IM Abdominal Pain

Abdominal Pain DDX Chart

Abdominal Pain

• Types:
  • – visceral
    
  • – parietal
    
  • – referred
• Visceral Pain:
  • – unmyelinated fibers
    
  • – dull, achy, crampy
    
  • – constant or intermittent
    
  • – organs are innervated from both sides of the spinal cord so pain is often poorly localized – may be midline
• Parietal Pain:
  • – myelinated fibers
    
  • – parietal peritoneum
    
  • – localized, sharp
    
  • – tenderness, guarding
    
  • – rigidity, rebound
• Referred Pain:
  • – pain originating from another site
    
  • – basis in embryology
    
  • – ureters/testes, gallbladder
    
  • – pain is typically ipsilateral (does not cross the midline)
• Think anatomically if visceral pain (vs. neuropathic vs. somatic)
  
  • Obstruction is colicky, restless
    
  • Inflammatory is constant fever, WBC
    
  • Perforation is high fever, WBC, motionless
    
  • Ischemia is pain out of proportion, bloody poop
    
• Questions to ask Patients:
  • – location & radiation
    
  • – duration
    
  • – quality
    
  • – provocative/palliative factors
    
  • – associated sx
    
  • – abdominal surgeries
    
  • – alcohol
    
  • – last menstrual period
    
  • – recent trauma
    
  • – previous similar pain
• Physical Exam:
  • Components:
    • – inspection
      
    • – auscultation
      
    • – percussion
      
    • – palpation
  • Findings:
    • – scars
      
    • – striae
      
    • – rash (shingles)
      
    • – cirrhotic abdomen
      
    • – ecchymosis
      
    • – distended belly
  • DDX based on Auscultation:
    • Decreased bowel sounds upon auscultating abdomen:
      • ileus
        
      • SBO
        
      • mesenteric ischemia
    • Increased bowel sounds upon auscultating abdomen:
      • SBO
        
      • gastroenteritis
  • Findings you may find when percussing abdomen:
    • – RUQ dullness (liver)
      
    • – resonant below and through abdomen
  • Palpating the abdomen:
    • – most helpful part of exam
      
    • – start with gentle palpation (3 fingers)
      
    • – deep palpation (4 fingers)
      
    • – have pt flex knees to relieve voluntary guarding
      
    • – distract with conversation
      
    • – revisit areas of focal tenderness
  • Questions to ask yourself when palpating the abdomen:
    • – how does the abdomen feel? is it soft, firm, rigid or distended
      
    • – any masses?
      
    • – peritoneal signs? rigidity? guarding? rebound? shake tenderness?
  • Adjuncts to the abdominal exam that may be helpful in distinguishing abdominal pain:
    • – pelvic exam
      
    • – testicular exam
      
    • – rectal exam
      
    • – cardiac/lung exam
• Imaging:
  • RUQ and GU = US
    
  • All other areas = CT

Abdominal Aortic Aneurysm

• Risk factors for AAA:
  • – male
    
  • – age >60 yo
    
  • – hx of smoking
• Presentation:
  • – abdominal pain
    
  • – syncope, flank, back pain
    
  • – often mistaken for renal colic
    
  • – severe pain, abrupt onset
    
  • – may or may not detect AAA on exam
• Management:
  • – IV fluids
    
  • – transfuse RBCs
    
  • – vascular surgery consultation/transfer
    
  • – cross-clamp aorta

Appendicitis

• Prevalence:
  • – most common surgical disease of abdomen
    
  • – any age affected, most commonly under 30 yo
• Causes:
  • – luminal obstruction of appendix (fecalith)
    
  • – swelling
    
  • – inflammation
    
  • – infection
    
  • – perforation
• Presentation:
  
  • – poorly localized, epigastric pain
    
  • – anorexia, n/v, fever
    
  • – migrates to RLQ
• Physical Exam:
  • – TTP over McBurney’s point
    
  • – guarding/rebound
    
  • – Rovsing’s sign (visceral pain)
  • – Obturator sign – internal rotation of right leg causes pain in RLQ
    
  • – Psoas sign – hip flexion against resistance causes pain
• Diagnosis:
  • – perform pelvic exam in females of child-bearing age
    
  • – labs: CBC, Chem7, coags, UA, urine hcg
    
  • – imaging: US/CT
• Management:
  • – abx often done (yet not evidence): Pip/tazo, Cipro/metronidazole
    
  • – surgical consultation

Bowel Obstruction

• Types:
  • paralytic ileus
    
  • mechanical obstruction
    • SBO
    • LBO
• Paralytic ileus:
  • – self-limiting, may be less painful
    
  • – diffuse
    
  • – distension
    
  • – tenderness with dec BW
• Mechanical obstruction:
  • – requires definitive intervention, surgery
    
  • – severe
    
  • – distension
    
  • – tenderness with high-pitched BS
• Causes of SBO:
  
  • #1 = adhesions
    
  • hernia
    
  • intussusception
    
  • lymphoma
    
  • stricture
• Causes of LBO:
  • carcinoma
    
  • fecal impaction
    
  • UC
    
  • volvulus
    
  • diverticulitis
    
  • intussusception
• Workup for bowel obstruction:
  • – NPO
    
  • – pain control
    
  • – labs: CBC, Chem7, coags, T&S
    
  • – x-ray or US
    
  • – may need CT
• SBO signs on Imaging:
  • – transition point
    
  • – dilated fluid-filled small bowel loops
    
  • – dilated air-filled proximal small bowel loops
• Management:
  • – pain control
    
  • – NPO
    
  • – NG tube
    
  • – surgical consultation

Diverticula

• Diverticula:
  • Def: small herniations through wall of colon
  • – associated with inc intraluminal pressure (low fiber, high-fat western diet) and weakening of bowel wall (age)
    
  • – left-sided in US
    
  • – right-sided in Asian societies
    
  • – caused by anaerobes, gram-negatives
• Diverticulitis:
  • develops when diverticula become inflamed/infected
  • Presentation:
    • – LLQ abdominal pain that is intermittent or constant
      
    • – often have prior episodes
      
    • – fever
      
    • – leukocytosis
      
    • – n/v, anorexia
      
    • – LLQ tenderness +/- rebound guarding
• Management:
  • Management of Diverticulitis:
    • high fiber diet & vigorous exercise
  • Management for diverticula bleeding:
    • resuscitation
      
    • admit for colonoscopy
  • Management for well-appearing, pain controlled, immunocompetent pt with uncomplicated diverticulitis:
    • – discharge home
      
    • – clear diet
      
    • – oral abx
      
    • – followed by outpatient colonoscopy in 6 weeks
      
    • – if fail tx, admit and start IV abx
  • Management for ill-appearing, uncontrolled pain, vomiting, comorbidities, and immunosuppressed pt with uncomplicated diverticulitis:
    • admit
      
    • NPO
      
    • IV abx
  • Management for complicated diverticulitis:
    • admit
      
    • NPO
      
    • IV abx
      
    • surgical consultation
  • Inpatient abx for diverticulitis:
    • Cipro/Metronidazole
      
    • Amp/Sulbactam
      
    • Pip/tazo
  • Outpatient abx for diverticulitis:
    • Amox/Clav
      
    • Cipro/Metronidazole

Gallbladder Disease

• Types:
  • Biliary colic
  • Cholelithiasis
  • Cholecystitis
  • Choledocholithiasis
  • Acute cholangitis
  • Chronic cholecystitis
  • Emphysematous cholecystitis
• Gallstones MCC Presentation:
  • – age >40 yo
    
  • – female gender
    
  • – family hx
    
  • – pregnancy & parity
    
  • – obesity
• Gallbladder Diseases MCC Presentation:
  • – post-prandial
    
  • – RUQ or epigastric
    
  • – may radiate to back or right shoulder
    
  • – sharp, colicky
    
  • – nausea, vomiting
    
  • – fever, RUQ tenderness
    
  • (+) Murphy’s sign
• Work-up:
  • labs: CBC, Chem7, LFTs, lipase
    
  • imaging: US
• US findings for Gallbladder Disease:
  • – gallstones
    
  • – gallbladder with wall thickness >3mm
    
  • – sonographic murphy’s sign
    
  • – pericholecystic fluid
• HIDA Scan:
  • – uses technetium 99m hepatobiliary iminodiacetic acid cholescintigraphy
    
  • – higher accuracy than US (more invasive)
    
  • – tracer in GB, CBD, small bowel
    
  • – can detect if GB is filling or not
• Presentation and Management:
  •  
  • Biliary colic:
    • RUQ pain for 2-6 hours that resolves spontaneously (gallbladder spasm)
  • Cholelithiasis:
    • Symptomatic – caused by gallstones with gallbladder contraction
    • if labs are normal and pt tolerating PO, can be managed as an outpatient
  • Cholecystitis:
    • caused by an obstructing gallstone typically in the gallbladder neck leading to inflammation and infection
    • – IV abx to cover gram-negative bacteria & gram-positive bacteria –> often use Vanco or Pip/tazo or Cipro/Metronidazole, or Aztreonam
      
    • – surgical consultation
  • Choledocholithiasis:
    • stones in the common bile duct
  • Acute cholangitis:
    
    • – infection of the biliary tree from bile duct obstruction
      
    • – charcot’s triad: jaundice, RUQ pain, fever
      
    • – prescribe IV antibiotics
      
    • – emergent surgical or endoscopic decompression
  • Chronic cholecystitis:
    
    • similar to acute cholecystitis but sx are less intense and longer duration
  • Emphysematous cholecystitis:
    • – air in gallbladder wall
      
    • – seen in diabetics
      
    • – progresses to gangrene and sepsis

Mesenteric ischemia

• Mesenteric Ischemia:
  • – rare but often fatal
    
  • – causes: embolic, arterial thrombus, venous thrombosis, nonocclusive
• Embolic mesenteric ischemia:
  • – elderly pts
    
  • – hx of Afib
    
  • – cardiac dysfunction
    
  • – atherosclerosis
    
  • – recent aortic or cardiac surgery
• Arterial thrombosis mesenteric ischemia:
  • elderly
    
  • atherosclerosis
    
  • htn
• Venous thrombosis mesenteric ischemia:
  • hypercoagulable states
    
  • inflammatory bowel
    
  • inflammatory conditions (pancreatitis)
• Nonocclusive mesenteric ischemia:
  • – low flow states
    
  • – CHF
    
  • – shock
    
  • – drug-induced splanchnic vasoconstriction
• Presentation:
  • – midline abdominal pain
    
  • – pain out of proportion to exam
    
  • – weight loss
    
  • – postprandial pain
    
  • – late: peritonitis, bloody diarrhea
• Workup for mesenteric ischemia:
  • CBC
    
  • Chem7
    
  • Coags
    
  • T&S
    
  • lactate
    
  • CT angiogram of abdomen/pelvis
• Management of mesenteric ischemia:
  • resuscitation
    
  • ABCs
    
  • vascular consultation

Pancreatitis

• Etiology:
  • – pancreatic inflammation
    
  • – ranges from mild-severe
    
  • – can lead to necrosis, multi-organ failure, and death
• Causes:
  • #1 cause = gallstones
    
  • #2 cause = alcohol
    
  • other causes: sphincter of Oddi dysfunction, ERCP, hypertriglyceridemia, meds
• Pancreatitis Presentation:
  • – persistent abdominal pain
    
  • – epigastric, radiates around the waist to back
    
  • – sudden onset
    
  • – better sitting up with knees flexed
    
  • – nausea/vomiting
    
  • – abdominal tenderness, epigastric
• Severe Pancreatitis Presentation:
  • – fever, tachycardia, hypotension, shock
    
  • – Cullen sign – periumbilical ecchymoses
    
  • – Turner sign – ecchymoses in flanks
    
  • – Pulmonary findings: respiratory distress, hypoxemia, pleural effusions
• Diagnosis:
  • (look for 2 of 3):
    
    • – characteristic abdominal pain
      
    • – lipase 3x ULN
      
    • – CT or US findings of pancreatitis
• Management:
  • – NPO
    
  • – pain control (morphine)
    
  • – fluid resuscitation
    
  • – abx for mod/severe cases (imipenem, meropenum, FQ/metronidazole)
    
  • – surgical consultation

Peptic Ulcer Diseases (PUD)

• Etiology:
  • – chronic illness with recurrent ulcerations
    
  • – very common in men, women, and obese pts
    
  • – related to ETOH, NSAIDs, H. pylori, meds, hereditary
• Presentation:
  • – burning epigastric pain
    
  • – may also be sharp, dull, achy, or “hungry” feeling
    
  • – relieved by food, antacids, milk
    
  • – may awaken pt at night
• Physical Exam:
  • – mild epigastric tenderness
    
  • – ulcer bleeding (hematemesis, melena)
    
  • – abrupt pain may suggest perforation (peritonitis, rigid abdomen, radiation to mid-back)
• Workup:
  • – CBC, coags, T&S, rectal exam
    
  • – upright CXR if severe pain
    
  • – GI cocktail
    
  • – IV PPI, Zantac

Perforated Bowel

• Causes/risk factors for bowel perforation (perforated viscus):
  • – 50% have PUD
    
  • – inflammatory bowel conditions
    
  • – iatrogenic from endoscopy, colonoscopy
    
  • – chronic steroid use, bowel malignancy
    
  • – may occur secondary to previously mentioned etiologies
• Workup for bowel perforation:
  • obtain immediate upright CXR in any patient with characteristic history, peritoneal signs or severe pain
    (low threshold to image elderly, immunosuppressed)
• Management:
  • immediately go to OR
    
  • resuscitate

Renal colic

• Etiology:
  • – first episode on average at 30 years old
    
  • – men ages 20-50
    
  • – women ages 35-55, bimodal
• Causes:
  • – stones may be calcium oxalate
    
  • – struvite (assoc with urea-splitting bacteria — proteus)
    
  • – uric acid
• Presentation:
  • – sudden onset pain
    
  • – severe (rivals childbirth)
    
  • – can’t get comfortable
    
  • – migratory pain from flank to lower quadrant (correlates with stone location)
    
  • – n/v
    
  • – abdomen and flank non-tender
    
  • – CVA tenderness may suggest infection
• Workup:
  • – labs
    
  • – Cr rise rarely due to kidney stone (unless only one kidney or bilateral stones)
    
  • – most have microscopic hematuria
    
  • – imaging: KUB, US, CT without contrast
• Management:
  • – pain control (morphine, toradol)
    
  • – IV fluids
    
  • – urology only if signs of infection or intractable pain
    
  • – Flomax (controversy)
    
  • – do not need to CT all stones, ok to send home

Neonatal / Infants Abdominal Pain

•  DDX:
  • – necrotizing enterocolitis
    
  • – malrotation with midgut volvulus
    
  • – incarcerated hernias
    
  • – testicular torsion
    
  • – non-accidental trauma
  • – bowel obstruction – Bilious vomiting in neonates/young infants
• Tests / Imaging:
  • X-ray
    
  • use distraction & examine pt in mother’s arm
    
  • check for other sources of pain: hair tourniquet

Infants / Toddlers Abdominal Pain

• DDX:
  • – intussusception
    
  • – acute gastroenteritis
    
  • – constipation
    
  • – UTI
    
  • – testicular torsion
    
  • – accidental and non-trauma
  • (can be difficult due to stranger anxiety)

Children 3-15 yo Abdominal Pain

• DDX:
  • – appendicitis
    
  • – constipation
    
  • – viral syndrome or gastroenteritis
    
  • – strep pharyngitis
    
  • – UTI
    
  • – pneumonia
    
  • – DKA
    
  • – pancreatitis
    
  • – IBD
    
  • – sickle cell anemia
    
  • – Henoch-schonlein purpura
    
  • – toxic ingestion
    
  • – testicular torsion
    
  • – ovarian cyst
    
  • – ectopic
    
  • – PID
    
  • – renal colic

Immunocompromised and Psychiatric Pts with Abdominal Pain

• Considerations when dealing with immunosuppressed:
  • they are fragile and do not mount a systemic response
• Considerations for pts with psychiatric histories:
  • may present atypically — do not ignore objective findings/focal tenderness

Summary of abdominal pain in ER setting

• – abdominal pain is high risk compliant
  
• – beware of focal tenderness
  
• – typically get labs and/or imaging
  
• – beware of elderly, immunosuppressed, psych
  
• – treat pain