An Approach to Abdominal An Approach to Abdominal Pain in the EDPain in the ED

Nisarg Shah MD, FACEPNisarg Shah MD, FACEP

IntroductionIntroduction

Complaints related to abdominal pain comprise Complaints related to abdominal pain comprise between 5-7% of all visits to the ED.between 5-7% of all visits to the ED.

Of those, the most common discharge diagnosis Of those, the most common discharge diagnosis is Abdominal Pain NOS. is Abdominal Pain NOS.

Although most abdominal pain is non-emergent Although most abdominal pain is non-emergent and self-limited in nature, attention must be paid and self-limited in nature, attention must be paid to not miss medical and/or surgical emergencies.to not miss medical and/or surgical emergencies.

Important FactorsImportant Factors

Patients rarely present with the classical Patients rarely present with the classical signs/symptoms of acute abdominal pain.signs/symptoms of acute abdominal pain.

Three important factors to consider are age, Three important factors to consider are age, gender, and co-morbidities.gender, and co-morbidities.

Age differencesAge differences

Greater than 50Greater than 50 Biliary diseaseBiliary disease NOSNOS AppendicitisAppendicitis Bowel obstructionBowel obstruction PancreatitisPancreatitis Diverticular diseaseDiverticular disease CancerCancer

Less than 50Less than 50 NOSNOS AppendicitisAppendicitis Biliary tract diseaseBiliary tract disease GynecologicGynecologic PancreatitisPancreatitis Bowel obstructionBowel obstruction

Gender differencesGender differences

MalesMales Perforated ulcerPerforated ulcer GastritisGastritis AppendicitisAppendicitis

FemalesFemales NonspecificNonspecific DiverticulitisDiverticulitis Acute cholecystitisAcute cholecystitis GynecologicGynecologic

ComorbiditiesComorbidities

Immunocompromised i.e. age, Immunocompromised i.e. age, steroids, HIV, sickle cell disease, steroids, HIV, sickle cell disease, malignancymalignancy

CAD, Atrial fibrillation, Peripheral CAD, Atrial fibrillation, Peripheral vascular diseasevascular disease

DiabetesDiabetesDementiaDementiaMultiple surgeriesMultiple surgeries

Types of PainTypes of Pain

Visceral Pain: caused by stretching of fibers Visceral Pain: caused by stretching of fibers innervating the walls of hollow organs or capsules innervating the walls of hollow organs or capsules of solid organs, described as crampy or dull painof solid organs, described as crampy or dull pain

Parietal Pain: caused by irritation of fibers that Parietal Pain: caused by irritation of fibers that innervate the parietal peritoneum, pain is more innervate the parietal peritoneum, pain is more sharp and localizedsharp and localized

Referred Pain: pain at a location distant to the Referred Pain: pain at a location distant to the diseased organ based on embryonological origindiseased organ based on embryonological origin

HistoryHistory

Most diagnoses can be made by Most diagnoses can be made by history alone.history alone.

Careful attention must be paid to:Careful attention must be paid to:Time/mode of onsetTime/mode of onsetDurationDurationLocationLocationCharacter/progressionCharacter/progressionMedical historyMedical historyContributing symptomsContributing symptoms

CaveatCaveat

Although we can agree that history is Although we can agree that history is usually the most important part of usually the most important part of the encounter, urgent determination the encounter, urgent determination of potential surgical emergencies is of potential surgical emergencies is essential.essential.

History – time/mode of History – time/mode of onsetonsetWoken up from sleepWoken up from sleepAbrupt/severe versus gradualAbrupt/severe versus gradualLess severe but increasingLess severe but increasingGradual onset with slow progressionGradual onset with slow progressionIntermittent painIntermittent painAssociated with certain activities – Associated with certain activities –

eating or exerciseeating or exercise

History-DurationHistory-Duration

Acute onset of pain vs. chronic painAcute onset of pain vs. chronic pain

Acute, severe, and worsening pain Acute, severe, and worsening pain suggests a surgical disordersuggests a surgical disorder

Very long duration often, but not Very long duration often, but not always, suggests a less acute causealways, suggests a less acute cause

History-LocationHistory-Location

Four basic Four basic quadrantsquadrants Right upper quadrantRight upper quadrant

Right lower quadrantRight lower quadrant

Left upper quadrantLeft upper quadrant

Left lower quadrantLeft lower quadrant

Three central areasThree central areas EpigastricEpigastric

PeriumbilicalPeriumbilical

SuprapubicSuprapubic

History-Character/ProgressionHistory-Character/Progression

Severity/magnitude of stimulusSeverity/magnitude of stimulusIntermittent crampyIntermittent crampySevere and colickySevere and colickySudden increase Sudden increase Sudden change in sensation or Sudden change in sensation or

locationlocation

Medical HistoryMedical History

Previous surgeryPrevious surgerySexual activitySexual activityMenstrual historyMenstrual historyTravelTravelExposure risk/occupationExposure risk/occupationPsychiatricPsychiatricMedicationsMedicationsComorbiditiesComorbidities

History-Contributing SymptomsHistory-Contributing Symptoms

AnorexiaAnorexiaVomiting (bilious? blood?)/NauseaVomiting (bilious? blood?)/NauseaDiarrheaDiarrheaBleedingBleedingConstipationConstipationObstipationObstipationDysuriaDysuriaSOBSOBChest painChest pain

Physical ExaminationPhysical Examination

The exam serves several important The exam serves several important purposespurposesTo confirm suspicions from the historyTo confirm suspicions from the historyTo localize the area of diseaseTo localize the area of diseaseTo avoid missing extra-abdominal To avoid missing extra-abdominal

causes of paincauses of pain

Physical ExaminationPhysical Examination

General appearance including facial General appearance including facial expression, diaphoresis, pallor, and expression, diaphoresis, pallor, and degree of agitation to distinguish the degree of agitation to distinguish the intensity of the painintensity of the pain

Vital signsVital signs

Physical ExaminationPhysical Examination

Inspection: look for distention, Inspection: look for distention, ecchymosis, scars, herniasecchymosis, scars, hernias

Auscultation: listen for bowel sounds, Auscultation: listen for bowel sounds, pitch, bruitspitch, bruits

Palpation: feel for guarding, masses, Palpation: feel for guarding, masses, tenderness, reboundtenderness, rebound

Percussion: liver size, tympanyPercussion: liver size, tympany

Differential DiagnosisDifferential Diagnosis

The next important step in the The next important step in the evaluation of abdominal pain is to evaluation of abdominal pain is to formulate a differential diagnosisformulate a differential diagnosis

It is helpful to construct a list based It is helpful to construct a list based upon location of abdominal painupon location of abdominal pain

Laboratory EvaluationLaboratory Evaluation

Dependent upon initial history and Dependent upon initial history and physical examinationphysical examination

Most frequently ordered study is the CBCMost frequently ordered study is the CBCAdditional studies may include Additional studies may include

electrolytes, amylase, lipase, LFTs, BUN, electrolytes, amylase, lipase, LFTs, BUN, creatinine, urinalysis, Beta Hcg, lactic acidcreatinine, urinalysis, Beta Hcg, lactic acid

EKGEKG

Imaging StudiesImaging Studies

Plain films:Plain films:CXR or Upright pCXRCXR or Upright pCXRAbdominal seriesAbdominal series

Imaging studies cont’dImaging studies cont’d

CXR help determine the following:CXR help determine the following:Abdominal pain of pulmonary origin - Abdominal pain of pulmonary origin -

pneumonia with diaphragmatic irritationpneumonia with diaphragmatic irritationFree air under diaphragm - perforated Free air under diaphragm - perforated

viscousviscousAir filled viscera in chest – Air filled viscera in chest –

diaphragmatic or hiatal herniadiaphragmatic or hiatal herniaMediastinal air - Boerhave’s tearMediastinal air - Boerhave’s tear

Imaging studies cont’dImaging studies cont’d

Abdominal films can help with:Abdominal films can help with:Fluid filled loops/air fluid levels – Fluid filled loops/air fluid levels –

obstructionobstructionRenal calculiRenal calculiGallstones or air in the biliary treeGallstones or air in the biliary treeMassive dilation of colonMassive dilation of colonLots of stoolLots of stool

ImagingImaging This person most This person most

likely haslikely has Large bowel obstr.Large bowel obstr. Small bowel obstr.Small bowel obstr. Generalized ileusGeneralized ileus Localized ileusLocalized ileus Normal bowel gas Normal bowel gas

patternpattern

ImagingImaging

This person most This person most likely haslikely has Large bowel obstr.Large bowel obstr. Small bowel obstr.Small bowel obstr. Generalized ileusGeneralized ileus Localized ileusLocalized ileus Normal bowel gas Normal bowel gas

patternpattern

ImagingImaging

This person most This person most likely haslikely has Large bowel obstr.Large bowel obstr. Small bowel obstr.Small bowel obstr. Generalized ileusGeneralized ileus Localized ileusLocalized ileus Normal bowel gas Normal bowel gas

patternpattern

ImagingImaging

This person most This person most likely haslikely has Large bowel obstr.Large bowel obstr. Small bowel obstr.Small bowel obstr. Generalized ileusGeneralized ileus Localized ileusLocalized ileus Normal bowel gas Normal bowel gas

patternpattern

ImagingImaging

This person most This person most likely haslikely has Large bowel obstr.Large bowel obstr. Small bowel obstr.Small bowel obstr. Generalized ileusGeneralized ileus Localized ileusLocalized ileus Free intraperitoneal airFree intraperitoneal air

ImagingImaging

Pneumobilia Pneumobilia after after passage of a passage of a gallstone. Take a gallstone. Take a good look at the good look at the liver where the liver where the biliary tract is biliary tract is outlined by air. outlined by air.

ImagingImaging

ImagingImaging

Imaging studies cont’dImaging studies cont’d

Likelihood ratio of finding Likelihood ratio of finding abnormality on xray is increased byabnormality on xray is increased byIncreased/high pitched bowel signsIncreased/high pitched bowel signsDistentionDistentionHistory of abdominal surgeryHistory of abdominal surgeryBlood in urine/history of kidney stonesBlood in urine/history of kidney stonesSevere abdominal pain and tendernessSevere abdominal pain and tendernessAbdominal pain for less than one dayAbdominal pain for less than one day

Imaging studies cont’dImaging studies cont’d

Sonography is the study of choice Sonography is the study of choice for:for:Biliary/hepatobiliary diseaseBiliary/hepatobiliary diseasePregnant womenPregnant womenEvaluation of gynecologic structures – Evaluation of gynecologic structures –

ovarian as well as testicularovarian as well as testicularRapid evaluation of hemoperitoniumRapid evaluation of hemoperitoniumAAAsAAAs

Imaging studies cont’dImaging studies cont’d

CT scanning is now the test of choice for:CT scanning is now the test of choice for: Intraabdominal infections such as diverticulitis, Intraabdominal infections such as diverticulitis,

appendicitis, and post operative infectionsappendicitis, and post operative infections Vasculature of the abdomenVasculature of the abdomen Kidney stonesKidney stones Abdominal herniasAbdominal hernias Defining obstructions, neoplasmsDefining obstructions, neoplasms

Special ConsiderationsSpecial Considerations

Patients bearing special Patients bearing special considerationconsiderationWomen of childbearing ageWomen of childbearing ageElderly patientsElderly patientsChildrenChildrenPatients on immunosuppressivesPatients on immunosuppressives

Women of childbearing ageWomen of childbearing age

Childbearing women – atypical Childbearing women – atypical presentations – pregnant women presentations – pregnant women with appendicitis may present with with appendicitis may present with RUQ pain when uterus displaced RUQ pain when uterus displaced other organs in 2other organs in 2ndnd/3/3rdrd trimesters trimesters

Elderly patientsElderly patients

A low threshold should be used for A low threshold should be used for admitting or admitting elderly admitting or admitting elderly patients.patients.

Their presentation is rarely typical.Their presentation is rarely typical.Their history is rarely clear.Their history is rarely clear.Their comorbidities are many.Their comorbidities are many.

ChildrenChildren

Young children often have difficulty Young children often have difficulty localizing their pain.localizing their pain.

History is limited.History is limited.Obtaining imaging is sometimes Obtaining imaging is sometimes

difficult but imaging has cut down on difficult but imaging has cut down on improper diagnoses.improper diagnoses.

ImmunosuppressivesImmunosuppressives

Anyone on prednisone or other Anyone on prednisone or other immunosuppressive medications be immunosuppressive medications be more careful with as they often more careful with as they often present atypically.present atypically.

Corticosteroids may mask pain.Corticosteroids may mask pain.

Aside About RadiationAside About Radiation

We now image a lot in abdominal We now image a lot in abdominal pain or chest pain. Try to keep in pain or chest pain. Try to keep in mind the large amount of radiation mind the large amount of radiation that we are exposing people to when that we are exposing people to when we are making our diagnostic plan.we are making our diagnostic plan.

Time course of ailmentTime course of ailment

Even if you image someone and the Even if you image someone and the results are normal remember to tell results are normal remember to tell people to still watch for warnings.people to still watch for warnings.

Abdominal CatastrophesAbdominal Catastrophes

Things not to missThings not to missMIMIAAAAAAMesenteric ischemiaMesenteric ischemiaEctopic pregnancyEctopic pregnancyRuptured viscousRuptured viscous

MIMI

Consider Consider in patients with risk factorsin patients with risk factorsIn patients with epigastric painIn patients with epigastric painIn patients who are vomiting, In patients who are vomiting,

particularly inferior wall MIsparticularly inferior wall MIsDiaphoresis is often commonDiaphoresis is often commondiabeticsdiabetics

AAAAAA

Used to be misdiagnosed commonly Used to be misdiagnosed commonly as nephrolithiasis.as nephrolithiasis.

Consider in any patient with CAD, Consider in any patient with CAD, hypertension, testicular pain, flank hypertension, testicular pain, flank pain.pain.

Check for pulsatile mass, abdominal Check for pulsatile mass, abdominal bruits.bruits.

Mesenteric IschemiaMesenteric Ischemia

Pain out of proportion to exam is the Pain out of proportion to exam is the classical description.classical description.

High morbidity/mortalityHigh morbidity/mortalityConsider in older patients with Consider in older patients with

comorbidities such as A. Fib., severe CAD, comorbidities such as A. Fib., severe CAD, CHFCHF

Angiography is test of choice but can be Angiography is test of choice but can be hard to set up in a timely manner so early hard to set up in a timely manner so early consultation is essential.consultation is essential.

Ectopic pregnancyEctopic pregnancy

Perform a pregnancy test in any Perform a pregnancy test in any woman of child bearing age.woman of child bearing age.

If positive get a BQuant.If positive get a BQuant.Depending on the number and your Depending on the number and your

clinical suspicion obtain a pelvic clinical suspicion obtain a pelvic sonogram.sonogram.

Extraabdominal causesExtraabdominal causes

Cardiopulmonary – MI, angina, ptx, Cardiopulmonary – MI, angina, ptx, pnapna

Abdominal wall – cellulitis, shinglesAbdominal wall – cellulitis, shinglesHerniasHerniasMetabolic – DKA, AKA or adrenal Metabolic – DKA, AKA or adrenal

crisis, sickle cell crisiscrisis, sickle cell crisis

Questions???Questions???