Project: Ghana Emergency Medicine Collaborative

Document Title: Management of Patients with Abdominal Pain in the Emergency Department

Author(s): Jim Holliman, M.D., F.A.E.C.P.

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Management of Patients Management of Patients with Abdominal Pain in with Abdominal Pain in

the Emergency the Emergency Department Department

Jim Holliman, M.D., F.A.C.E.P.Jim Holliman, M.D., F.A.C.E.P.Professor of Military and Emergency MedicineProfessor of Military and Emergency MedicineUniformed Services University of the Health Uniformed Services University of the Health SciencesSciencesClinical Professor of Emergency MedicineClinical Professor of Emergency MedicineGeorge Washington UniversityGeorge Washington UniversityBethesda, Maryland, U.S.A.Bethesda, Maryland, U.S.A.

3

Abdominal PainAbdominal PainLecture OutlineLecture Outline

• Recognition & resuscitation for Recognition & resuscitation for life-threatening causes of abd. life-threatening causes of abd. painpain

• Physical exam featuresPhysical exam features• Choosing diagnostic testsChoosing diagnostic tests• Initial treatmentInitial treatment• Differential diagnosisDifferential diagnosis• Key points about the most Key points about the most

common specific causescommon specific causes4

Abdominal Pain : Abdominal Pain : Diagnostic & Treatment Diagnostic & Treatment PrioritiesPriorities

• First : recognize presence of shock or First : recognize presence of shock or intraabdominal bleedingintraabdominal bleeding

• Second : start resuscitative measures for Second : start resuscitative measures for shock or bleeding (if these are present)shock or bleeding (if these are present)

• Third : determine if the abdomen is the Third : determine if the abdomen is the source of the shock or bleedingsource of the shock or bleeding

• Fourth : determine if emergency laparotomy Fourth : determine if emergency laparotomy is neededis needed

• Fifth : complete the secondary survey (head Fifth : complete the secondary survey (head to toe exam) ; obtain needed lab or to toe exam) ; obtain needed lab or radiographic studiesradiographic studies

• Sixth : Conduct frequent reassessments of Sixth : Conduct frequent reassessments of the patientthe patient

5

General Approach to the General Approach to the Patient Presenting with Patient Presenting with Abdominal PainAbdominal Pain

• Evaluate & treat the ABC's (Airway, Evaluate & treat the ABC's (Airway, Breathing, Circulation) first in same Breathing, Circulation) first in same sequence as for any other emergency patientsequence as for any other emergency patient

• Determine if an immediate life-threatening Determine if an immediate life-threatening cause of abd. pain may be present & if there cause of abd. pain may be present & if there is any history of possible abd. traumais any history of possible abd. trauma

• Start resuscitation and emergently consult a Start resuscitation and emergently consult a surgeon if an emergent laparotomy is surgeon if an emergent laparotomy is needed needed

• Complete the secondary survey, Complete the secondary survey, treat paintreat pain, , and decide what other diagnostic tests will and decide what other diagnostic tests will be neededbe needed 6

Immediate Life-Immediate Life-Threatening Causes of Threatening Causes of Abdominal PainAbdominal Pain

• These must be recognized from the primary These must be recognized from the primary survey :survey :

• Ruptured abdominal aortic aneurism Ruptured abdominal aortic aneurism (AAA)(AAA)

• Rupture of the spleen or liverRupture of the spleen or liver• Ruptured ectopic pregnancyRuptured ectopic pregnancy• Bowel infarctionBowel infarction• Perforated viscusPerforated viscus• Acute myocardial infarction (MI)Acute myocardial infarction (MI)

7

Ruptured Abdominal Aortic Ruptured Abdominal Aortic Aneurism (AAA)Aneurism (AAA)

• More common in males > 65 years of ageMore common in males > 65 years of age• May present initially as back or groin painMay present initially as back or groin pain• Typically would have epigastric or periumbilical pain Typically would have epigastric or periumbilical pain

radiating to backradiating to back• May present in shock from intraperitoneal rupture May present in shock from intraperitoneal rupture

(retroperitioneal rupture may initially be contained)(retroperitioneal rupture may initially be contained)• Often can feel pulsating supraumbilical mass (if you Often can feel pulsating supraumbilical mass (if you

can feel the aortic pulse width > 4 cm : suspect AAA)can feel the aortic pulse width > 4 cm : suspect AAA)• Can sometimes make this Dx from lateral X-ray of abd.Can sometimes make this Dx from lateral X-ray of abd.• Bedside ultrasound (U/S) is best Dx test for unstable Bedside ultrasound (U/S) is best Dx test for unstable

patientpatient• Abd. CT scan is best Dx test for stable patient Abd. CT scan is best Dx test for stable patient

(surgeon may also want angiography preop if patient (surgeon may also want angiography preop if patient is stable)is stable) 8

Ultrasound showing 7.5 cm AAA with intraluminal clot

Source Undetermined

9

CT scan of AAA (L = lumen, T = thrombus)

Source Undetermined

10

Emergency Management of Emergency Management of Ruptured AAARuptured AAA

• Oxygen & IV fluid resuscitation (normal Oxygen & IV fluid resuscitation (normal saline or lactated Ringer's) if systolic BP saline or lactated Ringer's) if systolic BP < 100 mm Hg (but do not < 100 mm Hg (but do not "overresuscitate" ; do not increase the BP "overresuscitate" ; do not increase the BP to over 120 systolic because higher BP to over 120 systolic because higher BP may cause increased bleeding)may cause increased bleeding)

• Type and cross for at least 6 units of Type and cross for at least 6 units of bloodblood

• Insert foley catheterInsert foley catheter• Obtain an electrocardiogramObtain an electrocardiogram• Emergently consult a surgeonEmergently consult a surgeon• Notify the operating roomNotify the operating room

11

Ruptured Spleen or LiverRuptured Spleen or Liver

• Usually due to trauma, but can be Usually due to trauma, but can be spontaneous from malaria, spontaneous from malaria, mononucleosis, or hematologic diseasesmononucleosis, or hematologic diseases

• Patient may present with shock ; may Patient may present with shock ; may also have referred pain to shoulder also have referred pain to shoulder (Kehr's sign)(Kehr's sign)

• Dx and Rx considerations & sequence Dx and Rx considerations & sequence same as for ruptured AAA (IV fluid, Type & same as for ruptured AAA (IV fluid, Type & cross, U/S or CT, call surgeon, etc.)cross, U/S or CT, call surgeon, etc.)

12

Ruptured Ectopic Ruptured Ectopic PregnancyPregnancy

• Most common cause of pregnancy-related Most common cause of pregnancy-related death in U.S.A.death in U.S.A.

• May NOT have missed menstrual periodMay NOT have missed menstrual period• Typically have severe sudden onset lower Typically have severe sudden onset lower

abd. pain +/- shockabd. pain +/- shock• Should obtain stat serum or urine HCG test in Should obtain stat serum or urine HCG test in

any female of reproductive age with abd. any female of reproductive age with abd. painpain

• Pelvic U/S is Dx test of choicePelvic U/S is Dx test of choice• Rx : Oxygen, IV fluid (NS or LR), Type & cross Rx : Oxygen, IV fluid (NS or LR), Type & cross

at least 2 units, emergently consult surgeon at least 2 units, emergently consult surgeon or obstetricianor obstetrician 13

Bowel InfarctionBowel Infarction

• Due to clot embolus or thrombosis in Due to clot embolus or thrombosis in mesenteric arterymesenteric artery

• Most patients have severe coronary artery Most patients have severe coronary artery disease (this can be a post-MI disease (this can be a post-MI complication)complication)

• May have "pain out of proportion to May have "pain out of proportion to findings" (may not demonstrate much findings" (may not demonstrate much tenderness)tenderness)

• Physical exam may show signs of Physical exam may show signs of peritonitis, hypoactive bowel sounds, peritonitis, hypoactive bowel sounds, blood in rectum or guiac positive stoolblood in rectum or guiac positive stool 14

Bowel Infarction (cont.)Bowel Infarction (cont.)

• Usual lab findings :Usual lab findings :• High WBCHigh WBC• Severe lactic acidosis (anion gap > 18)Severe lactic acidosis (anion gap > 18)

• Plain X-ray film findings :Plain X-ray film findings :• Free air, air in portal vein, air in bowel Free air, air in portal vein, air in bowel

wall ("pneumatosis intestinalis")wall ("pneumatosis intestinalis")• May need emergent angiography for DxMay need emergent angiography for Dx• Rx : Oxygen, IV fluid resuscitation, IV Rx : Oxygen, IV fluid resuscitation, IV

broad spectrum antibiotics, consult broad spectrum antibiotics, consult surgeonsurgeon

15

Non-occlusive mesenteric ischemia in 84-year-old man with abdominal pain

Source Undetermined

16

Angiogram (arrow shows superior mesenteric artery clot) of a 65 year old male with bowel ischemia

Source Undetermined 17

Perforated ViscusPerforated Viscus

• Causes :Causes :• Blunt or penetrating trauma, tumors, Blunt or penetrating trauma, tumors,

inflammaory bowel disease, typhoid inflammaory bowel disease, typhoid fever, amebiasis, other parasitesfever, amebiasis, other parasites

• Typically see free air under diaphragm on Typically see free air under diaphragm on plain films (Chest X-ray is most sensitive plain films (Chest X-ray is most sensitive to see small amounts of air)to see small amounts of air)

• Rx : Oxygen, IV fluids, IV broad spectrum Rx : Oxygen, IV fluids, IV broad spectrum antibiotics (such as cefoxitin & antibiotics (such as cefoxitin & metronidazole), emergently consult metronidazole), emergently consult surgeonsurgeon 18

Free air under the diaphragm from a perforated peptic ulcer

Source Undetermined 19

Chest X-ray showing colonic interposition (NOT free air)

Source Undetermined

20

Abdominal film showing the “Rigler double wall sign” of free intraperitoneal air (can see both inside and outside wall of bowel)

Source Undetermined

21

Acute Myocardial Infarction Acute Myocardial Infarction (MI) as a Cause of Abdominal (MI) as a Cause of Abdominal PainPain

• Suspect in adult patient with upper abd. Suspect in adult patient with upper abd. pain but no or minimal abd. tendernesspain but no or minimal abd. tenderness

• Inferior MI commonly presents as Inferior MI commonly presents as "indigestion" ; may also have emesis "indigestion" ; may also have emesis

• MI may also secondarily occur from shock MI may also secondarily occur from shock due to an intraabdominal cause (such as due to an intraabdominal cause (such as intraluminal bleed, etc.)intraluminal bleed, etc.)

• Dx by EKG +/- enzymes ; need Chest X-ray Dx by EKG +/- enzymes ; need Chest X-ray alsoalso

• Rx : Oxygen, IV line, nitrates, aspirin, Rx : Oxygen, IV line, nitrates, aspirin, consider thrombolytics, etc., & admit to consider thrombolytics, etc., & admit to monitor bed unitmonitor bed unit

22

Now That Immediate Life-Threatening Causes Now That Immediate Life-Threatening Causes of Abd. Pain Have Been Reviewed, Next the of Abd. Pain Have Been Reviewed, Next the Lecture Will Review History and Exam for the Lecture Will Review History and Exam for the Stable PatientStable Patient

• History items to ask the patient with abd. pain :History items to ask the patient with abd. pain :• Time and rapidity of onsetTime and rapidity of onset• Character of pain (burning, cramping, etc.)Character of pain (burning, cramping, etc.)• Associated symptomsAssociated symptoms• Signs of bleeding (dark vomitus or stool)Signs of bleeding (dark vomitus or stool)• Prior surgeries & illnessesPrior surgeries & illnesses• Last menstrual periodLast menstrual period• Medications (especially steroids, aspirin, Medications (especially steroids, aspirin,

warfarin)warfarin)• Alcohol intakeAlcohol intake• Unusual ingestion or foreign travelUnusual ingestion or foreign travel

23

Physical Exam for the Physical Exam for the Patient with Abdominal Patient with Abdominal PainPain

• Need complete set of vital signsNeed complete set of vital signs• Look in nose and mouth for sites of bleeding Look in nose and mouth for sites of bleeding

(swallowed blood may mimic an intraluminal (swallowed blood may mimic an intraluminal bleed)bleed)

• Look at skin for stigmata of liver disease or Look at skin for stigmata of liver disease or signs of coagulapathysigns of coagulapathy

• Careful chest & lung exam (basilar Careful chest & lung exam (basilar pneumonias can present as abd. pain)pneumonias can present as abd. pain)

• Palpate and observe the backPalpate and observe the back• Genital and rectal exam (& stool guiac) Genital and rectal exam (& stool guiac)

should usually be routineshould usually be routine24

Exam of the Abdomen in Exam of the Abdomen in the Patient with Abdominal the Patient with Abdominal PainPain

• Inspection : Look for :Inspection : Look for :• Scars from prior surgeriesScars from prior surgeries• DistensionDistension• Localized swelling or massLocalized swelling or mass• Eccymoses or erythemaEccymoses or erythema• Visible peristalsisVisible peristalsis

• Auscultation with stethescopeAuscultation with stethescope• Listen for bowel sounds & bruitsListen for bowel sounds & bruits

• Palpation & percussionPalpation & percussion

25

Interpretation of Bowel Interpretation of Bowel SoundsSounds(Associated, but not Definite, (Associated, but not Definite, Diagnoses)Diagnoses)

• High pitched or "tinkling" : bowel High pitched or "tinkling" : bowel obstructionobstruction

• Continuous & hyperactive : acute Continuous & hyperactive : acute gastroenteritisgastroenteritis

• Absent : ileus or peritonitis (need to Absent : ileus or peritonitis (need to listen for at least one minute)listen for at least one minute)

• Audible without stethescope : Audible without stethescope : "borborygmi""borborygmi"

26

Percussion of the AbdomenPercussion of the Abdomen

• Should tap with 2 fingers on all 4 Should tap with 2 fingers on all 4 quadrantsquadrants

• If tympanitic : implies bowel If tympanitic : implies bowel obstructionobstruction

• If dull, implies intraabdominal If dull, implies intraabdominal bleding or fluid (such as ascites)bleding or fluid (such as ascites)

• If tender, correlate with tender If tender, correlate with tender areas noted on palpationareas noted on palpation

27

Palpation of the AbdomenPalpation of the Abdomen

• Should be done following inspection & Should be done following inspection & auscultationauscultation

• Assess for tenderness, guarding, mass, Assess for tenderness, guarding, mass, crepitus, referred tendernesscrepitus, referred tenderness

• Differentiate lower rib tenderness from true Differentiate lower rib tenderness from true upper abd. tendernessupper abd. tenderness

• Don't need to directly assess rebound ; just Don't need to directly assess rebound ; just wiggle abdomen from the side & check for wiggle abdomen from the side & check for referred tenderness (direct rebound is cruel if referred tenderness (direct rebound is cruel if peritonitis is present)peritonitis is present)

• Don't forget leg maneuvers (psoas, obturator, Don't forget leg maneuvers (psoas, obturator, & heel tap signs)& heel tap signs) 28

Lab Studies for Patients Lab Studies for Patients with Abdominal Painwith Abdominal Pain

• Use selectively ; not all are Use selectively ; not all are needed for all patientsneeded for all patients

• For example, for young adults For example, for young adults with simple acute viral with simple acute viral gastroenteritis or food gastroenteritis or food poisoning, usually no lab studies poisoning, usually no lab studies are needed (they may just need are needed (they may just need IV fluids & parenteral IV fluids & parenteral antiemetics)antiemetics)

• Draw with the initial Draw with the initial venipuncture if an IV line is to be venipuncture if an IV line is to be establishedestablished

29

List of Lab Studies to List of Lab Studies to Consider for Patients with Consider for Patients with Abdominal PainAbdominal Pain• Type and Cross (the most important if patient has shock)Type and Cross (the most important if patient has shock)• Complete blood count (CBC)Complete blood count (CBC)• Urine or serum pregnancy test (HCG)Urine or serum pregnancy test (HCG)• Serum amylase, lipase Serum amylase, lipase • Urinalysis, urine culture and sensitivityUrinalysis, urine culture and sensitivity• Liver function tests (bilirubin, SGOT, SGPT, alk. phos.)Liver function tests (bilirubin, SGOT, SGPT, alk. phos.)• Electrolytes, glucose, creatinine, blood urea nitrogen Electrolytes, glucose, creatinine, blood urea nitrogen

(BUN)(BUN)• Serum alcohol, serum or urine drug screenSerum alcohol, serum or urine drug screen• Serum medication levels (such as digoxin)Serum medication levels (such as digoxin)• Clotting studies (platelet count, protime, PTT, fibrinogen)Clotting studies (platelet count, protime, PTT, fibrinogen)• Cardiac enzymes (if coronary ischemia suspected)Cardiac enzymes (if coronary ischemia suspected)• Blood culture (if sepsis or bacteremia suspected)Blood culture (if sepsis or bacteremia suspected)• Nonemergent tumor markers (CEA, AFP)Nonemergent tumor markers (CEA, AFP)

30

Interpretation of Lab Interpretation of Lab Studies for Abdominal PainStudies for Abdominal Pain

• WBC typically elevated (+/- "left-shifted") WBC typically elevated (+/- "left-shifted") in any cause of peritonitis & in bowel in any cause of peritonitis & in bowel infarction & in spleen & liver bleedinginfarction & in spleen & liver bleeding

• However often NOT elevated However often NOT elevated appropriately in :appropriately in :

• the elderly the elderly • immunocompromised patientsimmunocompromised patients• patients on chronic corticosteroid Rxpatients on chronic corticosteroid Rx

31

Interpretation of Lab Interpretation of Lab Studies for Abdominal Pain Studies for Abdominal Pain (cont.)(cont.)

• Hematocrit may be normal in early Hematocrit may be normal in early stages of even severe hemorrhagestages of even severe hemorrhage

• BUN to creatinine ratio of > 20 to 1 may BUN to creatinine ratio of > 20 to 1 may indicate upper gastrointestinal (GI) bleed indicate upper gastrointestinal (GI) bleed with digestion of blood in upper GI tractwith digestion of blood in upper GI tract

• Degree of elevation of amylase or lipase Degree of elevation of amylase or lipase does not always correlate with severity does not always correlate with severity of panceatitis or of pancreatic injuryof panceatitis or of pancreatic injury

• Amylase may also be chronically Amylase may also be chronically elevated in patients with renal elevated in patients with renal dysfunctiondysfunction 32

Plain Radiographs for Plain Radiographs for Abdominal PainAbdominal Pain

• If needed, usually the 3 view "Acute Abdomen If needed, usually the 3 view "Acute Abdomen Series " is best (upright Chest X-ray, upright Series " is best (upright Chest X-ray, upright and flat plate of the abd.)and flat plate of the abd.)

• Chest X-ray best shows small amounts of free Chest X-ray best shows small amounts of free airair

• Upright abd. film best shows bowel air-fluid Upright abd. film best shows bowel air-fluid levels (indicating bowel obstruction or ileus if levels (indicating bowel obstruction or ileus if multiple)multiple)

• Look also for abnormal calcificationsLook also for abnormal calcifications• "KUB" film is oriented to include all the pelvis, "KUB" film is oriented to include all the pelvis,

whereas "abd. flat plate" is oriented to include whereas "abd. flat plate" is oriented to include the diaphragms (so these two are different for the diaphragms (so these two are different for a tall patient)a tall patient)

33

Diagnostic Ultrasound for Diagnostic Ultrasound for Abdominal PainAbdominal Pain

• Dx test of choice for :Dx test of choice for :• Unstable patient in shock & Unstable patient in shock &

suspected intraabdominal bleedsuspected intraabdominal bleed• Gallstones (cholecystitis)Gallstones (cholecystitis)• Ectopic pregnancyEctopic pregnancy• Other complications of pregnancy Other complications of pregnancy

(placenta previa, abruptio, etc.)(placenta previa, abruptio, etc.)• Renal or ureteral stones in the Renal or ureteral stones in the

pregnant patientpregnant patient

34

Ultrasonogram, transverse view, reveals marked thickening of gallbladder wall (white arrows), cholelithiasis with shadowing (black arrows), and pericholecystic fluid consistent with acute cholecystitis.

Source Undetermined

35

Impacted stone in distal common bile duct in elderly patient with obstructive jaundice and sepsis. Longitudinal sonogram reveals markedly dilated common bile duct (CD) from a stone (arrow) with shadowing. P, portal vein

Source Undetermined

36

Disadvantages of Disadvantages of Diagnostic UltrasoundDiagnostic Ultrasound

• Visualization may be limited by Visualization may be limited by bowel gas or obesitybowel gas or obesity

• Good interpretation requires Good interpretation requires experienceexperience

• Not good at showing retroperitoneal Not good at showing retroperitoneal conditionsconditions

• May not directly visualize solid organ May not directly visualize solid organ lacerationslacerations

37

Use of Computed Use of Computed Tomography (CT) for Tomography (CT) for Abdominal PainAbdominal Pain

• Noncontrast spiral scan is now Noncontrast spiral scan is now method of choice for ureteral calculi method of choice for ureteral calculi (replaces intravenous pyelogram or (replaces intravenous pyelogram or IVP)IVP)

• Using both IV and oral (or via Using both IV and oral (or via nasogastric tube) contrast can then nasogastric tube) contrast can then show appendicitis, diverticulitis, show appendicitis, diverticulitis, etc.etc.

• However even with greater use of However even with greater use of CT for appendicitis, overall CT for appendicitis, overall accuracy of this Dx in the E.D. has accuracy of this Dx in the E.D. has not improvednot improved

38

Other Diagnostic Studies Other Diagnostic Studies to Consider for Abdominal to Consider for Abdominal PainPain

• If contrast CT not available :If contrast CT not available :• Gastrografin Upper GI study for Gastrografin Upper GI study for

suspected :suspected :• Stomach or bowel perforationStomach or bowel perforation• Diaphragm ruptureDiaphragm rupture• Duodenal hematomaDuodenal hematoma

• Never do barium GI study if any Never do barium GI study if any chance of barium leak (causes severe chance of barium leak (causes severe peritonitis)peritonitis)

• Intravenous pyelogram (IVP) for Intravenous pyelogram (IVP) for suspected :suspected :

• Ureteral stone or injuryUreteral stone or injury• Renal massRenal mass

39

Other Diagnostic Studies to Other Diagnostic Studies to Consider for Abdominal Pain Consider for Abdominal Pain (cont.)(cont.)

• Retrograde urethrogram / Retrograde urethrogram / cystogram for suspected urethral or cystogram for suspected urethral or bladder injurybladder injury

• Fistulogram for any suspected Fistulogram for any suspected abdominal wall fistulaabdominal wall fistula

• Technetium bleeding scan to Technetium bleeding scan to localize intraluminal GI bleedlocalize intraluminal GI bleed

• Angiography for preop planning of Angiography for preop planning of surgery for stable patient with AAA, surgery for stable patient with AAA, or for suspected arterial bleed or or for suspected arterial bleed or mesenteric ischemiamesenteric ischemia 40

Acute gangrenous cholecystitis in 82-year-old woman with history of gallstones had right upper quadratic pain, nausea, vomiting, and fever. DISIDA scan demonstrated non-visualization of gallbladder (GB) and increased radioactivity in adjacent right lobe of liber (curved arrow) from reactive hyperemia.

Source Undetermined

41

Post-Exam "Procedures" to Post-Exam "Procedures" to Consider for the Patient with Consider for the Patient with Abdominal PainAbdominal Pain

• Insertion of foley catheterInsertion of foley catheter• Indicated for monitoring of any unstable Indicated for monitoring of any unstable

patient or if urinary retention suspectedpatient or if urinary retention suspected• Insertion of nasogastric (NG) tube (see next Insertion of nasogastric (NG) tube (see next

slide)slide)• Paracentesis (needle aspirate of abd. fluid)Paracentesis (needle aspirate of abd. fluid)

• Indicated for :Indicated for :• Suspected infected ascites (check cell count Suspected infected ascites (check cell count

& culture)& culture)• Relieving tense ascitesRelieving tense ascites• Sometimes can make Dx of bowel Sometimes can make Dx of bowel

perforation or intraabd. bleedperforation or intraabd. bleed42

Usefulness Of NG Tube Suction Usefulness Of NG Tube Suction for the Patient with Abdominal for the Patient with Abdominal PainPain

• Allows decompression of Allows decompression of stomachstomach

• Lessens risk of aspirationLessens risk of aspiration• Can remove some of residual Can remove some of residual

toxins in stomachtoxins in stomach• May demonstrate upper GI May demonstrate upper GI

bleedingbleeding• Required before peritoneal Required before peritoneal

lavagelavage• Contraindicated if nasal or Contraindicated if nasal or

midface fractures or severe midface fractures or severe coagulapathy (insert via mouth coagulapathy (insert via mouth instead)instead)

43

General Mechanisms General Mechanisms Causing Abdominal PainCausing Abdominal Pain

• Pain originating in the abdomenPain originating in the abdomen• PeritonitisPeritonitis• Distension of hollow visceraDistension of hollow viscera• IschemiaIschemia

• Pain referred to the abdomen Pain referred to the abdomen from another part of the bodyfrom another part of the body

• Metabolic disordersMetabolic disorders• Neurogenic disordersNeurogenic disorders

44

Acute Cholecystitis

GI Reflux

Cholocystitis

Angina

Pleuritic Pain

Pancreatic Pain

Splenic Infarct

Appendicitis

Renal ColicDiverticulitis

Sources of Referral Abdominal Pain

Lena Carleton, University of Michigan

45

Causes of Referred Causes of Referred Abdominal Pain from Chest Abdominal Pain from Chest ConditionsConditions

• Acute coronary syndromes (and Acute coronary syndromes (and "angina equivalents")"angina equivalents")

• Pneumonia (especially basilar)Pneumonia (especially basilar)• Spontaneous pneumothoraxSpontaneous pneumothorax• Pulmonary embolus (rare cause)Pulmonary embolus (rare cause)• PericarditisPericarditis

46

Metabolic Causes of Metabolic Causes of Abdominal PainAbdominal Pain

• Diabetic ketoacidosisDiabetic ketoacidosis• Hyperlipidemia (often with Hyperlipidemia (often with

pancreatitis)pancreatitis)• Acute prophyriasAcute prophyrias• Black Widow spider bitesBlack Widow spider bites• Scorpion bitesScorpion bites• Sickle cell crisis (sequestration in Sickle cell crisis (sequestration in

spleen or liver, or vaso-occlusive)spleen or liver, or vaso-occlusive)

47

Neurogenic Causes of Neurogenic Causes of Abdominal PainAbdominal Pain

• Herpes zoster (Shingles)Herpes zoster (Shingles)• Pain often present several days Pain often present several days

before characteristic dermatomal before characteristic dermatomal vesicles appearvesicles appear

• Thoracic or lumbar spinal disc Thoracic or lumbar spinal disc disease or compressiondisease or compression

• Syphilis ("tabetic crisis")Syphilis ("tabetic crisis")

48

Patient with Herpes Zoster (“Shingles”) of the abdomen

Preston Hunt, Wikimedia Commons

49

Trauma-Related Causes of Trauma-Related Causes of Abdominal PainAbdominal Pain

• May present delayed, or from seemingly May present delayed, or from seemingly minor trauma in the elderly :minor trauma in the elderly :

• Ruptured spleen or liverRuptured spleen or liver• Bowel or stomach perforationBowel or stomach perforation• Pancreatic contusion or transectionPancreatic contusion or transection• Ruptured bladderRuptured bladder• Mesenteric hematomaMesenteric hematoma• Abdominal wall hematoma (U/S is good Abdominal wall hematoma (U/S is good

at diagnosing this)at diagnosing this)

50

Pregnancy-Related Causes Pregnancy-Related Causes of Abdominal Painof Abdominal Pain

• Ectopic (usually tubal) pregnancyEctopic (usually tubal) pregnancy• False labor (Braxton-Hicks False labor (Braxton-Hicks

contractions)contractions)• Active laborActive labor• Abruptio placentae (note that Abruptio placentae (note that

placenta previa which can cause placenta previa which can cause severe bleeding is usually severe bleeding is usually painlesspainless))

• Septic abortionSeptic abortion

51

Genitourinary Tract Causes Genitourinary Tract Causes of Abdominal Painof Abdominal Pain

• CystitisCystitis• PyelonephritisPyelonephritis• UreterolithiasisUreterolithiasis• Perinephric abscess (may see gas around Perinephric abscess (may see gas around

kidney on KUB film)kidney on KUB film)• Renal infarction (as from sickle cell Renal infarction (as from sickle cell

disease)disease)• Psoas abscessPsoas abscess• Testicular torsionTesticular torsion• Urinary retention (as from prostatic Urinary retention (as from prostatic

hypertrophy)hypertrophy) 52

Peritonitis Causing Abdominal Peritonitis Causing Abdominal PainPain

• Definition : inflammation of the peritoneumDefinition : inflammation of the peritoneum• Causes : exposure of peritoneum to gastric acid, bile, Causes : exposure of peritoneum to gastric acid, bile,

urine, blood, pancreatic enzymes, bacteria, stool, or urine, blood, pancreatic enzymes, bacteria, stool, or exogenous toxins exogenous toxins

• Complications : fluid & electrolyte disorders, "third Complications : fluid & electrolyte disorders, "third spacing" of fluid causing hypovolemia & shock, spacing" of fluid causing hypovolemia & shock, paralytic ileusparalytic ileus

• Symptoms and signs : abdominal pain, rebound Symptoms and signs : abdominal pain, rebound tenderness, abdominal muscle guarding or rigidity, tenderness, abdominal muscle guarding or rigidity, fever, emesis, decreased bowel sounds, abdominal fever, emesis, decreased bowel sounds, abdominal distentiondistention

• Key Rx : IV fluid resuscitation, IV antibiotics (usually), Key Rx : IV fluid resuscitation, IV antibiotics (usually), EARLY PAIN RELIEF WITH NARCOTICS, try to EARLY PAIN RELIEF WITH NARCOTICS, try to determine the most likely cause, emergently consult determine the most likely cause, emergently consult a surgeona surgeon

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List of Most Common Causes List of Most Common Causes of Acute Abdominal Pain in of Acute Abdominal Pain in AdultsAdults

• Acute gastroenteritisAcute gastroenteritis• Acute cholecystitisAcute cholecystitis

• Acute cholangitisAcute cholangitis• Acute appendicitisAcute appendicitis• Acute diverticulitisAcute diverticulitis• Acute gastritis or Acute gastritis or

peptic ulcerpeptic ulcer• Acute esophagitisAcute esophagitis

• Acute panceatitisAcute panceatitis• Bowel obstructionBowel obstruction• Inflammatory Bowel Inflammatory Bowel

DiseaseDisease

• Acute salpingitis Acute salpingitis (pelvic inflammatory (pelvic inflammatory disease)disease)

• Acute pyelonephritisAcute pyelonephritis• Acute cystitisAcute cystitis• UreterolithiasisUreterolithiasis• Urinary retentionUrinary retention• Acute viral hepatitisAcute viral hepatitis• Mesenteric ischemiaMesenteric ischemia• Ovarian cystsOvarian cysts• Complications of Complications of

pregnancypregnancy54

Caveat About Workup of Caveat About Workup of Abdominal Pain in the E.D.Abdominal Pain in the E.D.

• Several large studies show that even Several large studies show that even after complete workup, 60 % of E.D. after complete workup, 60 % of E.D. patients with abdominal pain do not patients with abdominal pain do not have a specific diagnosishave a specific diagnosis

• For most of these patients, it is For most of these patients, it is appropriate just to treat their appropriate just to treat their symptoms (pain meds, symptoms (pain meds, antispasmodics, antiemetics, etc.) and antispasmodics, antiemetics, etc.) and perform further diagnostic tests only perform further diagnostic tests only if their pain does not resolve in one to if their pain does not resolve in one to 2 days 2 days

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Acute GastroenteritisAcute Gastroenteritis

• Present with nausea / emesis / Present with nausea / emesis / diarrheadiarrhea

• Usually viral or reaction to foodUsually viral or reaction to food• If bacterial, usually have abd. If bacterial, usually have abd.

tenderness +/- lower GI bleedingtenderness +/- lower GI bleeding• If abd. nontender and diarrhea is If abd. nontender and diarrhea is

nonbloody, usually do not need lab nonbloody, usually do not need lab studiesstudies

• Rx with IV LR 1 to 5 liters, oral, rectal, Rx with IV LR 1 to 5 liters, oral, rectal, or parenteral antiemetics, +/- or parenteral antiemetics, +/- antidiarrhealsantidiarrheals

56

Choices for AntiEmetics in the Choices for AntiEmetics in the E.D.E.D.

• My favorite : hydroxyzine (Atarax, Vistaril)My favorite : hydroxyzine (Atarax, Vistaril)• Antihistamine, also an antianxiety agentAntihistamine, also an antianxiety agent• Very low incidence of side effectsVery low incidence of side effects• 25 to 50 mg IM or PO q 6 hours25 to 50 mg IM or PO q 6 hours

• Promethazine (Phenergan)Promethazine (Phenergan)• Some risk of dystonic reactions & sedationSome risk of dystonic reactions & sedation• 25 to 50 mg q 6 hours IV, IM, PO, or PR25 to 50 mg q 6 hours IV, IM, PO, or PR

• Prochlorperazine (Compazine)Prochlorperazine (Compazine)• 40 to 50 % incidence of dystonic reactions40 to 50 % incidence of dystonic reactions• 10 to 25 mg q 6 hours IV, IM, PO, or PR10 to 25 mg q 6 hours IV, IM, PO, or PR

• Metclopromide (Reglan) : 5 to 20 mg q 4 hrs. IV, IM, Metclopromide (Reglan) : 5 to 20 mg q 4 hrs. IV, IM, or POor PO

57

Choices for AntiDiarrheals Choices for AntiDiarrheals in the E.D.in the E.D.

• Do not use these in patients with tender Do not use these in patients with tender abdomen or toxicityabdomen or toxicity

• Lomotil (diphenoxylate and atropine)Lomotil (diphenoxylate and atropine)• 2 tabs PO, then one after each 2 tabs PO, then one after each

diarrheal stool up to 8 per daydiarrheal stool up to 8 per day• Loperamide (Imodium)Loperamide (Imodium)

• 2 mg tabs, same dosing as Lomotil2 mg tabs, same dosing as Lomotil• Codeine 15 to 60 mg PO q 4 hoursCodeine 15 to 60 mg PO q 4 hours• Donnatal elixir 2 tsp PO q 6 hours Donnatal elixir 2 tsp PO q 6 hours (good (good

antispasmodic)antispasmodic)

58

Acute CholecystitsAcute Cholecystits

• Usual clinical profile is obese female > age 40Usual clinical profile is obese female > age 40• May cause more complications in diabeticsMay cause more complications in diabetics• Usually RUQ +/- epigastric tenderness and emesisUsually RUQ +/- epigastric tenderness and emesis• U/S is best Dx testU/S is best Dx test• LFT's usually normal ; lipase & amylase elevated if LFT's usually normal ; lipase & amylase elevated if

secondary panceatitis (common duct stone)secondary panceatitis (common duct stone)• If cholangitis (severe RUQ tenderness, fever, emesis, If cholangitis (severe RUQ tenderness, fever, emesis,

usually elevated LFT's, +/- air in biliary tree on X-usually elevated LFT's, +/- air in biliary tree on X-ray) : consult surgery emergentlyray) : consult surgery emergently

• Rx : IV fluids, NPO at first, pain meds, surgery Rx : IV fluids, NPO at first, pain meds, surgery consult unless quickly resolvesconsult unless quickly resolves

59

Gallstone ileus in 75-year-old woman with intermittent abdominal distention, nausea and vomiting for 2 weeks. Supine abdominal film shows distended small bowel loops and faint lamellated gallstone in right pelvis.

Source Undetermined

60

Emphysematous cholecystitis (arrows show gas around the gallbladder)

Source Undetermined

61

Acute AppendicitisAcute Appendicitis

• Accuracy of Dx on clinical grounds alone Accuracy of Dx on clinical grounds alone is not goodis not good

• Usually periumbilical pain, then migrates Usually periumbilical pain, then migrates to RLQto RLQ

• Usually anorexia, nausea, +/- low grade Usually anorexia, nausea, +/- low grade feverfever

• KUB film rarely shows diagnostic KUB film rarely shows diagnostic appendicolith in RLQappendicolith in RLQ

• U/S and CT can make definitive DxU/S and CT can make definitive Dx• Consult surgeon if suspectedConsult surgeon if suspected

62

Acute DiverticulitisAcute Diverticulitis

• More common after age 45More common after age 45• Typically pain & tenderness in Typically pain & tenderness in

LLQ, but can be diffuseLLQ, but can be diffuse• Can result in inflammatory mass Can result in inflammatory mass

in LLQ or perforationin LLQ or perforation• CT with contrast is best Dx testCT with contrast is best Dx test• Milder cases can be discharged Milder cases can be discharged

on oral antibioticson oral antibiotics

63

Acute Gastritis ; Peptic Acute Gastritis ; Peptic UlcerUlcer

• Typically epigastric pain & Typically epigastric pain & tendernesstenderness

• If perforation or severe If perforation or severe bleeding, may require bleeding, may require laparotomylaparotomy

• Definitive Dx by endoscopy Definitive Dx by endoscopy preferred over Upper GI contrast preferred over Upper GI contrast study, but not needed for many study, but not needed for many patientspatients

• Rx with H2 blockers such as Rx with H2 blockers such as ranitidine (in addition to IV ranitidine (in addition to IV fluids, etc. for severe cases)fluids, etc. for severe cases)

64

Acute PancreatitisAcute Pancreatitis

• Usually diffuse abd. pain + back Usually diffuse abd. pain + back pain, emesis, elevated amylase & pain, emesis, elevated amylase & lipaselipase

• Often attributed to gallstones or Often attributed to gallstones or alcohol, but many cases idiopathicalcohol, but many cases idiopathic

• Can have severe complications :Can have severe complications :• Hypovolemia, ARDS, Hypovolemia, ARDS,

hypocalcemia, retroperitoneal hypocalcemia, retroperitoneal bleeding or abscessbleeding or abscess

• CT is Dx method of choiceCT is Dx method of choice65

Bowel ObstructionBowel Obstruction

• Can be either large or small bowelCan be either large or small bowel• Most common causes :Most common causes :

• Adhesions from prior surgery, Adhesions from prior surgery, incarcerated hernia, cancer, incarcerated hernia, cancer, volvulus, mass of parasites, volvulus, mass of parasites, inflammatory bowel diseaseinflammatory bowel disease

• Plain X-ray films are key Dx testPlain X-ray films are key Dx test• If possible associated bowel If possible associated bowel

necrosis (infarction), consult necrosis (infarction), consult surgeon emergentlysurgeon emergently 66

Plain film showing small bowel obstruction from adhesions in a 72 year old male

Source Undetermined

67

Upright film showing multiple air-fluid levels from small bowel obstruction

Source Undetermined

68

Upright film of sigmoid volvulus in a 67 year old male

Source Undetermined

69

Supine film showing sigmoid volvulus in a 67 year old male

Source Undetermined70

Upright film showing cecal volvulus in a 62 year old male

Source Undetermined71

Inflammatory Bowel Inflammatory Bowel DiseaseDisease

• Two types :Two types :• Ulcerative colitisUlcerative colitis• Crohn's DiseaseCrohn's Disease

• Ulcerative colitis can sometimes Ulcerative colitis can sometimes have complication of "toxic have complication of "toxic megacolon"megacolon"

• Complications of either type may Complications of either type may need Rx with high dose IV need Rx with high dose IV steroids in addition to other steroids in addition to other usual Rx'susual Rx's 72

Acute Salpingitis (Pelvic Acute Salpingitis (Pelvic Inflammatory Disease)Inflammatory Disease)

• Typically present as severe lower abd. Typically present as severe lower abd. pain & vaginal dischargepain & vaginal discharge

• Get cervical cultures as part of Get cervical cultures as part of workupworkup

• Usually caused by gonococcus or Usually caused by gonococcus or chlamydia, but can involve other chlamydia, but can involve other bacteriabacteria

• Rx : IV antibiotics, pain medsRx : IV antibiotics, pain meds• Admit to hospital if :Admit to hospital if :

• Toxic, pregnant, immunosuppressed, Toxic, pregnant, immunosuppressed, suspected tubo-ovarian abscesssuspected tubo-ovarian abscess

73

Acute PyelonephritisAcute Pyelonephritis

• Usually have dysuria & back pain Usually have dysuria & back pain & CVA tenderness, but can show & CVA tenderness, but can show projected anterior abd. projected anterior abd. tendernesstenderness

• Admit to hospital for IV Admit to hospital for IV antibiotics if :antibiotics if :

• Toxic, hypotensive, persistent Toxic, hypotensive, persistent emesis, pregnant, emesis, pregnant, immunosuppressed, chronic or immunosuppressed, chronic or structural renal disease, failure structural renal disease, failure of outpatient Rx, diabetic, age < of outpatient Rx, diabetic, age < 2 or > 602 or > 60

74

UreterolithiasisUreterolithiasis

• Commonly have sudden back or flank and/or Commonly have sudden back or flank and/or abd. pain +/- groin radiation, but not much abd. pain +/- groin radiation, but not much tendernesstenderness

• Need early Rx with pain meds (parenteral Need early Rx with pain meds (parenteral NSAID such as ketorolac 30 mg IV is most NSAID such as ketorolac 30 mg IV is most effective) ; IV morphine if more analgesia effective) ; IV morphine if more analgesia neededneeded

• Noncontrast spiral CT is Dx method of choiceNoncontrast spiral CT is Dx method of choice• IVP or U/S are alternativesIVP or U/S are alternatives

• Should "cover" with antibiotic (such as Should "cover" with antibiotic (such as Bactrim or Cipro) if any bacteria noted on Bactrim or Cipro) if any bacteria noted on urinalysisurinalysis

• Over 90 % of patients can be discharged Over 90 % of patients can be discharged from E.D.from E.D.

75

Urinary RetentionUrinary Retention

• Most common in elderly men with Most common in elderly men with benign prostatic hypertrophybenign prostatic hypertrophy

• Can occur also from acute prostatitisCan occur also from acute prostatitis• Rx with foley catheterRx with foley catheter• If bladder residual > 100 cc, should If bladder residual > 100 cc, should

leave foley catheter in at least 24 leave foley catheter in at least 24 hours to allow bladder to recover its hours to allow bladder to recover its muscle tonemuscle tone

• Routine use of coverage antibiotics Routine use of coverage antibiotics while foley is in is debatedwhile foley is in is debated 76

Acute Viral HepatitisAcute Viral Hepatitis

• Incidence greatly decreased by Incidence greatly decreased by use of Hep B and A vaccinesuse of Hep B and A vaccines

• Typically present with nausea, Typically present with nausea, emesis, +/- RUQ pain, +/- emesis, +/- RUQ pain, +/- jaundicejaundice

• Need to check serologies on Need to check serologies on close contacts of index caseclose contacts of index case

• Admit to hospital if Admit to hospital if encephalopathic, GI bleed, encephalopathic, GI bleed, increased protime, hypoglycemicincreased protime, hypoglycemic77

Ovarian Cysts and Ovarian Cysts and Complications of Complications of PregnancyPregnancy

• U/S is Dx method of choice for U/S is Dx method of choice for thesethese

• Ovarian cysts typically have Ovarian cysts typically have lower abd. pain & lateralizing lower abd. pain & lateralizing tenderness +/- adnexal mass on tenderness +/- adnexal mass on examexam

• If large amount of blood in pelvis If large amount of blood in pelvis or suspected ovarian torsion on or suspected ovarian torsion on U/S, emergently consult surgeon U/S, emergently consult surgeon or obstetricianor obstetrician 78

Some Caveats About Some Caveats About Abdominal PainAbdominal Pain

• Don't hesitate to treat the patient's Don't hesitate to treat the patient's abd. pain early, even if consulting a abd. pain early, even if consulting a surgeonsurgeon

• It has been definitively shown that It has been definitively shown that pain meds make the physical exam of pain meds make the physical exam of the abd. pain patient MORE reliablethe abd. pain patient MORE reliable

• Don't forget to consider child abuse Don't forget to consider child abuse or trauma as a cause for abd. painor trauma as a cause for abd. pain

• Repeated physical exams over time Repeated physical exams over time may be needed to clarify the Dxmay be needed to clarify the Dx 79

"Secondary" Aspects to "Secondary" Aspects to Remember for Abdominal Remember for Abdominal PainPain

• Oxygen if any possible major Oxygen if any possible major systemic compromisesystemic compromise

• Question patient about prior Question patient about prior anesthetic complications if surgery anesthetic complications if surgery anticipatedanticipated

• Additional doses of pain meds as Additional doses of pain meds as neededneeded

• Tetanus immunization if associated Tetanus immunization if associated skin injuryskin injury

• Antibiotics (+/- cultures if indicated)Antibiotics (+/- cultures if indicated)• Tell the patient & family what is Tell the patient & family what is

going ongoing on

80

Abdominal PainAbdominal PainSummarySummary

• Assess the ABC's & provide Assess the ABC's & provide emergent Rx if life-threatening emergent Rx if life-threatening cause suspectedcause suspected

• Complete exam prior to deciding Complete exam prior to deciding on other Dx testson other Dx tests

• Focus on the most likely Dx's Focus on the most likely Dx's initiallyinitially

• Decide early if surgical consult Decide early if surgical consult or hospital admission neededor hospital admission needed

• Don't forget "secondary" Don't forget "secondary" treatmentstreatments

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