Abdominal Pain

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Abdominal Pain

• Scope of the problem
• Anatomic Essentials
• Visceral Pain
• Parietal Pain
• Referred Pain

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History

• Where is your pain? Has it always been there?
• Does the pain radiate anywhere?
• How did the pain begin (sudden vs. gradual
  onset)? How long have you had the pain?
• What were you doing when the pain began?
• What does the pain feel like?
• On a scale of 010, how severe is the pain?
• Does anything make the pain better or worse?
• Have you had the pain before?

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History (continued)

• Associated symptoms
• Gastrointestinal
• Genitourinary
• Gynecologic
• Cardiopulmonary
• Past medical

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Physical Examination - Directed

• General appearance
• Vital Signs
• Abdomen
• Inspection
• Auscultation
• Percussion
• Palpation

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Physical Examination - Directed

• Pelvic
• Genital
• Back
• Rectal
• Head-to-toe

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Differential Diagnosis

• Appendicitis
• Biliary colic, cholecystitis, cholangitis
• Bowel obstruction
• Diverticulitis
• Ectopic pregnancy
• Gastroenteritis
• Intussuception
• Mesenteric Ischemia
• Ovarian torsion

• Pancreatitis
• Pelvic Inflammatory Disease (PID)
• Perforated peptic ulcer
• Ruptured or leaking abdominal aortic aneurysm
  (AAA)
• Testicular torsion
• Ureteral colic
• Volvulus

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Diagnostic Testing

• Laboratory Studies
• CBC
• Urinalysis
• Pregnancy
• Amylase/Lipase
• Other
• Electrocardiogram

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Diagnostic Testing - continued

• Radiologic Studies
• Plain Films
• Ultrasound
• Computed Tomography

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General Treatment Principles

• Volume repletion
• Pain relief
• Antibiotics
• Other

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Special Patients

• Elderly
• Pediatric
• Immune compromised

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Disposition

• Surgical consultation
• Serial evaluation
• Discharge

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Pearls, Pitfalls and Myths

• Do not restrict the diagnosis solely by the
  location of the pain.
• Consider appendicitis in all patients with
  abdominal pain and an appendix, especially in
  patients with the presumed diagnosis of
  gastroenteritis, PID or UTI.
• Do not use the presence or absence of fever to
  distinguish between surgical and medical causes
  of abdominal pain.
• The WBC count is of little clinical value in the
  patient with possible appendicitis.
• Any woman with childbearing potential and
  abdominal pain has an ectopic pregnancy until her
  pregnancy test comes back negative.
• Pain medications reduce pain and suffering
  without compromising diagnostic accuracy.

• An elderly patient with abdominal pain has a high
  likelihood of surgical disease.
• Obtain an ECG in elderly patients and those with
  cardiac risk factors presenting with abdominal
  pain.
• A patient with appendicitis by history and
  physical examination does not need a CT scan to
  confirm the diagnosis they need an operation.
• The use of abdominal ultrasound or CT may help
  evaluate patients over the age of 50 with
  unexplained abdominal or flank pain for the
  presence of AAA.