Common Chief Complaints

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Common Chief Complaints

• Abdominal Pain
• UCI Emergency Medicine

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Abdominal Pain
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Acute Abdominal Pain

• Acute Abd. Pain- pain of less than 1 weeks
  duration
• Single most common ED CC
• Admission rates 18- 42
• Age greater than age 65-admit rates 63

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Abdominal Pain

• Visceral Pain
• Stretching of fibers innervating hollow or solid
  organs
• Parietal Pain
• somatic irritation of fibers that innervate
  the parietal peritoneum

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Abdominal Pain

• Intra-abdominal
• GI- appy, biliary, SBO, pancreatitis,
  diverticulitis
• GU- renal colic, acute scrotum
• GYN- PID, Ectopic
• Vascular-AAA, mesenteric ischemia, ischemic
  colitis

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Abdominal Pain

• Extra-abdominal
• Cardiopulmonary
• Infectious
• Metabolic
• Nonspecific (Abdominal pain of unclear etiology)
• most common ED dx

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Abdominal Pain

• Historical Features
• Pain attributes location, quality, severity,
  onset, duration, aggravating and alleviating
  factors
• PMHX
• similar symptoms, dx
• meds, chronic diseases, trauma
• social history
• surgical history

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Abdominal Pain

• Associated symptoms
• GI- anorexia, nausea, vomiting
• least helpful, non-specific
• 40-60 patients
• GU- hallmark is alteration in urination
• dysuria, urgency, frequency

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Abdominal Pain

• Associated symptoms
• Gynecologic system
• Sexual history
• LMP, pregnancies, STDs presence of vaginal
  discharge
• Vascular system
• cardiac history, HTN, aortic aneurysm atrial
  fibrillation

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Abdominal Pain

• Physical Exam
• Vital Signs
• General appearance
• mental status
• diaphoresis, pallor, agitation

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Abdominal Pain

• Abdominal exam
• inspection
• distention (air or fluid), scars, masses
• Auscultation
• absent or diminished bowel sounds
• 100 pts w/ peritonitis- 1/2 had nl. bs
• 25 pts w/ SBO had absent bs

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Abdominal Pain

• Abdominal Exam
• Palpation- most clinically useful
• Start at point farthest from maximum pain
• Useful if localized to one quadrant

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Abdominal Pain

• Abdominal Exam
• Rebound-
• in 1 of 4 pts w/ o peritonitis
• cough pain more specific
• combination of rigidity and referred pain
• Rigidity- involuntary guarding
• reflex spasm of abdominal muscles
• suggestive of underlying peritoneal inflammation

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Abdominal Pain

• Abdominal exam
• check for masses, hernias
• pelvic exam in women
• GU exam in men
• rectal exam in all
• OB in 10 w/ NSAP
• appearance of stool

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Abdominal Pain

• Laboratory evaluation
• CBC- study of 1800 pts
• WBC gt 10,000 doubled odds of appendicitis
• WBC lt 10,000 decreased odds by 1/2
• 28 pts. W/ NSAP had WBC gt 10,500
• Not of value in distinguishing pts. W/ NSAP from
  more serious dx.
• Serial WBC may be useful

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Abdominal Pain

• Radiographs
• AAS- CXR, supine and erect abdominal films
• limited utility
• non-diagnostic
• over utilized
• almost always normal or non-specific

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Abdominal Pain

• Diagnosis vs. disposition
• appropriate disposition takes precedence over
  diagnosis
• diagnostic accuracy of 50-60
• discharge error rate 1-4

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Abdominal Pain

• Final Diagnosis
• 10,000 cases over 10 year period
• Nonspecific abdominal pain
• Appendicitis
• Biliary tract disease

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Appendicitis

• 20 of pts. Initial dx. is missed
• Normal appendices found intraoperatively 15-40
  of the time
• Helpful physical findings
• RLQ pain, pain that migrates from periumbilcal
  area to RLQ, pain before vomiting, rigidity,
  psoas sign

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Appendicitis

• Excluding appendicitis
• Absence of RLQ pain
• Presence of similar previous pain
• Absence of migratory pain
• Unsure ?
• CT- changed management in 59 of cases

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Biliary Tract Disease

• Encompasses cholecystitis, biliary colic and
  symptomatic common duct obstruction
• Most common ED Dx in ptsgt age 50
• Majority of pts lack fever
• A large minority lack leukocytosis

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Biliary Colic

• Evaluation
• CBC, LFTs Lipase
• Ultrasound
• Treatment
• IVF, pain control, antiemetics
• Surgical evaluation

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Small Bowel Obstruction

• 2/3 of pts present with generalized or central
  abdominal pain
• 1/3 have generalized tenderness
• Positive predictive value
• Previous abdominal surgery
• Intermittent/colicky pain
• Abdominal distention

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Small Bowel Obstruction

• Early presentation may be subtle
• AAS not always useful
• Consider CT

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Pancreatitis

• 80 caused by alcohol or gallstones
• Pain usually located in upper ½ of abdomen
• Best screening test- lipase
• Consider CT if peripancreatic fluid collection or
  glandular necrosis is suspected

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Diverticulitis

• Localized LLQ pain present in , ¼ of cases
• Tenderness generalized, or LLQ
• Elderly at risk for colonic perforation and
  abcess formation
• Diagnostic test- CT with contrast

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Renal Colic

• Typical features of pain
• Unilateral flank, radiation to groin, abrupt
  onset, colicky
• Stone lodged in UVJ may cause LQ pain and
  tenderness
• Evaluation-
• UA- hematuria in 2/3
• Non-contrast CT

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Acute Scrotum

• Causes
• Testicular torsion
• Epididymitis
• Torsion of appendix testes
• Acute hydrocele
• Inguinal hernia
• Diagnosis- UTZ/color flow Doppler

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Pelvic Inflammatory Disease

• No historical features that correlate with
  laparoscopic diagnosis
• Presence of vaginal discharge most common
  associated physical finding
• Inconsistent
• Fever, palpable adnexal mass, elevated WBC
• Must rule out pregnancy

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Ectopic Pregnancy

• Ectopic pregnancy MUST be considered in any woman
  of childbearing age who p/w abnormal vaginal
  bleeding or abdominal pain
• Many patients present prior to actual rupture
• Vaginal bleeding may be only abnl. sign

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Ectopic Pregnancy

• Poor predictive value of historical risk
  factors and physical exam
• Diagnosis
• Positive pregnancy test
• Transvaginal ultrasound

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Abdominal Aortic Aneurysm

• Less than ½ of patients p/w classic triad of
  hypotension, abdominal pain and pulsatile
  abdominal mass
• Aorta is unlikely to be palpable
• Femoral pulses may be normal
• Abdominal bruit may be absent

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Abdominal Aortic Aneurysm

• Consider dx. in all older patients who p/w recent
  onset of flank, abdominal or low back pain
• Diagnosis
• Low suspicion
• CT scan

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Cardiopulmonary

• Consider cardiac etiology in older pts. who p/w
  epigastric discomfort
• Tenderness is not usually significant
• Obtain ECG
• Consider pneumonia, PE or pleural effusion
• Obtain CXR

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Infectious Causes of Abdominal Pain

• Gastroenteritis- crampy abdominal pain with
  vomiting and diarrhea
• Usually does not cause significant tenderness on
  palpation
• Diagnosis of exclusion

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Other Causes of Abdominal Pain

• Toxicologic
• Black widow spider bite-
• rigid abdomen caused by muscular spasm
• Generally spreads to other large mm. Groups
• Iron ingestion
• Direct corrosive effects on GI tract
• Opiate withdrawal
• Crampy pain, ass. w/ diaphoresis and piloerection

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Other Causes of Abdominal Pain

• Metabolic
• DKA, AKA- may be attributed to gastric distention
  and paralytic ileus
• Consider that the abdominal problem may have
  caused the acidosis
• Sickle Cell Crisis
• Usually due to vasooclusion
• Consider splenic infarct, pancreatitis,
  salmonella infection, mesenteric venous
  thrombosis

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Nonspecific Abdominal Pain

• Most common ED diagnosis
• May be better termed undifferentiated abdominal
  pain, or abdominal pain of unclear etiology
• Diagnosis of exclusion
• Nausea is common
• Tenderness usually not severe
• Lab tests usually normal

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Treatment

• Hypotension
• Management depends on presumed etiology
• Isotonic Crystaolloid- NS
• Analgesics
• No evidence to support the long standing practice
  of withholding analgesia

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Treatment

• Analgesia
• Four clinical trials supporting safety of
  administration of opiates
• Short acting opiates
• Fentanyl 1mcg/kg IVP, adult dose 50-100mcg
• Antiemetics
• Phenergan 25-50 mg IVP, Compazine 5mg IVP

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Treatment

• Antibiotics
• Indicated in patients with suspected abdominal
  sepsis or peritonitis
• Anaerobes, aerobic gram negative organisms
• UCI- abdominal pain pathway
• Cefuroxime 1-2gm IVPB, Flagyl 500 mg IVPB

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Disposition

• General indications for admission
• Pts. With a specific diagnosis
• Elderly or immunocompromised pts. w/ unclear
  diagnosis
• Intractable pain or vomiting
• Those who appear acutely ill
• Inability to follow discharge instructions

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Disposition

• Nonspecific abdominal pain
• 90 pts discharged are better in 2-3 weeks
• Small percent readmitted for appendicitis
• Further eval- diagnosis
• Benign gyn problems, IBS
• Key is follow-up- all pts given strict d/c
  instructions and scheduled follow up apt.

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Questions ?