An Approach to Abdominal Pain in the ED

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An Approach to Abdominal Pain in the ED

• Nisarg Shah MD, FACEP

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Introduction

• Complaints related to abdominal pain comprise
  between 5-7 of all visits to the ED.
• Of those, the most common discharge diagnosis is
  Abdominal Pain NOS.
• Although most abdominal pain is non-emergent and
  self-limited in nature, attention must be paid to
  not miss medical and/or surgical emergencies.

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Important Factors

• Patients rarely present with the classical
  signs/symptoms of acute abdominal pain.
• Three important factors to consider are age,
  gender, and co-morbidities.

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Age differences

• Greater than 50
• Biliary disease
• NOS
• Appendicitis
• Bowel obstruction
• Pancreatitis
• Diverticular disease
• Cancer

• Less than 50
• NOS
• Appendicitis
• Biliary tract disease
• Gynecologic
• Pancreatitis
• Bowel obstruction

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Gender differences

• Males
• Perforated ulcer
• Gastritis
• Appendicitis

• Females
• Nonspecific
• Diverticulitis
• Acute cholecystitis
• Gynecologic

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Comorbidities

• Immunocompromised i.e. age, steroids, HIV, sickle
  cell disease, malignancy
• CAD, Atrial fibrillation, Peripheral vascular
  disease
• Diabetes
• Dementia
• Multiple surgeries

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Types of Pain

• Visceral Pain caused by stretching of fibers
  innervating the walls of hollow organs or
  capsules of solid organs, described as crampy or
  dull pain
• Parietal Pain caused by irritation of fibers
  that innervate the parietal peritoneum, pain is
  more sharp and localized
• Referred Pain pain at a location distant to the
  diseased organ based on embryonological origin

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History

• Most diagnoses can be made by history alone.
• Careful attention must be paid to
• Time/mode of onset
• Duration
• Location
• Character/progression
• Medical history
• Contributing symptoms

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Caveat

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

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History time/mode of onset

• Woken up from sleep
• Abrupt/severe versus gradual
• Less severe but increasing
• Gradual onset with slow progression
• Intermittent pain
• Associated with certain activities eating or
  exercise

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History-Duration

• Acute onset of pain vs. chronic pain
• Acute, severe, and worsening pain suggests a
  surgical disorder
• Very long duration often, but not always,
  suggests a less acute cause

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History-Location

• Four basic quadrants
• Right upper quadrant
• Right lower quadrant
• Left upper quadrant
• Left lower quadrant

• Three central areas
• Epigastric
• Periumbilical
• Suprapubic

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History-Character/Progression

• Severity/magnitude of stimulus
• Intermittent crampy
• Severe and colicky
• Sudden increase
• Sudden change in sensation or location

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Medical History

• Previous surgery
• Sexual activity
• Menstrual history
• Travel
• Exposure risk/occupation
• Psychiatric
• Medications
• Comorbidities

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History-Contributing Symptoms

• Anorexia
• Vomiting (bilious? blood?)/Nausea
• Diarrhea
• Bleeding
• Constipation
• Obstipation
• Dysuria
• SOB
• Chest pain

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Physical Examination

• The exam serves several important purposes
• To confirm suspicions from the history
• To localize the area of disease
• To avoid missing extra-abdominal causes of pain

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Physical Examination

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

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Physical Examination

• Inspection look for distention, ecchymosis,
  scars, hernias
• Auscultation listen for bowel sounds, pitch,
  bruits
• Palpation feel for guarding, masses, tenderness,
  rebound
• Percussion liver size, tympany

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Differential Diagnosis

• The next important step in the evaluation of
  abdominal pain is to formulate a differential
  diagnosis
• It is helpful to construct a list based upon
  location of abdominal pain

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Laboratory Evaluation

• Dependent upon initial history and physical
  examination
• Most frequently ordered study is the CBC
• Additional studies may include electrolytes,
  amylase, lipase, LFTs, BUN, creatinine,
  urinalysis, Beta Hcg, lactic acid
• EKG

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Imaging Studies

• Plain films
• CXR or Upright pCXR
• Abdominal series

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Imaging studies contd

• CXR help determine the following
• Abdominal pain of pulmonary origin - pneumonia
  with diaphragmatic irritation
• Free air under diaphragm - perforated viscous
• Air filled viscera in chest diaphragmatic or
  hiatal hernia
• Mediastinal air - Boerhaves tear

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Imaging studies contd

• Abdominal films can help with
• Fluid filled loops/air fluid levels obstruction
• Renal calculi
• Gallstones or air in the biliary tree
• Massive dilation of colon
• Lots of stool

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Imaging

• This person most likely has
• Large bowel obstr.
• Small bowel obstr.
• Generalized ileus
• Localized ileus
• Normal bowel gas pattern

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Imaging

• This person most likely has
• Large bowel obstr.
• Small bowel obstr.
• Generalized ileus
• Localized ileus
• Normal bowel gas pattern

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Imaging

• This person most likely has
• Large bowel obstr.
• Small bowel obstr.
• Generalized ileus
• Localized ileus
• Normal bowel gas pattern

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Imaging

• This person most likely has
• Large bowel obstr.
• Small bowel obstr.
• Generalized ileus
• Localized ileus
• Normal bowel gas pattern

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Imaging

• This person most likely has
• Large bowel obstr.
• Small bowel obstr.
• Generalized ileus
• Localized ileus
• Free intraperitoneal air

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Imaging

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

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Imaging
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Imaging
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Imaging studies contd

• Likelihood ratio of finding abnormality on xray
  is increased by
• Increased/high pitched bowel signs
• Distention
• History of abdominal surgery
• Blood in urine/history of kidney stones
• Severe abdominal pain and tenderness
• Abdominal pain for less than one day

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Imaging studies contd

• Sonography is the study of choice for
• Biliary/hepatobiliary disease
• Pregnant women
• Evaluation of gynecologic structures ovarian as
  well as testicular
• Rapid evaluation of hemoperitonium
• AAAs

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Imaging studies contd

• CT scanning is now the test of choice for
• Intraabdominal infections such as diverticulitis,
  appendicitis, and post operative infections
• Vasculature of the abdomen
• Kidney stones
• Abdominal hernias
• Defining obstructions, neoplasms

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Special Considerations

• Patients bearing special consideration
• Women of childbearing age
• Elderly patients
• Children
• Patients on immunosuppressives

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Women of childbearing age

• Childbearing women atypical presentations
  pregnant women with appendicitis may present with
  RUQ pain when uterus displaced other organs in
  2nd/3rd trimesters

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Elderly patients

• A low threshold should be used for admitting or
  admitting elderly patients.
• Their presentation is rarely typical.
• Their history is rarely clear.
• Their comorbidities are many.

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Children

• Young children often have difficulty localizing
  their pain.
• History is limited.
• Obtaining imaging is sometimes difficult but
  imaging has cut down on improper diagnoses.

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Immunosuppressives

• Anyone on prednisone or other immunosuppressive
  medications be more careful with as they often
  present atypically.
• Corticosteroids may mask pain.

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Aside About Radiation

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

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Time course of ailment

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

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Abdominal Catastrophes

• Things not to miss
• MI
• AAA
• Mesenteric ischemia
• Ectopic pregnancy
• Ruptured viscous

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MI

• Consider
• in patients with risk factors
• In patients with epigastric pain
• In patients who are vomiting, particularly
  inferior wall MIs
• Diaphoresis is often common
• diabetics

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AAA

• Used to be misdiagnosed commonly as
  nephrolithiasis.
• Consider in any patient with CAD, hypertension,
  testicular pain, flank pain.
• Check for pulsatile mass, abdominal bruits.

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Mesenteric Ischemia

• Pain out of proportion to exam is the classical
  description.
• High morbidity/mortality
• Consider in older patients with comorbidities
  such as A. Fib., severe CAD, CHF
• Angiography is test of choice but can be hard to
  set up in a timely manner so early consultation
  is essential.

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Ectopic pregnancy

• Perform a pregnancy test in any woman of child
  bearing age.
• If positive get a BQuant.
• Depending on the number and your clinical
  suspicion obtain a pelvic sonogram.

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Extraabdominal causes

• Cardiopulmonary MI, angina, ptx, pna
• Abdominal wall cellulitis, shingles
• Hernias
• Metabolic DKA, AKA or adrenal crisis, sickle
  cell crisis

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Questions???