International Health Services

Approach to Abdominal and Gastrointestinal Disorders

Abdominal pain is one of the emergency physicians most challenging complaints. It is a common emergency department (ED) presentation that often does not result in adefinitive diagnosis, but can represent a life-threatening disease that requires immediate intervention.

EpidemiologyAfter ED evaluation, various authors have found that nonspecific abdominal pain is the preliminary diagnosis in 41 to 50% of abdominal pain patients. These patients often have a benign prognosis. Many conditions that present as abdominal pain represent severe diseases that require immediate intervention. These diagnoses include appendicitis, acute cholecystitis, intestinal obstruction, intestinal ischemia, pelvic inflammatory disease, acute pancreatitis, symptomatic aortic aneurysm, perforated ulcer, and urolithiasis. Approximately 15% of patients seen for abdominal pain will require operation and 27% will require hospitalization. The age of the patient greatly impacts the differential diagnosis and incidence of severe disease and illness. Oneout of five children seeks medical help for abdominal pain by age 15 years. Approximately 5% of these require hospitalization. Presentations often vary by age. Infants commonly present with colic, gastroenteritis, and constipation. They also may have intussusception, malrotation, volvulus, renal neoplasm, necrotizing, or incarcerated hernia. Children frequently have belly pain from nonabdominal sources such as pneumonia or pharyngitis. Chronic illnesses may present acutely with belly pain. These illnesses include diabetes mellitus, sickle cell anemia, and cystic fibrosis. Adolescents may have other abdominal disorders such as pelvic inflammatory disease, urinary tract disease, and inflammatory bowel disease. Both school-age and adolescent children may have a psychosocial cause of abdominal pain. Acute abdominal pain in the elderly is frequently a lifethreatening illness. Nonspecific abdominal pain as a dischargediagnosis is relatively unusual (9 to 19%). Common diagnoses include malignant disease (13%), acute cholecystitis (26 to 41%), incarcerated hernia (5 to 10%), andpancreatitis (4 to 5%). Mortality in this patient population is significant (11 to 14%) and one-third of patients require operations.

PathophysiologyMost abdominal pain is transmitted through visceral components. Possible neural mechanisms include stretch fibers, which are in the wall of all organs, as well as thecapsules of solid organs. Input from these organs is conducted along afferent nerve fibers that return to the spinal cord at various levels. Visceral pain is often poorly localized and is characteristically vague. Somatic pain often originates in the peritoneum and is much better localized than visceral pain. Once the peritoneum is irritated, painis well localized and more easily described. Referred pain is frequently involved with evaluation of abdominal pain. Common referral patterns include pain originating in the chest (e.g., pneumonia) giving an upper quadrant tenderness, and pain near the diaphragm, giving a sensation in the neck or the back of the shoulder blade (C-3, -4, and -5 distribution).

Emergency Department Evaluation Historical FactorsFor patients who present with abdominal pain, the history should include location of pain, movement of pain, time of onset, and duration of pain. Also, aggravating or palliative factors should be queried. Pain often moves and, in many cases, its final destination is more predictive of the final diagnosis than its original location (e.g., appendicitis). Episodic sharp pain that comes in increasing waves is often considered colicky. Such pain may increase the suspicion of a hollow viscus as the origin (e.g., bowel or ureter). Pain that has been present for a long period of time is less likely to be emergent; however, many patients with acute appendicitis or cholecystitis present more than 12 to 24 hours after the onset of pain. Associated symptoms provide important clues to the diagnosis. The presence of nausea or vomiting may help indicate the presence of hollow viscus disease. Appendicitis pain classically occurs before vomiting; however, this rule is violated in many appendicitis patients. Bowel symptoms includingfrequency and nature of stools, and presence or absence of bright red blood or melena must be queried. Dysuria, urinary frequency or discoloration of urine should be noted, as should menstrual history in female patients. Symptoms referable to organs in the chest or retroperitoneum must also be reviewed. A history that reveals prior abdominal pathology or prior surgical procedures may provide important clues as to the final diagnosis. Multiple medical diseases (cardiac or pulmonary disease, atheroscleroticrisk factors, or diabetes) will impact and complicate the presentations of abdominal pain.

Physical ExaminationAbnormal vital signs including tachycardia and elevation of temperature can be important clues to patients who have truly emergent or surgical presentation of disease. Often the general appearance of the patient can be helpful. Patients with peritonitis will lie very still to avoid any movement that may irritate their inflamed peritoneum. Patients with colic will frequently be very mobile and be difficult to examine because of their unwillingness to lie still. Echymosis in the flank (Grey Turner Sign) or in the umbilicus (Cullens Sign) may indicate retroperitoneal necrosis or bleeding. Infrequently, simple inspection will reveal a localized mass or general distention of the abdomen. It is important to note location of surgical scars. The abdomen should be auscultated for presence or absence of bowel sounds. Very active bowel sounds may be a clue that the patient has increased gastrointestinal motility. The abdomen should be palpated for the point of maximal tenderness and total area of tenderness. It is wise to begin palpation away from the most tender area since the patient may provide more voluntary guarding after a tender area is elicited. The doctor must specifically search for masses and organomegaly. Hepatic or sphenic enlargement should be noted. Rebound tenderness may indicate peritonitis. A traditional method of testing for rebound tenderness is to palpate the abdomen somewhat deeply and then rapidly remove the hand. This withdrawal will move abdominal contents including the peritoneum and pain may indicate peritonitis. The test must be interpreted with care since abrupt movements startle patients and their response to the test may be difficult to interpret. Simply moving the stretcher, tapping the patients heel in order to move the abdomen, or lightly percussing the abdomen are alternative tests for detecting peritonitis. Many additional physical tests have been described. Murphys sign tests for possible cholecystitis. While palpating the right upper quadrant the patient is asked to take a deep breath. If the patient suddenly halts inspiration in response to pain in the right upper quadrant, it isconsidered a positive Murphy sign. Rovsings sign is positive when pain in the right lower quadrant occurs with palpation in the left lower quadrant. This may be indicativeof appendicitis. The iliopsoas and obturator signs also look for possible appendicitis. A positive iliopsoas sign is pain that occurs when the patient has right lower quadrantpain when he tries to flex at the right hip against resistance. The obturator sign is elicited with the right leg flexed at the hip and the hip is rotated internally. The testis positive if pain is elicited with this motion. Rectal examination should be performed for presence or absence of mass, pain, and quality of stool. Testing for occult blood should be done. Pelvic examination should be performed on all women with lower quadrant pain. Similarly, examination of male genitalia is mandatory in all patients with lower quadrant pain. Palpation of the back and percussion over costovertebral angles should always be performed. All patients should have pulmonary, vascular, and cardiac examinations as well.

Laboratory EvaluationLaboratory evaluations of patients with abdominal pain may be very specifically or very broadly undertaken. Certainly some patients have a clear diagnosis based on history and examination alone, so laboratory analysis is not required. Other patients may have a life-threatening presentation or a confusing presentation that requires multiple lab tests to be performed. Complete blood count is often ordered to examine the patients hematocrit and white blood cell count. Acute bleeding will have a normal hematocrit, but chronic blood loss with an insufficient compensatory mechanism will reveal a low hematocrit. Total white count and white count differential may imply presence of bacterial or surgical disease. The literature has addressed the place of leukocyte and neutrophil counts in the evaluation of appendicitis. Patients with appendicitis do tend to have higher white counts and a higher percentage of neutrophilia. However, there is extensive crossover with other diagnoses including benign diagnoses. Many patients with emergent presentations, including appendicitis, have normal total white blood cell counts and normal differential white blood cell percentages. Testing for hepatic enzymes may be very helpful in the setting of acute hepatitis, biliary tract disease, or pancreatitis. Hepatocellular enzymes (aspartate transaminase, alanine transaminase) will be elevated with hepatic inflammation or masses. These may be more modestly elevated with biliary tract disease. Alkaline phosphatase is often elevated in hepaticdisease, but more severely elevated in most cases of biliary tract disease. Bilirubin, both total and direct, should be measured to screen for hepatobiliary disease. Amylase and/or lipase may be measured to look for pancreatic inflammation. These will also be elevated in other disease states. Amylase is present in nearly all hollow organs, therefore it may be elevated with salivary gland or gastrointestinal disease. Lipase has been reported to have higher predictive value than serum amylase. However, it may be elevated in a large number of nonpancreatic disease states also. In general, higher elevations of lipase or amylase will be increasingly more specific for acute pancreatitis.Urinalysis should be performed on all patients with suspicion of urinary tract infection (UTI) or a suspected emergent cause of pain. Pyuria may occur with disease that isnot intrinsically renal such as appendicitis. Hematuria may indicate renal disease (e.g., urolithiasis) or a more systemic insult (e.g., endocarditis). A pregnancy test should be performed in all female patients of childbearing age who have not had a hysterectomy. It is clear that patients who have tubal ligation are still at risk for pregnancy-related diseases. Plain abdominal radiography may be performed to look for evidence of bowel obstruction, calcifications, foreign bodies, or free intraperitoneal air. Multiple radiographic tests including computed tomography, angiography, and ultrasonographycan help greatly with a diagnostic evaluation.

DispositionSince many patients have a potentially serious disease that is difficult to diagnose, a low threshold should be present for obtaining consultation and admitting patients with acute abdominal pain. Diseases that are notoriously difficult to diagnose include ischemic bowel disease, appendicitis, and pancreatic disease.

TreatmentEmergent treatment of these patients includes hemodynamic management, antibiotic therapy, and analgesia. A hemodynamically unstable patient should have two large-bore IV catheters placed and isotonic fluid administered. Control of emesis with antiemetics or nasogastric suction may aid in maintaining appropriate fluid hydration.Administration of analgesics has always been controversial in the setting of acute abdominal pain. Despite traditional concerns, it is clear that judicious use of analgesicsin closely observed patients can be safely performed. Patients with suspected urinary tract infections or bowel perforations require antibiotic administration. Adequate Gram-negative coverage is required in either case. Anaerobic and enterococcal coverage should also be provided if bowel perforation is suspected.

Medic Stefan Solomon, Taza 1 rig site

Trident Support ServicesSafety, Security, Life Support, Medical, EOD and Demining Services Providers