Download Abdominal Pain

Abdominal Pain
William Beaumont Hospital
Department of Emergency Medicine
Abdominal Pain
• One of the most common chief complaints
• Confounders making diagnosis difficult
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Age
Corticosteroids
Diabetics
Recent antibiotics
Pitfalls
• Consider non-GI causes
• Acute MI (inferior), ectopic pregnancy, DKA, sickle cell
anemia, porphyria, HSP, acute adrenal insufficiency
• History
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Location
Quality
Severity
Onset
Duration
Aggravating and alleviating factors
Prior symptoms
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
Physical Exam
• Abdomen
• Inspection
• Bowel sounds
• Tenderness (rebound, guarding)
• Extra-abdominal exam
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Lung
Cardiac
Pelvic
GU
Rectal
Labs
• Beta-hCG
• WBC – poor sensitivity and specificity
• LFTs – hepatobiliary
• Lipase – pancreatic
• Electrolytes – CO2
• Lactic acid
• Urinalysis – BEWARE
Imaging
• Acute Abdominal
Series
• Free air
• Bowel gas
• KUB
• Poor screening test
• Ultrasound
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Biliary disease
AAA
Free fluid or air
Pelvic pathology
• CT
• Appendicitis
• Diverticulitis
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?
Upper Abdominal Pain
• Biliary disease
• Pneumonia (RLL)
• Hepatitis
• Pyelonephritis
• Pancreatitis
• Acute MI
• PUD/gastritis/esoph
agitis
• Appendicitis
• AAA
• Fitz-Hugh Curtis
Gallstone Risk Factors
• Female 4:1
• Fertile
• Forty
• Fat
• Family history
• Others:
• Crohns, UC, SCA, thalassemia, rapid weight
loss, starvation, TPN, elevated TGs, cholesterol
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
Cholelithiasis:
Treatment
Symptomatic
Asymptomatic
• Pain control
• Incidental finding
• Anti-emetics
• 15-20% become
symptomatic
• Consult general surgery
• 90% with recurrent
symptoms
• 50% develop acute
cholecystitis
• Outpatient elective surgery if
• Frequent, severe attacks
• Diabetic
• Large calculi
Acute Cholecystitis
• Sudden gallbladder inflammation
• Bacterial infection in 50-80%
• E. coli, Klebsiella, Enterococci
• History/PE:
• Fever, tachycardia, RUQ tenderness
• Murphy’s sign – low sensitivity
• Labs:
• Elevated WBC with left shift
• LFTs – large elevation  CBD stone
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
Acute Cholecystitis
Acute Cholecystits:
Treatment
• Admit
• NPO
• IVF
• Pain control
• Anti-emetics
• Antibiotics
• Surgical consult
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
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)
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• AST > ALT – alcoholic hepatitis
Elevated bilirubin
Abnormal PT
Hepatitis panel
Tylenol level
Hepatitis: Treatment
• Symptomatic – IVF, electrolytes
• Remove toxins – ETOH, acetaminophen
• Admit if altered MS or coagulopathy
Pancreatitis
• Autodigestion of pancreatic tissue
• B – Biliary
• A – Alcohol
• D – Drugs
• S – Scorpion bite
• H – HyperTG, HyperCa
• I – Idiopathic, Infection
• T – Trauma
Pancreatitis: History and
Physical
• History:
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Boring pain in LUQ or epigastrium
Constant
Radiates to mid-back
Nausea, vomiting
• PE:
• Epigastric or LUQ tenderness
• Grey-Turner or Cullen sign
Gray-Turner sign
• Flank ecchymosis
• Intraperitoneal bleeding
• Hemorrhagic pancreatitis
• Ruptured abdominal aorta
• Ruptured ectopic pregnancy
Cullen's Sign
Pancreatitis: Diagnosis
• Lipase – most specific
• Ranson’s criteria – predicts outcome
• Acutely: >55 yo, glucose > 200, WBC >16k, ALT > 250,
LDH > 350
• 48 hrs: HCT decreases > 10%, BUN rises > 5, Ca < 8,
pO2 < 60, base deficit >4, fluid sequestration > 6L
• 3-4 criteria – 15% mortality
• 5-6 criteria – 40% mortality
• 7-8 criteria – 100% mortality
Pancreatitis: Imaging
• Plain films – sentinel loop (local ileus)
• Ultrasound – poor (biliary tree)
• CT scan with contrast
Pancreatitis: Treatment
• NPO
• IVF
• Pain control
• Antiemetics
• Antibiotics if gallstones or septic
• Surgical consult
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If gallstones, abscess, hemorrhage or pseudocyst
• ERCP if CBD stone
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
Peptic Ulcer Disease
• Workup:
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Hemoglobin
PT/PTT – if bleeding
Lipase – rule out pancreatitis
Hemoccult stool – rule out GI bleed
• Treatment:
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Antacids (GI cocktail)
PPI
Outpatient endoscopy
H. pylori testing
Perforated Viscus
• Rare in small bowel and mid-gut
• History: abrupt onset pain
• Diagnosis: upright CXR
• Treatment:
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IVF
IV antibiotics
NG tube
OR
Questions on
Upper Abdominal Pain?
Let’s Move On Down
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 >
L), no rebound or guarding.
• Other questions?
• Differential diagnosis?
• Testing?
Lower Abdominal Pain
• Appendicitis
• Diverticulitis
• UTI/Pyleonephritis
• Renal colic
• Torsion/TOA/PID
• Ectopic pregnancy
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
Appendicitis
• Abdominal pain (98%)
• Periumbilical migrating to RLQ < 48 hrs
• Anorexia 70%
• Nausea, vomiting 67%
• Common misdiagnosis – gastroenteritis, UTI
Appendicitis
• PE:
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RLQ tenderness 95%
Rovsing: RLQ pain palpating LLQ
Psoas: R hip elevation, extension
Obturator: flexion, internal rotation
Appendicitis:
Diagnosis
• Labs:
• WBC > 10k – 75%
• UA – sterile pyuria
• Imaging:
• Ultrasound
• CT scan
• MRI
Appendicitis: Treatment
• IV fluids
• NPO
• Analgesia
• Antibiotics
• Surgery consult
Diverticulitis
• Inflammation of a diverticulum (herniation of
mucosa through defects in bowel wall)
• Sigmoid colon is the most common site
• History:
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L>R
3% under 40
LLQ pain with BMs
N/V/constipation
• PE: LLQ tenderness
• Diagnosis: clinical, CT
Diverticulitis:
Treatment
• Admit if fever, abscess, elderly
• NPO
• IV fluids
• IV antibiotics
• Ciprofloxacin AND metronidazole
• Surgical consultation
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?
Differential Diagnosis
• Small bowel obstruction
• Large bowel obstruction
• Sigmoid volvulus
• Cecal volvulus
• Hernia
• Mesenteric ischemia
• GI Bleed
Small Bowel
Obstruction
• Etiology
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Adhesions (>50%)
Incarcerated hernia
Neoplasms
Adynamic ileus – non mechanical
• Abd trauma (post op), infection, hypokalemia,
opiates, MI, scleroderma, hypothyroidism
• Rare: intusseception, bezoar, Crohn’s disease,
abscess, radiation enteritis
Large Bowel
Obstruction
• Etiology
• Tumor
• Left  obstruct
• Right  bleeding
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Diverticulitis
Volvulus
Fecal impaction
Foreign body
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 > 3cm; LB > 10cm
SBO: Imaging
SBO: Treatment
• IV fluids!
• Correct electrolyte abnormalities
• NPO
• NG tube
• Broad spectrum antibiotics if peritonitis
• Surgery consult
Sigmoid Volvulus
• History:
• Elderly, bedridden, psychiatric pts
• Crampy lower abdominal pain, vomiting,
dehydration, obstipation
• Prior h/o constipation
• PE:
• Diffuse abdominal tenderness
• Distension
Sigmoid Volvulus
Sigmoid Volvulus:
Imaging and Treatment
• AAS: dilated loop of colon on left
• Barium enema: “bird’s beak”
• WBC > 20k: suggests strangulation
• CT scan
• Treatment
• IVF
• Surgical consult
• Antibiotics if suspect perforation
Cecal volvulus
• Most common in 25-35 year olds
• No underlying chronic constipation
• History:
• Severe, colicky abd pain
• Vomiting
• PE:
• Diffusely tender abdomen
• Distension
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
Hernias
• Inguinal (most common) 75%
• Indirect 50% vs. direct 25%
• Men > women
• High risk incarceration in kids
• Femoral 5% - women > men
• Incisional 10%
• Umbilical – newborns, women > men
• Incarcerated – unable to reduce
• Strangulated – incarcerated with vascular compromise
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
Mesenteric Ischemia
• Etiology
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50% arterial emboli
20% non-occlusive disease (CHF, sepsis, shock)
15% arterial thrombi
5% venous occlusion
• Mortality rates 70-90% - delayed diagnosis
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
Mesenteric Ischemia:
Diagnosis
• Pain out of proportion to exam!
• Heme positive stools (>50%)
• May present as LGIB
• Peritonitis and shock
• Late findings
• WBC > 15k
• Metabolic acidosis
• Lactic acid – high sensitivity, not specific
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:
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IVF
NG tube
IV antibiotics
IR consult for angiography
Surgical consult
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
GI hemorrhage
• Consider with chief complaints:
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Weakness
SOB
Dizzy
Abdominal pain
• PE: orthostatics, abdomen, rectal
• Conjunctival pallor
• Cool, clammy skin
• Spider angiomata, palmer erythema, jaundice,
bruises  liver disease
GIB: Diagnosis
• Hemoccult – iodide, methylene blue and red meat
cause false pos
• Labs:
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CBC (Hg < 8)
PT
T&S
Increased BUN (blood, hypovolemia)
• ECG – rule out silent MI (anemia)
• NG tube – rule out UGI bleed
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
Lower GI Hemorrhage:
Etiology
• Hemorrhoids – most common overall
• Diverticulosis – most common severe cause LGIB
• Angiodysplasia
• Polyps/cancer
• Rectal disease
• IBD
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
GIB: Treatment
• Colonscopy – ligate or sclerose diverticulosis,
AVM bleeds
• EGD – band ligation or sclerose varices
• Octreotide – varices, PUD
• Vasopressin – varices
• Sengstaken-Blakemore tube – varices
GIB: Surgical
Indications
• Hemodynamically unstable
• Unresponsive to endoscopy, IV fluids, and
correction of coagulopathy
• Transfused > 5units in 4-6 hrs
• Mortality 23% if emergent surgery
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
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?
Differential Diagnosis
• Renal colic
• Mesenteric ischemia
• PUD with perforation
• GI bleed
• Diverticulitis
• Cholecystitis
• Pancreatitis
• Low back pain
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
(Marfan’s, Ehlers-danlos)
AAA: Pathophysiology
• Atherosclerosis causes loss of elastin and
collagen in aortic wall
• Normal aorta diameter = 2 cm
• Uncommon to rupture if < 5 cm
• Elective repair
• 30% of aneurysms >5 cm rupture within 5 years
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:
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Pulsatile mass 50-90%
Abdominal distension due to RP or IP blood
Abdominal bruit 3-8%
Blue toe syndrome 5% due to emboli
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
AAA
AAA: Treatment
• Asymptomatic patient
• Incidental finding
• <4 cm – repeat US Q6 months
• >4 cm – elective repair
• Symptomatic patient
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CT to confirm diagnosis (if stable)
2 large bore IVs
T&C
pRBC - ~8 units
Admit via OR (vascular surgery consult)
AAA: Mortality
• Elective repair – 4%
• Post rupture – 45%
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Normal BP – 20%
Hypotensive, responds to volume – 40%
Hypotensive, incomplete response 60%
Hypotensive, no urinary output – 80%
The End
Any Questions?