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Abdominal Pain

Abdominal Pain. William Beaumont Hospital Department of Emergency Medicine. Abdominal Pain. One of the most common chief complaints Confounders making diagnosis difficult Age Corticosteroids Diabetics Recent antibiotics. Pitfalls. Consider non-GI causes

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Abdominal Pain

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  1. Abdominal Pain William Beaumont Hospital Department of Emergency Medicine

  2. Abdominal Pain • One of the most common chief complaints • Confounders making diagnosis difficult • Age • Corticosteroids • Diabetics • Recent antibiotics

  3. Pitfalls • Consider non-GI causes • Acute MI (inferior), ectopic pregnancy, DKA, sickle cell anemia, porphyria, HSP, acute adrenal insufficiency • History • Location • Quality • Severity • Onset • Duration • Aggravating and alleviating factors • Prior symptoms

  4. History • Sudden onset – perforated viscus • Crushing – esophageal or cardiac disease • Burning – peptic ulcer disease • Colicky – biliary or renal disease • Cramping – intestinal pathology • Ripping – aneurismal rupture

  5. Physical Exam • Abdomen • Inspection • Bowel sounds • Tenderness (rebound, guarding) • Extra-abdominal exam • Lung • Cardiac • Pelvic • GU • Rectal

  6. Labs • Beta-hCG • WBC – poor sensitivity and specificity • LFTs – hepatobiliary • Lipase – pancreatic • Electrolytes – CO2 • Lactic acid • Urinalysis – BEWARE

  7. Imaging • Acute Abdominal Series • Free air • Bowel gas • KUB • Poor screening test • Ultrasound • Biliary disease • AAA • Free fluid or air • Pelvic pathology • CT • Appendicitis • Diverticulitis

  8. Case #1 • 79 yo female presents with aching sharp pain in the epigastrium and right upper quadrant ½ hour after eating. Pain radiates to the back. +N, –V • Differential diagnosis? • Testing?

  9. Upper Abdominal Pain • Biliary disease • Hepatitis • Pancreatitis • PUD/gastritis/esophagitis • AAA • Pneumonia (RLL) • Pyelonephritis • Acute MI • Appendicitis • Fitz-Hugh Curtis

  10. Gallstone Risk Factors • Female 4:1 • Fertile • Forty • Fat • Family history • Others: • Crohns, UC, SCA, thalassemia, rapid weight loss, starvation, TPN, elevated TGs, cholesterol

  11. Cholelithiasis • History: • RUQ/epigastric pain • Nausea/vomiting with fatty meals • Similar episodes in past • PE: RUQ tenderness • Labs: may be normal • ECG: consider in older patients • Imaging: test of choice = US

  12. Cholelithiasis: Treatment Symptomatic Asymptomatic Incidental finding 15-20% become symptomatic Outpatient elective surgery if Frequent, severe attacks Diabetic Large calculi • Pain control • Anti-emetics • Consult general surgery • 90% with recurrent symptoms • 50% develop acute cholecystitis

  13. Acute Cholecystitis • Sudden gallbladder inflammation • Bacterial infection in 50-80% • E. coli, Klebsiella, Enterococci • History/PE: • Fever, tachycardia, RUQ tenderness • Murphy’s sign – low sensitivity • Labs: • Elevated WBC with left shift • LFTs – large elevation  CBD stone

  14. Acute Cholecystitis: Imaging • KUB – stones only seen ~ 10% • Air in biliary tree  gangrenous • CT scan – sensitivity 50% • Ultrasound – sensitivity 90-95% • Gallstones (absent in biliary stasis) • Thickened gallbladder wall • Pericholecystic fluid • HIDA scan – negative scan rules out diagnosis • Positive = no visualization of the GB

  15. Acute Cholecystitis

  16. Acute Cholecystits: Treatment • Admit • NPO • IVF • Pain control • Anti-emetics • Antibiotics • Surgical consult

  17. Hepatitis • Viral • Hepatitis A • RNA, fecal-oral • Hepatitis B • DNA, STD/parenteral • Chronic hepatitis (10%) • Hepatitis C • RNA, blood borne • Chronic hepatitis (50%), cirrhosis (20%) • Hepatitis D • RNA, co-infects Hep B • Bacterial • Alcoholic • Immune • Medications

  18. Hepatitis: Diagnosis • History: • Malaise, low-grade fever, anorexia • Nausea/vomiting, abd pain, diarrhea • Jaundice (altered MS, liver failure) • Labs: • ALT and AST (10-100x normal) • AST > ALT – alcoholic hepatitis • Elevated bilirubin • Abnormal PT • Hepatitis panel • Tylenol level

  19. Hepatitis: Treatment • Symptomatic – IVF, electrolytes • Remove toxins – ETOH, acetaminophen • Admit if altered MS or coagulopathy

  20. Pancreatitis • Autodigestion of pancreatic tissue • B – Biliary • A – Alcohol • D – Drugs • S – Scorpion bite • H – HyperTG, HyperCa • I – Idiopathic, Infection • T – Trauma

  21. Pancreatitis: History and Physical • History: • Boring pain in LUQ or epigastrium • Constant • Radiates to mid-back • Nausea, vomiting • PE: • Epigastric or LUQ tenderness • Grey-Turner or Cullen sign

  22. Flank ecchymosis Intraperitoneal bleeding Hemorrhagic pancreatitis Ruptured abdominal aorta Ruptured ectopic pregnancy Gray-Turner sign

  23. Cullen's Sign

  24. Pancreatitis: Diagnosis • Lipase – most specific • Ranson’s criteria – predicts outcome • Acutely: >55 yo, glucose > 200, WBC >16k, ALT > 250, LDH > 350 • 48 hrs: HCT decreases > 10%, BUN rises > 5, Ca < 8, pO2 < 60, base deficit >4, fluid sequestration > 6L • 3-4 criteria – 15% mortality • 5-6 criteria – 40% mortality • 7-8 criteria – 100% mortality

  25. Pancreatitis: Imaging • Plain films – sentinel loop (local ileus) • Ultrasound – poor (biliary tree) • CT scan with contrast

  26. Pancreatitis: Treatment • NPO • IVF • Pain control • Antiemetics • Antibiotics if gallstones or septic • Surgical consult • If gallstones, abscess, hemorrhage or pseudocyst • ERCP if CBD stone

  27. Gastritis/PUD • Duodenal 80%; gastric 20% • Etiology: • H pylori, NSAIDS, zollinger-ellison syndrome, smoking, ETOH, FHx, male, stress • H pylori – 95% duodenal; 85% gastric • History: • Epigastric constant, gnawing pain • Food lessens – duodenal • Food worsens – gastric

  28. Peptic Ulcer Disease • Workup: • Hemoglobin • PT/PTT – if bleeding • Lipase – rule out pancreatitis • Hemoccult stool – rule out GI bleed • Treatment: • Antacids (GI cocktail) • PPI • Outpatient endoscopy • H. pylori testing

  29. Perforated Viscus • Rare in small bowel and mid-gut • History: abrupt onset pain • Diagnosis: upright CXR • Treatment: • IVF • IV antibiotics • NG tube • OR

  30. Questions on Upper Abdominal Pain? Let’s Move On Down

  31. Case #2 • History: 35 y/o female c/o 1 day of periumbilical aching pain. +N,+V, +D, +F, +C, +anorexia. Today, she has crampy lower abdominal pain. No urinary sx. • Exam: afebrile, bilateral lower quadrant tenderness (R > L), no rebound or guarding. • Other questions? • Differential diagnosis? • Testing?

  32. Lower Abdominal Pain • Appendicitis • Diverticulitis • UTI/Pyleonephritis • Renal colic • Torsion/TOA/PID • Ectopic pregnancy

  33. Appendicitis • Incidence – 6% • Mortality – 0.1% • Perforation 2-6% (9% elderly) • All ages – peak 10 – 30 yo • Difficult diagnosis: • Young and old • Pregnant (RUQ) • Immunocompromised

  34. Appendicitis • Abdominal pain (98%) • Periumbilical migrating to RLQ < 48 hrs • Anorexia 70% • Nausea, vomiting 67% • Common misdiagnosis – gastroenteritis, UTI

  35. Appendicitis • PE: • RLQ tenderness 95% • Rovsing: RLQ pain palpating LLQ • Psoas: R hip elevation, extension • Obturator: flexion, internal rotation

  36. Appendicitis: Diagnosis • Labs: • WBC > 10k – 75% • UA – sterile pyuria • Imaging: • Ultrasound • CT scan • MRI

  37. Appendicitis: Treatment • IV fluids • NPO • Analgesia • Antibiotics • Surgery consult

  38. Diverticulitis • Inflammation of a diverticulum (herniation of mucosa through defects in bowel wall) • Sigmoid colon is the most common site • History: • L > R • 3% under 40 • LLQ pain with BMs • N/V/constipation • PE: LLQ tenderness • Diagnosis: clinical, CT

  39. Diverticulitis: Treatment • Admit if fever, abscess, elderly • NPO • IV fluids • IV antibiotics • Ciprofloxacin AND metronidazole • Surgical consultation

  40. Case #3 • History: 80 y/o male c/o nausea and crampy abdominal pain x 1 day. Emesis which was bilious and is now malodorous and brown. • PE: Diffusely tender, distended, with hyperactive bowel sounds. • Differential Diagnosis? • Workup?

  41. Differential Diagnosis • Small bowel obstruction • Large bowel obstruction • Sigmoid volvulus • Cecal volvulus • Hernia • Mesenteric ischemia • GI Bleed

  42. Small Bowel Obstruction • Etiology • Adhesions (>50%) • Incarcerated hernia • Neoplasms • Adynamic ileus – non mechanical • Abd trauma (post op), infection, hypokalemia, opiates, MI, scleroderma, hypothyroidism • Rare: intusseception, bezoar, Crohn’s disease, abscess, radiation enteritis

  43. Large Bowel Obstruction • Etiology • Tumor • Left  obstruct • Right  bleeding • Diverticulitis • Volvulus • Fecal impaction • Foreign body

  44. Bowel obstruction • Pathophysiology: 3rd spacing  bowel wall ischemia  perforates, peritonitis  sepsis  shock • History: crampy, colicky diffuse abdominal pain, vomiting (feculent), no flatus or BM • PE: abdominal distension, high pitched BS, diffuse tenderness • Diagnosis: AAS shows air fluid levels with dilated bowel • SB > 3cm; LB > 10cm

  45. SBO: Imaging

  46. SBO: Treatment • IV fluids! • Correct electrolyte abnormalities • NPO • NG tube • Broad spectrum antibiotics if peritonitis • Surgery consult

  47. Sigmoid Volvulus • History: • Elderly, bedridden, psychiatric pts • Crampy lower abdominal pain, vomiting, dehydration, obstipation • Prior h/o constipation • PE: • Diffuse abdominal tenderness • Distension

  48. Sigmoid Volvulus

  49. Sigmoid Volvulus: Imaging and Treatment • AAS: dilated loop of colon on left • Barium enema: “bird’s beak” • WBC > 20k: suggests strangulation • CT scan • Treatment • IVF • Surgical consult • Antibiotics if suspect perforation

  50. Cecal volvulus • Most common in 25-35 year olds • No underlying chronic constipation • History: • Severe, colicky abd pain • Vomiting • PE: • Diffusely tender abdomen • Distension

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