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Evaluation of the ED Patient with Abdominal Pain

Evaluation of the ED Patient with Abdominal Pain. University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation. A Common Complaint. 4-8% of all ED Visits Most Common Diagnoses pts > 50 Cholecystitis (21%) Nonspecific abdominal pain (16%) Appendicitis (15%)

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Evaluation of the ED Patient with Abdominal Pain

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  1. Evaluation of the ED Patient with Abdominal Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation

  2. A Common Complaint • 4-8% of all ED Visits • Most Common Diagnoses pts > 50 • Cholecystitis (21%) • Nonspecific abdominal pain (16%) • Appendicitis (15%) • SBO (12%) • Everything else (diverticulitis, hernia, cancer, vascular) • Most Common Diagnoses pts < 50: • Nonspecific Abdominal Pain ( ~40% ) • Appendicits (32%) • Cholecystitis (6%) • SBO and Pancreatitis (each ~ 2%)

  3. Key Consideration! • Extensive differential • Multiple Life-threatening causes • AAA • Perforation • Obstruction • Ischemia • Ectopic pregnancy

  4. Other Common Diagnoses • Gastroenteritis* • GERD • Cholecystitis • Appendicitis • Obstruction • Constipation* • UTI* • PID* *often misdiagnoses in patients w/significant abdominal pathology

  5. H&P are key (as usual)-they help guide your workup and whittle down the large ddx • Labs and Imaging are used to either support/refute your suspected diagnosis • Occasionally, the labs and imaging will help come up with a diagnosis when the history and exam are not particularly helpful (altered, confused pt)

  6. Abdominal Pain History • HPI • Onset • Palliates/Provokes • Quality • Radiation • Severity • Time course • Undo (what have they done to “undo” their pain) • PMH • PMHx • Surgical Hx • Allergies • Meds • Social Hx • EtOH

  7. High-Yield Historical Questions. • How old are you? (Advanced age means increased risk) • Which came first—pain or vomiting? (Pain first is worse [i.e., more likely to be caused by surgical disease]) • How long have you had the pain? (Pain for less than 48 hours is worse) • Have you ever had abdominal surgery? (Consider obstruction in patients who report previous abdominal surgery) • Is the pain constant or intermittent? (Constant pain is worse) • Have you ever had this before? (A report of no prior episodes is worse) • Do you have a history of cancer, diverticulosis, pancreatitis, kidney failure, gallstones, or inflammatory bowel disease? (All are bad)

  8. High-Yield Historical Questions. • Do you have HIV? (Consider occult infection or drug- related pancreatitis) • How much alcohol do you drink per day? (Consider pancreatitis, hepatitis, or cirrhosis) • Are you pregnant?( Test for pregnancy—consider ectopic pregnancy) • Are you taking antibiotics or steroids? (These may mask infection) • Did the pain start centrally and migrate to the right lower quadrant? (High specificity for appendicitis) • Do you have a history of vascular or heart disease, hypertension, or atrial fibrillation? (Consider mesenteric ischemia and abdominal aneurysm)

  9. Physical Exam • Vitals • Look • Listen • Percussion • Palpation- where tender, rebound or guarding? • Rectal and Pelvic-as indicated by history and exam • Rebound tenderness • 81% sensitive, 50% specific for peritonitis • 63-76% sensitive, 56-69% specific for appendicitis

  10. Rectal Exam • Generally indicated only in those with symptoms referable to the rectal/anal area or suspected GI bleeding, otherwise rarely useful in generalized abdominal pain workup • Prostatitis • GI bleeding: upper or lower • Hemorrhoids • Constipation: possible impaction? • Bloody diarrhea (enteritis)

  11. Causes of Abdominal Pain by Quadrants

  12. Stop and Think • Differential Diagnosis • Knowing that labs and radiographic studies will only aid what you already suspect, identify needed treatments and start them empirically as dictated by pt condition

  13. Laboratory Studies • These will rarely clinch diagnosis • CBC • Anywhere from 10-60% of patients with surgically proven appendicitis have an initially normal white count • An elevated white count detects a mere 53% of severe abdominal pathology. • Electrolyte, Lipase, UA, LFTs • Pregnancy Test! • ECG (especially in elderly)

  14. Radiographic Studies- Plain Film • Really only helpful in ED for: • Free air (suspected perforation) • Dilated loops of bowel with air fluid levels (obstruction) • Foreign body • Free air seen in only 30-50% of bowel perforation

  15. Sigmoid Volvulus

  16. Sigmoid Volvulus

  17. Sigmoid Volvulus

  18. What’s wrong with this picture??

  19. Radiology- Ultrasound • Excellent for Biliary Tract Disease (very sensitive for Gallstones (90+%) • AAA- can rapidly assess size at bedside • Ectopic Pregnancy- look for intrauterine yolk sac, assess adnexa, assess for free fluid • Appendicitis- 75%-90% sensitive (in experienced hands, best in thin patients) • Not routinely done in this country. May change. • Pelvic structures, testicles

  20. Gallstones

  21. AAA

  22. Radiology- CT Scan • Detect Leaking AAA ( in stable patient ) • Excellent for Renal Calculi • Evaluate for appendicitis, perforation (free air), diverticulitis, abscess, mesenteric ischemia, masses, obstruction The sensitivity and specificity for these vary. Nothing is 100% accurate • Not a place for unstable patients

  23. Kidney Stones- CT Style

  24. Sigmoid Tumor/Intussusception

  25. Psoas Abscess

  26. Retroperitoneal Abscess

  27. TOA

  28. Abdominal Pain in the Elderly • “An M&M waiting to happen” • Mortality & misdiagnosis rise exponentially w/each decade >50 yrs. • Elderly generally considered 65 and older • Approximately 60-70% get admitted, 40-50% go to the OR and 10% die (this is higher than mortality of acute MI at 6-8%) • These patients frequently get, and deserve, a full complement of imaging and labs

  29. Case #1- Presentation • 23 yo female • acute onset LLQ pain 2 hours ago • Constant, no radiation, no N/V/D • No exacerbating, alleviating factors • No vaginal discharge

  30. Case #1 -PMH • No medical problems • No medications, No allergies • Surg Hx: S/P Elective Abortion 1 year ago • No history of STDs, Sexually Active • LMP 4 weeks ago

  31. Case #1- Exam • Vitals: P105 R20 T37.7 BP 103/58 • Abd: soft, tender LLQ with guarding, no rebound pain detected • Pelvic: No cervical motion tenderness, L adnexal tenderness/fullness • Rectal: No masses, guaiac negative

  32. Case #1- Differential Diagnosis • Ectopic Pregnancy • Ovarian Cyst • Tubo-ovarian abscess • Ovarian Torsion

  33. Case#1- Intervention/Diagnosis • Pregnancy Test - Negative • IV Fluids - 500 cc bolus ( repeat P 90, BP110/65 ) • U/S- L ovary with absent blood flow, multiple cysts • Diagnosis: Ovarian Torsion • Disposition: To OR by GYN

  34. Case #2- Presentation • 47 yo male with sudden onset abd pain • Epigastric pain, vomited x2 • Pain 10/10 • Better if holds still, worse on car ride into hospital • Never had pain like this before

  35. Case #2- Past Medical History • Medical Hx: Arthritis, Chronic Low Back Pain • Surgical Hx: L knee meniscus repair • Meds: No prescribed meds, OTC ibuprofen • Allergies: NKDA • SH: 2 beers/night

  36. Case #2- Exam • Vitals: P95 R22 T37.4 BP 124/75 O2 100% • Gen: Anxious, Mild distress/diaphoretic, Remaining still • Abd: Decreased BS, Severe epigastric tenderness with guarding and rebound • Rectal: Guaiac positive

  37. Case #2- Actions • Large bore IV x2, Type and Screen, CBC, CMP, Lipase, Fluid bolus,ECG • Acute Abdominal Series • Orthostatic Vitals

  38. Case #2 - Interventions/Diagnosis • CXR reveals intra-abdominal free air • Diagnosis: Perforation, likely duodenal or gastric ulcer • Disposition: To OR for identification and repair

  39. Multiple Life Threatening Causes of Abdominal Pain • Identify the potential life threatening cause of the following cases. • Differential diagnosis is large but consider an acute event and test your intuition

  40. Rapid Cases #1 • 25 yo female • Recurrent vomiting, diffuse mild pain • Febrile, dehydrated, tachycardic • H/O Diabetes Mellitus • Diagnosis: DKA

  41. Rapid Cases #2 • Healthy 17 yo male, football player • L shoulder pain, not reproducible on exam • lightheaded, weak • U/S with free intraperitoneal fluid • Diagnosis: Splenic Lac

  42. Rapid Cases #3 • 16 yo female • Nausea, diffuse discomfort starting yesterday • Now worse RLQ • Abd exam: pain RLQ, +guarding • Diagnosis: Appendicitis

  43. 31 yo appy

  44. 73 yo appy

  45. Rapid Case #4 • 65 yo male • Hx of HTN, Renal Colic x3 episodes • Low back pain- ?new pain • Abd: obese, soft, no masses palpated • U/S shows 7cm AAA

  46. Rapid Case #5 • 56 yo female • H/O Alcoholic Cirrhosis • Diffuse abd pain, gradual onset • Distended abdomen, febrile • U/S: ascites • Peritoneal tap >500 WBC/cc • Spontaneous Bacterial Peritonitis

  47. Rapid Case #6 • 32 yo female, S/P Tubal ligation 2 weeks ago • Gradual onset diffuse pain • N/V/D, fever • Diffusely tender, guarding, + rebound • CXR with free air • Bowel perforation

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