Abdominal Pain

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Abdominal Pain
LSU Medical Student Clerkship, New Orleans, LA
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Historical Elements

• O- onset
• P-provocation /palliation
• Q- quality/quantity
• R- region/radiation
• S- severity/scale
• T- timing/time of onset

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Physical Exam
General Appearance and Vitals (sick vs Not
sick) Abdominal exam-Inspection (scars, masses,
ecchymosis, distention)-Auscultation (bowel
sounds, bruits),-Percussion (organomegaly,
dullness)-Palpation (tenderness, guarding,
rebound, referred pain, masses)-Don't forget GU,
Rectal and Pelvic
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Visceral Pain
Stretching of hollow viscus or capsule of solid
viscus Visceral fibers enter the spinal cord at
several levels leading to poorly localized,
poorly characterized pain. (dull, cramping,
aching)
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Visceral Pain
Visceral pain can be localized by the sensory
cortex to an approximate spinal cord level
determined by the embryologic origin of the organ
involved. Foregut organs (stomach, duodenum,
biliary tract) produce pain in the epigastric
region Midgut organs (most small bowel,
appendix, cecum) cause periumbilical
pain Hindgut organs (most of colon, including
sigmoid) as well as the intraperitoneal portions
of the genitourinary tract cause pain initially
in the suprapubic or hypogastric area.
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Parietal Pain
Parietal abdominal pain is caused by irritation
of fibers that innervate the parietal peritoneum
Parietal pain, in contrast to visceral pain,
can be localized to the dermatome superficial to
the site of the painful stimulus. As the
underlying disease process evolves, the symptoms
of visceral pain give way to the signs of
parietal pain, causing tenderness and guarding.
As localized peritonitis develops further,
rigidity and rebound appear.
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Referred Pain

• Pain or discomfort that is perceived at a site
  distant from the affected organ because of
  overlapping transmission pathways
• Also reflects embryologic origin
• subdiaphragmatic irritation -gt ipsilateral
  supraclavicular or shoulder pain gynecologic
  pathology -gt back or proximal lower extremity
  painbiliary tract disease -gt right infrascapular
  painmyocardial ischemia -gtmidepigastric, neck,
  jaw, or upper extremity painureteral obstruction
  -gt ipsilateral testicular pain

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Radiology Plain Films

• Advantages Quick, easy, non-invasive, lower
  radiation, lower cost, can be done at bedside and
  can help make decisions in certain disease
  states.
• Disadvantages
• Only useful in certain conditions otherwise
  low yield, difficult to position sick patients.

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Radiology Plain Films

• When are they useful?
• Obstruction/Ileus
• Volvulus (cecal and sigmoid)
• Free air
• Radiopaque foreign bodies
• Constipation?

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Plain Films Small bowel obstruction
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Cecal Volvulus and Sigmoid Volvulus
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Pneumoperitoneum
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Iron Overdose

• Remember the radiopaque foreign bodies
  mneumonic
• BAT CHIPS
• BariumAntihistaminesTricyclic
  antidepressantsChloral hydrate, calcium,
  cocaineHeavy metalsIodinePhenothiazine,
  potassiumSlow-release (enteric coated)

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Radiology Ultrasound

• Advantages Can be done at bedside, easy to
  learn, repeatable, no radiation, cheap, can be
  used in pregnancy, patient does not need to leave
  the department
• Disadvantages Highly dependent on users skill
  level. Limited by body habitus and bowel gas

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Radiology Ultrasound

• What conditions is it most useful for?
• Gallbladder disease
• AAA
• Hydronephrosis
• Volume status
• Ob/Gyn (Ectopic, IUP, Ovarian pathology)
• Appendicitis (particularly in children)

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Ultrasound Cholecystitis
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Ultrasound AAA
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Ultrasound Appendicitis
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Radiology CT

• Advantages Highly diagnostic for most disease
  processes. High yield exam. Helpful with
  multiple, competing diagnoses.
• Disadvantages Time. Cost. Radiation. Contrast
  exposure (for IV contrast). Patient should be
  stable to go to CT.

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Laboratory

• The labs you order should be used confirm or
  exclude specific diagnoses suspected by your
  history and physical examination.
• CBC, CMP, Amylase, Lipase and UA are routinely
  ordered as belly labs but should not be ordered
  blindly.
• The studies you obtain (labs and imaging) should
  be ordered with the intention of changing your
  management of the patient. They should not be
  ordered just because the patient is in the ED.

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Cases

• A 60 y/o male presents after a syncopal event
  with a complaint of abdominal pain.
• His pain is poorly localized but radiating to his
  back.
• His history is significant for HTN and tobacco
  abuse.
• His vitals are normal and his physical exam
  reveals only the following

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What is on the differential?

• Pancreatitis
• Mesenteric Ischemia
• MI
• Gallbladder Disease
• GERD
• Obstruction

• Peritonitis
• PE
• PUD
• AAA
• Valvular Insufficiency
• Perforated Viscus

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Abdominal Aortic Aneurysm

• What happens
• The media weakens over time, the vessel dilates
  and expands over time. As the vessel weakens and
  expands, rupture becomes more likely.
• The larger it becomes, the more likely is the
  rupture.

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AAA

• Fun facts
• They are typically infrarenal
• gt3cm at this level is a AAA
• Age, Family history, Atherosclerotic risk
  factors, infection, trauma, connective tissue
  disease are risk factors.
• Rupture is associated with 80-90 mortality.
• Vital signs can be normal. For now.

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AAA Diagnosis and Management

• HP May not be symptomatic until the rupture
• Syncope and Abdominal pain
• Cullens sign and Grey Turners sign
• Imaging U/S 100 sensitive when the aorta is
  visualized.
• CT requires a stable patient but is also highly
  sensitive and is better at detecting rupture and
  retroperitoneal fluid.
• Treatment is surgical!! Despite what surgery
  tells you There is no such thing as a stable
  rupture.
• EDs role is maintaining hemodynamic stability
  with blood products SBP 90-100mg until surgery.

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CT of Rupturing AAA
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Cases

• A 75 year old male presents with diffuse, severe
  abdominal pain after having a bloody bowel
  movement.
• His history is significant for A. Fib and CHF.
• His vitals show hypotension and tachycardia.
• You palpate a soft abdomen but even the lightest
  touch causes him extreme pain.
• You stabilize him and send him to the CT film

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Differential?

• Lower GI Bleed
• Brisk Upper GI bleed
• Mesenteric Ischemia
• Peritonitis
• Diverticulitis
• Aorto-enteric Fistula

• Small Bowel Obstruction
• Large Bowel Obstruction

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Selections from Diffuse pain Mesenteric
Ischemia

• What happens Most commonly from emboli but can
  be from thrombus or low-flow state to mesenteric
  vasculature which leads to ischemia of the bowel.
  
• Death of bowel leads to bacterial translocation
  which leads to peritonitis, sepsis, hemodynamic
  instability and death.

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Imaging

• XR pneumatosis intestinalis, air in the portal
  vein, pneumobilia, perforation.
• US Pneumatosis, decreased flow.
• CT The test of choice and the gold standard.
  Can determine etiology and extent of involvement,
  thus determining course of treatment. Requires a
  stable patient!
• MR No advantage over CT

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Mesenteric Ischemia Diagnosis and Management

• Begins with history/physical and a high degree of
  clinical suspicion.
• Initial treatment is resuscitative and
  supportive. What does that actually mean?
• Early surgical consult.
• May require IR depending on etiology of ischemia.

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Cases

• A 23 year old female presents with severe,
  intermittent right lower quadrant pain associated
  with nausea and vomiting.
• She has no medical history.
• Her vital signs reveal tachycardia but are
  otherwise normal.
• Physical exam shows a soft abdomen, RLQ TTP
  without peritoneal signs. Pelvic (which is part
  of the physical exam), shows scant discharge.
• If you could only order one test, what would it
  be?
• What is on your differential?

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Differential

• Ectopic Pregnancy
• Ruptured Ovarian Cyst
• Appendicitis
• Right-sided diverticulitis
• TOA
• Ovarian Torsion

• Nephrolithiasis
• Pyelonephritis
• Endometriosis
• UTI
• Heterotopic pregnancy
• Terminal ileitis

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Ovarian Torsion
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Increased ovarian volume (gt15cc), multiple
follicles and decreased blood flow.
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Cases

• A 24 y/o male presents with rapid onset,
  non-radiating, diffuse abdominal pain.
• He has no medical or surgical history.
• He is tachycardic and tachypneic.
• His exam reveals a distended abdomen which is
  diffusely tender. He has decreased bowel sounds.

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Differential?

• Appendicitis
• Bowel Obstruction
• Testicular torsion
• Perforated Viscus

• Colitis
• PUD
• Peritonitis
• Mesenteric Ischemia

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What happens and what it looks like
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Compared to a Sigmoid Volvulus
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Obstructions Small and Large Bowel

• Small
• Adhesions
• Hernias
• Masses

• Large
• Masses
• Diverticulitis
• Sigmoid Volvulus

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Treatment

• NPO
• NasoGastric Tube suction.
• Fluid and Electrolyte repletion
• Antibiotics
• Surgical consult

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Pitfalls

• Incomplete exams (rectals, pelvics and genital
  exams)
• Incomplete histories
• Missing abnormal vitals
• Relying on labs
• Relying on imaging
• Not performing serial exams
• Elderly, the young, the pregnant, altered or
  psychiatric patients
• Constipation GERD Gastroenteritis and UTI

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Other conditions

• Systemic
• DKA
• Alcoholic ketoacidosis
• Uremia
• Sickle cell disease
• Porphyria
• SLE
• Vasculitis
• Glaucoma
• Hyperthyroidism
• Toxic
• Methanol poisoning
• Heavy metal toxicity
• Scorpion bite
• Black widow spider bite

• Thoracic
• Myocardial infarction/ Unstable angina
• Pneumonia
• Pulmonary embolism
• Herniated thoracic disc (neuralgia)
• Genitourinary
• Testicular torison
• Renal colic
• Infectious
• Strep pharyngitis (more often in children)
• Rocky Mountain Spotted Fever
• Monocucleosis
• Abdominal wall
• Muscle spasm
• Muscle hematoma
• Herpes zoster

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References

• Me.
• SBO PICTURE http//www.healthhype.com/partial-and
  -complete-bowel-obstruction-symptoms-and-treatment
  .html
• CECAL VOL. http//bestpractice.bmj.com/best-practi
  ce/monograph/877/resources/image/bp/2.html
• Sigmoid http//www.learningradiology.com/archives
  2008/COW20338-Sigmoid20volvulus/sigmoidvolcorrec
  t.htm
• Pneumoperitnoeum http//new.medicalfinals.co.uk/?
  p425
• Foreign bodies http//lifeinthefastlane.com/2009/
  10/top-ten-foreign-bodies/
• Gallbladder http//imaging.consult.com/imageSearc
  h?queryimpactionsqyTypeANDglobal_searchSearch
  modalitythestruenormalVariantImagefalsegrou
  pByNodenoneanatomicRegionmodalityFilterUltras
  ound
• AAA http//www.keepingyouwell.com/CareAndServices
  /VascularLabServices/AbdominalAorticAneurysms.aspx
  
• Appendix 1 http//imagingsign.wordpress.com/categ
  ory/ultrasound/
• Appendix 2 http//www.madisonradiologists.com/Svc
  CTAbdominalPain.htm
• CT AAA http//radiographics.rsna.org/content/20/3
  /725/F44.expansion
• Cullens http//www.gastrointestinalatlas.com/Eng
  lish/Jejuno_and_Ileum/Etc__Etc_/etc__etc_.html
• Portal air http//www.nzma.org.nz/journal/119-124
  6/2343/
• Ovarian torsion http//medchrome.com/major/gynaeo
  bstr/complications-of-ovarian-cyst/
• Ovarian torsion U/S http//www.med-ed.virginia.ed
  u/courses/rad/edus/index13.html
• Cecal volvulus diagram http//imaging.consult.com
  /image/topic/dx/Gastrointestinal?titleColonic20O
  bstructionimagefig11locatorgr11piiS1933-0332
  (06)70677-2
• Cecal volvulus drawing http//www.radiologyassist
  ant.nl/en/4542eeacd78cf
• Sigmoid volvulus illustration http//alharthy.com
  /
• Sigmoid X ray http//rad.usuhs.edu/medpix/topic_d
  isplay.html?recnum1608pt_id10030imageid