Abdominal Pain

Abdominal PainAbdominal Pain

Acute abdominal pain is the chief Acute abdominal pain is the chief complaint in about 5% of ED visitscomplaint in about 5% of ED visits

Most patients are discharged after Most patients are discharged after ED evaluationED evaluation

Only about 10% require urgent Only about 10% require urgent surgerysurgery

Causes of Acute Abdominal Causes of Acute Abdominal Pain Stratified by AgePain Stratified by Age

FINAL DIAGNOSISFINAL DIAGNOSIS 50 Years50 Years <50 Years<50 Years

Biliary Tract DiseaseBiliary Tract Disease 21%21% 6%6%

Nonspecific abdominal pain (NSAP)Nonspecific abdominal pain (NSAP) 16%16% 40%40%

AppendicitisAppendicitis 15%15% 32%32%

Bowel obstructionBowel obstruction 12%12% 2%2%

PancreatitisPancreatitis 7%7% 2%2%

Diverticular diseaseDiverticular disease 6%6% <0.1%<0.1%

CancerCancer 4%4% <0.1%<0.1%

HerniaHernia 3%3% <0.1%<0.1%

VascularVascular 2%2% <0.1%<0.1%

GynecologicGynecologic <0.1%<0.1% 4%4%

OtherOther 13%13% 13%13%

8500 patients, 200 EDs in 17 countries over a 10-year period. [Gallagher EJ, in Gallagher EJ, in Emergency MedicineEmergency Medicine, Tintinalli JE, p 490], Tintinalli JE, p 490]

Causes of Acute Abdominal Causes of Acute Abdominal Pain Stratified by AgePain Stratified by Age

In all large series of acute abdominal pain in In all large series of acute abdominal pain in adults, the largest groups are (in order):adults, the largest groups are (in order):

1.1. Nonspecific abdominal pain (NSAP)Nonspecific abdominal pain (NSAP)

2.2. Appendicitis Appendicitis

3.3. Biliary disease (usually cholecystitis)Biliary disease (usually cholecystitis) This accounts for 75% of casesThis accounts for 75% of cases

In older patients, biliary disease is most In older patients, biliary disease is most common:common:

1.1. Biliary diseaseBiliary disease

2.2. Nonspecific abdominal pain (NSAP)Nonspecific abdominal pain (NSAP)

3.3. AppendicitisAppendicitis

Immediately Life-Immediately Life-Threatening Threatening 1 HOUR1 HOUR

Immediately Life-Immediately Life-Threatening Threatening 1 HOUR1 HOUR

Abdominal aortic aneurysm (AAA)Abdominal aortic aneurysm (AAA) Intra-abdominal hemorrhageIntra-abdominal hemorrhage Myocardial infarction (MI)Myocardial infarction (MI) Ruptured ectopic pregnancyRuptured ectopic pregnancy

Mesenteric ischemiaMesenteric ischemia PeritonitisPeritonitis Perforated viscusPerforated viscus Volvulus / IntussusceptionVolvulus / Intussusception Complicated herniaComplicated hernia Diabetic ketoacidosis (DKA)Diabetic ketoacidosis (DKA)

Rapidly Life-Rapidly Life-ThreateningThreatening

BETWEEN 1 H AND 1 DAY BETWEEN 1 H AND 1 DAY

Rapidly Life-Rapidly Life-ThreateningThreatening

BETWEEN 1 H AND 1 DAY BETWEEN 1 H AND 1 DAY

Serious Threat to Health Serious Threat to Health or Life or Life BETWEEN 1 DAY & 1 BETWEEN 1 DAY & 1

WEEK WEEK

Serious Threat to Health Serious Threat to Health or Life or Life BETWEEN 1 DAY & 1 BETWEEN 1 DAY & 1

WEEK WEEK

AppendicitisAppendicitis CholecystitisCholecystitis PancreatitisPancreatitis PneumoniaPneumonia Rupture or torsion Rupture or torsion

of ovarian cystof ovarian cyst

Small bowel Small bowel obstruction (SBO)obstruction (SBO)

Pelvic Pelvic inflammatory inflammatory disease (PID)disease (PID)

Intra-abdominal Intra-abdominal abscessabscess

Mild-Moderate Mild-Moderate MorbidityMorbidity> 1 WEEK> 1 WEEK

Mild-Moderate Mild-Moderate MorbidityMorbidity> 1 WEEK> 1 WEEK

DiverticulitisDiverticulitis Ovarian cystOvarian cyst EndometriosisEndometriosis ProstatitisProstatitis

Biliary or Renal Biliary or Renal coliccolic

HepatitisHepatitis Inflammatory Inflammatory

bowel disease bowel disease (IBD)(IBD)

Undifferentiated Undifferentiated abdominal pain abdominal pain (UDAP)(UDAP)

No MorbidityNo MorbidityNo MorbidityNo Morbidity

GastroenteritisGastroenteritis MittelschmerzMittelschmerz Musculoskeletal Musculoskeletal

painpain Herpes ZosterHerpes Zoster

DysmenorrheaDysmenorrhea ConstipationConstipation Normal Normal

intrauterine intrauterine pregnancy (IUP)pregnancy (IUP)

Urinary tract Urinary tract infection (UTI)infection (UTI)

Rapid Rapid Assessment/StabilizationAssessment/Stabilization

Up to 7% of patients with abdominal Up to 7% of patients with abdominal pain may have a life-threatening pain may have a life-threatening processprocess

Physiologically compromised Physiologically compromised patients should be identified in patients should be identified in triage and brought immediately to triage and brought immediately to the treatment area for resuscitationthe treatment area for resuscitation

Your worst nightmareYour worst nightmare

A 60 year old woman with Type II diabetes A 60 year old woman with Type II diabetes mellitus, hypertension, coronary artery mellitus, hypertension, coronary artery disease, chronic renal insufficiency, two prior disease, chronic renal insufficiency, two prior myocardial infarctions, Marfan’s syndrome, myocardial infarctions, Marfan’s syndrome, who is a smoker and drinker for >40 years, who is a smoker and drinker for >40 years, presents to the ED on Monday night with presents to the ED on Monday night with abdominal pain, fever, nausea, vomiting, abdominal pain, fever, nausea, vomiting, vaginal bleeding, bloody diarrhea, and vaginal bleeding, bloody diarrhea, and syncope. On exam, she is lethargic, syncope. On exam, she is lethargic, tachypneic, hypotensive, with a barely tachypneic, hypotensive, with a barely palpable pulse. Her abdomen is distended palpable pulse. Her abdomen is distended and rigid. She’s deaf and mute. and rigid. She’s deaf and mute.

What do you do?What do you do?


All critically ill patients require All critically ill patients require resuscitation resuscitation before beginning a before beginning a diagnostic assessmentdiagnostic assessment

What is important is What is important is notnot to make a specific to make a specific diagnosis, but to identify and treat life diagnosis, but to identify and treat life threatening conditionsthreatening conditions AAirway irway

Profound shock or protracted emesis may compromise Profound shock or protracted emesis may compromise airway and require intubationairway and require intubation

BBreathing: reathing: Provide supplemental OProvide supplemental O22

OO22 saturation monitoring saturation monitoring


CCirculation: irculation: IV access (2 large bore IV catheters)IV access (2 large bore IV catheters) Cardiac rhythm monitoring Cardiac rhythm monitoring Volume repletion with an isotonic crystalloid Volume repletion with an isotonic crystalloid

solutionsolution May require several liters of fluidMay require several liters of fluid

Titrate volume to hemodynamic status and urine Titrate volume to hemodynamic status and urine outputoutput

Extreme conditions e.g. ruptured AAA, massive GI Extreme conditions e.g. ruptured AAA, massive GI hemorrhage, ruptured spleen, and hemorrhagic hemorrhage, ruptured spleen, and hemorrhagic pancreatitis pancreatitis may require blood replacement may require blood replacement

12-lead EKG12-lead EKG Nasogastric tube (for bowel obstruction) Nasogastric tube (for bowel obstruction) Urinary catheter for critically ill patients (to monitor Urinary catheter for critically ill patients (to monitor

urine output)urine output)

Pivotal Findings: HistoryPivotal Findings: History How old are you?How old are you?

Advanced age means increased risk. Advanced age means increased risk. Which came first--pain or vomiting?Which came first--pain or vomiting?

Pain first is more likely caused by surgical disease.Pain first is more likely caused by surgical disease. How long have you had the pain?How long have you had the pain?

Pain < 48 hours is worse. Pain < 48 hours is worse. Have you ever had abdominal surgery?Have you ever had abdominal surgery?

Consider obstruction Consider obstruction Is the pain constant or intermittent?Is the pain constant or intermittent?

Constant pain is worse. Constant pain is worse. Have you ever had this before?Have you ever had this before?

No prior episodes is worse. No prior episodes is worse.

Colucciello SA, et al. Colucciello SA, et al. Emerg Emerg Med PractMed Pract 1:2, 1999. 1:2, 1999.

Pivotal Findings: HistoryPivotal Findings: History Do you have a history of cancer, Do you have a history of cancer,

diverticulosis, pancreatitis, kidney diverticulosis, pancreatitis, kidney failure, gallstones, or inflammatory bowel failure, gallstones, or inflammatory bowel disease?disease? All are suggestive of more serious disease. All are suggestive of more serious disease.

Do you have human immunodeficiency Do you have human immunodeficiency virus (HIV)?virus (HIV)? Consider occult infection or drug-related Consider occult infection or drug-related

pancreatitis. pancreatitis. Are you pregnant?Are you pregnant?

Obtain urine pregnancy test in Obtain urine pregnancy test in allall women of child- women of child-bearing age-consider ectopic pregnancy. bearing age-consider ectopic pregnancy.

Colucciello SA, et al. Colucciello SA, et al. Emerg Med PractEmerg Med Pract 1:2, 1999. 1:2, 1999.

Pivotal Findings: HistoryPivotal Findings: History

Are you taking antibiotics or steroids?Are you taking antibiotics or steroids? These may mask infection. These may mask infection.

Did the pain start centrally and migrate to Did the pain start centrally and migrate to the right lower quadrant?the right lower quadrant? High specificity for appendicitis. High specificity for appendicitis.

Do you have a history of vascular or heart Do you have a history of vascular or heart disease, hypertension, or atrial fibrillation?disease, hypertension, or atrial fibrillation? Consider mesenteric ischemia and abdominal Consider mesenteric ischemia and abdominal

aneurysm. aneurysm.

Colucciello SA, et al. Colucciello SA, et al. Emerg Med PractEmerg Med Pract 1:2, 1999. 1:2, 1999.

Pivotal Findings: HistoryPivotal Findings: History A few classic descriptions: A few classic descriptions:

diffuse, severe, colicky pain: diffuse, severe, colicky pain: bowel obstruction bowel obstruction

““pain out of proportion to examination”: pain out of proportion to examination”: mesenteric ischemia mesenteric ischemia

radiation of pain from epigastrium straight through to radiation of pain from epigastrium straight through to the midback: the midback:

pancreatitis, either primary or from a penetrating ulcer pancreatitis, either primary or from a penetrating ulcer Always obtain a thorough gynecologic history Always obtain a thorough gynecologic history

including including menses, mode of contraception (if any), vaginal menses, mode of contraception (if any), vaginal

discharge discharge history of: history of:

pregnancies, deliveries, abortions, ectopics, cysts, fibroids, pregnancies, deliveries, abortions, ectopics, cysts, fibroids, pelvic inflammatory disease, sexually transmitted diseases, pelvic inflammatory disease, sexually transmitted diseases, laparoscopylaparoscopy

Physical ExamPhysical Exam Vital signs:Vital signs:

Tachypnea may be an indication of Tachypnea may be an indication of metabolic acidosis from gangrenous viscera or sepsis or metabolic acidosis from gangrenous viscera or sepsis or

DKADKA hypoxemia from pneumonia hypoxemia from pneumonia

Tachycardia or hypotension Tachycardia or hypotension may indicate hypovolemia or shockmay indicate hypovolemia or shock

FeverFever does not accurately predict abdominal pathologydoes not accurately predict abdominal pathology

often no fever in elderly patients with intraperitoneal often no fever in elderly patients with intraperitoneal infections infections

Female patients should have a pelvic examFemale patients should have a pelvic exam All patients with possible obstruction and with All patients with possible obstruction and with

mid or lower abdominal pain should be mid or lower abdominal pain should be examined for herniasexamined for hernias

Serial exams may reveal a diagnosisSerial exams may reveal a diagnosis

Ancillary TestingAncillary Testing

UrinalysisUrinalysis and and urine pregnancy testurine pregnancy test are are perhaps the most cost-effective testsperhaps the most cost-effective tests UPT should be sent on all women of reproductive UPT should be sent on all women of reproductive

ageage The urinalysis must be interpreted with respect to The urinalysis must be interpreted with respect to

the clinical picturethe clinical picture Pyuria often present without UTI Pyuria often present without UTI Up to 30% of patients with appendicitis have abnormal Up to 30% of patients with appendicitis have abnormal

urinalysisurinalysis

Elevated WBC is neither sensitive nor Elevated WBC is neither sensitive nor specific for anythingspecific for anything

Electrolytes are abnormal in <1% of patientsElectrolytes are abnormal in <1% of patients

Ancillary TestingAncillary Testing Plain radiographyPlain radiography

limited to suspected bowel obstruction, foreign body, and limited to suspected bowel obstruction, foreign body, and perforated viscusperforated viscus

CT CT imaging modality of choice for nonobstetric abdominal pain. imaging modality of choice for nonobstetric abdominal pain. establishes a diagnosis in over 95% of cases establishes a diagnosis in over 95% of cases

unstable patients should not be moved to the radiology suite until unstable patients should not be moved to the radiology suite until stabilizedstabilized

Ultrasound:Ultrasound: In life-threatening processes: detection of In life-threatening processes: detection of

intrauterine pregnancyintrauterine pregnancy lowers the chances of ectopic pregnancy to < 1 in 20,000 but don’t lowers the chances of ectopic pregnancy to < 1 in 20,000 but don’t

forget about heterotopic pregnanciesforget about heterotopic pregnancies AAA AAA free intraperitoneal hemorrhage or pusfree intraperitoneal hemorrhage or pus

In non-life-threatening processes: detection ofIn non-life-threatening processes: detection of gallstones, dilated common bile duct gallstones, dilated common bile duct hydronephrosishydronephrosis ascites ascites ovarian torsionovarian torsion

AppendicitisAppendicitis The problem:The problem:

Up to 20% of appendicitis is missedUp to 20% of appendicitis is missed Normal appendix found in 15-40% of all Normal appendix found in 15-40% of all

operations for suspected appendicitisoperations for suspected appendicitis The acceptable number of negative The acceptable number of negative

appendectomies depends upon the age and sex appendectomies depends upon the age and sex of the patient:of the patient:

In young men: <10%In young men: <10% In young women: approaches 20% (other pelvic In young women: approaches 20% (other pelvic

processes make diagnosis more difficult)processes make diagnosis more difficult)

Two methods to achieve a low negative Two methods to achieve a low negative appendectomy rate:appendectomy rate: close in-hospital observation close in-hospital observation use of CT and ultrasounduse of CT and ultrasound

AppendicitisAppendicitis

““The use of abdominal CT and The use of abdominal CT and ultrasound has had a dramatic ultrasound has had a dramatic impact on the rate of negative impact on the rate of negative appendectomies.”appendectomies.”

True or False?True or False?


False. False. A large study suggests that the A large study suggests that the rate of negative appendectomies (15 to rate of negative appendectomies (15 to 20 percent) has 20 percent) has notnot declined during the declined during the last 15 years last 15 years despitedespite the increasing use the increasing use of CT and ultrasound of CT and ultrasound 63,707 appendectomies from 1987-199863,707 appendectomies from 1987-1998 despite the use of CT, US, and laparoscopy:despite the use of CT, US, and laparoscopy:

84.5% had appendicitis (25.8% with perforation) 84.5% had appendicitis (25.8% with perforation) 15.5% had 15.5% had nono evidence of appendicitis evidence of appendicitis

Flum DR, et al. Flum DR, et al. JAMAJAMA 2001 Oct 10;286(14):1748- 2001 Oct 10;286(14):1748-5353


““Among the history, physical exam, Among the history, physical exam, and laboratory tests, the clinical and laboratory tests, the clinical feature most predictive of feature most predictive of appendicitis is right lower quadrant appendicitis is right lower quadrant pain.”pain.”

True or False?True or False?

Appendicitis:Appendicitis:History and ExamHistory and Exam

True. True. Five clinical features have high Five clinical features have high predictive value for appendicitis predictive value for appendicitis the presence of any one should indicate an the presence of any one should indicate an

imaging procedureimaging procedureCLINICAL FEATURECLINICAL FEATURE LR(+)LR(+)

RLQ painRLQ pain 88

Pain migration from periumbilical Pain migration from periumbilical area to RLQarea to RLQ

33

RigidityRigidity 44

Pain before vomitingPain before vomiting 2-32-3

Positive psoas signPositive psoas sign 22Gallagher EJ, in Gallagher EJ, in Emergency MedicineEmergency Medicine, Tintinalli JE, McGraw Hill, 2004; p 491, Tintinalli JE, McGraw Hill, 2004; p 491

Appendicitis: Appendicitis: Ancillary TestingAncillary Testing

Laboratory tests are not particularly Laboratory tests are not particularly usefuluseful CBCCBC

30% of patients have normal WBC count30% of patients have normal WBC count However, more than 95% of these have a left shiftHowever, more than 95% of these have a left shift

UrinalysisUrinalysis microscopic hematuria and pyuria found in up microscopic hematuria and pyuria found in up

to 30% of ptsto 30% of pts(presumably because the inflamed appendix is in (presumably because the inflamed appendix is in

close proximity to the bladder and ureter)close proximity to the bladder and ureter)


UltrasoundUltrasound Technically challenging and operator dependentTechnically challenging and operator dependent High enough LR (+) to diagnose appendicitisHigh enough LR (+) to diagnose appendicitis

But LR (-) too high to rule out appendicitisBut LR (-) too high to rule out appendicitis

CTCT The LR (+) for all varieties of CT (with/without The LR (+) for all varieties of CT (with/without

oral, IV, rectal contrast) is so high that they oral, IV, rectal contrast) is so high that they invariably drive surgical interventioninvariably drive surgical intervention

LR (-) is not as strong as LR (+) LR (-) is not as strong as LR (+) Hence, Hence, absenceabsence of appendicitis on CT does not exclude of appendicitis on CT does not exclude

the diagnosis with as much certainty as a positive CT the diagnosis with as much certainty as a positive CT confirms itconfirms it


TestTest SensSens SpecSpec LR(LR(+)+)

LR(-LR(-))

Plain Abdominal Plain Abdominal RadiographRadiograph

48%48% 58%58% 11 0.90.9

Abdominopelvic Abdominopelvic ultrasoundultrasound

55%55% 95%95% 1111 0.50.5

Abdominopelvic Abdominopelvic helical CT (PO + helical CT (PO + IV contrast)IV contrast)

91%91% 95%95% 1818 0.10.1

Gallagher EJ, in Gallagher EJ, in Emergency MedicineEmergency Medicine, Tintinalli JE, McGraw Hill, 2004; p 492, Tintinalli JE, McGraw Hill, 2004; p 492

Appendicitis:Appendicitis:Special PopulationsSpecial Populations

Children <5 y.o.Children <5 y.o. Rate of misdiagnosis is highRate of misdiagnosis is high Poor communicationPoor communication Many childhood illnesses associated with anorexia, nausea, Many childhood illnesses associated with anorexia, nausea,

and vomiting and vomiting Appendiceal wall thin Appendiceal wall thin perforation perforation Omentum immature Omentum immature unable to wall off infection unable to wall off infection

peritonitisperitonitis Maintain high index of suspicion and get surgical Maintain high index of suspicion and get surgical

consultation earlyconsultation early The elderlyThe elderly

Misdiagnosis can exceed 50%Misdiagnosis can exceed 50% 3x more likely to perforate than the general population 3x more likely to perforate than the general population

(? Age-related weak appendiceal wall)(? Age-related weak appendiceal wall) Mortality for patients >70 y.o. with appendicitis ~ 30%Mortality for patients >70 y.o. with appendicitis ~ 30%

CaseCase A 34 year old woman in her 34A 34 year old woman in her 34thth week of week of

gestation presents with vague constant gestation presents with vague constant right-sided abdominal pain for about 12 right-sided abdominal pain for about 12 hours. The pain seems to be located more in hours. The pain seems to be located more in the RUQ than anywhere else. She feels the RUQ than anywhere else. She feels some mild nausea, but otherwise has no some mild nausea, but otherwise has no complaint. On exam, her vital signs are complaint. On exam, her vital signs are normal, and her abdomen is gravid with normal, and her abdomen is gravid with some tenderness in the right lateral mid-some tenderness in the right lateral mid-abdomen, and right upper quadrant. abdomen, and right upper quadrant.

What is your differential diagnosis?What is your differential diagnosis?

Appendicitis:Appendicitis:Special PopulationsSpecial Populations

Pregnant womenPregnant women Appendicitis the most common extra-uterine Appendicitis the most common extra-uterine

surgical emergency in pregnancysurgical emergency in pregnancy Diagnosis difficultDiagnosis difficult

Early symptoms (nausea/vomiting) are frequent in Early symptoms (nausea/vomiting) are frequent in normal pregnancynormal pregnancy

Enlarging uterus changes the location of the appendix Enlarging uterus changes the location of the appendix can cause RUQ pain can cause RUQ pain

diagnosis often delayed diagnosis often delayed rate of perforation 2- rate of perforation 2-3x higher than the general population3x higher than the general population

Fetal mortality in 20% of cases of perforationFetal mortality in 20% of cases of perforation Ultrasound the test of choiceUltrasound the test of choice

Appendicitis:Appendicitis:DispositionDisposition

Stratify patients into 4 groups:Stratify patients into 4 groups:1.1. Classic presentation Classic presentation

Prompt surgical consultation Prompt surgical consultation appendectomy appendectomy2.2. Presentation suspicious but not diagnosticPresentation suspicious but not diagnostic

Options:Options: Imaging studies (CT or US) Imaging studies (CT or US) Observation for 4-6 hrs with serial examsObservation for 4-6 hrs with serial exams

Surgical consultation for patients with evolving examSurgical consultation for patients with evolving exam

3.3. Appendicitis unlikelyAppendicitis unlikely Observation in ED with serial examsObservation in ED with serial exams If clinical course benign If clinical course benign discharge with diagnosis discharge with diagnosis

“nonspecific abdominal pain” (not “gastroenteritis”)“nonspecific abdominal pain” (not “gastroenteritis”) Explain worrisome symptoms and instruct to return if anyExplain worrisome symptoms and instruct to return if any Arrange for reevaluation by primary care MD or ED in 12-24 Arrange for reevaluation by primary care MD or ED in 12-24

hrshrs

4.4. High-risk patients: High-risk patients: Pediatric, elderly, pregnantPediatric, elderly, pregnant Maintain low threshold for imaging and surgical Maintain low threshold for imaging and surgical

consultationconsultation

Biliary DiseaseBiliary Disease The most common diagnosis in patients >50 y.oThe most common diagnosis in patients >50 y.o Cholecystitis, biliary colic, and common duct Cholecystitis, biliary colic, and common duct

obstruction often difficult to distinguish on clinical obstruction often difficult to distinguish on clinical grounds alonegrounds alone The majority of patients with pathologically proven The majority of patients with pathologically proven

cholecystitis have cholecystitis have nono fever fever 40% of patients with cholecystitis have 40% of patients with cholecystitis have nono leukocytosis leukocytosis

Individual signs and symptoms are weak clinical Individual signs and symptoms are weak clinical indicatorsindicators

Only 1/3 of patients have RUQ painOnly 1/3 of patients have RUQ pain The rest complain of diffuse upper abdominal painThe rest complain of diffuse upper abdominal pain A small group with RLQ painA small group with RLQ pain

Only 2/3 of patients have RUQ tendernessOnly 2/3 of patients have RUQ tenderness Murphy’s sign (inspiratory pause during RUQ palpation) Murphy’s sign (inspiratory pause during RUQ palpation)

is non-specificis non-specific

Biliary Disease:Biliary Disease:Diagnostic TestingDiagnostic Testing

UltrasoundUltrasound The most useful testThe most useful test

Can be performed at the bedside by EP’s with a high Can be performed at the bedside by EP’s with a high degree of accuracydegree of accuracy

Visualization of the gallbladder without stones has a Visualization of the gallbladder without stones has a high negative predictive value for cholecystitishigh negative predictive value for cholecystitis

Visualization of stones, a thickened gallbladder wall, Visualization of stones, a thickened gallbladder wall, and pericholecystic fluid has a positive predictive and pericholecystic fluid has a positive predictive value in excess of 90% [LR(+) = 29; LR(-) = 0.1]value in excess of 90% [LR(+) = 29; LR(-) = 0.1]

Nuclear scintigraphy with technetium-99m-Nuclear scintigraphy with technetium-99m-labeled iminodiacetic acid (IDA) is the most labeled iminodiacetic acid (IDA) is the most sensitive and specific imaging test for sensitive and specific imaging test for cholecystitis cholecystitis

Small Bowel ObstructionSmall Bowel Obstruction The main issues:The main issues:

Diagnosis of the primary disorderDiagnosis of the primary disorder Early detection of strangulation or ischemiaEarly detection of strangulation or ischemia

Only 2 historical features have predictive value:Only 2 historical features have predictive value: Previous abdominal surgeryPrevious abdominal surgery Intermittent/colicky painIntermittent/colicky pain

Only 2 physical findings have predictive value:Only 2 physical findings have predictive value: Abdominal distentionAbdominal distention Abnormal bowel soundsAbnormal bowel sounds

2/3 of patients complain of generalized or central 2/3 of patients complain of generalized or central abdominal painabdominal pain

½ of patients have generalized abdominal ½ of patients have generalized abdominal tendernesstenderness

Small Bowel ObstructionSmall Bowel Obstruction

Flat and upright plain abdominal Flat and upright plain abdominal filmsfilms demonstrate small bowel obstruction in demonstrate small bowel obstruction in

50% to 60% of cases 50% to 60% of cases suggest obstruction in another 20% to suggest obstruction in another 20% to

30% 30% are hampered by the large number of are hampered by the large number of

indeterminate readings indeterminate readings

Gallagher EJ, in Gallagher EJ, in Emergency MedicineEmergency Medicine, Tintinalli JE, McGraw Hill, 2004; p 490, Tintinalli JE, McGraw Hill, 2004; p 490




CT CT far superior to plain films in the far superior to plain films in the

detection of high-grade SBOdetection of high-grade SBO more limited in the detection of low-more limited in the detection of low-

grade obstructiongrade obstruction

Target diagnosisTarget diagnosis TestTest LR(+)LR(+) LR(-)LR(-)

SBOSBO Plain filmsPlain films 11 0.70.7

SBO high-gradeSBO high-grade CT CT + IV/po contrast+ IV/po contrast 2222 0.10.1

SBO low-gradeSBO low-grade CT CT + IV/po contrast+ IV/po contrast 33 0.50.5


CT, cont. CT, cont. notnot required in most cases for the required in most cases for the

diagnosis of bowel obstruction. diagnosis of bowel obstruction. main use is in better defining the site main use is in better defining the site

and cause of obstruction and cause of obstruction demonstrates intussusception, volvulus, and demonstrates intussusception, volvulus, and

extraluminal lesions like abscesses and extraluminal lesions like abscesses and tumors tumors

useful in the setting of abdominal useful in the setting of abdominal malignancy or inflammatory bowel diseasemalignancy or inflammatory bowel disease

demonstrates closed-loop obstruction and demonstrates closed-loop obstruction and findings suggestive of strangulation findings suggestive of strangulation

Large Bowel ObstructionLarge Bowel Obstruction

Causes: Cancer, Diverticulitis, and Causes: Cancer, Diverticulitis, and VolvulusVolvulus

Volvulus usually in elderly, bedridden, Volvulus usually in elderly, bedridden, or psychiatric patients taking or psychiatric patients taking anticholinergic medsanticholinergic meds

Sigmoid much more common than cecalSigmoid much more common than cecal Abdominal pain, crampy and Abdominal pain, crampy and

intermittent, distention, may hear intermittent, distention, may hear “rushes” – high pitched bowel sounds“rushes” – high pitched bowel sounds

PerforationPerforation

Rebound tendernessRebound tenderness Severe abdominal pain]Severe abdominal pain] Tympanitic to percussionTympanitic to percussion Bilious vomitus in proximal obstructionBilious vomitus in proximal obstruction Feculent vomitus in distal obstructionFeculent vomitus in distal obstruction Flat plate and upright xray to look for Flat plate and upright xray to look for

free airfree air Labs, elevated WBCLabs, elevated WBC

Perforated BowelPerforated Bowel

VolvulusVolvulus

NG tube to decompress the bowelNG tube to decompress the bowel Barium enema can be diagnostic and Barium enema can be diagnostic and

therapeutictherapeutic Sigmoidoscopy and rectal tube often Sigmoidoscopy and rectal tube often

successfulsuccessful Surgical with closed loop obstruction, Surgical with closed loop obstruction,

cecal volvulus, or necrotic bowelcecal volvulus, or necrotic bowel Intravenous fluidsIntravenous fluids AntibioticsAntibiotics

VolvulusVolvulus

Adynamic IleusAdynamic Ileus

Abdominal distentionAbdominal distention No Flatus, obstipationNo Flatus, obstipation Increased BelchingIncreased Belching Conservative Therapy: IVF, NG Conservative Therapy: IVF, NG

decompression, observationdecompression, observation Discontinue meds that inhibit bowel Discontinue meds that inhibit bowel

motilitymotility

CaseCase A 22 year old woman presents to the ED A 22 year old woman presents to the ED

complaining of severe lower abdominal pain. complaining of severe lower abdominal pain. The pain began the day before presentation, The pain began the day before presentation, and was crampy and intermittent, but she and was crampy and intermittent, but she was awakened today at 4 am with severe was awakened today at 4 am with severe pain which is constant, and lightheadedness. pain which is constant, and lightheadedness. On exam, her vital signs are: pulse 130 and On exam, her vital signs are: pulse 130 and thready, BP 80/60, RR 28, T 37, Othready, BP 80/60, RR 28, T 37, O22 sat 94%. sat 94%. She has lower abdominal tenderness. She has lower abdominal tenderness.

What is your diagnosis?What is your diagnosis?

Ectopic Pregnancy:Ectopic Pregnancy:EpidemiologyEpidemiology

2% of all pregnancies in the USA2% of all pregnancies in the USA The leading cause of pregnancy-related The leading cause of pregnancy-related

death during the first trimester death during the first trimester The second leading cause (10%) of all The second leading cause (10%) of all

maternal mortalitymaternal mortality Case-fatality rate per 100,000 ectopic Case-fatality rate per 100,000 ectopic

pregnancies has dropped considerably pregnancies has dropped considerably because of improved diagnostics because of improved diagnostics (pregnancy tests and US) and heightened (pregnancy tests and US) and heightened awareness:awareness: 19701970 35.535.5 19801980 8.88.8 19891989 3.83.8

Risk Factors for Ectopic Risk Factors for Ectopic PregnancyPregnancy

Degree of Degree of riskrisk

Risk factorsRisk factors Odds ratioOdds ratio

HighHigh Previous ectopic pregnancyPrevious ectopic pregnancy 8.38.3

Previous tubal surgeryPrevious tubal surgery 2121

Tubal pathologyTubal pathology 3.5 - 253.5 - 25

In utero DES exposureIn utero DES exposure 2.4 - 132.4 - 13

ModerateModerate Previous genital infectionsPrevious genital infections 2.5 - 3.72.5 - 3.7

InfertilityInfertility 2.5 - 212.5 - 21

Multiple sexual partnersMultiple sexual partners 2.12.1

LowLow Previous pelvic/abdominal Previous pelvic/abdominal surgerysurgery

0.9 - 3.80.9 - 3.8

SmokingSmoking 2.52.5

Vaginal douchingVaginal douching 1.1 - 3.11.1 - 3.1

Early age of intercourse (<18 Early age of intercourse (<18 years)years)

1.61.6

Ankum WM, et al. Fertil Steril 1996;65:1093

Ectopic PregnancyEctopic Pregnancy

Risk factors, history and physical exam Risk factors, history and physical exam have poor sensitivity and specificityhave poor sensitivity and specificity <50% of women with ectopic pregnancy give a <50% of women with ectopic pregnancy give a

history of risk factors history of risk factors Therefore, all women of reproductive age Therefore, all women of reproductive age

presenting with abdominal pain or presenting with abdominal pain or abnormal vaginal bleeding should receive abnormal vaginal bleeding should receive a qualitative pregnancy testa qualitative pregnancy test If the pregnancy test is positive If the pregnancy test is positive

further testing to exclude ectopic (ultrasound and further testing to exclude ectopic (ultrasound and quantitative HCG)quantitative HCG)

Ectopic PregnancyEctopic Pregnancy Bedside transvaginal sonography (TVS):Bedside transvaginal sonography (TVS):

OneOne question: “Is this pregnancy in the uterus?” question: “Is this pregnancy in the uterus?” Clear visualization of IUP excludes ectopic Clear visualization of IUP excludes ectopic

pregnancy except for the rare heterotopic pregnancy except for the rare heterotopic pregnancy : historically 0.3/10000 but now overall pregnancy : historically 0.3/10000 but now overall incidence 1.25/10000 (.3/10000 up to 2.5-incidence 1.25/10000 (.3/10000 up to 2.5-6.25/10000 in PID, and 33/10000 in reproductive 6.25/10000 in PID, and 33/10000 in reproductive technology and 100/10000 in IVF patientstechnology and 100/10000 in IVF patients

If an IUP is If an IUP is notnot seen, it is correlated with the seen, it is correlated with the discriminatory zone (DZ) of the quantitative HCGdiscriminatory zone (DZ) of the quantitative HCG

DZ = the threshold level above which a DZ = the threshold level above which a normalnormal IUP IUP should be seen on USshould be seen on US

A typical DZ is 1500-2000 mIU/ml for TVS A typical DZ is 1500-2000 mIU/ml for TVS (corresponds to 5-6 weeks from LMP)(corresponds to 5-6 weeks from LMP)

IUP

OB consultation

IUP No IUP

If low risk for ruptured ectopic:• Repeat hCG in 48 hrs • Repeat TVS in 48 hrs or when hCG >1500 to determine ectopic or miscarriage

Resuscitation:IV crystalloid + bloodbedside TVS

No IUP

“formal” TVSIUP

Ectopic or no IUP

“formal” TVS

bedsidebedside

(-)

Abdominal Aortic Abdominal Aortic Aneurysm:Aneurysm:

Physical ExamPhysical Exam <1/2 of ruptured AAA’s present with the triad of <1/2 of ruptured AAA’s present with the triad of

abdominal or back pain, hypotension, and pulsatile abdominal or back pain, hypotension, and pulsatile massmass >3/4 are normotensive>3/4 are normotensive

Absence of abdominal pain or tenderness does Absence of abdominal pain or tenderness does notnot rule out contained leak into the retroperitoneumrule out contained leak into the retroperitoneum

Neither the presence nor absence of femoral Neither the presence nor absence of femoral pulses or abdominal bruits are helpful clinicallypulses or abdominal bruits are helpful clinically LR’s ≈ 1 LR’s ≈ 1

Palpation of AAA is the only feature of the exam Palpation of AAA is the only feature of the exam with clinical utilitywith clinical utility LR(+) = 12 (for >3 cm) — 16 (for >4 cm)LR(+) = 12 (for >3 cm) — 16 (for >4 cm) LR(-) = 0.5-0.7 (i.e. poor)LR(-) = 0.5-0.7 (i.e. poor)

Therefore, inability to palpate an AAA should not deter Therefore, inability to palpate an AAA should not deter workupworkup

Abdominal Aortic Abdominal Aortic Aneurysm:Aneurysm:

Diagnostic TestingDiagnostic Testing UltrasoundUltrasound

Advantage: Advantage: bedside availabilitybedside availability can exclude AAA from the differential diagnosiscan exclude AAA from the differential diagnosis

Disadvantage: can’t identify leakage Disadvantage: can’t identify leakage CT: the standard test for leaking/ruptured CT: the standard test for leaking/ruptured

AAAAAA For For unstableunstable patients patients

If bedside US demonstrates AAA in suggestive If bedside US demonstrates AAA in suggestive clinical circumstances clinical circumstances this is taken as this is taken as evidence of ruptureevidence of rupture

AAAAAA

CaseCase An 85 year old man with HTN, Type II diabetes An 85 year old man with HTN, Type II diabetes

mellitus, CAD, history of MI x 2, CHF with an mellitus, CAD, history of MI x 2, CHF with an ejection fraction of 20%, paroxysmal atrial fibrillation ejection fraction of 20%, paroxysmal atrial fibrillation (not on warfarin), stroke x 2, presents with severe (not on warfarin), stroke x 2, presents with severe constant diffuse abdominal pain which began 1 hour constant diffuse abdominal pain which began 1 hour ago after dinner. He had a normal bowel movement ago after dinner. He had a normal bowel movement today and had a good appetite at dinner. On exam, today and had a good appetite at dinner. On exam, the patient is crying out in distress and writhing the patient is crying out in distress and writhing around on the stretcher. His vital signs are: pulse around on the stretcher. His vital signs are: pulse 110, BP 150/100, RR 24, T 37, O110, BP 150/100, RR 24, T 37, O22 sat 92%. His sat 92%. His abdomen is not distended, there are no bowel abdomen is not distended, there are no bowel sounds, and the abdomen is non-tender throughout. sounds, and the abdomen is non-tender throughout.

What is your diagnosis?What is your diagnosis?

Mesenteric IschemiaMesenteric Ischemia Several typesSeveral types

Mesenteric venous thrombosis (MVT)Mesenteric venous thrombosis (MVT) Usually hypercoagulableUsually hypercoagulable

Mesenteric artery disease (>60% of cases; Mesenteric artery disease (>60% of cases; mortality >60%)mortality >60%)

Occlusive disease (usually SMA)Occlusive disease (usually SMA) Thrombotic – usually long months of ischemiaThrombotic – usually long months of ischemia Embolic – 40-50% - usually mural thrombus from MI or a fibEmbolic – 40-50% - usually mural thrombus from MI or a fib

Nonocclusive disease (NOMI or low-flow state)Nonocclusive disease (NOMI or low-flow state) Young patients tend to have eitherYoung patients tend to have either

Arrhythmia (usually Afib) Arrhythmia (usually Afib) embolization embolization Hypercoagulable state Hypercoagulable state MVT MVT

Most patients are old with lots of Most patients are old with lots of comorbiditiescomorbidities

Mesenteric IschemiaMesenteric Ischemia Diagnosis is difficultDiagnosis is difficult

Pain is typically poorly localized and visceral, Pain is typically poorly localized and visceral, without tenderness (“pain out of proportion to without tenderness (“pain out of proportion to exam”)exam”)

May be abrupt in onset (embolism) or indolent (MVT)May be abrupt in onset (embolism) or indolent (MVT) Patients often become transiently better after a few Patients often become transiently better after a few

hours of ischemia because of mucosal infarction hours of ischemia because of mucosal infarction then develop peritoneal findings hours later after then develop peritoneal findings hours later after full thickness necrosisfull thickness necrosis

Nausea, vomiting, may also have bloody stoolsNausea, vomiting, may also have bloody stools Distention, late findingDistention, late finding Elderly patients often do not appear as ill as they Elderly patients often do not appear as ill as they

areare Timely diagnosis requires early angiographyTimely diagnosis requires early angiography

Must maintain a high clinical suspicionMust maintain a high clinical suspicion

Mesenteric IschemiaMesenteric Ischemia Elevated WBC countsElevated WBC counts Metabolic Acidosis, elevated lactateMetabolic Acidosis, elevated lactate Arteriography for early diagnosis if stableArteriography for early diagnosis if stable Key to make diagnosis before infarction Key to make diagnosis before infarction

occursoccurs IVF, Antibiotics, bowel decompressionIVF, Antibiotics, bowel decompression Surgery if infarction or dead bowel (70% Surgery if infarction or dead bowel (70%

mortality)mortality) Anticoagulation, infusion of vasodilating Anticoagulation, infusion of vasodilating

drugsdrugs

Mesenteric IschemiaMesenteric Ischemia

Date post:	03-Jun-2015
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Abdominal Pain

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