Adult Abdominal Pain: How to Work Up, When to Refer. Objectives. History 10/10/2013. By Michael Blew
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1 Adult Abdominal Pain: How to Work Up, When to Refer By Michael Blew Objectives Determine the correct assessments to perform on initial abdominal pain exam Evaluate the value of diagnostics and labs in the abdominal pain workup Initiate care and follow up for common causes of abdominal pain History Most important part of the exam Onset- is this acute or chronic Provocation- does anything make it better or worse Quality- is it visceral, parietal, or referred Radiation- does the pain go anywhere else Severity- how bad is the pain 1
2 Other questions History of the same problem/feeling Nausea/Vomiting Changes in stool Weight loss Medications Recent injuries Discharge Recent trauma Assessment Inspection- Round, hernia, bruising, pulsation Auscultation- Can be normal even with serious pathology. Listen before touching. Palpation- Light then deep. Start away from focal pain. Liver and spleen may be palpated. Percussion- Kidneys, liver, spleen 2
3 Assessment Findings Red Flags Signs of shock, sepsis, or dehydration such as hypotension, tachycardia, tachypnea, or confusion Pain prior to vomiting (more often surgical) No bowel sounds after 3 minutes (somewhat unreliable) Blood in stool or bloody emesis Patient lying still or writhing Involuntary guarding Tenderness to percussion Abdominal pain localized to the periphery of the abdomen or pelvis Laboratory Data Driven solely by assessment and exam findings CBC with diff, CMP, Lipase, Amylase, Lactic Acid, ESR, CRP, H Pylori, HIV, Hep Panel Urinalysis, Urine Culture, HCG Heme Stool, stool wbc, stool culture 3
4 Radiographic and Diagnostic Testing Xray- May miss a large amount of diagnoses, but does have specific indications CT- Gold standard. Needs IV contrast for organ and blood flow evaluation. May need by mouth contrast as well. Ultrasound- Can eval pregnancy and other uses EGD/Colonoscopy- Invasive, but can show ulcers, cancer, GERD, etc. Ectopic Pregnancy Must be a consideration in all women of childbearing age Sudden onset LLQ or RLQ pain Check HCG Normal increases in hcg and Progesterone levels not seen Need an ultrasound Refer to a surgeon Can be life threatening emergency Appendicitis Caused by obstruction of the lumen Most common in young, white, male patients Look for rebound tenderness and other exam discussed earlier Typically pain then nausea worsening over a few hours Urinalysis and CT will assist with diagnosis Ultrasound may be obtained in pregnant patients Can be surgical emergency 4
5 AAA Seen typically in men who are older and tobacco abusers Often time incidental finding Size and growth rate determine surgical need When leaking begins, typically tearing pain in back Poor survival of rupture Cholecystits Mostly females over 40. Obesity also risk factor. Pain is often preceded by fatty meals May have pain in RUQ or epigastric area Jaundice, fever, nausea, and vomiting are often seen in the acute patient Pain can radiate to infrascapular region Diagnosed with ultrasound or CT Labs include WBC, Alk phos, AST, ALT, Bili Cholecystitis Often finding is incidental on CT, does not need further workup unless symptomatic If symptomatic, refer to surgeon for cholecystectomy. If stone in CBD may need ERCP IVF is appropriate in most patients, ABX may be utilized in high risk populations If it is acute, requires hospitalization otherwise can be referred as outpatient 5
6 Sepsis Multiple potential sources such as liver, pancreas, abscess Important to find potential exposures of past medical infections or procedures Deep palpation may reveal prominent organs CT will often times show inflammation or abscess Sepsis CBC, sed rate, crp, procalcitonin, lactic acid may be useful Abscess may need to be drained, there may be other surgical needs IVF volume resuscitation is needed Usually broad spectrum abx used such as flagyl, cipro or levaquin, and zosyn Follow labs and patient assessment findings Obstruction Usually visceral pain and increased bowel sounds with rapid onset pain. Illeus may have decreased bowel sounds and longer onset Emesis of partially digested food Medical history important (opioids, decreased movement, surgical history) Distended abdomen, often times can see on CT (transition Point) and plain film Up to 25% abdominal pain in the elderly Can be hernia, carcinoma, adhesions, impaction/constipation 6
7 Treatment of Obstruction Bowel rest NGT (also assists with patient comfort with decompression) Can be surgical emergency if ischemia or perforation seen Pain can be managed with NSAIDs such as Toradol if there aren t other contraindications Avoid opiods if possible Significant amount of IVF are helpful GI Hemorrhage Upper vs Lower H+H Heme stool/heme emesis EGD/Colonoscopy Capsule Endoscopy Bleeding Scan Need for hospitalization? Peptic Ulcer Sharp pain after eating and at night Stress, ETOH, smoking, NSAIDs, steroids are risk factors as well as H pylori Can perforate and require surgery Can occur in gastric or duodenal area Often treated with PPIs If bleeding apparent or if dysphagia, weight loss, or persistent vomiting, probably needs endoscopy 7
8 H Pylori Common cause of peptic ulcers Diagnosed by egd with biopsy or c-labeled urea breath test Three treatment modalities: Amoxicillin or Tetracycline 500 mg QID plus Metronidazole 250 mg QID, plus Pepto Bismol tablets 2 QID for 7-14 days Metronidazole 500 mg BID plus Omeprazole 20 mg BID plus Clarithromycin 250 mg BID for 7-14 days Clarithromycin 500 mg TID plus Omeprazole 40 mg qd (or 20 mg BID) for 14 days GERD Described as heat burn, acid taste in mouth, dysphagia, chronic cough Motility disorder caused by reflux of acid Very prevalent especially in pregnant individuals Can perform 24hr esophageal ph monitoring EGD/bronchoscopy may show evidence of reflux GERD treatment Lifestyle modification PPIs (prilosec, prevacid, protonix, nexium) H2 Blockers (pepcid, zantac, tagamet) Antacids may help occasional symptoms Prokinetic agents may also be helpful in certain cases 8
9 Diverticulitis Diverticulosis may be found on colonoscopy Diverticulitis often times shows with pain in LLQ and other signs of infection Hx of alternating diarrhea and constipation CT will show the inflamation Bowel rest, hydration, abx (flagyl and floroquinolone) High fiber diet recommended for Diverticulosis Colonoscopy not recommended during diverticulitis due to risk of perforation Hemorrhoids Caused by increased pressure in veins Symptoms include painless bleeding, perianal soiling, itching Coagulation studies and rectal exam May be internal or external Hydrocortisone cream may help itching Stool softeners, sitz baths for non prolapsed Surgery is usually required for prolapsed Pancreatitis Epigastric tenderness and sudden, severe pain May also hear hypoactive bowel sounds History of ETOH or thiazide diuretics or mumps Pain usually worse with food improved with sitting up Check CT, CBC, Amylase, Lipase, CMP 9
10 Pancreatitis Needs hospitalization and close monitoring of electrolytes as well as for perforation (Cullen s or Ggrey Turner s signs) Surgical referral for stones, perforated ulcer, abscess NPO until nausea and pain improves (consider NGT) IVF, possible TPN Chronic pancreatitis occurs when there is persistent inflammation. More in males than females Pyelonephritis Presents with flank pain, fever, n/v U/A, Urine Culture, CBC Signs of sepsis indicate need for hospitalization Look for signs of dehydration for possible need for IVF ABX Ulcerative Colitis Bleeding reported in the acute phase Needs colonoscopy will possible biopsy Prednisone, aminosalicylates may help management Patients may need GI referral for continued care including biologics and immunosuppressive therapies 10
11 Crohns Diarrhea often times with blood, n/v, weight loss Colonoscopy, small bowel follow through will assist with diagnosis It may occur anywhere in the GI tract Skip lesions are seen as well as fistulas, and thickened bowel wall Similar treatment to Ulcerative Colitis Hernia Often benign finding Monitor for incarceration or strangulation Acute colicky pain and n/v may indicate emergent situation May increase risk of GERD Refer to surgeon Hepatitis Best treatment is prevention Vaccine for hep b and hep a, none for hep c A: self limiting seen in contaminated water, institutionalized adults, children in daycare. LFTs 8x normal. Outpatient follow up. B: Highly contagious. Seen in dialysis patients. 5-10% develop chronic HBV. 90% recovery. C: Common cause of nonalcoholic liver dz. Mostly in high risk groups. Often asymptomatic, persistent infection with chronic hepatits common. GI referral 11
12 IBS 75% of patients are female 15-20% of individuals have IBS Diagnosed by abdominal pain for at least 12 weeks plus at least two of the following Change in frequency or consistency of stool Mucus in stool Bloating or abdominal distention Straining, urgency, or inability to empty bowels IBS Treatment depends on predominant symptoms Food diary with stool chart can be very useful Constipation: increase fiber, stool softer, osmotic laxative, prokinetics Diarrhea: Imodium, lomotil, fiber Pain/Bloating: anticholimergics, antidepressants, prokinetics Ensure realistic goals are set 12
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