Download Evaluation of Abdominal Pain in the Emergency Dept.

Evaluation of the ED Patient with
Abdominal Pain
University of Utah Medical Center
Division of Emergency Medicine
Medical Student Orientation
A Common Complaint
• 4-8% of all ED Visits
• Most Common Diagnoses pts > 50
– Cholecystitis (21%)
– Nonspecific abdominal pain (16%)
– Appendicitis (15%)
– SBO (12%)
– Everything else (diverticulitis, hernia, cancer, vascular)
• Most Common Diagnoses pts < 50:
– Nonspecific Abdominal Pain ( ~40% )
– Appendicits (32%)
– Cholecystitis (6%)
– SBO and Pancreatitis (each ~ 2%)
Key Consideration!
• Extensive differential
• Multiple Life-threatening causes
– AAA
– Perforation
– Obstruction
– Ischemia
– Ectopic pregnancy
Other Common Diagnoses
• Gastroenteritis*
• GERD
• Cholecystitis
• Appendicitis
• Obstruction
• Constipation*
• UTI*
• PID*
*often misdiagnoses in patients w/significant
abdominal pathology
• H&P are key (as usual)-they help guide your
workup and whittle down the large ddx
• Labs and Imaging are used to either
support/refute your suspected diagnosis
– Occasionally, the labs and imaging will help come
up with a diagnosis when the history and exam
are not particularly helpful (altered, confused pt)
Abdominal Pain History
• HPI
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Onset
Palliates/Provokes
Quality
Radiation
Severity
Time course
Undo (what have they
done to “undo” their
pain)
• PMH
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PMHx
Surgical Hx
Allergies
Meds
Social Hx
• EtOH
High-Yield Historical Questions.
• How old are you? (Advanced age means increased risk)
• Which came first—pain or vomiting? (Pain first is worse [i.e., more likely to
be caused by surgical disease])
• How long have you had the pain? (Pain for less than 48 hours is worse)
• Have you ever had abdominal surgery? (Consider obstruction in patients
who report previous abdominal surgery)
• Is the pain constant or intermittent? (Constant pain is worse)
• Have you ever had this before? (A report of no prior episodes is worse)
• Do you have a history of cancer, diverticulosis, pancreatitis, kidney failure,
gallstones, or inflammatory bowel disease? (All are bad)
High-Yield Historical Questions.
• Do you have HIV? (Consider occult infection or drug- related pancreatitis)
• How much alcohol do you drink per day? (Consider pancreatitis, hepatitis,
or cirrhosis)
• Are you pregnant?( Test for pregnancy—consider ectopic pregnancy)
• Are you taking antibiotics or steroids? (These may mask infection)
• Did the pain start centrally and migrate to the right lower quadrant? (High
specificity for appendicitis)
• Do you have a history of vascular or heart disease, hypertension, or atrial
fibrillation? (Consider mesenteric ischemia and abdominal aneurysm)
Physical Exam
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Vitals
Rebound tenderness
Look •81% sensitive, 50% specific for peritonitis
Listen •63-76% sensitive, 56-69% specific for
appendicitis
Percussion
Palpation- where tender, rebound or
guarding?
• Rectal and Pelvic-as indicated by history and
exam
Rectal Exam
• Generally indicated only in those with
symptoms referable to the rectal/anal area or
suspected GI bleeding, otherwise rarely useful
in generalized abdominal pain workup
– Prostatitis
– GI bleeding: upper or lower
– Hemorrhoids
– Constipation: possible impaction?
– Bloody diarrhea (enteritis)
Causes of Abdominal Pain by Quadrants
RUQ
LUQ
•Gastric/Peptic
Ulcer
•Biliary Disease
•Hepatitis
•Pancreatitis
•Retrocecal Appendicitis
•Renal Stone
•Pyelonephritis
•MI
•Pulmonary Embolus
•Pneumonia
•Gastric
RLQ
LLQ
•Appendicitis
•Diverticulitis
•Ovarian
•Ovarian
Cyst
•Mittelschmerz
•Pregnancy
•Tubo-ovarian abscess
•PID
•Ovarian Torsion
•Cystitis
•Prostatitis
•Ureteral Stone
•Testicular Torsion
•Epididymitis
•Diverticulitis
•AAA
Ulcer
•Gastritis
•Pancreatitis
•Splenic injury
•Renal Stone
•Pyelonephritis
•MI
•Pulmonary Embolus
•Pneumonia
Cyst
•Mittelschmerz
•Pregnancy
•Tubo-ovarian abscess
•PID
•Ovarian Torsion
•Cystitis
•Prostatitis
•Ureteral Stone
•Testicular Torsion
•Epididymitis
•AAA
Stop and Think
• Differential Diagnosis
• Knowing that labs and radiographic studies
will only aid what you already suspect,
identify needed treatments and start them
empirically as dictated by pt condition
Laboratory Studies
• These will rarely clinch diagnosis
– CBC
• Anywhere from 10-60% of patients with surgically
proven appendicitis have an initially normal white
count
• An elevated white count detects a mere 53% of severe
abdominal pathology.
– Electrolyte, Lipase, UA, LFTs
– Pregnancy Test!
– ECG (especially in elderly)
Radiographic Studies- Plain Film
• Really only helpful in ED for:
– Free air (suspected perforation)
– Dilated loops of bowel with air fluid levels
(obstruction)
– Foreign body
• Free air seen in only 30-50% of bowel
perforation
Sigmoid Volvulus
Sigmoid Volvulus
Sigmoid Volvulus
What’s wrong with this picture??
Radiology- Ultrasound
• Excellent for Biliary Tract Disease (very
sensitive for Gallstones (90+%)
• AAA- can rapidly assess size at bedside
• Ectopic Pregnancy- look for intrauterine yolk
sac, assess adnexa, assess for free fluid
• Appendicitis- 75%-90% sensitive (in
experienced hands, best in thin patients)
– Not routinely done in this country. May change.
• Pelvic structures, testicles
Gallstones
AAA
Radiology- CT Scan
• Detect Leaking AAA ( in stable patient )
• Excellent for Renal Calculi
• Evaluate for appendicitis, perforation
(free air), diverticulitis, abscess, mesenteric
ischemia, masses, obstruction
The sensitivity and specificity for these vary.
Nothing is 100% accurate
• Not a place for unstable patients
Kidney Stones- CT Style
Sigmoid Tumor/Intussusception
Psoas Abscess
Retroperitoneal Abscess
TOA
Abdominal Pain in the Elderly
• “An M&M waiting to happen”
– Mortality & misdiagnosis rise exponentially
w/each decade >50 yrs.
– Elderly generally considered 65 and older
– Approximately 60-70% get admitted, 40-50% go to
the OR and 10% die (this is higher than mortality
of acute MI at 6-8%)
– These patients frequently get, and deserve, a full
complement of imaging and labs
Case #1- Presentation
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23 yo female
acute onset LLQ pain 2 hours ago
Constant, no radiation, no N/V/D
No exacerbating, alleviating factors
No vaginal discharge
Case #1 -PMH
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No medical problems
No medications, No allergies
Surg Hx: S/P Elective Abortion 1 year ago
No history of STDs, Sexually Active
LMP 4 weeks ago
Case #1- Exam
• Vitals: P105 R20 T37.7 BP 103/58
• Abd: soft, tender LLQ with guarding, no
rebound pain detected
• Pelvic: No cervical motion tenderness, L
adnexal tenderness/fullness
• Rectal: No masses, guaiac negative
Case #1- Differential Diagnosis
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Ectopic Pregnancy
Ovarian Cyst
Tubo-ovarian abscess
Ovarian Torsion
Case#1- Intervention/Diagnosis
• Pregnancy Test - Negative
• IV Fluids - 500 cc bolus ( repeat P 90,
BP110/65 )
• U/S- L ovary with absent blood flow, multiple
cysts
• Diagnosis: Ovarian Torsion
• Disposition: To OR by GYN
Case #2- Presentation
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47 yo male with sudden onset abd pain
Epigastric pain, vomited x2
Pain 10/10
Better if holds still, worse on car ride into
hospital
• Never had pain like this before
Case #2- Past Medical History
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Medical Hx: Arthritis, Chronic Low Back Pain
Surgical Hx: L knee meniscus repair
Meds: No prescribed meds, OTC ibuprofen
Allergies: NKDA
SH: 2 beers/night
Case #2- Exam
• Vitals: P95 R22 T37.4 BP 124/75 O2 100%
• Gen: Anxious, Mild distress/diaphoretic,
Remaining still
• Abd: Decreased BS, Severe epigastric
tenderness with guarding and rebound
• Rectal: Guaiac positive
Case #2- Actions
• Large bore IV x2, Type and Screen, CBC, CMP,
Lipase, Fluid bolus,ECG
• Acute Abdominal Series
• Orthostatic Vitals
Case #2 - Interventions/Diagnosis
• CXR reveals intra-abdominal free air
• Diagnosis: Perforation, likely duodenal or
gastric ulcer
• Disposition: To OR for identification and repair
Multiple Life Threatening Causes of
Abdominal Pain
• Identify the potential life threatening cause of
the following cases.
• Differential diagnosis is large but consider an
acute event and test your intuition
Rapid Cases #1
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25 yo female
Recurrent vomiting, diffuse mild pain
Febrile, dehydrated, tachycardic
H/O Diabetes Mellitus
Diagnosis: DKA
Rapid Cases #2
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Healthy 17 yo male, football player
L shoulder pain, not reproducible on exam
lightheaded, weak
U/S with free intraperitoneal fluid
Diagnosis: Splenic Lac
Rapid Cases #3
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16 yo female
Nausea, diffuse discomfort starting yesterday
Now worse RLQ
Abd exam: pain RLQ, +guarding
Diagnosis: Appendicitis
31 yo appy
73 yo appy
Rapid Case #4
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65 yo male
Hx of HTN, Renal Colic x3 episodes
Low back pain- ?new pain
Abd: obese, soft, no masses palpated
U/S shows 7cm AAA
Rapid Case #5
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56 yo female
H/O Alcoholic Cirrhosis
Diffuse abd pain, gradual onset
Distended abdomen, febrile
U/S: ascites
Peritoneal tap >500 WBC/cc
Spontaneous Bacterial Peritonitis
Rapid Case #6
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32 yo female, S/P Tubal ligation 2 weeks ago
Gradual onset diffuse pain
N/V/D, fever
Diffusely tender, guarding, + rebound
CXR with free air
Bowel perforation
Free Air
Rapid Case #7
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82 yo male S/P distant chole, appy
Gradual onset vomiting, nausea, distension
Distended abdomen, increased bowel sounds
KUB: multiple air fluid levels, dilated loops of
small bowel
• Small Bowel Obstruction
Small Bowel Obstruction
Rapid Case #8
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16 yo male
sudden onset lower abd, scrotal pain
No hx of trauma
Tender L testicle to exam
U/S: No vascular flow to L testicle
Acute Testicular Torsion
Rapid Case #9
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30 yo female, G3P3 IUD in place
LLQ pain, gradually worsening today
No fever, Tender L Adnexa
+ UPT
U/S with L Adnexal Gestational Sac
Ectopic Pregnancy
Rapid Case #10
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4 yo male
Crampy abdominal pain- crying
Tender diffusely to exam, afebrile
Guaiac positive stool
Complete relief with enema
Intussusception
Intussusception
Rapid Case #11
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23 yo healthy female
Severe lower abdominal pain
Gradual onset, no N/V/D
Abd Tender Bilateral Lower Quadrants
Cervix tender with movement, UPT Dx: PID
Rapid Case #12
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82 yo Female
H/O HTN, A. Fib, CAD, COPD
Acute severe diffuse abd pain
Exam: Soft, minimal tenderness to palpation
Angiography reveals occluded SMA
DX: Mesenteric Ischemia
Rapid Case #13
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46 yo female, G3P3
Post Prandial Epigastric pain
Exam: Obese, RUQ tender to palpation
U/S: Multiple Gallstones with GB wall
thickening
• DX: Acute Cholecystitis
Acute Cholecystitis
Rapid Case #14
• 78 yo male
• H/O HTN, DM
• Acute onset nausea, diaphoresis, epigastric
discomfort,
• Exam: Mild epigastric discomfort to palpation
• ECG ST elevation 3mm leads II, III aVF
• Dx: Inferior MI
Inferior STEMI
Rapid Case # 15
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65 yo female
LLQ pain, gradually worsening
Exam: Febrile, Tender LLQ to palpation
Guaiac + stool
CT: Diverticulitis with multiple
microperforations
• Dx: Acute Diverticulitis
Do you see the free air?
Rapid Case #16
• 52 yo alcoholic male
• Diffuse abd pain, gradually worsening,
vomiting recurrently
• Exam: soft abdomen, minimal tenderness
• Labs: Increased lipase
• Dx: Pancreatitis
Rapid Case #17
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14 yo healthy male
Acute crampy abd pain past day
Vomiting, Diaphoretic
Exam: Diffuse mildly tender abdomen with
palpable firm mass in R groin
• Dx: Incarcerated inguinal hernia
Incarcerated Hernia
Rapid Case #18
• 28 yo post-partum healthy female
• Acute R flank pain radiating to groin
• Exam: Abd soft, non-tender without CVA
tenderness
• UA with 2+ RBC, no WBCs
• CT with R Ureteral Calculi
• Dx: Renal Colic
Hydronephrosis
Renal Calculus
Hydro-ureter
UVJ Stone
Rapid Case #19
• 72 yo female c/o RUQ pain & cough
• PMHx: HTN, COPD on home O2
• Vitals: T38.5 HR 105 RR 26 BP 140/90 SpO2
88% on 2L
• Physical: dry mucous membranes, decreased
breath sounds, non-tender abdomen
• CXR: RLL infiltrate
• Diagnosis: RLL pneumonia
Summary
• The Differential Diagnosis of Abdominal Pain is
extensive. Large. Massive even.
• You need to identify patterns that place a
person at risk for serious causes of their pain
and rule out/in those causes
• History and Physical are the key to narrowing
the ddx
• Labs and Radiology support/refute your
diagnosis
Summary Continued
• Always get Pregnancy Test (doesn’t matter if
they are on OCP’s, had a tubal ligation, or
swear they can’t be pregnant due to saintly
behavior-OK, no, if hysterectomy or elderly)
• If discharging a patient, always alert patient of
symptoms they should watch for and when to
return
• If dx is “abdominal pain NOS” (unknown
etiology), consider f/u, even in ED, for reevaluation