approach to abdominal pain in the emergency department

Approach to Abdominal Pain in the Emergency Department

Richard Stair, MD, FACEP

Department of Emergency Medicine

Introduction At the end of this lecture you

should: Understand the generation and

presentation of types of abdominal pain

Develop critical elements of the history and physical for AP

Apply knowledge of utility of testing to diagnostic approach

Apply management principles to patient care in the ED

What Do They Have? As you go through this

presentation, think about each of these cases: An 18 mo old that suddenly

became inconsoleable from AP while playing

A 20 yo man with 12 hours of diffuse crampy AP that migrated to RLQ that became sharp

78 yo woman with h/o chronic steroid use with sudden sharp AP and a rigid exam

Acute Abdominal Pain Approximately 6% of ED visits Admission rates vary by

population, up to about to 65% in high risk elderly populations

Most common diagnosis is NONSPECIFIC (ie, “I dunno”)

Use H+P, risk factors, and directed studies to arrive at diagnosis

MUST rule out emergency conditions

Abdominal Pain Across the Ages

Ages 0-2 Colic, GE, viral illness, constipation

Ages 2-12 Functional, appendicitis, GE, toxins

Teens to adults Addition of genitourinary problems

Elderly Beware of what seems like

everything!

Special Populations

Elderly/ nursing home patients Immunocompromised Post operative patients Infants

Abdominal Pain in the Elderly

Diminished sensation of pain in the elderly

Comorbid diseases Polypharmacy Combinations of above result in

many more vague, nonspecific presentations

Twice as likely to require surgery with presentation over age 65

What’s the Problem

Imprecise pain generation and transmission to the central nervous system

Comorbid diseases Developmental stage Medications Social factors

Understanding the Types of Abdominal Pain

Visceral Stretch fibers in capsules or walls

of hollow viscus that enter both sides of spinal cord

Somatic Fibers dermatomally distributed

and enter unilaterally in the spinal cord

Referred Overlap of fibers from other

locations


Visceral Crampy, achy, diffuse, Poorly localized

Somatic Sharp, lancinating Well localized

Referred Distant from site of generation Symptoms, but no signs


Location, location, location Organs and their corresponding

fiber entry to the spinal cord C3-5 – liver, spleen, diaphragm T5-9 – gallbladder, stomach,

pancreas, small intestine T10-11– colon, appendix, pelvic

viscerat11-l1 – sigmoid, renal capsules, ureters, gonads

S2-4 - bladder

History Taking in Abdominal Pain Presentations

“OLD CARS”

O- onset L- location D- duration C- character A-alleviating/aggravating factors

associated symptoms R- radiation S- severity

History Taking for Abdominal Pain Presentations

PMH Similar episodes in past Other medical problems that increase disease

likelihood of problems (ex: DM and gastroparesis)

PSH Adhesions, hernias, tumors

MEDS Abx, NSAIDS, acid blockers, etc

GYN/URO LMP, bleeding, discharge

Social Tob/EtoH/drugs/home situation/agenda

Physical Exam in Abdominal Pain Presentations

General appearance “Sick versus not sick” Mobile versus still Obvious pain or discomfort “Doorway” impression

Vital signs “That’s why they’re called vital”


Inspection Distention, scars, bruises

Auscultation Present, hyper, or absent Actually not that helpful!

Palpation Often the most helpful part of exam Tenderness versus pain Start away from painful area first Guarding, rebound, masses


Signs Iliopsoas Obturator Rovsing’s Murphy’s

Extra-abdominal exam Pelvic or scrotal exams Lungs, heart Remember it’s a patient, not a part

Rectal Adds very little (despite the angst)

beyond gross blood or melena

Laboratory Testing

Everybody likes a CBC, but…

Lacks sensitivity, no specificity Little to no change in diagnostic

probabilities Should not dramatically alter

approach (tender is still tender)

Laboratory Testing

Directed approach to lab studies There are no “standard belly labs” Pregnancy test in women of child

bearing age Urine dipsticks

Imaging Plain films

Free air, obstruction, air-fluid, FBs Ultrasound

Rapid “yes or no” ED evaluations Formal studies May add doppler

Computed Tomography Revolutionized acute care Often better than we are!

Common Diagnoses by Quadrant

RUQ Cholecystitis Biliary colic Hepatitis Pancreatitis Renal stones PUD Pneumonia P E M I

LUQ Gastritis Gastric ulcer Pancreatitis Splenomegaly Splenic rupture Renal stone Pneumonia P E M I

Common Diagnoses by Quadrants

RLQ Appendicitis Renal stone Ovarian cyst Torsion Epididymitis Ectopic IBD AAA UTI

LLQ Diverticulitis Renal stone Ovarian cyst Torsion Epididymitis Ectopic IBD AAA UTI

Management of Abdominal Pain

Always right to start with ABC’s IV access Fluid administration Antiemetics Analgesics Directed testing and imaging Re-evaluations Antibiotics Consultants

Surgeons, OB/GYN, urologists, cardiologists, etc

Disposition of Abdominal Pain Patients

Operating Room Hospital bed/observation

Serial labs Serial exams

Home with abdominal warnings The art of emergency medicine 3 components of discharge plan Document, document, document

Now How About Those Cases

18 mo old had classic presentation of intussusception, and symptoms may wax and wane; rectal would be to look for current jelly stool. Air enema for diagnosis and reduction. Involve consultants early in the course.


20 year old with classic presentation of appendicits, which likely does not need CT scan. Most do not present so simply, quite a wide array of presentations. General surgery consultation, pain meds, IVF, and an operation would all be good, but don’t be shocked if CT requested.


78 yo has perforated abdomen, with age, multiple problems, and chronic steroids risks for perforation. Rapid resuscitation, plain films to confirm free air, antibiotics, pain medicine, and a surgeon as fast as you can would be good practice.

Take Home Points Perform a good history and

physical to guide assessment Lab studies have limitations…..and

costs Imaging studies also need to be

selected wisely Early involvement of consultants

for sick patients Treatment initiation, not just

diagnostics

approach to abdominal pain in the emergency department

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