Comprehensive Approach to Abdominal Pain in Emergency Medicine

1. Approach to Abdominal Pain in the Emergency Department Sezgin Sarıkaya, Assoc. Prof. MD, MBA Department of Emergency Medicine Yeditepe University

2. Introduction • At the end of this lecture you should: • Understand the generation and presentation of types of abdominal pain • Develop critical elements of the history and physical for AP • Apply knowledge of utility of testing to diagnostic approach • Apply management principles to patient care in the ED

3. The Epidemiology of Acute Abdominal Pain • 5-10% of all ED visits. • Among them, 14-40% patients need surgical intervention. • Most common diagnosis is NONSPECIFIC (ie, “I dunno”) • Challenge for emergency physician (EP): • About 1/3 have an atypical presentation. • If misdiagnosis, mortality rate 2.5 times higher than correct diagnosis in the elderly.

4. Three Subgroups of Patients with Abdominal Pain Who deserve Particular Focus • Elderly/ nursing home patients • Immunocompromised (e.g. HIV) • Women of childbearing age. • Post operative patients • Infants

5. The Most Important Concept for EP in Approaching Abdominal Pain • To Differentiate • Who is the patient of acute abdomen? • What are the probable diagnoses you have in mind? • Why do you consider such diagnosis? • How do you prove it? • When will you consult surgeon for operation?

6. Causes of Acute Abdominal Pain in the ED Cause Percentage of Cases Nonspecific abdominal pain41-46 Appendicitis 4-24 Cholecystitis 2.5-9 Gastroenteritis 7 Salpingitis 2-7 UTI 3-5 Small-bowel obstruction 2.5-4 Renal colic 1.5-4 Constipation 2 Pancreatitis 1-2 Diverticulitis 1-2 Abdominal aneurysm, ectopic pregnancy <1 (Brewer et al., 1979; Scand J Gastroenterol)

7. Abdominal Pain Across the Ages • Ages 0-2 • Colic, GE, viral illness, constipation • Ages 2-12 • Functional, appendicitis, GE, toxins • Teens to adults • Addition of genitourinary problems • Elderly • Beware of what seems like everything!

8. Important Extra-abdominal Causes of Abdominal Pain • Systemic • DKA • Alcoholic ketoacidosis • Uremia • Sickle cell disease • Porphyria • SLE • Vasculitis • Glaucoma • Hyperthyroidism • Toxic • Methanol poisoning • Heavy metal toxicity • Scorpion bite • Black widow spider bite • Thoracic • Myocardial infarction/ Unstable angina

9. Important Extra-abdominal Causes of Abdominal Pain • Pneumonia • Pulmonary embolism • Herniated thoracic disc (neuralgia) • Genitourinary • Testicular torsion • Renal colic • Infectious • Strep pharyngitis (more often in children) • Rocky Mountain Spotted Fever • Mononucleosis • Abdominal wall • Muscle spasm • Muscle hematoma • Herpes zoster Emerg Med Clin North Am 1989; 7: 21-740

10. Abdominal Pain in the Elderly • Diminished sensation of pain in the elderly • Comorbid diseases • Polypharmacy • Combinations of above result in many more vague, nonspecific presentations • Twice as likely to require surgery with presentation over age 65

11. What’s the Problem • Imprecise pain generation and transmission to the central nervous system • Comorbid diseases • Developmental stage • Medications • Social factors

12. Understanding the Types of Abdominal Pain • Visceral • Stretch fibers in capsules or walls of hollow viscus that enter both sides of spinal cord • Somatic • Fibers dermatomally distributed and enter unilaterally in the spinal cord • Referred • Overlap of fibers from other locations

13. Understanding the Types of Abdominal Pain • Visceral • Crampy, achy, diffuse, • Poorly localized • Somatic • Sharp, lancinating • Well localized • Referred • Distant from site of generation • Symptoms, but no signs

14. Understanding the Types of Abdominal Pain • Location, location, location • Organs and their corresponding fiber entry to the spinal cord • C3-5 – liver, spleen, diaphragm • T5-9 – gallbladder, stomach, pancreas, small intestine • T10-11– colon, appendix, pelvic viscerat11-l1 – sigmoid, renal capsules, ureters, gonads • S2-4 - bladder

16. Visceral

17. Somatic

18. History Taking in Abdominal Pain Presentations • “OLD CARS” • O- onset • L- location • D- duration • C- character • A-alleviating/aggravating factors associated symptoms • R- radiation • S- severity

19. History Taking for Abdominal Pain Presentations • PMH • Similar episodes in past • Other medical problems that increase disease likelihood of problems (ex: DM and gastroparesis) • PSH • Adhesions, hernias, tumors • MEDS • Abx, NSAIDS, acid blockers, etc • GYN/URO • LMP, bleeding, discharge • Social • Tob/EtoH/drugs/home situation/agenda

23. Physical Exam in Abdominal Pain Presentations • Inspection • Distention, scars, bruises • Auscultation • Present, hyper, or absent • Actually not that helpful! • Palpation • Often the most helpful part of exam • Tenderness versus pain • Start away from painful area first • Guarding, rebound, masses

24. Physical Exam in Abdominal Pain Presentations • Signs • Mc burney • Murphy’s • Extra-abdominal exam • Pelvic or scrotal exams • Lungs, heart • Remember it’s a patient, not a part • Rectal • Adds very little (despite the angst) beyond gross blood or melena

25. Laboratory Testing • Everybody likes a CBC, but… • Lacks sensitivity, no specificity • Little to no change in diagnostic probabilities • Should not dramatically alter approach (tender is still tender)

26. Laboratory Testing • Directed approach to lab studies • There are no “standard belly labs” • Pregnancy test in women of child bearing age • Urine dipsticks

27. Imaging • Plain films • Free air, obstruction, air-fluid, FBs • Ultrasound • Rapid “yes or no” ED evaluations • Formal studies • May add doppler • Computed Tomography • Revolutionized acute care • Often better than we are!

30. RUQ Cholecystitis Biliary colic Hepatitis Pancreatitis Renal stones PUD Pneumonia P E M I LUQ Gastritis Gastric ulcer Pancreatitis Splenomegaly Splenic rupture Renal stone Pneumonia P E M I Common Diagnoses by Quadrant

31. RLQ Appendicitis Renal stone Ovarian cyst Torsion Epididymitis Ectopic IBD AAA UTI LLQ Diverticulitis Renal stone Ovarian cyst Torsion Epididymitis Ectopic IBD AAA UTI Common Diagnoses by Quadrants

32. Dangerous Mimics True DiagnosisInitial Misdiagnosis Appendicitis Gastroenteritis, PID, UTI Ruptured abdominal Renal colic, diverticulitis, lumbar strain aortic aneurysm Ectopic pregnancy PID, UTI, corpus luteum cyst Diverticulitis Constipation,GE ,pyelonephritis Perforated viscus PUD, pancreatitis, nsp abdominal pain Bowel obstruction Constipation, gastroenteritis,nonspecific abdominal pain Mesenteric ischemia GE, constipation, ileus small bowel obstruction Incarcerated or Ileus or small bowel obstruction strangulated hernia Shock or sepsis from Urosepsis or pneumonia (in elderly) perforation, bleed, abdominal infection

33. Five Major Categories of Acute Abdomen (BIOPI) • Bleeding or rupture of vessels or tumor • Ischemia or Infarction • Obstruction • Perforation • Inflammation

34. Common Pitfalls in Acute Appendicitis • Abdominal pain and tenderness are present in nearly 100% of patients with appendicitis; other clinical features are less reliable. • Feveroccurs in only 16% of patients with acute appendicitis; its presence is more suggestive of appendiceal perforation. • Murphy sequence appears in only 22% elderly. • Perforation rate about 60% (age > 60 Y/O)

35. Management of Abdominal Pain • Always right to start with ABC’s • IV access • Fluid administration • Antiemetics • Analgesics • Directed testing and imaging • Re-evaluations • Antibiotics • Consultants • Surgeons, OB/GYN, urologists, cardiologists, etc

36. Disposition of Abdominal Pain Patients • Operating Room • Hospital bed/observation • Serial labs • Serial exams • Home with abdominal warnings • The art of emergency medicine • 3 components of discharge plan • Document, document, document

37. TEŞEKKÜRLER • SORU VE KATKI