Vishal Bhella, MD, CCFP PGY3, Academic Family Medicine Acute Abdominal Pain Vishal Bhella, MD, CCFP PGY3, Academic Family Medicine

Objectives Review relevant history for abdominal pain presentations Review differentials for various abdominal pain presentations Review some common and important presentations

History Onset – What was the patient doing when the symptoms started? Acute versus Gradual? Provoking/Palliative factors – Factors that exacerbate or improve symptoms for example food, antacids, exertion, defecation? Quality – Characteristics of pain/symptoms – Is it sharp or dull? Is it constant or it comes and goes?

History continued Region/Radiation – Can you point with one finger where it hurts the most? Does the pain radiate or move anywhere else? Severity - On a scale of 1 to 10, how would you rate your level of discomfort right now? Using the same scale, how would you rate your discomfort when it first began? Timing - When did the symptoms first begin? Have you ever experienced these symptoms before? If so, when?

History continued Associated symptoms: fevers, chills, weight loss/gain, nausea, vomiting, diarrhea, constipation, melena, jaundice, change of colour of urine or stool Past medical and surgical history Family history Alcohol intake/Smoking Medications including NSAIDS Women: Menstrual history, ?Pregnancy

Is this a surgical abdomen? The 'surgical abdomen' can be usefully defined as a condition with a rapidly worsening prognosis in the absence of surgical intervention Two syndromes that constitute urgent surgical referrals are complete obstruction and peritonitis. Patients with peritonitis tend to lie very still to minimize discomfort Peritonitis manifests on physical examination as rebound tenderness, or pain upon removal of pressure rather than application of pressure to the abdomen. Rigidity and tenderness with percussion Often patients will be guarding during physical examination .

Obstruction Obstruction presents as pain with anorexia, bloating, nausea and vomiting along with constipation and obstipation Patients who have evolved from partial to complete bowel obstruction may present with weeks of vague abdominal pain, followed by a sudden deterioration Typically in cases of surgical abdomen – pain is severe and it can be associated with unstable vital signs, fever, and dehydration.

Investigations Patients with a surgical abdomen – consider the following laboratory measurements: CBC, Electrolytes, BUN, creatinine, and glucose LFTs: Aminotransferases, alkaline phosphatase, and bilirubin Lipase Urinalysis, Pregnancy test in women of childbearing potential In the presence of fever or unstable vital signs, blood and urine cultures should be performed. Abdominal radiograph: proximally dilated loops of bowel are the hallmark of intestinal obstruction, and free intra-peritoneal air can confirm a suspicion of hollow organ perforation In the case of suspected partial or complete intestinal obstruction, a CT scan of the abdomen is more sensitive than plain abdominal radiographs Ultrasound a good initial test to assess - ?Appendicitis/Intra-pelvic pathology/Abdominal abscess

Case 1 Mr. D is a 46 year old man complaining of stomach pain Subacute onset of epigastric pain, stable vitals, mild to moderate discomfort

Dyspepsia Dyspepsia is a group of symptoms which alerts physicians to consider diseases of the upper gastrointestinal tract including - upper abdominal discomfort, nausea, bloating, fullness and early satiety amongst others

Dyspepsia Eliminate precipitating agents – NSAIDS, Alcohol Consider trial of PPI or H2 receptor antagonist for 4 weeks H. Pylori treatment - HP-PAC-(lansoprazole, amoxicillin, clarithromycin package) Timely investigations including endoscopy is indicated for New onset symptoms over age 50 Alarm features Failure to respond to pharmacotherapy

Case 2 Mr. P is a 50 year old man complaining of nausea and vomiting Relatively sudden onset, no appetite, history of alcohol use

Pancreatitis Sudden onset epigastric pain associated with nausea, vomiting, anorexia – think pancreatitis Risk factors for pancreatitis Gallstones Alcohol use Recent ERCP Trauma Lab findings: High amylase/lipase Treatment: NPO/hydration/analgesia/antibiotics May need urgent ERCP

Epigastric pain Biliary: cholecystitis, cholelithiasis, cholangitis Cardiac: myocardial infarction, pericarditis Gastric: esophagitis, gastritis, peptic ulcer Pancreatic: mass, pancreatitis Vascular: aortic dissection, mesenteric ischemia

Case 3 Mrs. C is a 40 year old woman complaining of off/on sharp pains after eating Slightly obese lady, severe pain episodes, right upper quadrant, worse with heavy meals

Cholecystitis

Cholecystitis The patient with acute cholecystitis usually presents with unremitting and intensifying pain at the right side of the abdomen, often associated with fever and vomiting. Indicators such as right upper quadrant pain and Murphy’s sign (i.e., inspiratory arrest with palpation of the right upper quadrant) are present in about one half of older patients Complications include acute ascending cholangitis, gallbladder perforation, emphysematous cholecystitis, bile peritonitis, and gallstone ileus. Acute ascending cholangitis :Charcot’s triad (i.e., fever, jaundice, and right upper quadrant pain). The majority of patients have an elevated alkaline phosphatase level, 50 percent have positive blood cultures, and approximately 40 percent have hyperbilirubinemia. Reynold’s pentad (i.e., Charcot’s triad plus shock and mental status changes.

Right upper quadrant pain Biliary: cholecystitis, cholelithiasis, cholangitis Colonic: colitis, diverticulitis Hepatic: abscess, hepatitis, mass Pulmonary: pneumonia, embolus Renal: nephrolithiasis, pyelonephritis

Case 4 Mrs. P is a 35 year old female with left sided pain, fever, nausea. Pain is worst in left flank, having nausea, with a couple of episodes of emesis, decreased appetite

Pyelonephritis Typical microorganisms: E.coli, Klebsiella, Proteus, Enterococcus, S. Saprophyticus Symptoms – Fever, chills, nausea, vomiting, myalgia, malaise, CVA tenderness or exquisite flank pain, lower urinary tract symptoms (urgency, frequency, dysuria) Tx with 10-14 day course of Septra. Ciprofloxacin x 7 days has activity against Pseudomonas IV antibiotics in severe cases. Switch to oral when tolerating po intake

Left upper quadrant pain Cardiac: angina, myocardial infarction, pericarditis Gastric: esophagitis, gastritis, peptic ulcer Pancreatic: mass, pancreatitis Renal: nephrolithiasis, pyelonephritis Vascular: aortic dissection, mesenteric ischemia

Case 5 Mr. A is a 67 year old gentleman with sudden onset severe abdominal pain. Pain severe, sharp, mid to upper abdominal pain. Mr. A looks very unwell, is hypotensive and exhibits signs of shock and peritonitis. A pulsatile abdominal mass is noted.

AAA AAA dissection is a life threatening emergency Some other differentials in such a presentation include Perforated PUD Appendicitis/diverticulitis with perforation Mesenteric ischemia Always remember to r/o AAA and mesenteric ischemia in an elderly presenting with moderate- severe abdominal pain

Periumbilical Pain Colonic: early appendicitis Gastric: esophagitis, gastritis, peptic ulcer, small-bowel mass or obstruction Vascular: aortic dissection, mesenteric ischemia

Case 6 Ms. A is an 18 year old female presenting with nausea, vomiting and abdominal pain Acute onset, slight fever, significant right lower quadrant pain

Appendicitis Abdominal pain with anorexia, nausea and vomiting Classic pattern is pain initially periumbilical, constant, dull, poorly localized and then localized over McBurney’s point CBC may show leukocytosis β-hCG in women to rule out ectopic pregnancy Management: Hydrate, correct electrolyte abnormalities, appendectomy

Right lower quadrant pain Colonic: appendicitis, colitis, diverticulitis, IBD, IBS Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID Renal: nephrolithiasis, pyelonephritis

Case 7 Mrs. D is a 60 year old woman presenting with LLQ pain. Elderly woman with subacute onset of abdominal pain, localized peritoneal signs, lack of severe systemic symptoms

Diverticulitis Key learning points: Some differentials to consider: Generally a disease of the elderly, 20% < 50 Distinguish between complicated vs. uncomplicated diverticulitis, complicated is characterized by: Large abscess > 4cm (requires CT-guided drainage generally) Generalized peritoneal signs Fistula formations: colovesical (male), colovaginal, colocutaneous Some differentials to consider: Intra-abdominal abscess Mesenteric ischemia Ovarian cysts (consider malignancy in post-menopausal women) Renal colic, pyelonephritis/UTI

Diverticulitis Require broad-spectrum antibiotics 7-10d: Outpatient: ciprofloxacin + metronidazole Inpatient: 3rd generation cephalosporin/fluoroquinolne + metronidazole CT is best imaging modality Recurrence rate for 1st-timers ~ 60-70%; ~20% of initial presentations require surgical intervention

Left lower quadrant pain Colonic: colitis, diverticulitis, IBD, IBS Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID Renal: nephrolithiasis, pyelonephritis

Case 8 Ms. P is a 19 year old female complaining of not feeling well and having lower abdominal pain. LMP 1 week ago, is sexually active – uses OCP for birth control but no other protection. Cervical motion tenderness on pelvic exam

PID Case presents woman of child bearing age with lower abdo pain and risk factors for STI. Consider Pelvic Inflammatory Disease in this setting. Note that 1 out of 3 women with PID have a fever. As well, difficult to rule in or out PID based on history, physical or lab work. Should rule out ectopic pregnancy, ovarian abscess and appendicitis. Some other considerations include: Ovarian torsion Cystitis Large bowel: constipation, mesenteric adenitis, inflammatory bowel disease Urinary stone – bladder stone (uncommon)

PID Diagnostic Considerations: Only 1/3 women with PID have fever No history/physical/lab test can definitively rule in/out PID Minimal criteria: Lower abdo pain Adnexal tenderness Cervical motion tenderness Additional criteria: Fever > 38.3  ESR, CRP Swabs/urine confirm Gonorrhea/Chlamydia Transvaginal U/S – fluid filled tubes, tubo-ovarian complex Endometritis from endometrial biopsy / laparoscopy

PID Management: Determine if needs admission: Surgical emergencies such as appendicitis cannot be excluded. Pregnant No response to oral antimicrobial therapy Unable to follow or tolerate an outpatient oral regimen Severe illness, nausea and vomiting, or high fever Tubo-ovarian abscess Think of Gonorrhea, Chlamydia, and anerobes Outpatient therapy: 1st: Ceftriaxone 250 mg IM X1, doxycycline 100 mg po bid 14d +/- metronidazole 500 mg po bid 14d 2nd: Ofloxacin 400 mg po bid 14d +/- metronidazole 500 mg po bid 14d, OR Levofloxacin 500 mg po od 14 d +/- metronidazole 500 mg po bid 14d

Suprapubic pain Colonic: appendicitis, colitis, diverticulitis, IBD, IBS Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID Renal: cystitis, nephrolithiasis, pyelonephritis

Case 9 Ms I is a 70 year old female who presents with rapid onset of severe periumbilical abdominal pain, which is out of proportion to findings on physical examination. Nausea and vomiting are present.

Intestinal Ischemia Acute abdomen with metabolic acidosis = Ischemic bowel until proven otherwise. Risk factors: Atrial Fibrillation, CHF, Peripheral Vascular Disease, or a history of hypercoagulability, Atherosclerotic disease Common sites: Superior Mesenteric Artery supplied territory “watershed” areas of colon - splenic flexure, left colon, sigmoid colon Lab investigations: Leukocytosis. Serum lactate elevation. Amylase, LDH, CK, ALP Contrast CT CT angiography is gold standard for acute arterial ischemia Treatment: Fluid resuscitation, NPO, antibiotics, Laparotomy

Case 10 Mr. M is a 55 year old man with vague, constant, upper abdominal discomfort Sudden onset while doing errands, some SOB, worse with continued exertion, settles slightly at complete rest. Physical exam - no palpable abdominal pain.

Cardiac pain MYCARDIAL INFARCTION – Topic for another lecture.

Differential Diagnosis Should Include Extra-Abdominal Sources Toxic, MSK, Trauma, Psych Cardiac, Respiratory Metabolic, Vascular Specific diseases Gynecological, GI, Genitourinary, Vascular Organs within each system