Abdominal Pain

Scenario

You are called by a nurse to evaluate a patient on the inpatient medicine service with abdominal pain (cross-cover)

“Worst case scenario” DDx

“Surgical abdomen” – condition with rapidly worsening prognosis without surgical intervention• Obstruction

• Peritonitis– Viscus perforation (e.g., intestine, pelvic organ)

– Intraperitoneal hemorrhage (e.g., ruptured AAA)

– Intraabdominal abscess

– (SBP is medically managed)

Location, location, location

RUQ:• Biliary colic

• Cholecystitis

• Cholangitis

• Hepatitis

DDx

Epigastric:• Pancreatitis

• Dyspepsia/PUD

• Gastroparesis

• Cardiac ischemia

• Pulmonary pathology affecting lower lungs/pleura (PNA, PE, pulmonary infarct, empyema)

DDx Lower abdominal:

• Colitis/enteritis (infectious, ischemic, IBD)• Diverticulitis• Appendicitis• Cystitis• Renal colic (flank), pyelonephritis (CVA tenderness)• Gynecologic: PID, adnexal cysts/masses (bleeding,

torsion, rupture), fibroids, ectopic

DDx

Generalized:• Intestinal ischemia/infarction

• Endocrinopathies: DKA, hypercalcemia, adrenal insufficiency

• Constipation

• Pain syndromes: functional abdominal pain, IBS, fibromyalgia, somatoform disorder, narcotic-seeking behavior

First steps

Is the patient unstable (phone)? Is the patient sick (bedside)? If yes to above ABCs, consider ICU Xfer

History All about the pain

• Onset, what patient was doing/had recently done (e.g. just finished a meal, ERCP yesterday)

• Ever had this pain before?• Location, radiation• Character:

– Dull/achy/vague (visceral)– Sharp/well-localized : parietal (2/2 peritoneal irritation)– Colicky

• Severity

History

Aggravating/alleviating factors– Food : aggravates intestinal ischemia, alleviates some cases

of PUD

– Position : peritonitis aggravated by any movement, pancreatitis alleviated by sitting up and leaning forward

Associated symptoms– N/V (bloody, bilious, feculent), diarrhea/constipation,

melena/hematochezia, vaginal discharge/bleeding

History

STD risk/symptoms

Possibility of pregnancy

Medical history: diabetes, chronic liver disease, IBD, rheumatologic disease, immunocompromised, prior abdominal surgeries

Abdominal Exam General appearance, level of discomfort Vitals: fever, HoTN Inspection

• Bulging (ascites, mass)• Signs of chronic liver disease (jaundice, dilated superficial

veins, spider angiomata)• Scars

Auscultation:• Absent bowel sounds (adynamic ileus, advanced

peritonitis)• Hyperactive, high-pitched bowel sounds (early bowel

obstruction)

Abdominal Exam Palpation/Percussion

• Gently assess for peritonitis– Muscle rigidity (guarding) – may be focal or diffuse– Rebound tenderness– “Shake tenderness” – bump the bed

• Start away from the pain• Tympany (distended bowel)• Pain out of proportion to exam (intestinal

ischemia/infarction)• Murphy’s sign, hepatomegaly• Ascites (SBP)• Pulsatile mass (AAA)

Exam Rectal exam

• Have to justify not doing it• Impaction, tenderness, check stool for occult blood

Pelvic exam• If suspect pelvic pathology (e.g., woman with lower abdominal

pain)• Bleeding, discharge• CMT• Adnexal/uterine pathology

Don’t forget the heart, lungs, eyes/skin (jaundice), pulses (AAA)

Whole exam can be done rapidly

Labs• CBC: leukocytosis, anemia• CMP: hepatic/renal function, electrolytes, anion gap• Lipase• UA• Lactate (ischemia/infarction)• Urine hcg• Blood Cultures: if febrile or unstable• Stool Cx/O+P/C. Diff• Wet mount of vaginal discharge/GC/Chlamydia• Troponin, EKG• ABG

Imaging Abdominal X-ray:

• “bones, stones, mass, and gas”

• Different from KUB which is centered lower in the abdomen

• Supine and upright/L lateral decubitus views

• Obstruction proximally dilated bowel loops, air-fluid levels

• Viscus rupture intraperitoneal free air (see under diaphragm, over liver)

• Toxic megacolon (C. Diff) markedly dilated bowel +/- perforation

• Ileus, intestinal pseudoobstruction dilated bowel extending to rectum

• Constipation

Imaging

CT Abdomen/Pelvis (with contrast):• Higher diagnostic accuracy than plain radiographs

• Intraperitoneal free air

• Obstruction (may see transition point)

• Intestinal ischemia

• Viscus inflammation

• Abscess

• AAA leak/rupture

• Pancreatitis

Imaging Ultrasound:

• RUQ : cholecystitis, gallstones, biliary dilation, cholangitis

• Pelvic: fibroids, adnexal masses, IUP, ectopic pregnancy, free pelvic fluid

• Renal

• Pregnancy

CXR:• If pulmonary pathology suspected

• May need follow-up chest CT

Therapy/Management

Consultation:• Emergent surgical consult if acute abdomen

• Biliary consult if biliary dilation, choledocholithiasis ERCP/MRCP

• GI consult if dyspepsia with red flag symptoms (e.g., dysphagia, wt. loss, persistent vomiting) EGD +/- Bx

• GYN consult if complex pelvic disease

Therapy/Management

Some therapeutic examples:• Ileus:

– Decompression with NGT to suction, NPO

• Constipation/fecal impaction: – Manual disimpaction, stool softeners, laxatives

• Enterocolitis, diverticulitis, cholangitis, PID: – ABx

Therapy/Management

Diagnosis is often unclear after initial assessment• Serial assessments, watchful waiting

If you didn’t document, you didn’t do it• Initial assessment, f/u assessments

• If cross-covering, give appropriate sign-out

Take-Home Points Is the patient sick? (phone, prompt bedside

assessment) R/o surgical abdomen Very focused history and exam Relevant labs and imaging (think before you order) Use your consultants Watchful waiting – good medicine when used

correctly Documentation