Approach to Abdominal Pain

1. Approach to Abdominal Pain Brian Bizik MS PA-C Clinic Coordinator – Acute Care Clinic Associate Medical Director Family Health Services

2. Time is rolling like a river . . . Has much changed in the past few years?

3. Why do we have abdominal pain??

4. Why is this important? • Abdominal pain is one of the most common reasons for outpatient and ER visits • Variation in degree of pathology is vast, some of which needs immediate attention • A lot can happen in the abdomen and you need an organized approach

5. Esophagitis GERD Gastric ulcer Gastritis Duodenal ulcer Duodenitis Gastric outlet obstruction Bowel obstruction Intussusception Bowel perforation Cancer Hepatitis Splenic infarct Splenic abscess Mesenteric ischemia Somatization IBS Crohn’s disease Ulcerative colitis Gastroenteritis Familial Mediterranean fever Acute intermittent porphyria Appendicitis AAA rupture Esophageal spasm Diverticulitis Ectopic pregnancy Pelvic inflammatory disease Fitz-Hugh-Curtis HSV Abdominal epilepsy Endometriosis Vitamin D deficiency Adrenal insufficiency Pancreatitis Cholangitis Cholecystitis Choledocholithiasis Incarcerated hernia UTI Nephrolithiasis Abdominal migraine Celiac artery compression syndrome Uterine pathology HIV Hemophilia Sickle cell disease Trauma Pneumonia Subdiaphragmatic abscess Myocardial infarction Pericarditis Prostatitis Idiopathic inflammatory disorders Epiploicappendagitis Hereditary angioedema Painful rib syndrome Wandering spleen syndrome Abdominal wall pain Leukemia HSP Lead poisoning Here are a couple of possibilities

6. So how do we organize this? • Location • Acute v. chronic • Surgical v. nonsurgical

7. Daaaaaa, Bulls. I mean, Daaaaa Belly.

8. OK – Let’s lay out the map and be able to give good directions! No GPS here!

9. Localizing pain -- RUQ • Hepatitis • Cholecystitis • Cholangitis • RLL pneumonia • Subdiaphragmatic abscess

10. Localizing pain -- LUQ • Splenic infarct • Splenic abscess • Gastritis/PUD

11. Localizing pain -- RLQ • Appendicitis • Inguinal hernia • Nephrolithiasis • IBD • Salpingitis • Ectopic pregnancy • Ovarian pathology

12. Localizing pain -- LLQ • Diverticulitis • Inguinal hernia • Nephrolithiasis • IBD • Salpingitis • Ectopic pregnancy • Ovarian pathology

13. Localizing pain -- epigastric • PUD • Gastritis • Pancreatitis • GERD • Cardiac (MI, pericarditis, etc)

14. Localizing pain -- periumbilical • Pancreatitis • Obstruction • Early appendicitis • Small bowel pathology • Gastroenteritis

15. Localizing pain -- pelvic • UTI • Prostatitis • Bladder outlet obstruction • PID • Uterine pathology

16. Diffuse pain – “it hurts all over” • Gastroenteritis • Ischemia • Obstruction • DKA • IBS • What other options – what have you seen??

17. X-Ray fun • Couple X-rays first. . . for the fun of it! • By the way. . In terms of radiation exposure, one abdominal CT is equal to how many chest x-rays??

18. X-Ray fun Small Bowel Obstruction – see the air-fluid levels.

19. X-Ray fun Constipation – need to poop, and quickly

20. X-Ray fun OK, the bottle is not the most disturbing part of this x-ray. What is??? How do you get it out?

21. Acute abdominal pain • Generally present for less than a couple weeks • Usually days to hours old • Don’t forget about the chronic pain that has acutely worsened • More immediate attention is required

22. Surgical Appendicitis Cholecystitis Bowel obstruction Acute mesenteric ischemia Perforation Trauma Peritonitis Nonsurgical Cholangitis Pancreatitis Nonabdominal causes Diverticulitis PUD gastroenteritis Acute abdominal pain

23. Completely random tip - Which end of a suppository goes in first?? Really, put the flat end in first. . . Now, on to the surgical belly

24. Surgical abdomen • This is the first thing to be considered in acute abdominal pain • Early identification is a must as prognosis worsens rapidly with delay in treatment • Important to get surgeons involved early if this is even mildly suspected • This is a clinicaldiagnosis-THIS MEANS YOU ARE MORE IMPORTANT THAN ME MOST OF THE TIME!!!!

25. A review of terms • Surgical Belly – the patient with severe pain and. . . • Peritoneal signs – more in a second, but this is the patient that won’t move, can’t find a comfortable position. • Visceral pain – pain from hollow organs, stomach etc. Dull, achy, nausea. . Nerves from both sides of gut run together, so pain diffuse, hard to localize. • Parietal pain – sharp, localized pain. Nerves from the same level and same side – so easierlocalize. Inflammation, ischemia, trauma. Re • Referred pain – pain in another location thatthe problem. Afferent nerves share pathway.Example is pneumonia that has abdominal pain.

26. Surgical abdomen • Presentation is usually bad • Fevers, tachycardia, hypotension • VERY tender abdomen, possibly rigid • Presentation can vary with other demographic and medical factors • Advanced age • Immunosuppression

27. Surgical abdomen • Peritonitis (means “don’t move me” in Latin) • Often signals an intraabdominal catastrophe • Perforation, big abscess, severe bleeding • Patient usually appears ill • Exam findings • Rebound, rigidity, tender to percussion or light palpation, pain with shaking bedand GUARDING, both voluntary and involuntary.

28. Surgical abdomen • Obstruction • May be acute or acute on chronic • Symptoms include persistent vomiting, abdominal distention (or not), pain • Exam findings depend on level of obstruction (proximal v. distal) • Distal – distention, tympany, absent or high-pitched bowel sounds • Proximal – similar, but may not see distention and tympany

29. Surgical abdomen • Ischemia • Mesenteric ischemia usually seen in patients with CAD risk factors, but anyone can infarct bowel for a variety of reasons • Symptoms include pain OUT OF PROPORTION TO EXAM • Exam findings • Severe tenderness to minimal palpation, unstable vital signs, and a very uncomfortable patient

30. Surgical abdomen • Work-up • Start with stat labs • Surgical abdominal series (plain films) • Consider stat CT if readily available • Sometimes patients go straight to surgery as initial step • Again, get surgeons involved early for guidance and early intervention

31. Chronic abdominal pain • Generally present for months to years • Generally not immediately life threatening • Outpatient work-up is prudent

32. Approach to the patient • History is THE MOST IMPORTANT part of the diagnostic process – THIS IS YOU! • Location, quality, severity, radiation, exacerbating or alleviating factors, associated symptoms • Visceral v. peritoneal • A good thorough medical history • A good thorough social history, including alcohol, drugs, domestic abuse, stressors, etc. • Family history is important (IBD, cancers, etc) • MEDICATION INVENTORY (BRING THEM!)

33. Approach to the patient • Physical exam • Vitals • A good thorough medical exam • Jaundice, signs of chronic liver disease, signs of vitamin deficiency, etc. • Abdominal exam • Look, listen, feel • Don’t forget the rectal exam

34. Approach to the patient • Labs • CMP, CBC, coags • Amylase and lipase • UA • Pregnancy • Stool test if indicated

35. Approach to the patient • Imaging • Plain films • CT • Ultrasound • MRI • Angiography • Endoscopy • EGD • Colonoscopy

36. Approach to the patient • By quadrant: • RUQ - US • LUQ – C • RLQ – CT with contrast • LLQ – CT with oral and IV contrast • Low abdomen, pubic – US • Plain films ever???

37. Approach to the patient • Summary – • Know the layout of the belly • Understand the quadrants and basic tests • Get a great history – look for clues at scene. Your input is key to an accurate diagnosis Thanks!!!

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