Resident Version

Abdominal Pain Module

Created by Dr. Robert Leverence

Objectives:

1)  List four important causes of abdominal pain for patients who present to the Emergency Department.

2)  Recognize a surgical abdomen based on three clinical criteria.

3)  Identify three steps for the assessment and management of patients presenting with abdominal pain.

References:

1.  Kamin RA, Nowicki TA, et al. Pearls and pitfalls in the emergency department evaluation of abdominal pain. Emerg Med Clin N Am 21 2003; 61-72.

2.  Powers RD, Guertler AT. Abdominal Pain in the ED: Stability and Change Over 20 Years. American Journal of Emergency Medicine 1995:13: 301-03.

3.  Gerhardt RT, Nelson BK, et al. Derivation of clinical guideline for the assessment of nonspecific abdominal pain: the Guideline for Abdominal Pain in the ED Setting (GAPEDS) Phase 1 Study. American Journal of Emergency Medicine 2005: 23:709-17.

CASE

HPI: A 70 yo female presents with a two day history of generalized abdominal pain and bloating. She is not able to characterize the pain any further. Onset was two days ago, prior to that she felt normal. She has vomited twice but has been tolerating sips of fluids. No BM for 3 days, but has been passing small amounts of gas intermittently. Has not noticed any blood in the last BM or vomitus. No fevers or night sweats. No new foods or recent travel. Some mild dysuria.

PMH:

1.  S/P appendectomy 40 yrs ago

2.  S/P TAH BSO for stage I endometrial cancer 5 yrs ago

3.  “PUD”

4.  Recurrent UTIs

Medications:

1.  Nexium 20 mg daily

2.  MVI with Calcium

Shx:

Lives alone although daughter lives nearby. Denies alcohol or tobacco use.

PE: T37.7, P100, BP 100/60, RR 18, O2 NL on RA

General- patient laying quietly in bed, groaning. Conversant although slightly confused.

HEENT – normal, notable for no icterus.

Lungs - clear to auscultation, no crackles or wheezes appreciated.

CV – mildly tachycardic, regular rhythm, no murmur, gallop, nl JVD

Abd – obese, soft, mildly distended with mild generalized tenderness, no localizing signs. Voluntary guarding, no rebound. Bowel sounds are diminished. No palpable masses.

Ext - fem pulses 2+ bilat.

Rectal: guaiac negative, vault fairly empty.

Labs/Studies:

WBC 11.0 with left shift, Hct 36, Plt 400

Chemistries all normal including LFTs, Amylase, Lipase.

UA - 1+ heme, 5 RBC, 12 WBC, many bacteria.

3 way of abdomen x-ray: non-specific mildly dilated loops of bowel, no free air. Moderate amount of stool present, air in rectum.

CXR: clear.

1. What would be on your differential for this patient for causes of abdominal pain?

2. What would be your management based on most likely diagnosis, and what further imaging/studies need to be obtained?

Discussion Outline:

I. Epidemiology: Abdominal pain is common. It is present on questioning of 75% of otherwise healthy adolescents and about half of all adults in the general population. Many if not most of these cases would be given the diagnosis of nonspecific abdominal pain (NSAP). In the population of patients presenting to an Emergency Department, the prevalence of NSAP would be lower, yet still not negligible. Table 1 summarizes the cause of abdominal pain in 1000 patients presenting to a large tertiary care university emergency department.

Table1. Cause of abdominal pain in 1000 consecutive ED patients

Diagnois / % Patients

NSAP

/ 24.9%

Specific GI

/ 18.4%
Gastritis / 5.3%
Pancreatitis / 3.9%
Constipation / 3.3%
Ulcer / 1.5%
Hernia / 1.4%
Malignancy, Diverticular Disease, Esophagitis, Fecal impaction, Crohn’sDisease, Ileus, Alcoholic Hepatitis / <1.0%

Female pelvic

/ 11.7%
Pelvic inflammatory disease / 3.4%
Ovarian cyst / 1.9%
Dysmenorrhea / 1.9%
Vaginitis/cervicitis / 1.3%
Menometrorrhagia, Intrauterine pregnancy, Misscarriage,
Threatoned abortion, Ectopic pregnancy, other / <1.0%

Urinary tract

/ 11.5%
Cystitis / 6.6%
Ureteral calculus / 2.8%
Pyelonephritis / 1.4%
Prostatitis / 0.4%
Epididymitis / 0.2%
Urinary retention / 0.1%

Nausea/Vomiting

/ 9.7%

GI surgical

/ 7.6%
Cholecystitis / 3.6%
Bowel obstruction / 1.6%
Appendicitis / 1.4%
Hernia, Mesenteric Insufficiency, Peritonitis / <1.0%

Other

/ 6.4%
Musculoskeletal / 2.9%
Cardiovascular / 1.5%
Psych / 1.2%
Infectious / 0.8%

Unspecified

/ 8.9%

Table adapted from Powers RD, Guertler AT. See reference number 2.

II. History and Physical: Physicians are responsible for trying to determine which patients require urgent intervention and which can be safely observed. Generally we are fairly accurate at recognizing the acute or surgical abdomen (obstruction or peritonitis), however for the remaining patients, our sensitivity for recognizing conditions which require other urgent intervention may be as low as 30-50%.

Table 2. Diagnoses requiring urgent intervention (i.e. you don’t want to miss)

Abdominal aortic aneurysm / Liver abscess
Aortic dissection / Mesenteric ischemia/ischemic colitis
Appendicitis / Neoplasm, newly diagnosed
Bowel obstruction / Ovarian cyst, ruptures with hemorrhage
Choledocolithiasis, with or without ascending cholangitis / Pancreatitis, with or without cholelithiasis
Cholecystitis / Perforated viscus
Colitis or regional ileitis / Pyelonephritis
Diverticulitis, with or without perforation / Renal arterial or venous thrombosis
Gastrointestinal hemorrhage / Sigmoid volvulus
Hepatitis, acute fulminant / Spontaneous bacterial peritonitis
Ileus / Tubo-ovarian abscess

Table adapted from Gerhardt RT et al, see reference 3.

History:

·  Duration, characterization, location and radiation of pain

·  Factors that exacerbate or improve pain (e.g. foods, exertion)

·  Associated symptoms (e.g. F/C/N/V/D/ bloody stools)

·  Alcohol intake/medications (e.g. NSAIDs, immunosuppressants)

·  Past h/o abdominal surgery, PUD, nephrolithiasis, malignancy, radiation, etc.

·  Menstrual and OB/gyn history in women. Pay particular attention to h/o PID or current IUD use.

Physical exam:

·  Vital signs

·  General: Does this patient look ill*? Is patient writhing in pain or avoid movement? Does the pain worsen when you bump the bed?

·  Examine eyes and skin for jaundice

·  Bowel sounds – high pitched* or diminished*?

·  Palpate to localize pain, for rebound tenderness or rigidity, for mass or HSM, distension or tympany*

·  DRE and test stool for occult blood

·  Pelvic exam in all women with lower abdominal pain.

*Bold indicates findings in obstruction, italics indicate findings in peritonitis, and bold italics indicate findings in both.

Diagnostic Investigations:

CBC with differential, electrolytes, BUN, creatinine, glucose

·  LFTs, Amylase/Lipase

·  Urinalysis

·  Pregnancy test in all women of childbearing potential

·  Blood cultures and urine cultures if unstable VS, fever/elevated wbc, or risk factors present (immunosuppressed, line in place, IVDU, etc.)

·  Abdominal radiographs (plain radiograph and an upright or lateral decubitus radiograph – proximally dilated loops of bowel are the hallmark for obstruction and free intraperitoneal air can confirm hollow organ perforation).

·  EKG in elderly

III. Management: Many patients will not have a firm diagnosis after initial assessment (we call this nonspecific or undifferentiated abdominal pain), and in these cases, careful observation of the patient’s course will be the most important factor in their management. It is here that good clinical acumen (and admittedly a little luck) comes into play.

·  A nonenhanced CT is a rational choice for decision support.

·  For women with lower abd pain, a pelvic ultrasound should be considered.

·  Elderly patients with abdominal pain have a much higher mortality rate due to a) lack of physical findings, b) delay in seeking medical care, and c) their increased prevalence of disorders such as mesenteric ischemia, leaking/ruptured AAA, and MI. For these reasons, our threshold for admission is lower in the elderly.

·  If observation at home is decided, then a clear and detailed follow-up plan must be arranged.


Review Questions

  1. A 62-year-old woman presents to the emergency department complaining of intense abdominal pain, nausea, and vomiting for the past 48 hours. On physical examination, the patient is visibly uncomfortable, with a low-grade fever, mild tachycardia, and normal blood pressure; her upper abdomen is markedly tender. Laboratory tests are remarkable for an amylase of 1150, bilirubin of 2.5, and creatinine of 2.3.

Which of the following is the most useful imaging test to determine whether this patient’s pancreatitis is caused by gallstones?

A. Plain film

B. Ultrasonography

C. CT scan

D. Endoscopic retrograde cholangiopancreatography (ERCP)

2.  A 49-year-old man presents with right upper quadrant abdominal pain that began 8 hours ago. The pain is constant and is associated with nausea, vomiting, and fever. Over the past few months, he has had intermittent episodes of similar pain, but those were less intense, resolved spontaneously within 1 or 2 hours, and were never associated with vomiting or fever. Results of physical examination are as follows: temperature, 101.3° F (38.5° C); blood pressure, 130/90 mm Hg; pulse 90 beats/min; and respirations, 16 breathes/min. The patient looks tired and moderately uncomfortable. Bowel sounds are present, but he had right upper quadrant tenderness. There is no palpable liver or gallbladder. Laboratory results are remarkable for a white blood cell count of 14,000, with a left shift. Bilirubin, amylase, and alkaline phosphatase levels are normal.

Which of the following is the best diagnostic imaging test for this patient?

A. Oral cholecystogram

B. HIDA scan

C. Ultrasound

D. CT scan

E. Plain abdominal x-ray

  1. A 54-year-old man presents with a 3-day history of left lower quadrant pain. He reports that his appetite has decreased and that he had been experiencing mild nausea. He denies having any significant changes in bowel function, hematochezia, or melena. On examination, his temperature is 101.3° F (38.5° C) and his blood pressure is 145/84 mm Hg. He has significant tenderness in the left lower quadrant, with some mild local fullness. No rebound is appreciated. The white blood cell count is 13,400.

What is the most appropriate diagnostic test for this patient?

A. Barium enema

B. Colonoscopy

C. Abdominal CT

D. Anoscopy

E. Diagnostic laparotomy

  1. A 67-year-old woman presents to the office with 6 days of mild left-lower-quadrant cramping. She describes previous bouts of diverticulitis similar in character. She denies having fever, chills, nausea, or evidence of gastrointestinal bleeding. On examination, she is afebrile with mild left-lower-quadrant tenderness. A presumptive diagnosis of diverticulitis is made. She denies having any allergies to medication.

What is the most appropriate choice for antibiotic monotherapy?

A. Metronidazole

B. Amoxicillin-clavulanate

C. Cephalexin

D. Clindamycin

E. Azithromycin

Post Module Evaluation

Please place completed evaluation in an interdepartmental mail envelope and address to Dr. Wendy Gerstein, Department of Medicine, VAMC (111).

1) Topic of module:______

2) On a scale of 1-5, how effective was this module for learning this topic? ______

(1= not effective at all, 5 = extremely effective)

3) Were there any obvious errors, confusing data, or omissions? Please list/comment below:

______

4) Was the attending involved in the teaching of this module? Yes/no (please circle).

5) Please provide any further comments/feedback about this module, or the inpatient curriculum in general:

6) Please circle one:

Attending Resident (R2/R3) Intern Medical student