Download Attending Abdominal Pain Module

Resident Version
Abdominal Pain Module
Created by Dr. Robert Leverence
Objectives:
1) List four important causes of abdominal pain for patients who present to the
Emergency Department.
2) Recognize a surgical abdomen based on three clinical criteria.
3) Identify three steps for the assessment and management of patients
presenting with abdominal pain.
References:
1. Kamin RA, Nowicki TA, et al. Pearls and pitfalls in the emergency
department evaluation of abdominal pain. Emerg Med Clin N Am 21 2003;
61-72.
2. Powers RD, Guertler AT. Abdominal Pain in the ED: Stability and Change
Over 20 Years. American Journal of Emergency Medicine 1995:13: 301-03.
3. Gerhardt RT, Nelson BK, et al. Derivation of clinical guideline for the
assessment of nonspecific abdominal pain: the Guideline for Abdominal Pain
in the ED Setting (GAPEDS) Phase 1 Study. American Journal of Emergency
Medicine 2005: 23:709-17.
CASE
HPI: A 70 yo female presents with a two day history of generalized abdominal pain and
bloating. She is not able to characterize the pain any further. Onset was two days ago,
prior to that she felt normal. She has vomited twice but has been tolerating sips of fluids.
No BM for 3 days, but has been passing small amounts of gas intermittently. Has not
noticed any blood in the last BM or vomitus. No fevers or night sweats. No new foods or
recent travel. Some mild dysuria.
PMH:
1.
2.
3.
4.
S/P appendectomy 40 yrs ago
S/P TAH BSO for stage I endometrial cancer 5 yrs ago
“PUD”
Recurrent UTIs
Medications:
1. Nexium 20 mg daily
2. MVI with Calcium
Shx:
Lives alone although daughter lives nearby. Denies alcohol or tobacco use.
PE: T37.7, P100, BP 100/60, RR 18, O2 NL on RA
General- patient laying quietly in bed, groaning. Conversant although slightly confused.
HEENT – normal, notable for no icterus.
Lungs - clear to auscultation, no crackles or wheezes appreciated.
CV – mildly tachycardic, regular rhythm, no murmur, gallop, nl JVD
Abd – obese, soft, mildly distended with mild generalized tenderness, no localizing signs.
Voluntary guarding, no rebound. Bowel sounds are diminished. No palpable masses.
Ext - fem pulses 2+ bilat.
Rectal: guaiac negative, vault fairly empty.
Labs/Studies:
WBC 11.0 with left shift, Hct 36, Plt 400
Chemistries all normal including LFTs, Amylase, Lipase.
UA - 1+ heme, 5 RBC, 12 WBC, many bacteria.
3 way of abdomen x-ray: non-specific mildly dilated loops of bowel, no free air.
Moderate amount of stool present, air in rectum.
CXR: clear.
1. What would be on your differential for this patient for causes of abdominal pain?
2. What would be your management based on most likely diagnosis, and what
further imaging/studies need to be obtained?
Discussion Outline:
I. Epidemiology: Abdominal pain is common. It is present on questioning of 75% of
otherwise healthy adolescents and about half of all adults in the general population.
Many if not most of these cases would be given the diagnosis of nonspecific abdominal
pain (NSAP). In the population of patients presenting to an Emergency Department, the
prevalence of NSAP would be lower, yet still not negligible. Table 1 summarizes the
cause of abdominal pain in 1000 patients presenting to a large tertiary care university
emergency department.
Table1. Cause of abdominal pain in 1000 consecutive ED patients
Diagnois
NSAP
Specific GI
Gastritis
Pancreatitis
Constipation
Ulcer
Hernia
Malignancy, Diverticular Disease, Esophagitis, Fecal
impaction, Crohn’sDisease, Ileus, Alcoholic Hepatitis
Female pelvic
Pelvic inflammatory disease
Ovarian cyst
Dysmenorrhea
Vaginitis/cervicitis
Menometrorrhagia, Intrauterine pregnancy, Misscarriage,
Threatoned abortion, Ectopic pregnancy, other
Urinary tract
Cystitis
Ureteral calculus
Pyelonephritis
Prostatitis
Epididymitis
Urinary retention
Nausea/Vomiting
GI surgical
Cholecystitis
Bowel obstruction
Appendicitis
Hernia, Mesenteric Insufficiency, Peritonitis
Other
Musculoskeletal
Cardiovascular
Psych
Infectious
Unspecified
Table adapted from Powers RD, Guertler AT. See reference number 2.
% Patients
24.9%
18.4%
5.3%
3.9%
3.3%
1.5%
1.4%
<1.0%
11.7%
3.4%
1.9%
1.9%
1.3%
<1.0%
11.5%
6.6%
2.8%
1.4%
0.4%
0.2%
0.1%
9.7%
7.6%
3.6%
1.6%
1.4%
<1.0%
6.4%
2.9%
1.5%
1.2%
0.8%
8.9%
II. History and Physical: Physicians are responsible for trying to determine which
patients require urgent intervention and which can be safely observed. Generally we are
fairly accurate at recognizing the acute or surgical abdomen (obstruction or peritonitis),
however for the remaining patients, our sensitivity for recognizing conditions which
require other urgent intervention may be as low as 30-50%.
Table 2. Diagnoses requiring urgent intervention (i.e. you don’t want to miss)
Abdominal aortic aneurysm
Liver abscess
Aortic dissection
Mesenteric ischemia/ischemic colitis
Appendicitis
Neoplasm, newly diagnosed
Bowel obstruction
Ovarian cyst, ruptures with hemorrhage
Choledocolithiasis, with or without ascending cholangitis
Pancreatitis, with or without cholelithiasis
Cholecystitis
Perforated viscus
Colitis or regional ileitis
Pyelonephritis
Diverticulitis, with or without perforation
Renal arterial or venous thrombosis
Gastrointestinal hemorrhage
Sigmoid volvulus
Hepatitis, acute fulminant
Spontaneous bacterial peritonitis
Ileus
Tubo-ovarian abscess
Table adapted from Gerhardt RT et al, see reference 3.
History:
 Duration, characterization, location and radiation of pain
 Factors that exacerbate or improve pain (e.g. foods, exertion)
 Associated symptoms (e.g. F/C/N/V/D/ bloody stools)
 Alcohol intake/medications (e.g. NSAIDs, immunosuppressants)
 Past h/o abdominal surgery, PUD, nephrolithiasis, malignancy, radiation, etc.
 Menstrual and OB/gyn history in women. Pay particular attention to h/o PID or
current IUD use.
Physical exam:
 Vital signs
 General: Does this patient look ill*? Is patient writhing in pain or avoid
movement? Does the pain worsen when you bump the bed?
 Examine eyes and skin for jaundice
 Bowel sounds – high pitched* or diminished*?
 Palpate to localize pain, for rebound tenderness or rigidity, for mass or HSM,
distension or tympany*
 DRE and test stool for occult blood
 Pelvic exam in all women with lower abdominal pain.
*Bold indicates findings in obstruction, italics indicate findings in peritonitis, and bold italics indicate
findings in both.
Diagnostic Investigations:
CBC with differential, electrolytes, BUN, creatinine, glucose

LFTs, Amylase/Lipase
 Urinalysis
 Pregnancy test in all women of childbearing potential
 Blood cultures and urine cultures if unstable VS, fever/elevated wbc, or
risk factors present (immunosuppressed, line in place, IVDU, etc.)
 Abdominal radiographs (plain radiograph and an upright or lateral
decubitus radiograph – proximally dilated loops of bowel are the
hallmark for obstruction and free intraperitoneal air can confirm
hollow organ perforation).
 EKG in elderly
III. Management: Many patients will not have a firm diagnosis after initial assessment
(we call this nonspecific or undifferentiated abdominal pain), and in these cases, careful
observation of the patient’s course will be the most important factor in their management.
It is here that good clinical acumen (and admittedly a little luck) comes into play.




A nonenhanced CT is a rational choice for decision support.
For women with lower abd pain, a pelvic ultrasound should be
considered.
Elderly patients with abdominal pain have a much higher mortality
rate due to a) lack of physical findings, b) delay in seeking medical
care, and c) their increased prevalence of disorders such as
mesenteric ischemia, leaking/ruptured AAA, and MI. For these
reasons, our threshold for admission is lower in the elderly.
If observation at home is decided, then a clear and detailed followup plan must be arranged.
Review Questions
1. A 62-year-old woman presents to the emergency department complaining of
intense abdominal pain, nausea, and vomiting for the past 48 hours. On physical
examination, the patient is visibly uncomfortable, with a low-grade fever, mild
tachycardia, and normal blood pressure; her upper abdomen is markedly tender.
Laboratory tests are remarkable for an amylase of 1150, bilirubin of 2.5, and
creatinine of 2.3.
Which of the following is the most useful imaging test to determine whether this
patient’s pancreatitis is caused by gallstones?
A.
B.
C.
D.
Plain film
Ultrasonography
CT scan
Endoscopic retrograde cholangiopancreatography (ERCP)
2. A 49-year-old man presents with right upper quadrant abdominal pain that began
8 hours ago. The pain is constant and is associated with nausea, vomiting, and
fever. Over the past few months, he has had intermittent episodes of similar pain,
but those were less intense, resolved spontaneously within 1 or 2 hours, and were
never associated with vomiting or fever. Results of physical examination are as
follows: temperature, 101.3° F (38.5° C); blood pressure, 130/90 mm Hg; pulse
90 beats/min; and respirations, 16 breathes/min. The patient looks tired and
moderately uncomfortable. Bowel sounds are present, but he had right upper
quadrant tenderness. There is no palpable liver or gallbladder. Laboratory results
are remarkable for a white blood cell count of 14,000, with a left shift. Bilirubin,
amylase, and alkaline phosphatase levels are normal.
Which of the following is the best diagnostic imaging test for this patient?
A.
B.
C.
D.
E.
Oral cholecystogram
HIDA scan
Ultrasound
CT scan
Plain abdominal x-ray
3. A 54-year-old man presents with a 3-day history of left lower quadrant pain. He
reports that his appetite has decreased and that he had been experiencing mild
nausea. He denies having any significant changes in bowel function,
hematochezia, or melena. On examination, his temperature is 101.3° F (38.5° C)
and his blood pressure is 145/84 mm Hg. He has significant tenderness in the left
lower quadrant, with some mild local fullness. No rebound is appreciated. The
white blood cell count is 13,400.
What is the most appropriate diagnostic test for this patient?
A.
B.
C.
D.
E.
Barium enema
Colonoscopy
Abdominal CT
Anoscopy
Diagnostic laparotomy
4. A 67-year-old woman presents to the office with 6 days of mild left-lowerquadrant cramping. She describes previous bouts of diverticulitis similar in
character. She denies having fever, chills, nausea, or evidence of gastrointestinal
bleeding. On examination, she is afebrile with mild left-lower-quadrant
tenderness. A presumptive diagnosis of diverticulitis is made. She denies having
any allergies to medication.
What is the most appropriate choice for antibiotic monotherapy?
A. Metronidazole
B. Amoxicillin-clavulanate
C. Cephalexin
D. Clindamycin
E. Azithromycin
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to
Dr. Wendy Gerstein, Department of Medicine, VAMC (111).
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment
below:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient
curriculum in general:
6) Please circle one:
Attending
Resident (R2/R3)
Intern
Medical student