Clinical Approach to Acute Subacute Abdominopelvic Pain

1
Clinical Approach to Acute/ Subacute
Abdominopelvic Pain

• Eric Wong, MD, MClSc (FM), CCFP
• Family Medicine Residency Program Director

2
Outline

• Go over objectives
• Quick review 10 minutes
• Interactive case studies 35 minutes
• Summary and review 5 minutes

3
Objectives

• By the end of the session, you will be able to
• Ready to tackle abdominopelvic presentations that
  you will encounter in clerkship

4
Quick review of the approach
5
Step-wise approach

• Before you ever see a patient with acute
  abdominal/pelvic pain
• Have a pretty complete list of all things that
  can cause abdominal pain in ANY patient
• Assess preliminary likelihood of certain causes
  based on available information
• Age
• Gender
• Race
• PMHx
• Vitals General condition

6
Step-wise approach

• While youre managing a patient with
  abdominal/pelvic pain
• (Determine quickly if there can be an acute
  abdomen)
• Further shortlist your differential diagnoses by
  (think of CAT Scan)
• Characterize the abdominal pain
• Ask and examine for features that support certain
  diseases
• Ask and examine for red flags
• Test selectively (x-rays, laboratory) to
  confirm/refute your suspicions, identify more red
  flags

7
Step-wise approach

• Other management to remember
• Monitor what should patient watch for?
• Reassess when to come back to office?
• Interim treatment analgesics, etc.

8
Approach to DDx in the undifferentiated patient
Yes
No
9
Case studies

• Lets see how good you are

10
Rules of engagement

• Room divided into 4 quadrants
• Within each quadrant, you will work in pairs
• Each quadrant for itself
• Winner declared after each case based on quality
  of questions and clinical reasoning
• You can group your questions
• E.g. Can you characterize the pain
• Dont lie!

11
Rules of engagement

• With each case
• History/Physical
• Limited of questions
• Each quadrant asks all of their questions at
  once repeat questions okay
• DDx/Diagnosis Management Plan
• I choose one pair from each quadrant to give
  answer for quadrant

12
Youre in the Peds ER
13
Timothy

• 10 year-old boy brought in by dad with chief
  complaint of tummy ache.
• You have 3 minutes to write down top 5 questions
  (group of question)
• You have 2 minutes to write down your
• Diagnosis
• 2 differential diagnoses
• Management plan investigations, treatment,
  followup

14
Timothy

• Summary
• Acute onset diffuse abdominal pain associated
  primarily with nausea and vomiting in a non-toxic
  presentation with mild dehydration
• Dx
• Most likely viral gastroenteritis
• Key things to r/o
• Peritonitis
• Diabetic Ketoacidosis
• UTI/pyelonephritis
• Testicular torsion
• Potential heavy metal poisoning

15
Timothy

• Management
• Canadian Pediatric Society Oral rehydration
  therapy (http//www.cps.ca/english/statements/N/N0
  6-01.htm)

16
Timothy

• Management

17
Timothy

• Management

18
Timothy

• Management key things to remember with ORT
• Ongoing losses 10mL/kg per diarrheal stool,
  estimate volume of vomit, urinary output
• Start low, go slow
• As effective, if not better than IV, for mild to
  moderately dehydration
• Use premixed formulas Pedialyte or freezer forms
• Use syringe if child refuses
• Discourage pop/juices high CHO, low
  electrolyte, high osmolality
• Contraindications refractory vomiting, decreased
  LOC, shock, malabsorption

19
Tina

• Tina, a 16 year-old girl, comes in with chief
  complaint of not feeling well and lower abdominal
  pain
• You have 3 minutes to write down top 5 questions
  (group of question)
• You have 2 minutes to write down your
• Diagnosis
• 2 differential diagnoses
• Management plan investigations, treatment,
  followup

20
Tina

• Summary
• Child-bearing age woman with lower abdominal pain
  and risk factors for sexually transmitted
  infections
• Dx
• Most likely pelvic inflammatory disease
• Must r/o
• Ectopic pregnancy
• Ovarian abscess
• Appendicitis
• DDx
• Ovarian torsion
• Cystitis
• Large bowel constipation, mesenteric adenitis,
  inflammatory bowel disease
• Urinary stone bladder stone (uncommon)

21
Tina

• Key learning points
• http//www.phac-aspc.gc.ca/std-mts/sti_2006/pdf/40
  4_Pelvic_Inflammatory_Disease.pdf
• Diagnosis
• Only 1/3 women with PID have fever
• No history/physical/lab test can rule in/out PID

22
Tina

• Diagnosis
• Minimal criteria
• Lower abdo pain
• Adnexal tenderness
• Cervical motion tenderness
• Additional criteria
• Fever gt 38.3
• ? ESR, CRP
• Swabs/urine confirm Gonorrhea/Chlamydia
• Tranvaginal U/S fluid filled tubes,
  tubo-ovarian complex
• Endometritis from endometrial biopsy /
  laparoscopy

23
Tina

• Management
• Determine if needs admission
• Surgical emergencies such as appendicitis cannot
  be excluded.
• Pregnant
• No response to oral antimicrobial therapy
• Unable to follow or tolerate an outpatient oral
  regimen
• Severe illness, nausea and vomiting, or high
  fever
• Tubo-ovarian abscess

24
Tina

• Management
• Think of Gonorrhea, Chlamydia, and anerobes
• Outpatient therapy
• 1st Ceftriaxone 250 mg IM X1, doxycycline 100 mg
  po bid 14d /- metronidazole 500 mg po bid 14d
• 2nd
• ofloxacin 400 mg po bid 14d /- metronidazole 500
  mg po bid 14d, OR
• Levofloxacin 500 mg po od 14 d /- metronidazole
  500 mg po bid 14d

25
Don

• 46 year-old man with stomach pain
• You have 3 minutes to write down top 5 questions
  (group of question)
• You have 2 minutes to write down your
• Diagnosis
• 2 differential diagnoses
• Management plan investigations, treatment,
  followup

26
Don

• Summary
• 46 y.o. male with subacute epigastric pain in
  stable condition with no red flags
• Dx
• Dyspepsia - Most likely gastritis
• Must r/o
• Acute coronary syndrome
• GI bleed secondary to gastric/duodenal ulcer
• DDx
• GERD
• Pancreatitis
• Biliary colic, choledocholithiasis
• Gastric/duodenal ulcer

27
Don

• Key learning points
• Figure out underlying cause of gastritis
• Infectious H.pylori
• Chemical EtOH, NSAIDs/ASA
• Ischemic (bowel angin)
• Cancer
• Others granulomatous, autoimmune

28
Don

• Key learning points
• Red flags of dyspepsia http//www.albertadoctors.o
  rg/bcm/ama/ama-website.nsf/AllDocSearch/87256DB000
  705C3F87256E0500553509/File/DYSPEPSIA.PDF?OpenEle
  ment
• Constitutional
• Unexplained weight loss
• Fever/Chills/night sweats
• Complications
• Hematemesis
• Melena
• Abdominal mass
• Hoarseness/Cough
• Symptoms of anemia
• Dysphagia/Odynophagia

29
Don

• Key learning points
• Management
• Eliminate offending agents EtOH, NSAIDs/ASA
• H. pylori gastritis (http//www.albertadoctors.org
  /bcm/ama/ama-website.nsf/AllDocSearch/87256DB00070
  5C3F87256E0500553581/File/H_PYLORI.PDF?OpenElemen
  t)
• PPI bid amoxicillin 1g bid OR metronidazole 500
  mg bid clarithromycin 500mg bid X 7 days
• Eradication rates 90, side effects lt 5
• HP-PAC-lansoprazole, amoxicillin, clarithromycin
  package

30
Don

• Key learning points
• Management
• If symptoms do not resolve after treatment, may
  need to confirm eradication of H.pylori
• Urea breath test (H. pylori has urease that
  splits urea from radioactive C13 or 14 and
  produceds CO2
• If positive, treat with alternate regimens
• If negative, consider other diagnoses or
  functional dyspepsia

31
Mr. Telamer

• 67 year-old brought in by ambulance because of
  severe abdominal pain.
• You have 3 minutes to write down top 5 questions
  (group of question)
• You have 2 minutes to write down your
• Diagnosis
• 2 differential diagnoses
• Management plan investigations, treatment,
  followup

32
Mr. Telamer

• Summary
• Eldelry man with sudden onset acute abdominal
  pain, pulsatile abdominal mass with signs of
  peritonitis and shock
• Dx
• Ruptured AAA
• DDx
• Perforated PUD
• Appendicitis/diverticulitis with perforation
• Mesenteric ischemia

33
Mr. Telamer

• Key learning points
• Always remember to r/o AAA and mesenteric
  ischemia in an elderly presenting with
  moderate-severe abdominal pain

34
Review
35
Step-wise approach

• Before you ever see a patient with acute
  abdominal/pelvic pain
• Have a pretty complete list of all things that
  can cause abdominal pain in ANY patient
• Assess preliminary likelihood of certain causes
  based on available information
• Age
• Gender
• Race
• PMHx
• Vitals General condition

36
Step-wise approach

• While youre managing a patient with
  abdominal/pelvic pain
• (Determine quickly if there can be an acute
  abdomen)
• Further shortlist your differential diagnoses by
  (think of CAT Scan)
• Characterize the abdominal pain
• Ask and examine for features that support certain
  diseases
• Ask and examine for red flags
• Test selectively (x-rays, laboratory) to
  confirm/refute your suspicions, identify more red
  flags

37
Step-wise approach

• Other management to remember
• Monitor what should patient watch for?
• Reassess when to come back to office?
• Interim treatment analgesics, etc.

38
Approach to DDx in the undifferentiated patient
Yes
No