Transcript Slide 1

Abdominal Pain
Scenario
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You are called by a nurse to evaluate a patient on
the inpatient medicine service with abdominal
pain (cross-cover)
“Worst case scenario” DDx
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“Surgical abdomen” – condition with rapidly
worsening prognosis without surgical intervention
• Obstruction
• Peritonitis
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Viscus perforation (e.g., intestine, pelvic organ)
Intraperitoneal hemorrhage (e.g., ruptured AAA)
Intraabdominal abscess
(SBP is medically managed)
Location, location, location
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RUQ:
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Biliary colic
Cholecystitis
Cholangitis
Hepatitis
DDx
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Epigastric:
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Pancreatitis
Dyspepsia/PUD
Gastroparesis
Cardiac ischemia
Pulmonary pathology affecting lower lungs/pleura
(PNA, PE, pulmonary infarct, empyema)
DDx
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Lower abdominal:
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Colitis/enteritis (infectious, ischemic, IBD)
Diverticulitis
Appendicitis
Cystitis
Renal colic (flank), pyelonephritis (CVA tenderness)
Gynecologic: PID, adnexal cysts/masses (bleeding,
torsion, rupture), fibroids, ectopic
DDx
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Generalized:
• Intestinal ischemia/infarction
• Endocrinopathies: DKA, hypercalcemia, adrenal
insufficiency
• Constipation
• Pain syndromes: functional abdominal pain, IBS,
fibromyalgia, somatoform disorder, narcotic-seeking
behavior
First steps
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Is the patient unstable (phone)?
 Is the patient sick (bedside)?
 If yes to above  ABCs, consider ICU Xfer
History
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All about the pain
• Onset, what patient was doing/had recently done (e.g.
just finished a meal, ERCP yesterday)
• Ever had this pain before?
• Location, radiation
• Character:
– Dull/achy/vague (visceral)
– Sharp/well-localized : parietal (2/2 peritoneal irritation)
– Colicky
• Severity
History
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Aggravating/alleviating factors
– Food : aggravates intestinal ischemia, alleviates some cases
of PUD
– Position : peritonitis aggravated by any movement,
pancreatitis alleviated by sitting up and leaning forward
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Associated symptoms
– N/V (bloody, bilious, feculent), diarrhea/constipation,
melena/hematochezia, vaginal discharge/bleeding
History
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STD risk/symptoms
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Possibility of pregnancy
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Medical history: diabetes, chronic liver disease,
IBD, rheumatologic disease,
immunocompromised, prior abdominal surgeries
Abdominal Exam
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General appearance, level of discomfort
Vitals: fever, HoTN
Inspection
• Bulging (ascites, mass)
• Signs of chronic liver disease (jaundice, dilated superficial
veins, spider angiomata)
• Scars
Auscultation:
• Absent bowel sounds (adynamic ileus, advanced
peritonitis)
• Hyperactive, high-pitched bowel sounds (early bowel
obstruction)
Abdominal Exam
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Palpation/Percussion
• Gently assess for peritonitis
– Muscle rigidity (guarding) – may be focal or diffuse
– Rebound tenderness
– “Shake tenderness” – bump the bed
• Start away from the pain
• Tympany (distended bowel)
• Pain out of proportion to exam (intestinal
ischemia/infarction)
• Murphy’s sign, hepatomegaly
• Ascites (SBP)
• Pulsatile mass (AAA)
Exam
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Rectal exam
• Have to justify not doing it
• Impaction, tenderness, check stool for occult blood
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Pelvic exam
• If suspect pelvic pathology (e.g., woman with lower abdominal
pain)
• Bleeding, discharge
• CMT
• Adnexal/uterine pathology
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Don’t forget the heart, lungs, eyes/skin (jaundice), pulses
(AAA)
Whole exam can be done rapidly
Labs
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CBC: leukocytosis, anemia
CMP: hepatic/renal function, electrolytes, anion gap
Lipase
UA
Lactate (ischemia/infarction)
Urine hcg
Blood Cultures: if febrile or unstable
Stool Cx/O+P/C. Diff
Wet mount of vaginal discharge/GC/Chlamydia
Troponin, EKG
ABG
Imaging
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Abdominal X-ray:
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“bones, stones, mass, and gas”
Different from KUB which is centered lower in the abdomen
Supine and upright/L lateral decubitus views
Obstruction  proximally dilated bowel loops, air-fluid levels
Viscus rupture  intraperitoneal free air (see under diaphragm,
over liver)
• Toxic megacolon (C. Diff)  markedly dilated bowel +/perforation
• Ileus, intestinal pseudoobstruction  dilated bowel extending to
rectum
• Constipation
Imaging
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CT Abdomen/Pelvis (with contrast):
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Higher diagnostic accuracy than plain radiographs
Intraperitoneal free air
Obstruction (may see transition point)
Intestinal ischemia
Viscus inflammation
Abscess
AAA leak/rupture
Pancreatitis
Imaging
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Ultrasound:
• RUQ : cholecystitis, gallstones, biliary dilation, cholangitis
• Pelvic: fibroids, adnexal masses, IUP, ectopic pregnancy, free
pelvic fluid
• Renal
• Pregnancy
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CXR:
• If pulmonary pathology suspected
• May need follow-up chest CT
Therapy/Management
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Consultation:
• Emergent surgical consult if acute abdomen
• Biliary consult if biliary dilation, choledocholithiasis
 ERCP/MRCP
• GI consult if dyspepsia with red flag symptoms (e.g.,
dysphagia, wt. loss, persistent vomiting)  EGD +/Bx
• GYN consult if complex pelvic disease
Therapy/Management
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Some therapeutic examples:
• Ileus:
– Decompression with NGT to suction, NPO
• Constipation/fecal impaction:
– Manual disimpaction, stool softeners, laxatives
• Enterocolitis, diverticulitis, cholangitis, PID:
– ABx
Therapy/Management
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Diagnosis is often unclear after initial assessment
• Serial assessments, watchful waiting
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If you didn’t document, you didn’t do it
• Initial assessment, f/u assessments
• If cross-covering, give appropriate sign-out
Take-Home Points
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Is the patient sick? (phone, prompt bedside
assessment)
 R/o surgical abdomen
 Very focused history and exam
 Relevant labs and imaging (think before you
order)
 Use your consultants
 Watchful waiting – good medicine when used
correctly
 Documentation