Abdominal Pain pdf
Content
Ron Diekmann, MD
ABDOMINAL PAIN
Objectives:
1.
Distingu Distinguish ish between between somatic somatic and referred pain
2.
Nam Name the most ost common common abdominal emergenci emergencies es for each each of the major anatomic areas of the abdomen
3.
Understand Understand age-related differences in causes of abdominal abdominal pain
4.
Define Define the symptom ymptom review of patients with abdominal pain and know the significance of different historical presentations
5.
Describe Describe the physical assess ass essm ment of the the abdomen abdomen
6.
Know the value of ancillary testing in evaluation of abdominal abdominal pain
7.
P rovide the major ajor steps in E D treatment treatment of the acute abdomen
Copyright UC Regents
1
Ron Diekmann, MD
ABDOMINAL PAIN Introduction
Abdominal pain accounts for 5% of all emergency department (ED) visits and is an important and challenging component of emergency medicine practice in all center centers. s. There are myriad myriad presentations. presentations. P atients atients may have acute acute exacerbations of chronic problems (e.g., peptic disease, pancreatitis in alcoholics, inflammatory bowel disease), acute surgical abdomens (e.g., appendicitis, ruptured viscus, acute volvulus) or nonsurgical abdominal emergencies (e.g., gastritis, biliary colic, gastroenteritis). Sometimes abdominal pain is related to acute trauma (e.g., splenic rupture, hepatic laceration, small bowel rupture). The clinical evaluation, diagnostic workup and disposition of patients with acute abdominal pain vary significantly, depending upon the initial history and physical assessment. All patients with abdominal pain do not require diagnostic tests. S ometim ometimes, es, clinical clinical evaluation alone is sufficient to to provide provide treatment and appropriate disposition. Identification of the patient with an “acute abdomen” requiring immediate surgical intervention, is a critical skill for emergency emergency physicians physicians..
As ses sm ent
Appearance and general impression: As you approach the patient, consider the degree of pain and note the vital vital signs. signs. If the patient patient is obviously obviously uncomfor uncomfortable, table, select an analgesic drug for parenteral administration. Sometimes, oral medication is acceptable if the pain is not too severe. But one way or another, treat the pain immediately. If the vital vital signs signs are are abnormal (HR> (HR >100, BP <100, RR RR >20, T> T>38), approach the patient with a high degree of vigilance, and obtain vascular access early for diagnostic testing and drug and fluid administration. Pain Pain management
If the patient patient is in pain, give analgesia right away. away. Ordinarily, use use morphine morphine sulfate at 0.5-0.1 0.5-0.1 mg/kg or 2-4 mg mg IV or IM. IM. S ometim ometimes, es, especially especially if the the patient has probable renal colic, use ketolorac 30-60 mg IV or IM. In patients with low or borderline BP, BP , choose choos e the the short acting narcotic narcotic fentanyl, fentanyl, 0.5-1 ug/kg IV, IV, which is associated ass ociated with with less BP effects. These These drugs will not interfere interfere with with the the physic physical al examination, and in fact will usually enhance the sensitivity of the exam. Tip : Give mos mostt patients with severe severe abdominal abdominal pain parenteral morphine morphine immediately.
Copyright UC Regents
2
Ron Diekmann, MD
History History is the most important part of the assessment. Delineate the character of the patient's pain carefully. There are several essential ingredients of pain: 1.
Location—ask ocation—ask the the patient patient where where the the pain is. There There are six anatom anatomic ic locations: locations: RUQ, RU Q, epigast epigastriu rium m, LUQ, L UQ, RLQ, LQ , sup suprap rapub ubic, ic, and LLQ. LLQ . Pain P ain originating in any of these locations may suggest the source of the pathology. Tip: The more more midline midline the the pain is, the more more likely it is bowel based. P ain that localizes is of high concern and usually requires more diagnostic evaluation.
2. Onset—this Onset—this is a key characteristic. E xplore onset carefully carefully and determ determine trend of pain over time. Tip: P ain that begins abruptly abruptly and is undiminished undiminished suggests suggests renal colic colic,, perforated viscus, ischemia (myocardial infarction, testicular or ovarian torsion) or hemorrhage. hemorrhage.
3. S everity—this everity—this is best evaluated with with a familiar familiar 1-10 scale. scale. The value value of a pain severity scale for abdominal pain is unknown, but in any single patient it allows assessment of trends and response to therapy. 4. Quality Quality—this —this is occasionally occasionally helpful, but some patients patients are highly suggestible, suggestible, or unable to to describe pain very very precisely. Quality Quality of pain needs to be used with other characteristics for interpretation. Tip: Always inquire if the patient has had pain of this quality before. If yes, consider peptic disease, biliary disease, IBD, hepatitis, and pancreatitis.
5. Radiation (if any)— any)—when when present, this is quite helpful. P ain radiating radiating into the back or groin groin suggests renal colic. P ain into into the the right shoulder suggests biliary disease. 6. Alleviating and aggravating aggravating factors—the factors—the effect of eating on pain is especially especially valuable. valuable. P ain that that starts or gets gets worse with with eating eating is usually related to the the pancreas and gall bladder. P ain relieved by eating is often often peptic disease.
Review of systems Associated Assoc iated sympt symptom oms s are important important information information to to distinguish etiologies. etiologies. F ever and chills point to to a possible possible acute inflammatory condition. condition. P atients atients with with Copyright UC Regents
3
Ron Diekmann, MD
respiratory respiratory complaints may may have pneumonia with with upper quadrant radiation. radiation. The presence or absence of anorexia, nausea or vomiting helps diagnose or rule out certain conditions. The absence of anorexia strongly rules against against an acute inflammatory condition. Diarrhea suggests gastroenteritis but may be present with 20% of acute appendicitis. Ask women about pregnancy, vaginal bleeding, S TDs and and LMP LMP . Inquire Inquire about bowel movem movements, ents, melena melena and hematochezia, hematochezia, and symptoms of UTIs—dysuria, frequency, and back pain. Tip: Be careful calling abdominal pain gastroenteritis if diarrhea is not present.
P ast medical medical history Ask about prior abdominal surgeries. Tip : Abdominal pain w with ith vom vomiting, iting, no flatus flatus or BM, BM, and and a midline midline abdominal scar suggests an SBO.
Inquire about medical diagnoses such as DM, HTN, A fib and ESRD. In elderly patients, these conditions are associated with ischemic bowel—an elusive but sometimes lethal condition. List medications and consider iatrogenic causes of abdominal pain. Erythromycin at 500 BID causes abdominal pain in 50% of recipients. Habits Bad habits and co-morbidities strongly influence assessment. Ask about alcohol and quantity of consumption, IVDA, cocaine/amphetamine, HIV and prior bowel problems. Tip: Most alcoholics have some combination of pancreatitis, hepatitis and gastritis.
Physical Examination As you begin your hands-on examination, check for: General characteristics 1. patient appearance appearance (extremely (extremely important) important) 2. patient level of distress (after analgesia) analgesia) 3. diaphoresis ("If the the patient is sweating, so should the doctor be.") 4. abnormal vital signs signs Tip: P ersistent ersistent fever, tachycardia, tachycardia, tachypnea, tachypnea, or hypotension are red flags for serious abdominal pathology
Copyright UC Regents
4
Ron Diekmann, MD
5.
body posture. S pecifically note if the patient: patient: is writhing writhing about (suggestiv (suggestive e of renal, biliary or intestinal colic), prefers to sit, leaning forward a little (suggestive of pericarditis or pancreatitis) Tip : If the patient lies very quietly, quietly, often with with hips and knees flexed, and does not like to move, consider peritonitis.
Complete abdominal examination
After completing the rest of the exam, focus on these features of the abdomen. abdomen. But be sure you have have listened to the the lungs for crackles, crackles, palpated the back for CVA tenderness and looked in the pharynx for pharyngitistonsillitis. 1. Check for peritoneal peritoneal irritation irritation (rock gurney, gurney, ask patient to cough) 2. Inspect Inspect the the abdomen abdomen for distention, ascites, ascites, contusions 3 Aus Auscultat cultate e for the presence or absence of bowel sounds 4. P ercuss the abdomen abdomen to to determ determine ine the the presence presence of percussion percussion tenderness (optional) 5. P alpate alpate the abdomen to determine determine the location location of maximal tenderness, tenderness , the presence or absence of guarding and/or rebound tenderness, and the presence of masses, organomegaly and/or hernias. Start gently, away from the area of pain, distract the patient, and then palpate more deeply. 6.Try to elicit a Murphy’s Sign. A positive Murphy’s Sign (arrest of inspiration with the examiner’s palpating fingers in the RUQ) suggests irritation in the RUQ. It will always be present in cholecystitis, but may also occur with pancreatitis, hepatitis and even peptic disease. 7.Consider eliciting other signs, to evaluate specific anatomic areas for tenderness: a. P soas soas Sign S ign (extend (extend patient’ patient’s s leg at hip with with patient in lateral lateral decubitus position (to move psoas muscle). b. Obturator sign sign (flex and externally and internally rotate rotate hip) c. Rovsings Sign (palpation (palpation in LLQ LL Q causes pain in RLQ suggestive suggestive of appendicitis). 8. Do a rectal examination examination to to rule-out a mas mass s or foreign body and to to determine the presence of tenderness or blood. Always document whether there is rectal tenderness, the color of the stool (brown or black) and whether it is heme+ or heme-.
Copyright UC Regents
5
Ron Diekmann, MD
Tip: Sometimes tenderness on the rectal examination is the only physical finding in retroflexed appendicitis
9. Do at least a bimanual bimanual pelvic exam examination ination of wom women, en, evaluating only for CMT and adnexal masses. 10. Examine the testicles, scrotum, groin, prostate of males Diagnostic testing Obtain laboratory tests if the diagnosis is not clinically apparent, if the patient is sick, or if there is a suspected complication of a known diagnosis (e.g., rectal bleeding in IBD, fever in diverticulitis). Laboratory testing ("belly labs") CBC Electrolytes and anion gap BUN/Creatinine GlucoseLFTs (transaminases, bilirubin, albumin, alk phos)LipaseUA Upreg Tip : A fever >38, or a WBC WBC > 15K in the presence of abdominal pain suggests a serious etiology. If a clear-cut benign diagnosis such as gastroenteritis or renal colic cannot be established, image the patient. Imaging1. Abdominal CT—workhorse-imaging study. Give contrast orally and IV in most most patients. patients. S ometim ometimes es rectal contrast contrast is also als o helpful to to look for large bowel problems. Tip: Be careful giving IV contrast in patients with renal insufficiency. Consider ultrasound as an alternative alternative if possible. possible. A high creatinine >1.5 usually requires bicarbonate and fluid hydration to minimize contrast nephropathy.
2. Abdominal ultraso ultrasound—es und—especially pecially good for the the gall bladder, ovaries ovaries and scrotum 3. Abdominal film films— s—rarely rarely indicated except to evaluate an SBO SBO 4. CXR—us XR —useful eful in upper upper quadrant quadrant pain 5. E RCP —essential —essential for common duct duct obstruct obstruction ion (gallstones, (gallstones, sludge, compression, stricture) Other ancillary tests1. tests1. On patients patients who are over 40, 40, it is wise to add an E KG. This is especially especially true true in patients patients who are diabetic and/or who have epigastric pain. 2. ABGs ABGs are indicated in patients patients who who are elderly and in severe pain. Acidosis is highly suggestive of intestinal infarction (usually SMA ischemia). Copyright UC Regents
6
Ron Diekmann, MD
Differential Differential diagnosis based upon pain type Sudden onset of severe severe pain pain whi ch does not di minis h renal colic perforated viscous myocardial infarction
torsion hemorrhage (e.g., AAA)
Crampy Crampy pain biliary colic
renal colic intestinal obstr obstruction uction gastr gastroenter oenteritis itis ectopic pregnancy Severe pain renal colic intestinal infarction dissecting aortic aneurysm perforated ulcer Referred pain Some diseases outside of the abdominal cavity manifest as abdominal pain because of shared sensory afferent fibers. For example: 1. myocardial infarction may present as epigastric pain pneumonia in children often appears to be abdominal pain 2. strep tonsillitis may may present present as abdominal abdominal pain. Treatment Treatment of A bdomi nal Pain Pain
1.
2. 3.
4. 5.
6.
F luids—m luids— most patients patients with with serious abdominal abdominal pain are dehydrated. dehydrated. Unless there is concern for fluid overload in patients with CHF or ESRD, give a bolus of 1-2 liters in adults then a rapid infusion rate. Analgesia— Analgesia—give give ongoing pain relief with with morphine in most cases. cases. Antibiotics for acute inflamm inflammatory processes process es (cholecystitis, diverticulitis). Many surgeons also request broad-spectrum antibiotics for appendicitis. NG tube—dec tube—decom ompress press the the stomach stomach for S BOs, BO s, ischem ischemic ic bowel or any serious condition where the bowel has stopped working (ileus). Blood Blood transfus transfusion— ion—Us Use e in any symptom symptomatic atic hemorrhagic hemorrhagic event, event, such as a ruptured abdominal aortic aneurysm or GI bleed from an active ulcer or IBD S urgical consultation—obtain early in all patients patients with with peritonitis, peritonitis, hemorrhage, ischemia or abdominal pain of uncertain etiology
Copyright UC Regents
7
Ron Diekmann, MD
Disposition Admit
Surgery
The The su surrgical ical ser service is the best ser service ice for patie atien nts wi with acu acute inflammatory conditions (appendicitis, cholecystitis, cholangitis), ruptured viscus, severe third spacing (hemorrhagic pancreatitis), ischemic bowel, incarcerated hernia, or SBO. Medicine
The The medical ical ser service ice is usu sual allly the prefe eferred ser service ice for hepati atitis, most ost pancreatitis, peptic disease, IBD, gastroenteritis, pyelonephritis, and GI bleeds. Ob/Gyn
The The Ob/ Ob/Gyn Gyn ser service ice adm admits ov ovari arian torsi orsion on,, ectop ctopic ic pregnanci ancies es,, PID an and TOAs. Urology
The The urolog ology y ser service adm admits its scr scrot otal al and and testic sticu ular lar proble oblem ms an and complicated renal colic. Discharge Most patients can be discharged who have normal vital signs, pain controllable with with oral analgesia, analgesia, and minimal minimal exam findings. S ometim ometimes, es, acidlowering agents or antibiotics are indicated for conditions such as peptic disease or mild diverticulit diverticulitis. is. P epto-Bism epto-Bismol and anti-diarrheal agents, sometim sometimes es with with antiemetics, are useful for gastroenteritis. Remember to caution patients to return immediately if their pain becomes worse or their condition worsens. Tip: Discharged patients must be able to tolerate fluids without emesis.
Copyright UC Regents
8
ABDOMINAL PAIN
Objectives:
1.
Distingu Distinguish ish between between somatic somatic and referred pain
2.
Nam Name the most ost common common abdominal emergenci emergencies es for each each of the major anatomic areas of the abdomen
3.
Understand Understand age-related differences in causes of abdominal abdominal pain
4.
Define Define the symptom ymptom review of patients with abdominal pain and know the significance of different historical presentations
5.
Describe Describe the physical assess ass essm ment of the the abdomen abdomen
6.
Know the value of ancillary testing in evaluation of abdominal abdominal pain
7.
P rovide the major ajor steps in E D treatment treatment of the acute abdomen
Copyright UC Regents
1
Ron Diekmann, MD
ABDOMINAL PAIN Introduction
Abdominal pain accounts for 5% of all emergency department (ED) visits and is an important and challenging component of emergency medicine practice in all center centers. s. There are myriad myriad presentations. presentations. P atients atients may have acute acute exacerbations of chronic problems (e.g., peptic disease, pancreatitis in alcoholics, inflammatory bowel disease), acute surgical abdomens (e.g., appendicitis, ruptured viscus, acute volvulus) or nonsurgical abdominal emergencies (e.g., gastritis, biliary colic, gastroenteritis). Sometimes abdominal pain is related to acute trauma (e.g., splenic rupture, hepatic laceration, small bowel rupture). The clinical evaluation, diagnostic workup and disposition of patients with acute abdominal pain vary significantly, depending upon the initial history and physical assessment. All patients with abdominal pain do not require diagnostic tests. S ometim ometimes, es, clinical clinical evaluation alone is sufficient to to provide provide treatment and appropriate disposition. Identification of the patient with an “acute abdomen” requiring immediate surgical intervention, is a critical skill for emergency emergency physicians physicians..
As ses sm ent
Appearance and general impression: As you approach the patient, consider the degree of pain and note the vital vital signs. signs. If the patient patient is obviously obviously uncomfor uncomfortable, table, select an analgesic drug for parenteral administration. Sometimes, oral medication is acceptable if the pain is not too severe. But one way or another, treat the pain immediately. If the vital vital signs signs are are abnormal (HR> (HR >100, BP <100, RR RR >20, T> T>38), approach the patient with a high degree of vigilance, and obtain vascular access early for diagnostic testing and drug and fluid administration. Pain Pain management
If the patient patient is in pain, give analgesia right away. away. Ordinarily, use use morphine morphine sulfate at 0.5-0.1 0.5-0.1 mg/kg or 2-4 mg mg IV or IM. IM. S ometim ometimes, es, especially especially if the the patient has probable renal colic, use ketolorac 30-60 mg IV or IM. In patients with low or borderline BP, BP , choose choos e the the short acting narcotic narcotic fentanyl, fentanyl, 0.5-1 ug/kg IV, IV, which is associated ass ociated with with less BP effects. These These drugs will not interfere interfere with with the the physic physical al examination, and in fact will usually enhance the sensitivity of the exam. Tip : Give mos mostt patients with severe severe abdominal abdominal pain parenteral morphine morphine immediately.
Copyright UC Regents
2
Ron Diekmann, MD
History History is the most important part of the assessment. Delineate the character of the patient's pain carefully. There are several essential ingredients of pain: 1.
Location—ask ocation—ask the the patient patient where where the the pain is. There There are six anatom anatomic ic locations: locations: RUQ, RU Q, epigast epigastriu rium m, LUQ, L UQ, RLQ, LQ , sup suprap rapub ubic, ic, and LLQ. LLQ . Pain P ain originating in any of these locations may suggest the source of the pathology. Tip: The more more midline midline the the pain is, the more more likely it is bowel based. P ain that localizes is of high concern and usually requires more diagnostic evaluation.
2. Onset—this Onset—this is a key characteristic. E xplore onset carefully carefully and determ determine trend of pain over time. Tip: P ain that begins abruptly abruptly and is undiminished undiminished suggests suggests renal colic colic,, perforated viscus, ischemia (myocardial infarction, testicular or ovarian torsion) or hemorrhage. hemorrhage.
3. S everity—this everity—this is best evaluated with with a familiar familiar 1-10 scale. scale. The value value of a pain severity scale for abdominal pain is unknown, but in any single patient it allows assessment of trends and response to therapy. 4. Quality Quality—this —this is occasionally occasionally helpful, but some patients patients are highly suggestible, suggestible, or unable to to describe pain very very precisely. Quality Quality of pain needs to be used with other characteristics for interpretation. Tip: Always inquire if the patient has had pain of this quality before. If yes, consider peptic disease, biliary disease, IBD, hepatitis, and pancreatitis.
5. Radiation (if any)— any)—when when present, this is quite helpful. P ain radiating radiating into the back or groin groin suggests renal colic. P ain into into the the right shoulder suggests biliary disease. 6. Alleviating and aggravating aggravating factors—the factors—the effect of eating on pain is especially especially valuable. valuable. P ain that that starts or gets gets worse with with eating eating is usually related to the the pancreas and gall bladder. P ain relieved by eating is often often peptic disease.
Review of systems Associated Assoc iated sympt symptom oms s are important important information information to to distinguish etiologies. etiologies. F ever and chills point to to a possible possible acute inflammatory condition. condition. P atients atients with with Copyright UC Regents
3
Ron Diekmann, MD
respiratory respiratory complaints may may have pneumonia with with upper quadrant radiation. radiation. The presence or absence of anorexia, nausea or vomiting helps diagnose or rule out certain conditions. The absence of anorexia strongly rules against against an acute inflammatory condition. Diarrhea suggests gastroenteritis but may be present with 20% of acute appendicitis. Ask women about pregnancy, vaginal bleeding, S TDs and and LMP LMP . Inquire Inquire about bowel movem movements, ents, melena melena and hematochezia, hematochezia, and symptoms of UTIs—dysuria, frequency, and back pain. Tip: Be careful calling abdominal pain gastroenteritis if diarrhea is not present.
P ast medical medical history Ask about prior abdominal surgeries. Tip : Abdominal pain w with ith vom vomiting, iting, no flatus flatus or BM, BM, and and a midline midline abdominal scar suggests an SBO.
Inquire about medical diagnoses such as DM, HTN, A fib and ESRD. In elderly patients, these conditions are associated with ischemic bowel—an elusive but sometimes lethal condition. List medications and consider iatrogenic causes of abdominal pain. Erythromycin at 500 BID causes abdominal pain in 50% of recipients. Habits Bad habits and co-morbidities strongly influence assessment. Ask about alcohol and quantity of consumption, IVDA, cocaine/amphetamine, HIV and prior bowel problems. Tip: Most alcoholics have some combination of pancreatitis, hepatitis and gastritis.
Physical Examination As you begin your hands-on examination, check for: General characteristics 1. patient appearance appearance (extremely (extremely important) important) 2. patient level of distress (after analgesia) analgesia) 3. diaphoresis ("If the the patient is sweating, so should the doctor be.") 4. abnormal vital signs signs Tip: P ersistent ersistent fever, tachycardia, tachycardia, tachypnea, tachypnea, or hypotension are red flags for serious abdominal pathology
Copyright UC Regents
4
Ron Diekmann, MD
5.
body posture. S pecifically note if the patient: patient: is writhing writhing about (suggestiv (suggestive e of renal, biliary or intestinal colic), prefers to sit, leaning forward a little (suggestive of pericarditis or pancreatitis) Tip : If the patient lies very quietly, quietly, often with with hips and knees flexed, and does not like to move, consider peritonitis.
Complete abdominal examination
After completing the rest of the exam, focus on these features of the abdomen. abdomen. But be sure you have have listened to the the lungs for crackles, crackles, palpated the back for CVA tenderness and looked in the pharynx for pharyngitistonsillitis. 1. Check for peritoneal peritoneal irritation irritation (rock gurney, gurney, ask patient to cough) 2. Inspect Inspect the the abdomen abdomen for distention, ascites, ascites, contusions 3 Aus Auscultat cultate e for the presence or absence of bowel sounds 4. P ercuss the abdomen abdomen to to determ determine ine the the presence presence of percussion percussion tenderness (optional) 5. P alpate alpate the abdomen to determine determine the location location of maximal tenderness, tenderness , the presence or absence of guarding and/or rebound tenderness, and the presence of masses, organomegaly and/or hernias. Start gently, away from the area of pain, distract the patient, and then palpate more deeply. 6.Try to elicit a Murphy’s Sign. A positive Murphy’s Sign (arrest of inspiration with the examiner’s palpating fingers in the RUQ) suggests irritation in the RUQ. It will always be present in cholecystitis, but may also occur with pancreatitis, hepatitis and even peptic disease. 7.Consider eliciting other signs, to evaluate specific anatomic areas for tenderness: a. P soas soas Sign S ign (extend (extend patient’ patient’s s leg at hip with with patient in lateral lateral decubitus position (to move psoas muscle). b. Obturator sign sign (flex and externally and internally rotate rotate hip) c. Rovsings Sign (palpation (palpation in LLQ LL Q causes pain in RLQ suggestive suggestive of appendicitis). 8. Do a rectal examination examination to to rule-out a mas mass s or foreign body and to to determine the presence of tenderness or blood. Always document whether there is rectal tenderness, the color of the stool (brown or black) and whether it is heme+ or heme-.
Copyright UC Regents
5
Ron Diekmann, MD
Tip: Sometimes tenderness on the rectal examination is the only physical finding in retroflexed appendicitis
9. Do at least a bimanual bimanual pelvic exam examination ination of wom women, en, evaluating only for CMT and adnexal masses. 10. Examine the testicles, scrotum, groin, prostate of males Diagnostic testing Obtain laboratory tests if the diagnosis is not clinically apparent, if the patient is sick, or if there is a suspected complication of a known diagnosis (e.g., rectal bleeding in IBD, fever in diverticulitis). Laboratory testing ("belly labs") CBC Electrolytes and anion gap BUN/Creatinine GlucoseLFTs (transaminases, bilirubin, albumin, alk phos)LipaseUA Upreg Tip : A fever >38, or a WBC WBC > 15K in the presence of abdominal pain suggests a serious etiology. If a clear-cut benign diagnosis such as gastroenteritis or renal colic cannot be established, image the patient. Imaging1. Abdominal CT—workhorse-imaging study. Give contrast orally and IV in most most patients. patients. S ometim ometimes es rectal contrast contrast is also als o helpful to to look for large bowel problems. Tip: Be careful giving IV contrast in patients with renal insufficiency. Consider ultrasound as an alternative alternative if possible. possible. A high creatinine >1.5 usually requires bicarbonate and fluid hydration to minimize contrast nephropathy.
2. Abdominal ultraso ultrasound—es und—especially pecially good for the the gall bladder, ovaries ovaries and scrotum 3. Abdominal film films— s—rarely rarely indicated except to evaluate an SBO SBO 4. CXR—us XR —useful eful in upper upper quadrant quadrant pain 5. E RCP —essential —essential for common duct duct obstruct obstruction ion (gallstones, (gallstones, sludge, compression, stricture) Other ancillary tests1. tests1. On patients patients who are over 40, 40, it is wise to add an E KG. This is especially especially true true in patients patients who are diabetic and/or who have epigastric pain. 2. ABGs ABGs are indicated in patients patients who who are elderly and in severe pain. Acidosis is highly suggestive of intestinal infarction (usually SMA ischemia). Copyright UC Regents
6
Ron Diekmann, MD
Differential Differential diagnosis based upon pain type Sudden onset of severe severe pain pain whi ch does not di minis h renal colic perforated viscous myocardial infarction
torsion hemorrhage (e.g., AAA)
Crampy Crampy pain biliary colic
renal colic intestinal obstr obstruction uction gastr gastroenter oenteritis itis ectopic pregnancy Severe pain renal colic intestinal infarction dissecting aortic aneurysm perforated ulcer Referred pain Some diseases outside of the abdominal cavity manifest as abdominal pain because of shared sensory afferent fibers. For example: 1. myocardial infarction may present as epigastric pain pneumonia in children often appears to be abdominal pain 2. strep tonsillitis may may present present as abdominal abdominal pain. Treatment Treatment of A bdomi nal Pain Pain
1.
2. 3.
4. 5.
6.
F luids—m luids— most patients patients with with serious abdominal abdominal pain are dehydrated. dehydrated. Unless there is concern for fluid overload in patients with CHF or ESRD, give a bolus of 1-2 liters in adults then a rapid infusion rate. Analgesia— Analgesia—give give ongoing pain relief with with morphine in most cases. cases. Antibiotics for acute inflamm inflammatory processes process es (cholecystitis, diverticulitis). Many surgeons also request broad-spectrum antibiotics for appendicitis. NG tube—dec tube—decom ompress press the the stomach stomach for S BOs, BO s, ischem ischemic ic bowel or any serious condition where the bowel has stopped working (ileus). Blood Blood transfus transfusion— ion—Us Use e in any symptom symptomatic atic hemorrhagic hemorrhagic event, event, such as a ruptured abdominal aortic aneurysm or GI bleed from an active ulcer or IBD S urgical consultation—obtain early in all patients patients with with peritonitis, peritonitis, hemorrhage, ischemia or abdominal pain of uncertain etiology
Copyright UC Regents
7
Ron Diekmann, MD
Disposition Admit
Surgery
The The su surrgical ical ser service is the best ser service ice for patie atien nts wi with acu acute inflammatory conditions (appendicitis, cholecystitis, cholangitis), ruptured viscus, severe third spacing (hemorrhagic pancreatitis), ischemic bowel, incarcerated hernia, or SBO. Medicine
The The medical ical ser service ice is usu sual allly the prefe eferred ser service ice for hepati atitis, most ost pancreatitis, peptic disease, IBD, gastroenteritis, pyelonephritis, and GI bleeds. Ob/Gyn
The The Ob/ Ob/Gyn Gyn ser service ice adm admits ov ovari arian torsi orsion on,, ectop ctopic ic pregnanci ancies es,, PID an and TOAs. Urology
The The urolog ology y ser service adm admits its scr scrot otal al and and testic sticu ular lar proble oblem ms an and complicated renal colic. Discharge Most patients can be discharged who have normal vital signs, pain controllable with with oral analgesia, analgesia, and minimal minimal exam findings. S ometim ometimes, es, acidlowering agents or antibiotics are indicated for conditions such as peptic disease or mild diverticulit diverticulitis. is. P epto-Bism epto-Bismol and anti-diarrheal agents, sometim sometimes es with with antiemetics, are useful for gastroenteritis. Remember to caution patients to return immediately if their pain becomes worse or their condition worsens. Tip: Discharged patients must be able to tolerate fluids without emesis.
Copyright UC Regents
8
