Download Abdominal Pain

Abdominal Pain
LSU Medical Student Clerkship, New
Orleans, LA
Historical Elements
O- onset
P-provocation /palliation
Q- quality/quantity
R- region/radiation
S- severity/scale
T- timing/time of onset
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
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)
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.
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.
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 -> ipsilateral supraclavicular or
shoulder pain
gynecologic pathology -> back or proximal lower extremity
pain
biliary tract disease -> right infrascapular pain
myocardial ischemia ->midepigastric, neck, jaw, or upper
extremity pain
ureteral obstruction -> ipsilateral testicular pain
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.
Radiology: Plain Films
When are they useful?
Obstruction/Ileus
Volvulus (cecal and sigmoid)
Free air
Radiopaque foreign bodies
Constipation?
Plain Films: Small bowel obstruction
Cecal Volvulus and Sigmoid Volvulus
Pneumoperitoneum
Iron Overdose:
Remember the radiopaque
foreign bodies mneumonic:
BAT CHIPS:
Barium
Antihistamines
Tricyclic antidepressants
Chloral hydrate, calcium,
cocaine
Heavy metals
Iodine
Phenothiazine, potassium
Slow-release (enteric
coated)
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 user’s skill
level. Limited by body habitus and bowel gas
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)
Ultrasound: Cholecystitis
Ultrasound: AAA
Ultrasound: Appendicitis
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.
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.”
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:
What is on the differential?
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Pancreatitis
Mesenteric Ischemia
MI
Gallbladder Disease
GERD
Obstruction
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Peritonitis
PE
PUD
AAA
Valvular Insufficiency
Perforated Viscus
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.
AAA
Fun facts:
They are typically infrarenal
>3cm 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.
AAA: Diagnosis and
Management
H&P: May not be symptomatic until the rupture
Syncope and Abdominal pain
Cullen’s sign and Grey Turner’s 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.
ED’s role is maintaining hemodynamic stability with blood
products – SBP 90-100mg until surgery.
CT of Rupturing AAA:
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…
Differential?
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Lower GI Bleed
Brisk Upper GI bleed
Mesenteric Ischemia
Peritonitis
Diverticulitis
Aorto-enteric Fistula
• Small Bowel Obstruction
• Large Bowel Obstruction
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.
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
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.
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?
Differential
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Ectopic Pregnancy
Ruptured Ovarian Cyst
Appendicitis
Right-sided diverticulitis
TOA
Ovarian Torsion
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Nephrolithiasis
Pyelonephritis
Endometriosis
UTI
Heterotopic pregnancy
Terminal ileitis
Ovarian Torsion…
Increased ovarian volume (>15cc),
multiple follicles and decreased blood
flow.
Cases…
• A 24 y/o male presents with rapid onset, nonradiating, 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.
Differential?
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Appendicitis
Bowel Obstruction
Testicular torsion
Perforated Viscus
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Colitis
PUD
Peritonitis
Mesenteric Ischemia
What happens and what it looks
like:
Compared to a Sigmoid Volvulus…
Obstructions: Small and Large Bowel
Small
Large
Adhesions
Hernias
Masses
Masses
Diverticulitis
Sigmoid Volvulus
Treatment…
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NPO
NasoGastric Tube suction.
Fluid and Electrolyte repletion
Antibiotics
Surgical consult
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”
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
References:
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Me.
SBO PICTURE: http://www.healthhype.com/partial-and-complete-bowel-obstruction-symptoms-and-treatment.html
CECAL VOL. http://bestpractice.bmj.com/best-practice/monograph/877/resources/image/bp/2.html
Sigmoid: http://www.learningradiology.com/archives2008/COW%20338-Sigmoid%20volvulus/sigmoidvolcorrect.htm
Pneumoperitnoeum: http://new.medicalfinals.co.uk/?p=425
Foreign bodies: http://lifeinthefastlane.com/2009/10/top-ten-foreign-bodies/
Gallbladder:
http://imaging.consult.com/imageSearch?query=impactions&qyType=AND&global_search=Search&modality=&thes=true&nor
malVariantImage=false&groupByNode=none&anatomicRegion=&modalityFilter=Ultrasound
AAA: http://www.keepingyouwell.com/CareAndServices/VascularLabServices/AbdominalAorticAneurysms.aspx
Appendix 1: http://imagingsign.wordpress.com/category/ultrasound/
Appendix 2: http://www.madisonradiologists.com/SvcCTAbdominalPain.htm
CT AAA: http://radiographics.rsna.org/content/20/3/725/F44.expansion
Cullen’s: http://www.gastrointestinalatlas.com/English/Jejuno_and_Ileum/Etc__Etc_/etc__etc_.html
Portal air: http://www.nzma.org.nz/journal/119-1246/2343/
Ovarian torsion: http://medchrome.com/major/gynaeobstr/complications-of-ovarian-cyst/
Ovarian torsion U/S: http://www.med-ed.virginia.edu/courses/rad/edus/index13.html
Cecal volvulus diagram:
http://imaging.consult.com/image/topic/dx/Gastrointestinal?title=Colonic%20Obstruction&image=fig11&locator=gr11&pii=S19
33-0332(06)70677-2
Cecal volvulus drawing: http://www.radiologyassistant.nl/en/4542eeacd78cf
Sigmoid volvulus illustration: http://alharthy.com/
Sigmoid X ray; http://rad.usuhs.edu/medpix/topic_display.html?recnum=1608&pt_id=10030&imageid=
Small bowel obstruction XR: http://allbleedingstops.blogspot.com/2009/01/solution-to-puzzle.html
“other conditions” slide: http://erweb.vghtpe.gov.tw/ skhou/ abdominal%20pain.ppt 91k