abdominal pain
Post on 28-Jul-2015
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Primary Care:Abdominal Pain &
Gastroenteritis
PROF/ GOUDA ELLABBAN
Objectives
I. ABDOMINAL PAIN Obtain a targeted history in a pt with abd
pain Perform a physical exam to determine cause
of pain Interpret lab tests to determine etiology of
pain Describe the differential dx of abd pain
Types of Abdominal Pain
Visceral Somatic Referred
Visceral Pain
Originates from internal organs and viceral peritoneum
Results from stretching, inflammation, or ischemia
Dull, crampy, burning, gnawing Poorly localized
Somatic Pain
Originates from abdominal wall or parietal peritoneum
Sharper, more localized
Referred pain
Pain felt in areas remote to the disease organ
History Onset (acute vs. chronic) Duration of pain Location Radiation Quality and severity Associated symptoms Alleviating or aggravating factors Past medical/surgical history
Physical Exam
Vital signs Constitutional findings Abdomen- inspection, auscultation,
percussion, palpation Pelvic exam Rectal exam Cardiac/ respiratory exam
Physical Exam
Start away from area of pain Look for areas of localized tenderness Rebound/guarding Masses or enlarged organs
Lab Evaluation
CBC with diff LFT, amylase, lipase UA HCG on reproductive age women electrolytes
Radiologic Evaluation
Plain films Upright and supine abdomen and CXR
Ultrasound Biliary and pelvic symptoms
CT abdomen and pelvic Evaluate vasculature, inflammation, and solid
organs
Differential Diagnoses Acute
Appendicitis Cholecystitis Pancreatitis Diverticulitis Perforation Obstruction Acute ischemia Ruptured aortic
aneurysm Ectopic pregnancy PID Nephrolithiasis
Chronic Peptic ulcer Esophagitis IBD Chronic pancreatitis Chronic ischemia Diabetes Irritable bowel
syndrome Abdominal wall pain
Neurogenic musculoskeletal
Differential
Acute Cholecystitis Cystic duct obstructed RUQ or epigastric pain radiating to R
scapula n/v, fever Murphy’s sign or tender enlarged
gallbladder LFTs, amylase
Differential
Acute appendicitis Anorexia, fever, n/v vague periumbilical pain that
progresses to RLQ (McBurney’s point) Rovsing’s, psoas, obturator signs Elevated WBC CT may be useful in dx
Differential
Small Bowel Obstruction Due to adhesions, hernia Crampy, periumbilical pain, n/v, high
pitched bowel sounds Xray- dilated loops of bowel with AF
levels Partial vs complete obstruction
Differential
Perforated duodenal ulcer usually in ant duodenal bulb Acute abdomen with peritonitis CXR with free intraperitoneal air under
diaphragm
Differential
GYN Ectopic pregnancy Ovarian torsion PID/TOA
Chronic Abdominal Pain
Abd pain lasting > 6 months Differentiate organic pain from a
pathologic process from functional pain
Functional pain more common
Irritable Bowel Syndrome
Affects 15% of Americans Abd distention, flatulence, disordered
bowel function More common in women Treat with anticholinergic meds and
stool softeners
Benign Chronic Abd Pain Syndrome
Pain present for months to years Negative workup Women > men Obtain social history (sexual/physical
abuse) May need psych evaluation or pain
management specialist
Summary
Obtain detailed history Thorough exam Consider pt circumstances (age,
med/surgical history) Evaluate for progression Consult if needed
Objectives
II. Gastroenteritis Describe the usual cause of
gastroenteritis Describe the signs and symptoms Perform focused physical exam Interpret diagnostic tests to determine
etiology of gastroenteritis Treat selected pts with gastroenteritis
Gastroenteritis
Inflammation of GI tract Due to infectious virus, bacteria, or
protozoa Acute onset Usually < 10 days Self limiting
Etiology
Microbes directly invade gut mucosa Microbes secrete toxins
Entertoxin Cytotoxin neurotoxin
Etiology Bacteria
Campylobacter jejuni (most common in US)
Shigella Salmonella E. Coli Vibrio cholera Yersinia C. dificile Vibrio Parahaemolyticus
Etiolgy
Viral Rotavirus Norwalk virus Adenovirus Calicivirus Coronavirus astrovirus
Etiology
Protozoa Giardia lamblia Entamoeba histolytica Cryptosporidium parvum Isospora belli
Etiology
Heavy metal (arsenic, lead, Hg, cadmium)
Broad spectrum antibiotics Antacids Laxatives Cardiac meds
Symptoms
Fever n/v Diarrhea Abd cramping Malaise and muscular aches may
occur
History
Ingestion of potentially contaminated food or untreated water
Recent travel Sick contacts Recent Abx use Outbreaks Bloody diarrhea
Physical Exam
Vital signs Constitutional findings Abdomen- inspection, auscultation,
percussion, palpation Pelvic exam Rectal exam Cardiac/ respiratory exam
Diagnosis
Stool exam for fecal WBCs, ova , parasites
Stool culture Endoscopy if noninfectious etiology
suspected (inflammatory bowel disease)
Treatment
Rehydration – oral vs. IV Antiemetics Antidiarrheals
Decrease intestinal motility Diphenoxylate, loperamide, codeine
+/- antibiotics Shigella, Yersinia, campylobacter,
cholera, c. dificile, giardia
Antibiotic associated diarrhea
Develops in 1-15% of pts receiving broad spectrum abx
C. Dificile proliferates in colonic mucosa when normal flora is disturbed
May cause pseudomembranous colitis Stop responsible abx Stool assay for C. dif toxins Rx:
Moderately ill- flagyl 500 mg q8hr x 7 days Extremely ill- oral vancomycin
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