abdominal pain. scenario you are called by a nurse to evaluate a patient on the inpatient medicine...
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Abdominal Pain
Scenario
You are called by a nurse to evaluate a patient on the inpatient medicine service with abdominal pain (cross-cover)
“Worst case scenario” DDx
“Surgical abdomen” – condition with rapidly worsening prognosis without surgical intervention• Obstruction
• Peritonitis– Viscus perforation (e.g., intestine, pelvic organ)
– Intraperitoneal hemorrhage (e.g., ruptured AAA)
– Intraabdominal abscess
– (SBP is medically managed)
Location, location, location
RUQ:• Biliary colic
• Cholecystitis
• Cholangitis
• Hepatitis
DDx
Epigastric:• Pancreatitis
• Dyspepsia/PUD
• Gastroparesis
• Cardiac ischemia
• Pulmonary pathology affecting lower lungs/pleura (PNA, PE, pulmonary infarct, empyema)
DDx Lower abdominal:
• Colitis/enteritis (infectious, ischemic, IBD)• Diverticulitis• Appendicitis• Cystitis• Renal colic (flank), pyelonephritis (CVA tenderness)• Gynecologic: PID, adnexal cysts/masses (bleeding,
torsion, rupture), fibroids, ectopic
DDx
Generalized:• Intestinal ischemia/infarction
• Endocrinopathies: DKA, hypercalcemia, adrenal insufficiency
• Constipation
• Pain syndromes: functional abdominal pain, IBS, fibromyalgia, somatoform disorder, narcotic-seeking behavior
First steps
Is the patient unstable (phone)? Is the patient sick (bedside)? If yes to above ABCs, consider ICU Xfer
History All about the pain
• Onset, what patient was doing/had recently done (e.g. just finished a meal, ERCP yesterday)
• Ever had this pain before?• Location, radiation• Character:
– Dull/achy/vague (visceral)– Sharp/well-localized : parietal (2/2 peritoneal irritation)– Colicky
• Severity
History
Aggravating/alleviating factors– Food : aggravates intestinal ischemia, alleviates some cases
of PUD
– Position : peritonitis aggravated by any movement, pancreatitis alleviated by sitting up and leaning forward
Associated symptoms– N/V (bloody, bilious, feculent), diarrhea/constipation,
melena/hematochezia, vaginal discharge/bleeding
History
STD risk/symptoms
Possibility of pregnancy
Medical history: diabetes, chronic liver disease, IBD, rheumatologic disease, immunocompromised, prior abdominal surgeries
Abdominal Exam General appearance, level of discomfort Vitals: fever, HoTN Inspection
• Bulging (ascites, mass)• Signs of chronic liver disease (jaundice, dilated superficial
veins, spider angiomata)• Scars
Auscultation:• Absent bowel sounds (adynamic ileus, advanced
peritonitis)• Hyperactive, high-pitched bowel sounds (early bowel
obstruction)
Abdominal Exam Palpation/Percussion
• Gently assess for peritonitis– Muscle rigidity (guarding) – may be focal or diffuse– Rebound tenderness– “Shake tenderness” – bump the bed
• Start away from the pain• Tympany (distended bowel)• Pain out of proportion to exam (intestinal
ischemia/infarction)• Murphy’s sign, hepatomegaly• Ascites (SBP)• Pulsatile mass (AAA)
Exam Rectal exam
• Have to justify not doing it• Impaction, tenderness, check stool for occult blood
Pelvic exam• If suspect pelvic pathology (e.g., woman with lower abdominal
pain)• Bleeding, discharge• CMT• Adnexal/uterine pathology
Don’t forget the heart, lungs, eyes/skin (jaundice), pulses (AAA)
Whole exam can be done rapidly
Labs• CBC: leukocytosis, anemia• CMP: hepatic/renal function, electrolytes, anion gap• Lipase• UA• Lactate (ischemia/infarction)• Urine hcg• Blood Cultures: if febrile or unstable• Stool Cx/O+P/C. Diff• Wet mount of vaginal discharge/GC/Chlamydia• Troponin, EKG• ABG
Imaging Abdominal X-ray:
• “bones, stones, mass, and gas”
• Different from KUB which is centered lower in the abdomen
• Supine and upright/L lateral decubitus views
• Obstruction proximally dilated bowel loops, air-fluid levels
• Viscus rupture intraperitoneal free air (see under diaphragm, over liver)
• Toxic megacolon (C. Diff) markedly dilated bowel +/- perforation
• Ileus, intestinal pseudoobstruction dilated bowel extending to rectum
• Constipation
Imaging
CT Abdomen/Pelvis (with contrast):• Higher diagnostic accuracy than plain radiographs
• Intraperitoneal free air
• Obstruction (may see transition point)
• Intestinal ischemia
• Viscus inflammation
• Abscess
• AAA leak/rupture
• Pancreatitis
Imaging Ultrasound:
• RUQ : cholecystitis, gallstones, biliary dilation, cholangitis
• Pelvic: fibroids, adnexal masses, IUP, ectopic pregnancy, free pelvic fluid
• Renal
• Pregnancy
CXR:• If pulmonary pathology suspected
• May need follow-up chest CT
Therapy/Management
Consultation:• Emergent surgical consult if acute abdomen
• Biliary consult if biliary dilation, choledocholithiasis ERCP/MRCP
• GI consult if dyspepsia with red flag symptoms (e.g., dysphagia, wt. loss, persistent vomiting) EGD +/- Bx
• GYN consult if complex pelvic disease
Therapy/Management
Some therapeutic examples:• Ileus:
– Decompression with NGT to suction, NPO
• Constipation/fecal impaction: – Manual disimpaction, stool softeners, laxatives
• Enterocolitis, diverticulitis, cholangitis, PID: – ABx
Therapy/Management
Diagnosis is often unclear after initial assessment• Serial assessments, watchful waiting
If you didn’t document, you didn’t do it• Initial assessment, f/u assessments
• If cross-covering, give appropriate sign-out
Take-Home Points Is the patient sick? (phone, prompt bedside
assessment) R/o surgical abdomen Very focused history and exam Relevant labs and imaging (think before you order) Use your consultants Watchful waiting – good medicine when used
correctly Documentation