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, HEELP
BMP◦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.