Abdominal Pain

1. Abdominal Pain

2. Scenario • You are called by a nurse to evaluate a patient on the inpatient medicine service with abdominal pain (cross-cover)

3. “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)

4. Location, location, location • RUQ: • Biliary colic • Cholecystitis • Cholangitis • Hepatitis

5. DDx • Epigastric: • Pancreatitis • Dyspepsia/PUD • Gastroparesis • Cardiac ischemia • Pulmonary pathology affecting lower lungs/pleura (PNA, PE, pulmonary infarct, empyema)

6. 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

7. DDx • Generalized: • Intestinal ischemia/infarction • Endocrinopathies: DKA, hypercalcemia, adrenal insufficiency • Constipation • Pain syndromes: functional abdominal pain, IBS, fibromyalgia, somatoform disorder, narcotic-seeking behavior

8. First steps • Is the patient unstable (phone)? • Is the patient sick (bedside)? • If yes to above  ABCs, consider ICU Xfer

9. 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

10. 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

11. History • STD risk/symptoms • Possibility of pregnancy • Medical history: diabetes, chronic liver disease, IBD, rheumatologic disease, immunocompromised, prior abdominal surgeries

12. 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)

13. 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)

14. 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

15. 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

16. 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

19. 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

21. 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

22. 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

23. 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

24. 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

25. 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