Primary Care: Abdominal Pain

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Primary CareAbdominal Pain Gastroenteritis

• Leslie Hershberger, MD

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Objectives

• I. ABDOMINAL PAIN
• Obtain a targeted history in a pt with abd pain
• Perform a physical exam to determine cause of
  pain
• Interpret lab tests to determine etiology of
  pain
• Describe the differential dx of abd pain

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Types of Abdominal Pain

• Visceral
• Somatic
• Referred

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Visceral Pain

• Originates from internal organs and viceral
  peritoneum
• Results from stretching, inflammation, or
  ischemia
• Dull, crampy, burning, gnawing
• Poorly localized

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Somatic Pain

• Originates from abdominal wall or parietal
  peritoneum
• Sharper, more localized

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Referred pain

• Pain felt in areas remote to the disease organ

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Abdominal pain
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History

• Onset (acute vs. chronic)
• Duration of pain
• Location
• Radiation
• Quality and severity
• Associated symptoms
• Alleviating or aggravating factors
• Past medical/surgical history

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Physical Exam

• Vital signs
• Constitutional findings
• Abdomen- inspection, auscultation, percussion,
  palpation
• Pelvic exam
• Rectal exam
• Cardiac/ respiratory exam

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Physical Exam

• Start away from area of pain
• Look for areas of localized tenderness
• Rebound/guarding
• Masses or enlarged organs

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Lab Evaluation

• CBC with diff
• LFT, amylase, lipase
• UA
• HCG on reproductive age women
• electrolytes

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Radiologic Evaluation

• Plain films
• Upright and supine abdomen and CXR
• Ultrasound
• Biliary and pelvic symptoms
• CT abdomen and pelvic
• Evaluate vasculature, inflammation, and solid
  organs

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Differential Diagnoses

• Acute
• Appendicitis
• Cholecystitis
• Pancreatitis
• Diverticulitis
• Perforation
• Obstruction
• Acute ischemia
• Ruptured aortic aneurysm
• Ectopic pregnancy
• PID
• Nephrolithiasis

• Chronic
• Peptic ulcer
• Esophagitis
• IBD
• Chronic pancreatitis
• Chronic ischemia
• Diabetes
• Irritable bowel syndrome
• Abdominal wall pain
• Neurogenic
• musculoskeletal

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Differential

• Acute Cholecystitis
• Cystic duct obstructed
• RUQ or epigastric pain radiating to R scapula
• n/v, fever
• Murphys sign or tender enlarged gallbladder
• LFTs, amylase

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Differential

• Acute appendicitis
• Anorexia, fever, n/v
• vague periumbilical pain that progresses to RLQ
  (McBurneys point)
• Rovsings, psoas, obturator signs
• Elevated WBC
• CT may be useful in dx

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Differential

• Small Bowel Obstruction
• Due to adhesions, hernia
• Crampy, periumbilical pain, n/v, high pitched
  bowel sounds
• Xray- dilated loops of bowel with AF levels
• Partial vs complete obstruction

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Differential

• Perforated duodenal ulcer
• usually in ant duodenal bulb
• Acute abdomen with peritonitis
• CXR with free intraperitoneal air under diaphragm

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Differential

• GYN
• Ectopic pregnancy
• Ovarian torsion
• PID/TOA

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Chronic Abdominal Pain

• Abd pain lasting gt 6 months
• Differentiate organic pain from a pathologic
  process from functional pain
• Functional pain more common

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Irritable Bowel Syndrome

• Affects 15 of Americans
• Abd distention, flatulence, disordered bowel
  function
• More common in women
• Treat with anticholinergic meds and stool
  softeners

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Benign Chronic Abd Pain Syndrome

• Pain present for months to years
• Negative workup
• Women gt men
• Obtain social history (sexual/physical abuse)
• May need psych evaluation or pain management
  specialist

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Summary

• Obtain detailed history
• Thorough exam
• Consider pt circumstances (age, med/surgical
  history)
• Evaluate for progression
• Consult if needed

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Objectives

• II. Gastroenteritis
• Describe the usual cause of gastroenteritis
• Describe the signs and symptoms
• Perform focused physical exam
• Interpret diagnostic tests to determine etiology
  of gastroenteritis
• Treat selected pts with gastroenteritis

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Gastroenteritis

• Inflammation of GI tract
• Due to infectious virus, bacteria, or protozoa
• Acute onset
• Usually lt 10 days
• Self limiting

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Etiology

• Microbes directly invade gut mucosa
• Microbes secrete toxins
• Entertoxin
• Cytotoxin
• neurotoxin

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Etiology

• Bacteria
• Campylobacter jejuni (most common in US)
• Shigella
• Salmonella
• E. Coli
• Vibrio cholera
• Yersinia
• C. dificile
• Vibrio Parahaemolyticus

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Etiolgy

• Viral
• Rotavirus
• Norwalk virus
• Adenovirus
• Calicivirus
• Coronavirus
• astrovirus

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Etiology

• Protozoa
• Giardia lamblia
• Entamoeba histolytica
• Cryptosporidium parvum
• Isospora belli

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Etiology

• Heavy metal (arsenic, lead, Hg, cadmium)
• Broad spectrum antibiotics
• Antacids
• Laxatives
• Cardiac meds

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Symptoms

• Fever
• n/v
• Diarrhea
• Abd cramping
• Malaise and muscular aches may occur

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History

• Ingestion of potentially contaminated food or
  untreated water
• Recent travel
• Sick contacts
• Recent Abx use
• Outbreaks
• Bloody diarrhea

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Physical Exam

• Vital signs
• Constitutional findings
• Abdomen- inspection, auscultation, percussion,
  palpation
• Pelvic exam
• Rectal exam
• Cardiac/ respiratory exam

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Diagnosis

• Stool exam for fecal WBCs, ova , parasites
• Stool culture
• Endoscopy if noninfectious etiology suspected
  (inflammatory bowel disease)

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Treatment

• Rehydration oral vs. IV
• Antiemetics
• Antidiarrheals
• Decrease intestinal motility
• Diphenoxylate, loperamide, codeine
• /- antibiotics
• Shigella, Yersinia, campylobacter, cholera, c.
  dificile, giardia

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Antibiotic associated diarrhea

• Develops in 1-15 of pts receiving broad spectrum
  abx
• C. Dificile proliferates in colonic mucosa when
  normal flora is disturbed
• May cause pseudomembranous colitis
• Stop responsible abx
• Stool assay for C. dif toxins
• Rx
• Moderately ill- flagyl 500 mg q8hr x 7 days
• Extremely ill- oral vancomycin

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The End!