Transcript Systematic Approach to Abdominal Pain

Systematic Approach
to Abdominal Pain
Dr Devinder Singh Bansi BM DM FRCP
Consultant Gastroenterologist
Imperial College Healthcare NHS Trust
What Do They Have?
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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
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Scale of the Problem
GI symptoms in primary care
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7.1-9.6% of all primary consultations are with
regard to GI complaints
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Gastric pain:
Regurgitation:
Abdominal pain:
Nausea:
Diarrhoea:
Constipation:
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5.0
2.0
6.1
2.9
6.7
8.1
per 1000/yr
– Thompson WG, Gut 2000: 46: 78-82
Scale of the Problem:
Abdominal pain in the general population
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Community prevalence 15-20%
75% of these abdominal complaints
non-consulting
25% consulting
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23.5% stay in primary care
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1-2% referred to secondary care
Scale of the Problem:
Abdominal pain in general practice
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578 cases of non-acute abdominal pain presenting to
11 general practices
Follow up 15 months
Females predominated in the younger age groups
80% visited GP <3 times during F/U
83% managed entirely in the practices
64% received a prescription
Only 20% were additionally investigated in anyway by
the GP
Hardly any differences in dx between patients who had
complaints less than 1 week or more than 1 week
before presenting to their GP
Family Practice Vol 10: 4. 387-400
Scale of the Problem:
Prevalence of GI disease
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Peptic ulcer:
Oesophagitis:
IBD:
GI cancer:
1.9 per 1000/yr
2.9
1.5
1.6
Functional dyspepsia:
GORD:
IBS:
12
5.8
10.5
80% of chronic GI disease has a functional background
Thompson WG . Gut 2000: 46: 78-82
Scale of the problem;
Acute abdominal pain
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Acute abdominal pain is not
uncommon.
Approximately 5 admissions to the
MRI/day with acute abdominal pain
from a population base of 500,000.
1 case per GP per month for an
average list size of 2,000.
Acute Abdominal Pain
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Approximately 6% of ED visits
Admission rates vary by
population, up to about 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
Acute Abdominal Pain
Causes in 10320 patients
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Appendicitis
Cholecystitis
Small bowel obstruction
Gynaecological
Pancreatitis
Renal colic
Peptic ulcer
Cancer
No clinical diagnosis
28%
10%
4%
4%
3%
3%
2%
2%
34%
De Dombal, Scand J Gastroenterol 1988
Abdominal Pain Across
the Ages
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Ages 0-2
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Ages 2-12
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Functional, appendicitis, GE, toxins
Teens to adults
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Colic, GE, viral illness, constipation
Addition of genitourinary problems
Elderly
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Beware of what seems like
everything!
Special Populations
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Elderly/ nursing home patients
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Immunocompromised
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Post operative patients
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Infants
Abdominal Pain in the Elderly
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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
Social factors
Understanding the Types of
Abdominal Pain
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Visceral
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Somatic
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Stretch fibers in capsules or walls
of hollow viscus that enter both
sides of spinal cord
Fibers dermatomally distributed
and enter unilaterally in the spinal
cord
Referred
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Overlap of fibers from other
locations
Understanding the Types of
Abdominal Pain
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Visceral
Crampy, achy, diffuse,
 Poorly localized
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Somatic
Sharp, lancinating
 Well localized
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Referred
Distant from site of generation
 Symptoms, but no signs
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Understanding the Types of
Abdominal Pain
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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
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History Taking in Abdominal
Pain Presentations
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“OLD CARS”
O- onset
 L- location
 D- duration
 C- character
 A-alleviating/aggravating factors
associated symptoms
 R- radiation
 S- severity
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History Taking for Abdominal
Pain Presentations
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PMH
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PSH
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Abx, NSAIDS, acid blockers, etc
GYN/URO
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Adhesions, hernias, tumors
MEDS
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Similar episodes in past
Other medical problems that increase
disease likelihood of problems (ex: DM
and gastroparesis)
LMP, bleeding, discharge
Social
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Tob/EtoH/drugs/home situation/agenda
Physical Exam in Abdominal
Pain Presentations
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General appearance
“Sick versus not sick”
 Mobile versus still
 Obvious pain or discomfort
 “Doorway” impression
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Vital signs
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“That’s why they’re called vital”
Physical Exam in Abdominal
Pain Presentations
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Inspection
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Distention, scars, bruises
Auscultation
Present, hyper, or absent
 Actually not that helpful!
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Palpation
Often the most helpful part of exam
 Tenderness versus pain
 Start away from painful area first
 Guarding, rebound, masses
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Physical Exam in Abdominal
Pain Presentations
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Signs
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Extra-abdominal exam
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Iliopsoas
Murphy’s
Pelvic or scrotal exams
Lungs, heart
Remember it’s a patient, not a part
Rectal
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Adds very little (despite the angst) beyond
gross blood or melena
Laboratory Testing
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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)
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Laboratory Testing
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Directed approach to lab studies
There are no “standard belly labs”
Pregnancy test in women of child
bearing age
Urine dipsticks
Imaging
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Plain films
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Free air, obstruction, air-fluid, FBs
Ultrasound
Rapid “yes or no” ED evaluations
 Formal studies
 May add doppler
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Computed Tomography
Revolutionized acute care
 Often better than we are!
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Common Diagnoses by Quadrant
Management of
Abdominal Pain
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Always right to start with ABC’s
IV access
Fluid administration
Antiemetics
Analgesics
Directed testing and imaging
Re-evaluations
Antibiotics
Consultants
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Surgeons, OB/GYN, urologists,
cardiologists, etc
Now How About Those Cases
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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.
Now How About Those Cases
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20 year old with classic
presentation of appendicitis, 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.
Now How About Those Cases
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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.
Pearls, Pitfalls and Myths
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Do not restrict the diagnosis solely by
the location of the pain.
Consider appendicitis in all patients
with abdominal pain and an appendix,
especially in patients with the
presumed diagnosis of gastroenteritis,
PID or UTI.
Do not use the presence or absence of
fever to distinguish between surgical
and medical causes of abdominal pain.
The WBC count is of little clinical value
in the patient with possible
appendicitis.
Any woman with childbearing potential
and abdominal pain has an ectopic
pregnancy until her pregnancy test
comes back negative.
Pain medications reduce pain and
suffering without compromising
diagnostic accuracy.
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An elderly patient with
abdominal pain has a high
likelihood of surgical disease.
Obtain an ECG in elderly
patients and those with
cardiac risk factors
presenting with abdominal
pain.
A patient with appendicitis by
history and physical
examination does not need a
CT scan to confirm the
diagnosis; they need an
operation.
The use of abdominal
ultrasound or CT may help
evaluate patients over the
age of 50 with unexplained
abdominal or flank pain for
the presence of AAA.
Simplified rules for the diagnosis of
acute abdominal pain.
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Think in terms of the area of the
pain.
Common conditions are common.
Disease prevalence changes with
age.
Different patterns of disease
between men and women.