Abdominal Pain

Case 1A 19 year old male presents with a two

day history of abdominal pain. He states that at onset, his pain was in the middle of his abdomen, and has since moved to the right lower side. He notes nausea, emesis, anorexia, and a low grade fever. On exam, he has rebound tenderness to the RLQ, pain with leg movement, hip rotation, and pain in the RLQ on LLQ palpation. How often do perfect clinical cases like this present to the ED?

Introduction6.7% of ED visits are for abdominal painHistory, physical, labs often not as

helpful as Cope would have you believe.Goal is to detect life-threatening causes

of abdominal pain, if not to make a solid diagnosis.

The Elderly, the Young, and those who cannot get follow-up are high risk groups that may require further study and admission even in the absence of abnormal findings.

PainVisceral

◦Stretching of unmyelinated fibers that innervate walls or capsules of organs.

◦Crampy, dull, achey pain.◦Localized to a sensory level, but often

midlineParietal

◦Irritaion of myelinated fibers in the parietal peritoneum

◦Localizable, causing guarding, rebound◦Patients like to stay still

PainReferred pain

◦Pain that is remote from the source◦Caused by developmental

embryology◦Normally ipsilateral◦Boaz Sign?◦Kehr’s Sign?◦Where might renal pain get referred

to?

PrioritesFinding critical illness and

stabilizing◦Normal vitals signs are not excluding

for critical illness◦Resuscitate and diagnose at the

same time 2 LB IV’s, O2, monitor CBC, BMP, Coag, T&S

◦Don’t neglect to do a thorough exam.

◦Intensity of pain bears no relation to severity of illness.

PrioritiesFinding critical illness

◦Red Flags Extremes of age Rapid onset of severe pain Abnormal vitals Dehydration Pallor, vomiting, diaphoresis

◦Shock most likely hemorrhagic if of rapid onset

◦Temperature least helpful of vitals

HistoryOPQRST

◦Onset◦Provocations/palliations◦Quality◦Radiation◦Severity◦Timing

What has been doneLast oral intake

HistoryPertinent illnesses

◦DM◦HTN, CAD, PVD◦Liver or Renal disease◦Surgical history◦Sexual history◦Meds/IUDs◦Any trauma◦Any similar episodes?

Physical ExamUncover as much as necessary

◦Check for that perirectal abscess and Fournier’s

First, inspect◦Distended, stigmata of liver disease,

surgical scars? Masses?Then, auscultate

◦Low sensitivity!

Physical examFinally palpate

◦Have the patient point to where it hurts

◦Hit that area last◦May have patient bend knees if they

cannot otherwise relax abdominal wall muscles

◦Interrater reliability 60-92% for abdominal tenderness (Yen, K, et al, Arch Ped Adol Med, 2005, Apr, 159(4):373-6)

◦Consider early use of Ultrasound at the time of palpation.

LabsShould be diagnosis specificConsider pattern of painHow likely is it that an LFT will

help someone with LLQ pain?Preg test – always necessary for

women of childbearing age and capability

LabsCBC

◦WBC least useful in the panel◦Hemoglobin – anemia from what?

Can be useful for trending◦Platelet counts – liver disease, ITP,

HEELPBMP

◦Renal function most important◦Calcium◦CO2 level as a flag for metabolic

acidosis

ImagingUltrasound

◦Many choose to use ultrasound like a stethoscope

◦Modality of choice for RUQ pain◦Recommended as first line for flank

pain, RLQ pain in kids – operator dependent

◦Modality of choice for pelvic pain

ImagingPlain films

◦Useful only for Free air Obstruction/volvulus Pneumonia

◦Overall, low value

ImagingCT

◦High sensitivity◦High specificity◦High radiation risk◦High cost

Elderly, immune compromised, those who you are uncertain, but look ill.

PO contrast – bowel obstruction, bowel mass

No contrast – renal stone, renal insufficiency

Name that Story!Dull RUQ pain in a 16 year old

male, worse with eating, associated with nausea and

diarrhea?

Name that Story!Low grade fever, LLQ tenderness,

and rectal bleeding in a 55 year old male.

Name that Story!Epigastric pain which is boring

and cramping, which radiates to back, and is associated with eating cheese and alchohol. Amylase and lipase are normal. This is the 6th visit for this in a year.

What level of bilirubin is needed to produce scleral icterus?

Name that Story55 year old diabetic with

epigastric pain, weakness, nausea and vomiting. Some SOA, no diarrhea. Hx of HTN. Pain is off and on for the past week.

Name that StoryPost parandial pain in a 65 year

old female who has nausea, emesis, appears to be in pain, but a benign abdominal exam, trace blood on rectal exam.

Name that Story65 year old male who presents

with left flank pain that is gnawing, kept him up at night, and is not associated with syncope or hypotension. His last US showed a 3.5cm AAA.

Name that Story20 year old male sharp flank pain

after backing into something. Has a 1 inch laceration to left flank. Vitals signs are stable. 30 minutes later, he is dead.

Name that Story!16 year old virgin presents with

vaginal bleeding, RLQ abdominal pain and weakness. She is tachycardic, and her rosary-holding mother (who has been in the room) is concerned about fibroids.

High Risk Groups

TreatmentTRUE OR FALSE?

Pain should not be treated until a surgeon has laid hands on the

patient?

TreatmentFluidsSymptom managementNPO status until you know a

surgeon won’t be needed anytime soon

Antibiotics◦Gram negative for gut (flagyl, AG)◦E.coli for gut and urine (Cipro)◦Gram positives for SBP◦STD guidelines for PID

DispositionDischarge

◦Pain better◦Nasuea better◦Tolerates PO◦Negative eval, or no critical findings◦Adequate follow-up

Otherwise admitSurgical consults as needed.

Gastric BypassHigh risk for leak

◦Septic, abdominal pain, feverDumping Syndrome

◦Dietary changes◦Octreotide SQ drips for severe cases

Internal herniaImmediate bowel obstruction

may cause gastric rupture.