Download Abdominal_Pain_ED

Management of Patients
with Abdominal Pain in
the Emergency Department
Abdominal Pain
Lecture Outline
Recognition & resuscitation for lifethreatening causes of abd. pain
 Physical exam features
 Choosing diagnostic tests
 Initial treatment
 Differential diagnosis
 Key points about the most common
specific causes

Abdominal Pain : Diagnostic &
Treatment Priorities
First : recognize presence of shock or intraabdominal
bleeding
 Second : start resuscitative measures for shock or
bleeding (if these are present)
 Third : determine if the abdomen is the source of the
shock or bleeding
 Fourth : determine if emergency laparotomy is needed
 Fifth : complete the secondary survey (head to toe
exam) ; obtain needed lab or radiographic studies
 Sixth : Conduct frequent reassessments of the patient

General Approach to the Patient
Presenting with Abdominal Pain
Evaluate
& treat the ABC's (Airway, Breathing,
Circulation) first in same sequence as for any other
emergency patient
Determine if an immediate life-threatening cause of abd.
pain may be present & if there is any history of possible
abd. trauma
Start resuscitation and emergently consult a surgeon if
an emergent laparotomy is needed
Complete the secondary survey, treat pain, and decide
what other diagnostic tests will be needed
Immediate Life-Threatening
Causes of Abdominal Pain
These
must be recognized from the primary survey :
Ruptured abdominal aortic aneurism (AAA)
Rupture of the spleen or liver
Ruptured ectopic pregnancy
Bowel infarction
Perforated viscus
Acute myocardial infarction (MI)
Ruptured Abdominal Aortic
Aneurism (AAA)
More
common in males > 65 years of age
May present initially as back or groin pain
Typically would have epigastric or periumbilical pain radiating to
back
May present in shock from intraperitoneal rupture (retroperitioneal
rupture may initially be contained)
Often can feel pulsating supraumbilical mass (if you can feel the
aortic pulse width > 4 cm : suspect AAA)
Can sometimes make this Dx from lateral X-ray of abd.
Bedside ultrasound (U/S) is best Dx test for unstable patient
Abd. CT scan is best Dx test for stable patient (surgeon may also
want angiography preop if patient is stable)
Ultrasound showing 7.5 cm AAA with intraluminal clot
CT scan of AAA (L = lumen, T = thrombus)
Emergency Management of
Ruptured AAA
Oxygen
& IV fluid resuscitation (normal saline or
lactated Ringer's) if systolic BP < 100 mm Hg (but
do not "overresuscitate" ; do not increase the BP to
over 120 systolic because higher BP may cause
increased bleeding)
Type and cross for at least 6 units of blood
Insert foley catheter
Obtain an electrocardiogram
Emergently consult a surgeon
Notify the operating room
Ruptured Spleen or Liver
Usually
due to trauma, but can be spontaneous from
malaria, mononucleosis, or hematologic diseases
Patient may present with shock ; may also have
referred pain to shoulder (Kehr's sign)
Dx and Rx considerations & sequence same as for
ruptured AAA (IV fluid, Type & cross, U/S or CT, call
surgeon, etc.)
Ruptured Ectopic Pregnancy
Most
common cause of pregnancy-related death in
U.S.A.
May NOT have missed menstrual period
Typically have severe sudden onset lower abd. pain +/shock
Should obtain stat serum or urine HCG test in any
female of reproductive age with abd. pain
Pelvic U/S is Dx test of choice
Rx : Oxygen, IV fluid (NS or LR), Type & cross at least 2
units, emergently consult surgeon or obstetrician
Bowel Infarction
Due
to clot embolus or thrombosis in mesenteric
artery
Most patients have severe coronary artery disease
(this can be a post-MI complication)
May have "pain out of proportion to findings" (may
not demonstrate much tenderness)
Physical exam may show signs of peritonitis,
hypoactive bowel sounds, blood in rectum or guiac
positive stool
Bowel Infarction (cont.)
Usual
lab findings :
High WBC
Severe lactic acidosis (anion gap > 18)
Plain X-ray film findings :
Free air, air in portal vein, air in bowel wall
("pneumatosis intestinalis")
May need emergent angiography for Dx
Rx : Oxygen, IV fluid resuscitation, IV broad
spectrum antibiotics, consult surgeon
Angiogram (arrow
shows superior
mesenteric artery
clot) of a 65 year
old male with
bowel ischemia
Perforated Viscus
Causes
:
Blunt or penetrating trauma, tumors, inflammaory
bowel disease, typhoid fever, amebiasis, other
parasites
Typically see free air under diaphragm on plain films
(Chest X-ray is most sensitive to see small amounts
of air)
Rx : Oxygen, IV fluids, IV broad spectrum antibiotics
(such as cefoxitin & metronidazole), emergently
consult surgeon
Free air under the
diaphragm from a
perforated peptic
ulcer
Chest X-ray showing colonic interposition (NOT free air)
Abdominal film
showing the
“Rigler double
wall sign” of free
intraperitoneal
air (can see both
inside and
outside wall of
bowel)
Acute Myocardial Infarction (MI) as
a Cause of Abdominal Pain
Suspect
in adult patient with upper abd. pain but no
or minimal abd. tenderness
Inferior MI commonly presents as "indigestion" ; may
also have emesis
MI may also secondarily occur from shock due to an
intraabdominal cause (such as intraluminal bleed,
etc.)
Dx by EKG +/- enzymes ; need Chest X-ray also
Rx : Oxygen, IV line, nitrates, aspirin, consider
thrombolytics, etc., & admit to monitor bed unit
Now That Immediate Life-Threatening Causes of Abd.
Pain Have Been Reviewed, Next the Lecture Will
Review History and Exam for the Stable Patient
History
items to ask the patient with abd. pain :
Time and rapidity of onset
Character of pain (burning, cramping, etc.)
Associated symptoms
Signs of bleeding (dark vomitus or stool)
Prior surgeries & illnesses
Last menstrual period
Medications (especially steroids, aspirin, warfarin)
Alcohol intake
Unusual ingestion or foreign travel
Physical Exam for the Patient
with Abdominal Pain
Need
complete set of vital signs
Look in nose and mouth for sites of bleeding
(swallowed blood may mimic an intraluminal bleed)
Look at skin for stigmata of liver disease or signs of
coagulapathy
Careful chest & lung exam (basilar pneumonias can
present as abd. pain)
Palpate and observe the back
Genital and rectal exam (& stool guiac) should usually
be routine
Exam of the Abdomen in the
Patient with Abdominal Pain
Inspection
: Look for :
Scars from prior surgeries
Distension
Localized swelling or mass
Eccymoses or erythema
Visible peristalsis
Auscultation with stethescope
Listen for bowel sounds & bruits
Palpation & percussion
Interpretation of Bowel Sounds
(Associated, but not Definite, Diagnoses)
High
pitched or "tinkling" : bowel obstruction
Continuous & hyperactive : acute
gastroenteritis
Absent : ileus or peritonitis (need to listen for
at least one minute)
Audible without stethescope : "borborygmi"
Percussion of the Abdomen
Should
tap with 2 fingers on all 4
quadrants
If tympanitic : implies bowel obstruction
If dull, implies intraabdominal bleding or
fluid (such as ascites)
If tender, correlate with tender areas
noted on palpation
Palpation of the Abdomen
Should
be done following inspection & auscultation
Assess for tenderness, guarding, mass, crepitus, referred
tenderness
Differentiate lower rib tenderness from true upper abd.
tenderness
Don't need to directly assess rebound ; just wiggle
abdomen from the side & check for referred tenderness
(direct rebound is cruel if peritonitis is present)
Don't forget leg maneuvers (psoas, obturator, & heel tap
signs)
Lab Studies for Patients with
Abdominal Pain
Use
selectively ; not all are needed for all
patients
For example, for young adults with
simple acute viral gastroenteritis or food
poisoning, usually no lab studies are
needed (they may just need IV fluids &
parenteral antiemetics)
Draw with the initial venipuncture if an IV
line is to be established
List of Lab Studies to Consider for
Patients with Abdominal Pain
Type
and Cross (the most important if patient has shock)
Complete blood count (CBC)
Urine or serum pregnancy test (HCG)
Serum amylase, lipase
Urinalysis, urine culture and sensitivity
Liver function tests (bilirubin, SGOT, SGPT, alk. phos.)
Electrolytes, glucose, creatinine, blood urea nitrogen (BUN)
Serum alcohol, serum or urine drug screen
Serum medication levels (such as digoxin)
Clotting studies (platelet count, protime, PTT, fibrinogen)
Cardiac enzymes (if coronary ischemia suspected)
 Blood culture (if sepsis or bacteremia suspected)
 Nonemergent tumor markers (CEA, AFP)
Interpretation of Lab Studies for
Abdominal Pain
WBC
typically elevated (+/- "left-shifted") in any
cause of peritonitis & in bowel infarction & in spleen
& liver bleeding
However often NOT elevated appropriately in :
ƒ the elderly
ƒ immunocompromised patients
ƒ patients on chronic corticosteroid Rx
Interpretation of Lab Studies for
Abdominal Pain (cont.)
Hematocrit
may be normal in early stages of even
severe hemorrhage
BUN to creatinine ratio of > 20 to 1 may indicate
upper gastrointestinal (GI) bleed with digestion of
blood in upper GI tract
Degree of elevation of amylase or lipase does not
always correlate with severity of panceatitis or of
pancreatic injury
Amylase may also be chronically elevated in
patients with renal dysfunction
Plain Radiographs for
Abdominal Pain
If
needed, usually the 3 view "Acute Abdomen Series " is
best (upright Chest X-ray, upright and flat plate of the abd.)
Chest X-ray best shows small amounts of free air
Upright abd. film best shows bowel air-fluid levels
(indicating bowel obstruction or ileus if multiple)
Look also for abnormal calcifications
"KUB" film is oriented to include all the pelvis, whereas
"abd. flat plate" is oriented to include the diaphragms (so
these two are different for a tall patient)
Diagnostic Ultrasound for
Abdominal Pain
Dx
test of choice for :
Unstable patient in shock & suspected
intraabdominal bleed
Gallstones (cholecystitis)
Ectopic pregnancy
Other complications of pregnancy
(placenta previa, abruptio, etc.)
Renal or ureteral stones in the pregnant
patient
Disadvantages of Diagnostic
Ultrasound
Visualization
may be limited by bowel gas or
obesity
Good interpretation requires experience
Not good at showing retroperitoneal
conditions
May not directly visualize solid organ
lacerations
Use of Computed Tomography
(CT) for Abdominal Pain
Noncontrast
spiral scan is now method of
choice for ureteral calculi (replaces
intravenous pyelogram or IVP)
Using both IV and oral (or via nasogastric
tube) contrast can then show appendicitis,
diverticulitis, etc.
However even with greater use of CT for
appendicitis, overall accuracy of this Dx in
the E.D. has not improved
Other Diagnostic Studies to
Consider for Abdominal Pain
If
contrast CT not available :
Gastrografin Upper GI study for suspected :
ƒ Stomach or bowel perforation
ƒ Diaphragm rupture
ƒ Duodenal hematoma
Never do barium GI study if any chance of
barium leak (causes severe peritonitis)
Intravenous pyelogram (IVP) for suspected :
ƒ Ureteral stone or injury
ƒ Renal mass
Other Diagnostic Studies to Consider
for Abdominal Pain (cont.)
Retrograde
urethrogram / cystogram for
suspected urethral or bladder injury
Fistulogram for any suspected abdominal
wall fistula
Technetium bleeding scan to localize
intraluminal GI bleed
Angiography for preop planning of surgery
for stable patient with AAA, or for suspected
arterial bleed or mesenteric ischemia
Post-Exam "Procedures" to Consider for
the Patient with Abdominal Pain
Insertion
of foley catheter
Indicated for monitoring of any unstable patient or if
urinary retention suspected
Insertion of nasogastric (NG) tube (see next slide)
Paracentesis (needle aspirate of abd. fluid)
Indicated for :
Suspected infected ascites (check cell count & culture)
Relieving tense ascites
Sometimes can make Dx of bowel perforation or
intraabd. bleed
Usefulness Of NG Tube Suction for
the Patient with Abdominal Pain
Allows
decompression of stomach
Lessens risk of aspiration
Can remove some of residual toxins in
stomach
May demonstrate upper GI bleeding
Required before peritoneal lavage
Contraindicated if nasal or midface
fractures or severe coagulapathy (insert
via mouth instead)
General Mechanisms Causing
Abdominal Pain
Pain
originating in the abdomen
Peritonitis
Distension of hollow viscera
Ischemia
Pain
referred to the abdomen from
another part of the body
Metabolic disorders
Neurogenic disorders
Causes of Referred Abdominal
Pain from Chest Conditions
Acute
coronary syndromes (and "angina
equivalents")
Pneumonia (especially basilar)
Spontaneous pneumothorax
Pulmonary embolus (rare cause)
Pericarditis
Metabolic Causes of Abdominal
Pain
Diabetic
ketoacidosis
Hyperlipidemia (often with pancreatitis)
Acute prophyrias
Black Widow spider bites
Scorpion bites
Sickle cell crisis (sequestration in spleen or
liver, or vaso-occlusive)
Neurogenic Causes of
Abdominal Pain
Herpes
zoster (Shingles)
Pain often present several days before
characteristic dermatomal vesicles appear
Thoracic
or lumbar spinal disc disease or
compression
Syphilis ("tabetic crisis")
Patient with Herpes Zoster (“Shingles”) of the abdomen
Trauma-Related Causes of
Abdominal Pain
May
present delayed, or from seemingly minor
trauma in the elderly :
Ruptured spleen or liver
Bowel or stomach perforation
Pancreatic contusion or transection
Ruptured bladder
Mesenteric hematoma
Abdominal wall hematoma (U/S is good at
diagnosing this)
Pregnancy-Related Causes of
Abdominal Pain
Ectopic
(usually tubal) pregnancy
False labor (Braxton-Hicks contractions)
Active labor
Abruptio placentae (note that placenta previa
which can cause severe bleeding is usually
painless)
Septic abortion
Genitourinary Tract Causes of
Abdominal Pain
Cystitis
Pyelonephritis
Ureterolithiasis
Perinephric
abscess (may see gas around kidney on
KUB film)
Renal infarction (as from sickle cell disease)
Psoas abscess
Testicular torsion
Urinary retention (as from prostatic hypertrophy)
Peritonitis Causing Abdominal Pain
Definition
: inflammation of the peritoneum
Causes : exposure of peritoneum to gastric acid, bile, urine, blood,
pancreatic enzymes, bacteria, stool, or exogenous toxins
Complications : fluid & electrolyte disorders, "third spacing" of
fluid causing hypovolemia & shock, paralytic ileus
Symptoms and signs : abdominal pain, rebound tenderness,
abdominal muscle guarding or rigidity, fever, emesis, decreased
bowel sounds, abdominal distention
Key Rx : IV fluid resuscitation, IV antibiotics (usually), EARLY PAIN
RELIEF WITH NARCOTICS, try to determine the most likely cause,
emergently consult a surgeon
List of Most Common Causes of
Acute Abdominal Pain in Adults
Acute
gastroenteritis
Acute cholecystitis
Acute cholangitis
Acute appendicitis
Acute diverticulitis
Acute gastritis or peptic
ulcer
Acute esophagitis
Acute panceatitis
Bowel obstruction
Inflammatory Bowel
Disease
Acute
salpingitis (pelvic
inflammatory disease)
Acute pyelonephritis
Acute cystitis
Ureterolithiasis
Urinary retention
Acute viral hepatitis
Mesenteric ischemia
Ovarian cysts
Complications of
pregnancy
Caveat About Workup of
Abdominal Pain in the E.D.
Several
large studies show that even after
complete workup, 60 % of E.D. patients with
abdominal pain do not have a specific
diagnosis
For most of these patients, it is appropriate just
to treat their symptoms (pain meds,
antispasmodics, antiemetics, etc.) and perform
further diagnostic tests only if their pain does
not resolve in one to 2 days
Acute Gastroenteritis
Present
with nausea / emesis / diarrhea
Usually viral or reaction to food
If bacterial, usually have abd. tenderness +/lower GI bleeding
If abd. nontender and diarrhea is nonbloody,
usually do not need lab studies
Rx with IV LR 1 to 5 liters, oral, rectal, or
parenteral antiemetics, +/- antidiarrheals
Choices for AntiEmetics in the E.D.
My
favorite : hydroxyzine (Atarax, Vistaril)
Antihistamine, also an antianxiety agent
Very low incidence of side effects
25 to 50 mg IM or PO q 6 hours
Promethazine (Phenergan)
Some risk of dystonic reactions & sedation
25 to 50 mg q 6 hours IV, IM, PO, or PR
Prochlorperazine (Compazine)
40 to 50 % incidence of dystonic reactions
10 to 25 mg q 6 hours IV, IM, PO, or PR
Metclopromide (Reglan) : 5 to 20 mg q 4 hrs. IV, IM, or PO
Choices for AntiDiarrheals in the
E.D.
Do
not use these in patients with tender abdomen or
toxicity
Lomotil (diphenoxylate and atropine)
2 tabs PO, then one after each diarrheal stool up
to 8 per day
Loperamide (Imodium)
2 mg tabs, same dosing as Lomotil
Codeine 15 to 60 mg PO q 4 hours
Donnatal elixir 2 tsp PO q 6 hours (good antispasmodic)
Acute Cholecystits
Usual
clinical profile is obese female > age 40
May cause more complications in diabetics
Usually RUQ +/- epigastric tenderness and emesis
U/S is best Dx test
LFT's usually normal ; lipase & amylase elevated if secondary
panceatitis (common duct stone)
If cholangitis (severe RUQ tenderness, fever, emesis, usually
elevated LFT's, +/- air in biliary tree on X-ray) : consult surgery
emergently
Rx : IV fluids, NPO at first, pain meds, surgery consult unless
quickly resolves
Emphysematous cholecystitis (arrows show gas around the
gallbladder)
Acute Appendicitis
Accuracy
of Dx on clinical grounds alone is not
good
Usually periumbilical pain, then migrates to RLQ
Usually anorexia, nausea, +/- low grade fever
KUB film rarely shows diagnostic appendicolith in
RLQ
U/S and CT can make definitive Dx
Consult surgeon if suspected
Acute Diverticulitis
More
common after age 45
Typically pain & tenderness in LLQ, but
can be diffuse
Can result in inflammatory mass in LLQ
or perforation
CT with contrast is best Dx test
Milder cases can be discharged on oral
antibiotics
Acute Gastritis ; Peptic Ulcer
Typically
epigastric pain & tenderness
If perforation or severe bleeding, may
require laparotomy
Definitive Dx by endoscopy preferred
over Upper GI contrast study, but not
needed for many patients
Rx with H2 blockers such as ranitidine
(in addition to IV fluids, etc. for severe
cases)
Acute Pancreatitis
Usually
diffuse abd. pain + back pain,
emesis, elevated amylase & lipase
 Often attributed to gallstones or alcohol, but
many cases idiopathic
Can have severe complications :
Hypovolemia, ARDS, hypocalcemia,
retroperitoneal bleeding or abscess
CT is Dx method of choice
Bowel Obstruction
Can
be either large or small bowel
Most common causes :
 Adhesions from prior surgery, incarcerated
hernia, cancer, volvulus, mass of parasites,
inflammatory bowel disease
Plain
X-ray films are key Dx test
If possible associated bowel necrosis
(infarction), consult surgeon emergently
Plain film
showing small
bowel
obstruction from
adhesions in a
72 year old male
Upright film showing multiple air-fluid levels from small bowel
obstruction
Upright film of
sigmoid volvulus in a
67 year old male
Supine film showing
sigmoid volvulus in a
67 year old male
Upright film showing
cecal volvulus in a 62
year old male
Inflammatory Bowel Disease
Two
types :
Ulcerative colitis
Crohn's Disease
Ulcerative
colitis can sometimes have
complication of "toxic megacolon"
Complications of either type may need
Rx with high dose IV steroids in addition
to other usual Rx's
Acute Salpingitis (Pelvic
Inflammatory Disease)
Typically
present as severe lower abd. pain &
vaginal discharge
Get cervical cultures as part of workup
Usually caused by gonococcus or chlamydia,
but can involve other bacteria
Rx : IV antibiotics, pain meds
Admit to hospital if :
Toxic, pregnant, immunosuppressed, suspected
tubo-ovarian abscess
Acute Pyelonephritis
Usually
have dysuria & back pain & CVA
tenderness, but can show projected
anterior abd. tenderness
Admit to hospital for IV antibiotics if :
Toxic, hypotensive, persistent emesis,
pregnant, immunosuppressed, chronic or
structural renal disease, failure of
outpatient Rx, diabetic, age < 2 or > 60
Ureterolithiasis
Commonly
have sudden back or flank and/or abd. pain
+/- groin radiation, but not much tenderness
Need early Rx with pain meds (parenteral NSAID such
as ketorolac 30 mg IV is most effective) ; IV morphine if
more analgesia needed
Noncontrast spiral CT is Dx method of choice
IVP or U/S are alternatives
Should "cover" with antibiotic (such as Bactrim or
Cipro) if any bacteria noted on urinalysis
Over 90 % of patients can be discharged from E.D.
Urinary Retention
Most
common in elderly men with benign
prostatic hypertrophy
Can occur also from acute prostatitis
Rx with foley catheter
If bladder residual > 100 cc, should leave foley
catheter in at least 24 hours to allow bladder to
recover its muscle tone
Routine use of coverage antibiotics while foley
is in is debated
Acute Viral Hepatitis
Incidence
greatly decreased by use of
Hep B and A vaccines
Typically present with nausea, emesis,
+/- RUQ pain, +/- jaundice
Need to check serologies on close
contacts of index case
Admit to hospital if encephalopathic, GI
bleed, increased protime, hypoglycemic
Ovarian Cysts and
Complications of Pregnancy
U/S
is Dx method of choice for these
Ovarian cysts typically have lower abd.
pain & lateralizing tenderness +/- adnexal
mass on exam
If large amount of blood in pelvis or
suspected ovarian torsion on U/S,
emergently consult surgeon or
obstetrician
Some Caveats About Abdominal Pain
Don't
hesitate to treat the patient's abd. pain
early, even if consulting a surgeon
It has been definitively shown that pain meds
make the physical exam of the abd. pain patient
MORE reliable
Don't
forget to consider child abuse or trauma
as a cause for abd. pain
Repeated physical exams over time may be
needed to clarify the Dx
"Secondary" Aspects to
Remember for Abdominal Pain
Oxygen
if any possible major systemic
compromise
Question patient about prior anesthetic
complications if surgery anticipated
Additional doses of pain meds as needed
Tetanus immunization if associated skin injury
Antibiotics (+/- cultures if indicated)
Tell the patient & family what is going on
Abdominal Pain
Summary
Assess
the ABC's & provide emergent
Rx if life-threatening cause suspected
Complete exam prior to deciding on
other Dx tests
Focus on the most likely Dx's initially
Decide early if surgical consult or
hospital admission needed
Don't forget "secondary" treatments