Abdominal Pain. Abdominal Pain

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 Gastritis, PUD, gastroenteritis Intestines Appendicitis, SBO, diverticulitis, incarcerated hernia, ischemic gut, IBD Pancreas Pancreatitis, pseudocyst Liver Acute hepatitis, biliary tract disease Vessels AAA, Renal/splenic aneurysm Spleen: Splenic rupture Ureters Colic, stones, UTI Uterus PID, fibroids Ovaries and fallopian tubes (ruptured) ectopic, ovarian cyst, Mittelschmerz, torsion Prostate Prostatitis Testicles and associated structures 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 onset P palliation/provocation Q quality R radiation S severity T 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 Need to go to OR! Gallbladder disease Pancreatitis Bowel obstruction PID Torsions 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

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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