Abdominal Pain

1
Abdominal Pain

• William Beaumont Hospital
• Department of Emergency Medicine

2
Abdominal Pain

• One of the most common chief complaints
• Confounders making diagnosis difficult
• Age
• Corticosteroids
• Diabetics
• Recent antibiotics

3
Pitfalls

• Consider non-GI causes
• Acute MI (inferior), ectopic pregnancy, DKA,
  sickle cell anemia, porphyria, HSP, acute adrenal
  insufficiency
• History
• Location
• Quality
• Severity
• Onset
• Duration
• Aggravating and alleviating factors
• Prior symptoms

4
History

• Sudden onset perforated viscus
• Crushing esophageal or cardiac disease
• Burning peptic ulcer disease
• Colicky biliary or renal disease
• Cramping intestinal pathology
• Ripping aneurismal rupture

5
Physical Exam

• Abdomen
• Inspection
• Bowel sounds
• Tenderness (rebound, guarding)
• Extra-abdominal exam
• Lung
• Cardiac
• Pelvic
• GU
• Rectal

6
Labs

• Beta-hCG
• WBC poor sensitivity and specificity
• LFTs hepatobiliary
• Lipase pancreatic
• Electrolytes CO2
• Lactic acid
• Urinalysis BEWARE

7
Imaging

• Acute Abdominal Series
• Free air
• Bowel gas
• KUB
• Poor screening test

• Ultrasound
• Biliary disease
• AAA
• Free fluid or air
• Pelvic pathology
• CT
• Appendicitis
• Diverticulitis

8
Case 1

• 79 yo female presents with aching sharp pain in
  the epigastrium and right upper quadrant ½ hour
  after eating. Pain radiates to the back. N, V
• Differential diagnosis?
• Testing?

9
Upper Abdominal Pain

• Biliary disease
• Hepatitis
• Pancreatitis
• PUD/gastritis/esophagitis
• AAA

• Pneumonia (RLL)
• Pyelonephritis
• Acute MI
• Appendicitis
• Fitz-Hugh Curtis

10
Gallstone Risk Factors

• Female 41
• Fertile
• Forty
• Fat
• Family history
• Others
• Crohns, UC, SCA, thalassemia, rapid weight loss,
  starvation, TPN, elevated TGs, cholesterol

11
Cholelithiasis

• History
• RUQ/epigastric pain
• Nausea/vomiting with fatty meals
• Similar episodes in past
• PE RUQ tenderness
• Labs may be normal
• ECG consider in older patients
• Imaging test of choice US

12
Cholelithiasis Treatment

• Symptomatic

• Asymptomatic

• Pain control
• Anti-emetics
• Consult general surgery
• 90 with recurrent symptoms
• 50 develop acute cholecystitis

• Incidental finding
• 15-20 become symptomatic
• Outpatient elective surgery if
• Frequent, severe attacks
• Diabetic
• Large calculi

13
Acute Cholecystitis

• Sudden gallbladder inflammation
• Bacterial infection in 50-80
• E. coli, Klebsiella, Enterococci
• History/PE
• Fever, tachycardia, RUQ tenderness
• Murphys sign low sensitivity
• Labs
• Elevated WBC with left shift
• LFTs large elevation ? CBD stone

14
Acute Cholecystitis Imaging

• KUB stones only seen 10
• Air in biliary tree ? gangrenous
• CT scan sensitivity 50
• Ultrasound sensitivity 90-95
• Gallstones (absent in biliary stasis)
• Thickened gallbladder wall
• Pericholecystic fluid
• HIDA scan negative scan rules out diagnosis
• Positive no visualization of the GB

15
Acute Cholecystitis
16
Acute Cholecystits Treatment

• Admit
• NPO
• IVF
• Pain control
• Anti-emetics
• Antibiotics
• Surgical consult

17
Hepatitis

• Viral
• Hepatitis A
• RNA, fecal-oral
• Hepatitis B
• DNA, STD/parenteral
• Chronic hepatitis (10)
• Hepatitis C
• RNA, blood borne
• Chronic hepatitis (50), cirrhosis (20)
• Hepatitis D
• RNA, co-infects Hep B

• Bacterial
• Alcoholic
• Immune
• Medications

18
Hepatitis Diagnosis

• History
• Malaise, low-grade fever, anorexia
• Nausea/vomiting, abd pain, diarrhea
• Jaundice (altered MS, liver failure)
• Labs
• ALT and AST (10-100x normal)
• AST gt ALT alcoholic hepatitis
• Elevated bilirubin
• Abnormal PT
• Hepatitis panel
• Tylenol level

19
Hepatitis Treatment

• Symptomatic IVF, electrolytes
• Remove toxins ETOH, acetaminophen
• Admit if altered MS or coagulopathy

20
Pancreatitis

• Autodigestion of pancreatic tissue
• B Biliary
• A Alcohol
• D Drugs
• S Scorpion bite
• H HyperTG, HyperCa
• I Idiopathic, Infection
• T Trauma

21
Pancreatitis History and Physical

• History
• Boring pain in LUQ or epigastrium
• Constant
• Radiates to mid-back
• Nausea, vomiting
• PE
• Epigastric or LUQ tenderness
• Grey-Turner or Cullen sign

22
Gray-Turner sign

• Flank ecchymosis
• Intraperitoneal bleeding
• Hemorrhagic pancreatitis
• Ruptured abdominal aorta
• Ruptured ectopic pregnancy

23
Cullen's Sign
24
Pancreatitis Diagnosis

• Lipase most specific
• Ransons criteria predicts outcome
• Acutely gt55 yo, glucose gt 200, WBC gt16k, ALT gt
  250, LDH gt 350
• 48 hrs HCT decreases gt 10, BUN rises gt 5, Ca lt
  8, pO2 lt 60, base deficit gt4, fluid sequestration
  gt 6L
• 3-4 criteria 15 mortality
• 5-6 criteria 40 mortality
• 7-8 criteria 100 mortality

25
Pancreatitis Imaging

• Plain films sentinel loop (local ileus)
• Ultrasound poor (biliary tree)
• CT scan with contrast

26
Pancreatitis Treatment

• NPO
• IVF
• Pain control
• Antiemetics
• Antibiotics if gallstones or septic
• Surgical consult
• If gallstones, abscess, hemorrhage or pseudocyst
• ERCP if CBD stone

27
Gastritis/PUD

• Duodenal 80 gastric 20
• Etiology
• H pylori, NSAIDS, zollinger-ellison syndrome,
  smoking, ETOH, FHx, male, stress
• H pylori 95 duodenal 85 gastric
• History
• Epigastric constant, gnawing pain
• Food lessens duodenal
• Food worsens gastric

28
Peptic Ulcer Disease

• Workup
• Hemoglobin
• PT/PTT if bleeding
• Lipase rule out pancreatitis
• Hemoccult stool rule out GI bleed
• Treatment
• Antacids (GI cocktail)
• PPI
• Outpatient endoscopy
• H. pylori testing

29
Perforated Viscus

• Rare in small bowel and mid-gut
• History abrupt onset pain
• Diagnosis upright CXR
• Treatment
• IVF
• IV antibiotics
• NG tube
• OR

30
Questions on Upper Abdominal Pain?

• Lets Move On Down

31
Case 2

• History 35 y/o female c/o 1 day of periumbilical
  aching pain. N,V, D, F, C, anorexia.
  Today, she has crampy lower abdominal pain. No
  urinary sx.
• Exam afebrile, bilateral lower quadrant
  tenderness (R gt L), no rebound or guarding.
• Other questions?
• Differential diagnosis?
• Testing?

32
Lower Abdominal Pain

• Appendicitis
• Diverticulitis
• UTI/Pyleonephritis
• Renal colic
• Torsion/TOA/PID
• Ectopic pregnancy

33
Appendicitis

• Incidence 6
• Mortality 0.1
• Perforation 2-6 (9 elderly)
• All ages peak 10 30 yo
• Difficult diagnosis
• Young and old
• Pregnant (RUQ)
• Immunocompromised

34
Appendicitis

• Abdominal pain (98)
• Periumbilical migrating to RLQ lt 48 hrs
• Anorexia 70
• Nausea, vomiting 67
• Common misdiagnosis gastroenteritis, UTI

35
Appendicitis

• PE
• RLQ tenderness 95
• Rovsing RLQ pain palpating LLQ
• Psoas R hip elevation, extension
• Obturator flexion, internal rotation

36
Appendicitis Diagnosis

• Labs
• WBC gt 10k 75
• UA sterile pyuria
• Imaging
• Ultrasound
• CT scan
• MRI

37
Appendicitis Treatment

• IV fluids
• NPO
• Analgesia
• Antibiotics
• Surgery consult

38
Diverticulitis

• Inflammation of a diverticulum (herniation of
  mucosa through defects in bowel wall)
• Sigmoid colon is the most common site
• History
• L gt R
• 3 under 40
• LLQ pain with BMs
• N/V/constipation
• PE LLQ tenderness
• Diagnosis clinical, CT

39
Diverticulitis Treatment

• Admit if fever, abscess, elderly
• NPO
• IV fluids
• IV antibiotics
• Ciprofloxacin AND metronidazole
• Surgical consultation

40
Case 3

• History 80 y/o male c/o nausea and crampy
  abdominal pain x 1 day. Emesis which was bilious
  and is now malodorous and brown.
• PE Diffusely tender, distended, with hyperactive
  bowel sounds.
• Differential Diagnosis?
• Workup?

41
Differential Diagnosis

• Small bowel obstruction
• Large bowel obstruction
• Sigmoid volvulus
• Cecal volvulus
• Hernia
• Mesenteric ischemia
• GI Bleed

42
Small Bowel Obstruction

• Etiology
• Adhesions (gt50)
• Incarcerated hernia
• Neoplasms
• Adynamic ileus non mechanical
• Abd trauma (post op), infection, hypokalemia,
  opiates, MI, scleroderma, hypothyroidism
• Rare intusseception, bezoar, Crohns disease,
  abscess, radiation enteritis

43
Large Bowel Obstruction

• Etiology
• Tumor
• Left ? obstruct
• Right ? bleeding
• Diverticulitis
• Volvulus
• Fecal impaction
• Foreign body

44
Bowel obstruction

• Pathophysiology 3rd spacing ? bowel wall
  ischemia ? perforates, ?peritonitis ? sepsis ?
  shock
• History crampy, colicky diffuse abdominal pain,
  vomiting (feculent), no flatus or BM
• PE abdominal distension, high pitched BS,
  diffuse tenderness
• Diagnosis AAS shows air fluid levels with
  dilated bowel
• SB gt 3cm LB gt 10cm

45
SBO Imaging
46
SBO Treatment

• IV fluids!
• Correct electrolyte abnormalities
• NPO
• NG tube
• Broad spectrum antibiotics if peritonitis
• Surgery consult

47
Sigmoid Volvulus

• History
• Elderly, bedridden, psychiatric pts
• Crampy lower abdominal pain, vomiting,
  dehydration, obstipation
• Prior h/o constipation
• PE
• Diffuse abdominal tenderness
• Distension

48
Sigmoid Volvulus
49
Sigmoid Volvulus Imaging and Treatment

• AAS dilated loop of colon on left
• Barium enema birds beak
• WBC gt 20k suggests strangulation
• CT scan
• Treatment
• IVF
• Surgical consult
• Antibiotics if suspect perforation

50
Cecal volvulus

• Most common in 25-35 year olds
• No underlying chronic constipation
• History
• Severe, colicky abd pain
• Vomiting
• PE
• Diffusely tender abdomen
• Distension

51
Cecal Volvulus

• KUB
• Coffee bean large dilated loop colon in
  midabdomen
• Empty distal bowel
• Treatment
• Surgery
• Mortality 10-15 if bowel viable 30-40 if
  gangrene

52
Hernias

• Inguinal (most common) 75
• Indirect 50 vs. direct 25
• Men gt women
• High risk incarceration in kids
• Femoral 5 - women gt men
• Incisional 10
• Umbilical newborns, women gt men
• Incarcerated unable to reduce
• Strangulated incarcerated with vascular
  compromise

53
Hernias

• Clinical presentations
• Most are asymptomatic
• Leads to SBO sxs
• Peritonitis and shock if strangulation
• Treatment
• Reduce if non-tender trendelenberg, sedation,
  warm compresses
• Do not reduce if possible dead bowel
• Admit via OR if strangulation

54
Mesenteric Ischemia

• Etiology
• 50 arterial emboli
• 20 non-occlusive disease (CHF, sepsis, shock)
• 15 arterial thrombi
• 5 venous occlusion
• Mortality rates 70-90 - delayed diagnosis

55
Mesenteric Ischemia

• Pathophysiology impaired blood supply from SMA,
  IMA, celiac trunk ? adynamic ileus ? mucosal
  infarction 3rd spacing ? bacterial invasion ?
  sepsis ? shock
• History
• Acute, severe, colicky, poorly localized pain
• Postprandial pain
• Nausea, vomiting and diarrhea

56
Mesenteric Ischemia Diagnosis

• Pain out of proportion to exam!
• Heme positive stools (gt50)
• May present as LGIB
• Peritonitis and shock
• Late findings
• WBC gt 15k
• Metabolic acidosis
• Lactic acid high sensitivity, not specific

57
Mesenteric Ischemia Diagnosis

• CT scan
• Bowel wall edema/gas, /- mesenteric thrombus
• Normal CT does NOT rule out
• Plain films late findings
• Portal venous gas
• Pneumatosis intestinalis
• Treatment
• IVF
• NG tube
• IV antibiotics
• IR consult for angiography
• Surgical consult

58
GI hemorrhage Upper GIB vs. Lower GIB

• History
• Hematemesis seen in 50 UGIB
• Melena
• 70 UGIB
• 30 LGIB
• Hematochezia LGIB vs. rapid UGIB
• Ask about
• NSAID, ASA, ETOH, Plavix, warfarin
• Night sweats, weight loss, bowel changes ?
  malignancy
• Iron, bismuth guaiac negative, black stools

59
GI hemorrhage

• Consider with chief complaints
• Weakness
• SOB
• Dizzy
• Abdominal pain
• PE orthostatics, abdomen, rectal
• Conjunctival pallor
• Cool, clammy skin
• Spider angiomata, palmer erythema, jaundice,
  bruises ? liver disease

60
GIB Diagnosis

• Hemoccult iodide, methylene blue and red meat
  cause false pos
• Labs
• CBC (Hg lt 8)
• PT
• T S
• Increased BUN (blood, hypovolemia)
• ECG rule out silent MI (anemia)
• NG tube rule out UGI bleed

61
Upper GI Hemorrhage Etiology

• PUD 60
• Gastritis/esophagitis 15
• Varices portal HTN, liver disease
• Mallory-Weiss
• Aortoenteric fistula H/o AAA repair
• Other Stress ulcers, malignancy, AVM, ENT
  bleeds, hemoptysis

62
Lower GI Hemorrhage Etiology

• Hemorrhoids most common overall
• Diverticulosis most common severe cause LGIB
• Angiodysplasia
• Polyps/cancer
• Rectal disease
• IBD

63
GIB Treatment

• Unstable
• IV x 2, O2, monitor
• Blood products FFP, pRBCs, platelets
• NG tube with lavage if upper GIB suspected
• Upper GI bleed ? GI for endoscopy
• Lower GI bleed ? GI and/or surgery consults
• Tagged red blood cell study need 0.1 0.2
  ml/min of hemorrhage

64
GIB Treatment

• Colonscopy ligate or sclerose diverticulosis,
  AVM bleeds
• EGD band ligation or sclerose varices
• Octreotide varices, PUD
• Vasopressin varices
• Sengstaken-Blakemore tube varices

65
GIB Surgical Indications

• Hemodynamically unstable
• Unresponsive to endoscopy, IV fluids, and
  correction of coagulopathy
• Transfused gt 5units in 4-6 hrs
• Mortality 23 if emergent surgery

66
GIB Disposition

• Admit
• Any UGIB
• Any hemodynamic instability
• Significant LGIB
• Observation
• LGIB with stable vital signs and HgB
• Discharge home
• Hemorrhoid bleed, rectal negative with normal HgB

67
Case 4

• 70 y/o male with HTN, DM c/o acute onset right
  flank pain. Pain is sharp and crampy, radiates to
  the groin. He is pale, diaphoretic. Abdomen is
  soft, diffusely tender, no rebound or guarding.
• What are you thinking and what are you going to
  do?

68
Differential Diagnosis

• Renal colic
• Mesenteric ischemia
• PUD with perforation
• GI bleed
• Diverticulitis
• Cholecystitis
• Pancreatitis
• Low back pain

69
AAA

• 4 male 1 female
• Peak incidence 70 yo
• 98 infrarenal (50 involve iliacs)
• 33 of cases initially misdiagnosed
• Renal colic, low back pain
• Risk factors HTN, smoking, COPD, diabetes,
  hyperlipidemia, connective tissue disease
  (Marfans, Ehlers-danlos)

70
AAA Pathophysiology

• Atherosclerosis causes loss of elastin and
  collagen in aortic wall
• Normal aorta diameter 2 cm
• Uncommon to rupture if lt 5 cm
• Elective repair
• 30 of aneurysms gt5 cm rupture within 5 years

71
AAA

• History
• Sudden onset severe constant mid-abdomen or back
  pain
• Pain may radiate to the thigh or testes
• Back/flank pain retroperitoneal ureteral
  irritation
• PE
• Pulsatile mass 50-90
• Abdominal distension due to RP or IP blood
• Abdominal bruit 3-8
• Blue toe syndrome 5 due to emboli

72
AAA Diagnosis

• ECG
• Plain films
• R/o free air or SBO
• Calcified aorta
• US
• Helpful to diagnosis
• Does not delineate rupture or leaking aneurysm

• CT
• Evaluates size, leakage and extent
• Angiography
• May miss AAA if mural thrombus

73
AAA
74
AAA Treatment

• Asymptomatic patient
• Incidental finding
• lt4 cm repeat US Q6 months
• gt4 cm elective repair
• Symptomatic patient
• CT to confirm diagnosis (if stable)
• 2 large bore IVs
• TC
• pRBC - 8 units
• Admit via OR (vascular surgery consult)

75
AAA Mortality

• Elective repair 4
• Post rupture 45
• Normal BP 20
• Hypotensive, responds to volume 40
• Hypotensive, incomplete response 60
• Hypotensive, no urinary output 80

76
The End

• Any Questions?