abdominal pain - kerg werman revised -...
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Abdominal Pain
Melissa Kerg MDHoward Werman MD
Abdominal Pain
· Can be a challenge to diagnose· Personal biases
· Presumptive diagnosis hastily made· Inefficient use of time and tests· Delay in making actual diagnosis
· Mortality doubles with incorrect diagnosis
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Introduction
· 10% of all undifferentiated patients presenting to ED have abdominal pain as a major complaint
· missed appendicitis and missed abdominal aortic aneurysm are among the leading causes of malpractice actions
Abdominal Pain
· Pain· Subjective· No objective measures of pain
· Vital signs without sensitivity or specificity
· Pain Scales· Ask the patient· Useful to tract progress of treatment
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Treat the Pain
· Goal is pain control not pain relief, there is a difference!
· Patients are very receptive to being told that we want to lessen the pain and make it tolerable but that its not realistic to remove it completely.
Abdominal Pain
· It can be anything from the nipples to the pelvis
· Abdominal pain may not be associated with disease processes in the abdomen
· Abdominal pain may be associated with disease processes not in the abdomen
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Abdominal Pain
· At least 5-10% of ED visits· Up to 50% remain undiagnosed at
discharge· 5-10% of these have significant disease
· Small % of admitted patients are misdiagnosed· Delays treatment· Added morbidity and mortality
Goals
· to identify any immediate life-threatening causes of abdominal pain· 15-30% of patients require immediate
surgery· to make an educated guess as to
underlying medical condition· most common dx: nonspecific abdominal
pain (40-60% patients)
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General Approach
· Rule out surgical pathology· Look for non-surgical causes
· Referred pain· Systemic illness
· Gut feelings are important and develop over a career
Causes of Abdominal Painwithin the Chest
· Angina/MI· Pleuritic irritation· Great vessels
· Aortic dissection· Aortic aneurysm
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Causes of Abdominal Pain Abdomen/Pelvic Organs
· Stomach Gastritis, PUD, gastroenteritis
· Intestines· Appendicitis, SBO, diverticulitis,
incarcerated hernia, ischemic gut, IBD
· Pancreas· Pancreatitis, pseudocyst
· Liver· Acute hepatitis, biliary tract disease
· Vessels· AAA, Renal/splenic aneurysm
· Spleen: Splenic rupture
· Ureters· Colic, stones, UTI
· Uterus· PID, fibroids
· Ovaries and fallopian tubes· (ruptured) ectopic, ovarian
cyst, Mittelschmerz, torsion· Prostate
· Prostatitis· Testicles and associated
structures· Torsion, hydrocele,
Retroperitoneal
· Kidneys· Pyelonephritis, infarction
· Great Vessels· AAA
· Muscles (psoas)
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Miscellaneous
· Abdominal Wall· Shingles· Hernias· Spontaneous
Bacterial Peritonitis· Acute Intermitent
Porphyria
· Strep Throat (think pediatrics)
· Diabetes (DKA)· Acute narrow angle
glaucoma· Black Widow Spider
Bite
History
· Many symptoms are neither sensitive or specific
· Few disease processes in abdomen have pathognomonic historical features
· The “typical appendicitis” occurs in only 33% of cases
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But with that being said….
· Inadequate history most common feature of leading to a misdiagnosis
History
· In assessing the patient with abdominal pain, a careful history will lead to a reasonable diagnosis in more than 80% of cases
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History
· Suggestive of a surgical cause??· Sudden onset
· Lasting 1-2 days· Subsequent peritoneal signs· Anorexia
History· location: major factor in developing a
differential diagnosis· character· radiation· onset/chronology· aggrevating/alleviating factors· associated symptoms: anorexia,
nausea, vomiting, bowel changes, urinary sx, vaginal sx
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History
History
· O onset
· P palliation/provocation
· Q quality
· R radiation
· S severity
· T time
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How Fast Did It Start
· Sudden onset· Perforated ulcer, mesenteric infarction, ruptured AAA,
ruptured ectopic pregnancy, ovarian torsion, ruptured ovarian cyst, PE, AMI, testicular torsion
· Rapid onset (minutes to hours to max)· Strangulated hernia, volvulus, intussuception, acute
pancreatitis, biliary colic, diverticulitis, ureteral colic
How Fast Did It Start
· Gradual Onset· Appendicitis, chronic pancreatitis, PUD,
inflammatory bowel diseases, mesenteric adenititis, uti, urinary retention, salpingitis, prostatitis
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History
· Where did it start?· Migratory?
· Where is it at? · What makes it worse or better?
· Movement, bumps, cough· Eating
· How soon after· Position
· Associated symptoms
History
· PMH· Have you ever had this before??
· SH· Alcohol· Tobacco· Recreational drugs
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Abdominal Pain
· There are 2 types of abdominal pain
Abdominal Pain
· VisceralForegut, midgut, hindgut
· Autonomic nerves· Innervates involuntary
muscles, heart and glands
· Poorly localized· Achy/colicky· Intermittent· Felt in the abdominal
wall in the area of embryonic origin of the pain
· Somatic· Typical pain and
temperature fibers that innervate the skin
· Irritation of the parietal peritoneum or mesenteric root
· Intense and well localized· Sharp· Felt directly over area of
inflammation
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Abdominal Pain
· A 20 yo female OSU student presents with sharp RLQ abdominal pain. The patient reports that the pain began approximately 6 hours previously as a dull periumbilicalpain which suddenly became localized 30 minutes ago. Can you explain?
Abdominal Pain
· Referred pain: pain felt at a site distant from the involved abdominal organ due to a shared cutaneous sensory nerve
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Abdominal Pain
Vital Signs
· Vital signs· Orthostatics---when would they not be useful? · Fever
· When is it unreliable?· Heart Rate
· Intra-peritoneal blood may be associated with a relative bradycardia (ectopics)
· Medications· Respiratory Rate· Vital signs do not correlate well with patients level
of pain
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Physical Examination
· General Appearance· May the most useful
· HEENT· Cardiac· Pulmonary
· Abdominal· Rectal
· What will cause black, but heme negative stools?
· GU· Check for hernias,
especially in the pediatric population
Physical Examination
· Observation· “What do I see?” Look as you enter.
· Level of comfort· Position· Still vs active· Diaphoresis· Breathing pattern· Distention· Icterus
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Physical Examination
· Auscultation-prior to palpation· Bowel sounds
· Poor predictor of peritonitis· People with peritonitis do have bowel sounds!!
· Listen for minutes-not practical in the ER· rushes
· Bruits
Physical Examination
· Palpation· Masses, organomegaly
· If you don’t think to check for it you will not find it· Tenderness
· Abdominal pain with coughing or heal strike more sensitive than palpation or Rovsing’s
· Guarding· Voluntary· Involuntary
· Unilateral always involuntary· 25% of patients with rebound tenderness do not have surgical
pathology
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Physical Examination
· Hernia· Ventral, inguinal, femoral, umbilical
· Rectal· Pelvic· Carnett’s Test
· Straight leg raise or have patient lift head and tightened abdominal muscles and palpate
· If the pain increases - abdominal wall
Rectal Examination
· Only useful to check guaiac or for local phenomena (perirectal abscess)
· Will not/can not help with the diagnosis of appendicitis/diverticulitis
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Signs
· Carnett’s· Murphy’s
· 50% specific (less in elderly)· Presence or absence should not preclude diagnosis· Ultrasonic (radiographic) murphy’s sign
· Psoas· Not specific but sensitive
· Obturators and Rovsing’s· Not predictive of anything good or bad
What are we trying to diagnosis?
· Bad stuff!!· Ruptured viscus’· AAA· Ischemic bowel· Appendicitis· Strangulated hernia· Ectopic pregnancy
· Need to go to OR!
· Gallbladder disease· Pancreatitis· Bowel obstruction· PID· Torsions
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The Rest
· Could be the early presentation of more serious disease
· Usually nonspecific self limiting diseases· Follow up is going to be important
Diagnostic Approach
· Prior to ordering any tests you should have a reasonably short differential to act on
· In a significant minority of patients with abdominal pain, no tests are needed other than a u/a (and pregnancy test in females)
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The Tests
· What is needed?· We over-utilize every test we can· CBC, AAS, Amylase, LFT’s· Pregnancy Tests may be under-utilized
But….
· Always consider an ECG on patients with upper abdominal pain or non-specific symptoms in their coronary years
· Consider a Chest x-ray on young children
· Consider glucose testing (DKA)
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Blood
· WBC· Not sensitive, not specific, not predictive· Can be misleading
· Amylase· Not specific, > 3 times upper level of normal
· Lipase· More specific and sensitive
· Rises as quickly as the amylase but stays elevated 2x longer
Blood
· LFT’s· Abnormal in only 50% of acute cholecytitis· Just a ALT and urine bilirubin to screen for hepatitis· Full battery if patient icteric
· Chem 7· Why??? Only needed for protracted vomiting or
dehydration. BUN/Creatinine is needed prior to IV contrast
· Lactate-late finding· Type and screen vs type and cross
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Urinalysis
· Up to 33% of patients with appendicitis have blood or WBC’s in the urine· 50% with ruptured appy have wbc’s
· 33-67% of AAA have blood in their urine
· Urine pregnancy
Radiology
· AAS· No role in undifferentiated abd pain· Obstruction, perforation, or foreign body
· The patient needs to be upright for 10 minutes to increase sensitivity
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Radiology
· Ultrasound· Not useful in undifferentiated abd pain
· Wonderful for directed exams
· Screening exam for most diagnoses by EP· Sensitive for AAA but not for dissection
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Special Considerations
· Elderly· Higher prevalence of disease
· Up to 40% require surgery· Majority have co-morbid illnesses· Longer delay to presentations (2X)· Less likely to have a fever· Higher morbidity and mortality· Higher atypical cholecystitis incidence
Special Considerations
· Steroids· Blunt inflammatory response· No peritonitis possible
· Children· Transfer to a higher level of care if you are not
comfortable with children, especially the infants· Intussusception
· Typical: male, 5-10 months old, involves ileocecal valve
· Colicy pain, bloody stool or mucus within several hours
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The Most Common Causes of Children Presenting with Acute
Abdominal Pain· URI/OM 18.6%· Pharyngitis 16.6%· Viral Syndrome 16%· Abdominal Pain ?
Etiology 15.6%· Gastroenteritis
10.9%
· Acute Febrile Illness 7.8%
· Bronchitis/Asthma 2.6%
· Pneumonia 2.3%· Constipation 2.0%· UTI 1.6%· Appendicitis 0.9%
Gastroenteritis
· Vomiting (Gastro) and diarrhea (enteritis)
· Frequently used as diagnosis· Appendicitis malpractice issue
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It’s not simple
· Frustrating to patient, family, staff and you at times
· Don’t forget repeat exams · If ever in doubt, obtain second opinion· CLEAR discharge instructions
· Problem could not be identified· Repeat evaluation in 8 - 12 hours· Precautions
Discharge Instructions
· write all discharge instructions in language understandable to the patient
· avoid medical abbreviations· carefully describe any therapies prescribed· identify clear follow-up for each patient· list the signs and symptoms for which the
patient should immediately return for evaluation
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Cases
· 35 y/o female with upper abdominal pain· Vitals: Temp 97.5, BP 122/70, HR 92, RR 18· Hx: Pain, some nausea, no vomiting. Radiates to back· PHx: S/P cesarean 6 weeks ago, known gallstones· PE: RUQ tenderness, soft elsewhere· Test?· Labs?· Medications?
Continued
· WBC 14.5, LFTs normal· Ultrasound shows:
· Gallstones, gallbladder wall is not thick, no pericholic edema. Common bile duct is 1.5cm diameter
· Disposition of patient?
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Case 2
· 79 y/o female from ECF with Abdominal pain
· Vitals: Temp 99.4, BP 110/66, HR 60, RR 20· Hx: Little ostomy output today, urinated once today,
feels bloated· PHx: Colon Ca 1999 s/p partial colectomy, SBO, UTI,
Mild dementia, Renal insufficiency, HTN· PE: Diffuse tenderness, worse in the RLQ, mild
distention. Rectal: no stool. Thin liquid in ostomy bag
Case 2
· Labs?· X-rays?· Medications?· Differential diagnosis?
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Case 2
· WBC 19.9· BUN 43, Creatinine 2.7 (baseline 1.6)· AAS: Mildly dilated small bowel,
possible ileus vs. PSBO· What is the next step?
Case 2
· CT without IV contrast:· Diverticulitis of the right colon
· Disposition?
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Case 3
· 82 y/o male with left side pain· Vitals: Temp 98.5, BP 188/110, HR 105, RR 22· Hx: Intermittent sharp pain, hurts to the back, no pain
now· PHx: Mass in the abdomen, told to keep a watch on it
(this was 5 years ago), kidney stone >40ys ago, HTN, CAD
· PE: RRR, CTA, Abd soft, NT, pulsatile mass midline, pulses equal
Case 3
· Differential Diagnosis?· Labs?· Medications?· X-rays?
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Case 3
· WBC nl, Hgb 10.8· PT/PTT nl· UA: 1+ blood· BUN and Creatinine of 30 and 3.0
· Diagnostic dilemma?· Disposition?
Case 3
· Follow up: Pt was admitted with BP control.· Surgical repair of 7cm AAA performed,
however pt died of post-op complications.
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Case 4
· 13 y/o girl arrives 6:30Am with RLQ pain· Mom talks 99% fo the time· Vitals: All normal· Hx: Similar pains in the past, never lasting more than 1 hour at a
time. This time non-stop since 8PM. Sharp pain, sudden onset. Now has N/V
· PHs: Menarche 11 y/o, never regular; never had a pelvic before.· Soc: Never sexually active, Started OCPs 4 days ago by PMD to
help regulate her cycle and stop the pains.· PE: Flat abd, slender, keeps knees and hips flexed. Severely tender
in RLQ and suprapubic areas (pelvic deferred until pain meds)
Case 4
· Differential Diagnosis?· Labs?· Medications?· X-rays?
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Case 4
· After pain meds and anti-emetics…pelvic reveals pain and fullness of the right adnexa
· Pregnancy test is negative, WBC 17· Differential diagnosis further narrowed?
Case 4
Ultrasound: right ovarian torsion· Pt went to surgery and the ovary was saved· Pt had numerous cysts
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Case 5
· 44 y/o male complains of abd pain· Vitals: Temp 99.2, BP 90/66, HR 120, RR 28· Hx: Sharp, constant pain epigastic area, some N/V· PHx: Similar pain in the past, never this intense, told of
elevated BR in the past· Soc: Drinks significant ETOH whenever possible,
homeless · PE: Dry mouth, tachy, CTA, scaphoid abdomen, tender
in the epigastric area
Case 5
· Differential diagnosis?· Labs?· Meds?· X-rays?
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Case 5
· Rectal: little stool, heme positive· AAS: no free air· WBC 14, Hgb 9· Lipase 120· LFTs: AST and Alk Phos are elevated
· Why are these elevated?
· NG: positive for dark blood….>200cc· Management?
Summary/Conclusions
· abdominal pain is a common presenting complaint
· goal is to identify immediately life-threatening (surgical) problems and make an educated guess as to other causes
· identify the ‘toxic’ patient· the history is most important is establishing
the diagnosis· give clear discharge instructions
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