to oral when tolerating po intake

Pyelonephritis

Cardiac: angina, myocardial infarction, pericarditis

Gastric: esophagitis, gastritis, peptic ulcer Pancreatic: mass, pancreatitis Renal: nephrolithiasis, pyelonephritis Vascular: aortic dissection, mesenteric

ischemia

Left upper quadrant pain

Mr. A is a 67 year old gentleman with sudden onset severe abdominal pain.◦ Pain severe, sharp, mid to upper abdominal pain.

Mr. A looks very unwell, is hypotensive and exhibits signs of shock and peritonitis. A pulsatile abdominal mass is noted.

Case 5

AAA dissection is a life threatening emergency

Some other differentials in such a presentation include◦ Perforated PUD◦ Appendicitis/diverticulitis with perforation◦ Mesenteric ischemia

• Always remember to r/o AAA and mesenteric ischemia in an elderly presenting with moderate-severe abdominal pain

AAA

Colonic: early appendicitis Gastric: esophagitis, gastritis, peptic ulcer,

small-bowel mass or obstruction Vascular: aortic dissection, mesenteric

ischemia

Periumbilical Pain

Ms. A is an 18 year old female presenting with nausea, vomiting and abdominal pain◦ Acute onset, slight fever, significant right lower

quadrant pain

Case 6

Abdominal pain with anorexia, nausea and vomiting

Classic pattern is pain initially periumbilical, constant, dull, poorly localized and then localized over McBurney’s point

CBC may show leukocytosis β-hCG in women to rule out ectopic

pregnancy Management: Hydrate, correct electrolyte

abnormalities, appendectomy

Appendicitis

Colonic: appendicitis, colitis, diverticulitis, IBD, IBS

Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID

Renal: nephrolithiasis, pyelonephritis

Right lower quadrant pain

Mrs. D is a 60 year old woman presenting with LLQ pain.◦ Elderly woman with subacute onset of abdominal

pain, localized peritoneal signs, lack of severe systemic symptoms

Case 7

Key learning points:◦ Generally a disease of the elderly, 20% < 50◦ Distinguish between complicated vs. uncomplicated

diverticulitis, complicated is characterized by: Large abscess > 4cm (requires CT-guided drainage generally) Generalized peritoneal signs Fistula formations: colovesical (male), colovaginal,

colocutaneous Some differentials to consider:

◦ Intra-abdominal abscess◦ Mesenteric ischemia◦ Ovarian cysts (consider malignancy in post-menopausal

women)◦ Renal colic, pyelonephritis/UTI

Diverticulitis

Require broad-spectrum antibiotics 7-10d: Outpatient: ciprofloxacin + metronidazole Inpatient: 3rd generation

cephalosporin/fluoroquinolne + metronidazole CT is best imaging modality

• Recurrence rate for 1st-timers ~ 60-70%; ~20% of initial presentations require surgical intervention

Diverticulitis

Colonic: colitis, diverticulitis, IBD, IBS Gynecologic: ectopic pregnancy, fibroids,

ovarian mass, torsion, PID Renal: nephrolithiasis, pyelonephritis

Left lower quadrant pain

Ms. P is a 19 year old female complaining of not feeling well and having lower abdominal pain.◦ LMP 1 week ago, is sexually active – uses OCP for

birth control but no other protection. Cervical motion tenderness on pelvic exam

Case 8

Case presents woman of child bearing age with lower abdo pain and risk factors for STI.

Consider Pelvic Inflammatory Disease in this setting. Note that 1 out of 3 women with PID have a fever.

As well, difficult to rule in or out PID based on history, physical or lab work.

Should rule out ectopic pregnancy, ovarian abscess and appendicitis. Some other considerations include:◦ Ovarian torsion◦ Cystitis◦ Large bowel: constipation, mesenteric adenitis,

inflammatory bowel disease◦ Urinary stone – bladder stone (uncommon)

PID

Diagnostic Considerations:◦ Only 1/3 women with PID have fever◦ No history/physical/lab test can definitively rule in/out PID◦ Minimal criteria:

Lower abdo pain Adnexal tenderness Cervical motion tenderness

◦ Additional criteria: Fever > 38.3 ESR, CRP Swabs/urine confirm Gonorrhea/Chlamydia Transvaginal U/S – fluid filled tubes, tubo-ovarian complex Endometritis from endometrial biopsy / laparoscopy

PID

Management:◦ Determine if needs admission:

Surgical emergencies such as appendicitis cannot be excluded. Pregnant No response to oral antimicrobial therapy Unable to follow or tolerate an outpatient oral regimen Severe illness, nausea and vomiting, or high fever Tubo-ovarian abscess

◦ Think of Gonorrhea, Chlamydia, and anerobes◦ Outpatient therapy:

1st: Ceftriaxone 250 mg IM X1, doxycycline 100 mg po bid 14d +/- metronidazole 500 mg po bid 14d

2nd: Ofloxacin 400 mg po bid 14d +/- metronidazole 500 mg po bid 14d, OR Levofloxacin 500 mg po od 14 d +/- metronidazole 500 mg po bid 14d

PID

Colonic: appendicitis, colitis, diverticulitis, IBD, IBS

Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID

Renal: cystitis, nephrolithiasis, pyelonephritis

Suprapubic pain

Ms I is a 70 year old female who presents with rapid onset of severe periumbilical abdominal pain, which is out of proportion to findings on physical examination. Nausea and vomiting are present.

Case 9

Acute abdomen with metabolic acidosis = Ischemic bowel until proven otherwise.

Risk factors: Atrial Fibrillation, CHF, Peripheral Vascular Disease, or a history of hypercoagulability, Atherosclerotic disease

Common sites: Superior Mesenteric Artery supplied territory “watershed” areas of colon - splenic flexure, left colon, sigmoid colon

Lab investigations: Leukocytosis. Serum lactate elevation. Amylase, LDH, CK, ALP

Contrast CT CT angiography is gold standard for acute arterial ischemia Treatment: Fluid resuscitation, NPO, antibiotics,

Laparotomy

Intestinal Ischemia

Mr. M is a 55 year old man with vague, constant, upper abdominal discomfort◦ Sudden onset while doing errands, some SOB,

worse with continued exertion, settles slightly at complete rest. Physical exam - no palpable abdominal pain.

Case 10

MYCARDIAL INFARCTION – Topic for another lecture.

Cardiac pain

Extra-abdominal?

Cardiac, RespiratoryMetabolic, Vascular

Toxic, MSK, Trauma, Psych

Specific diseases

Differential Diagnosis Should Include Extra-Abdominal Sources