Approach to Abdominal Pain in the Emergency Department

1
Approach to Abdominal Pain in the Emergency
Department

• Richard Stair, MD, FACEP
• Department of Emergency Medicine

2
Introduction

• At the end of this lecture you should
• Understand the generation and presentation of
  types of abdominal pain
  
• Develop critical elements of the history and
  physical for AP
  
• Apply knowledge of utility of testing to
  diagnostic approach
  
• Apply management principles to patient care in
  the ED
  

3
What Do They Have?

• As you go through this presentation, think about
  each of these cases
  
• An 18 mo old that suddenly became inconsoleable
  from AP while playing
  
• A 20 yo man with 12 hours of diffuse crampy AP
  that migrated to RLQ that became sharp
  
• 78 yo woman with h/o chronic steroid use with
  sudden sharp AP and a rigid exam
  

4
Acute Abdominal Pain

• Approximately 6 of ED visits
• Admission rates vary by population, up to about
  to 65 in high risk elderly populations
  
• Most common diagnosis is NONSPECIFIC (ie, I
  dunno)
  
• Use HP, risk factors, and directed studies to
  arrive at diagnosis
  
• MUST rule out emergency conditions

5
Abdominal Pain Across the Ages

• Ages 0-2
• Colic, GE, viral illness, constipation
• Ages 2-12
• Functional, appendicitis, GE, toxins
• Teens to adults
• Addition of genitourinary problems
• Elderly
• Beware of what seems like everything!

6
Special Populations

• Elderly/ nursing home patients
• Immunocompromised
• Post operative patients
• Infants

7
Abdominal Pain in the Elderly

• Diminished sensation of pain in the elderly
• Comorbid diseases
• Polypharmacy
• Combinations of above result in many more vague,
  nonspecific presentations
  
• Twice as likely to require surgery with
  presentation over age 65

8
Whats the Problem

• Imprecise pain generation and transmission to the
  central nervous system
  
• Comorbid diseases
• Developmental stage
• Medications
• Social factors

9
Understanding the Types of Abdominal Pain

• Visceral
• Stretch fibers in capsules or walls of hollow
  viscus that enter both sides of spinal cord
  
• Somatic
• Fibers dermatomally distributed and enter
  unilaterally in the spinal cord
  
• Referred
• Overlap of fibers from other locations

10
Understanding the Types of Abdominal Pain

• Visceral
• Crampy, achy, diffuse,
• Poorly localized
• Somatic
• Sharp, lancinating
• Well localized
• Referred
• Distant from site of generation
• Symptoms, but no signs

11
Understanding the Types of Abdominal Pain

• Location, location, location
• Organs and their corresponding fiber entry to the
  spinal cord
  
• C3-5 liver, spleen, diaphragm
• T5-9 gallbladder, stomach, pancreas,
  small intestine
  
• T10-11 colon, appendix, pelvic viscerat11-l1
  sigmoid, renal capsules, ureters, gonads
  
• S2-4 - bladder

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History Taking in Abdominal Pain Presentations

• OLD CARS
• O- onset
• L- location
• D- duration
• C- character
• A-alleviating/aggravating factors
• associated symptoms
• R- radiation
• S- severity

13
History Taking for Abdominal Pain Presentations

• PMH
• Similar episodes in past
• Other medical problems that increase disease
  likelihood of problems (ex DM and
  gastroparesis)
  
• PSH
• Adhesions, hernias, tumors
• MEDS
• Abx, NSAIDS, acid blockers, etc
• GYN/URO
• LMP, bleeding, discharge
• Social
• Tob/EtoH/drugs/home situation/agenda

14
Physical Exam in Abdominal Pain Presentations

• General appearance
• Sick versus not sick
• Mobile versus still
• Obvious pain or discomfort
• Doorway impression
• Vital signs
• Thats why theyre called vital

15
Physical Exam in Abdominal Pain Presentations

• Inspection
• Distention, scars, bruises
• Auscultation
• Present, hyper, or absent
• Actually not that helpful!
• Palpation
• Often the most helpful part of exam
• Tenderness versus pain
• Start away from painful area first
• Guarding, rebound, masses

16
Physical Exam in Abdominal Pain Presentations

• Signs
• Iliopsoas
• Obturator
• Rovsings
• Murphys
• Extra-abdominal exam
• Pelvic or scrotal exams
• Lungs, heart
• Remember its a patient, not a part
• Rectal
• Adds very little (despite the angst) beyond gross
  blood or melena

17
Laboratory Testing

• Everybody likes a CBC, but
• Lacks sensitivity, no specificity
• Little to no change in diagnostic probabilities
• Should not dramatically alter approach (tender is
  still tender)

18
Laboratory Testing

• Directed approach to lab studies
• There are no standard belly labs
• Pregnancy test in women of child bearing age
• Urine dipsticks

19
Imaging

• Plain films
• Free air, obstruction, air-fluid, FBs
• Ultrasound
• Rapid yes or no ED evaluations
• Formal studies
• May add doppler
• Computed Tomography
• Revolutionized acute care
• Often better than we are!

20
Common Diagnoses by Quadrant

• RUQ
• Cholecystitis
• Biliary colic
• Hepatitis
• Pancreatitis
• Renal stones
• PUD
• Pneumonia
• P E
• M I

• LUQ
• Gastritis
• Gastric ulcer
• Pancreatitis
• Splenomegaly
• Splenic rupture
• Renal stone
• Pneumonia
• P E
• M I

21
Common Diagnoses by Quadrants

• RLQ
• Appendicitis
• Renal stone
• Ovarian cyst
• Torsion
• Epididymitis
• Ectopic
• IBD
• AAA
• UTI

• LLQ
• Diverticulitis
• Renal stone
• Ovarian cyst
• Torsion
• Epididymitis
• Ectopic
• IBD
• AAA
• UTI

22
Management of Abdominal Pain

• Always right to start with ABCs
• IV access
• Fluid administration
• Antiemetics
• Analgesics
• Directed testing and imaging
• Re-evaluations
• Antibiotics
• Consultants
• Surgeons, OB/GYN, urologists, cardiologists, etc

23
Disposition of Abdominal Pain Patients

• Operating Room
• Hospital bed/observation
• Serial labs
• Serial exams
• Home with abdominal warnings
• The art of emergency medicine
• 3 components of discharge plan
• Document, document, document

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Now How About Those Cases

• 18 mo old had classic presentation of
  intussusception, and symptoms may wax and wane
  rectal would be to look for current jelly stool.
  Air enema for diagnosis and reduction. Involve
  consultants early in the course.

25
Now How About Those Cases

• 20 year old with classic presentation of
  appendicits, which likely does not need CT scan.
  Most do not present so simply, quite a wide array
  of presentations. General surgery consultation,
  pain meds, IVF, and an operation would all be
  good, but dont be shocked if CT requested.

26
Now How About Those Cases

• 78 yo has perforated abdomen, with age, multiple
  problems, and chronic steroids risks for
  perforation. Rapid resuscitation, plain films to
  confirm free air, antibiotics, pain medicine, and
  a surgeon as fast as you can would be good
  practice.

27
Take Home Points

• Perform a good history and physical to guide
  assessment
  
• Lab studies have limitations..and costs
• Imaging studies also need to be selected wisely
• Early involvement of consultants for sick
  patients
  
• Treatment initiation, not just diagnostics