Evaluation of the ED Patient with Abdominal Pain University of Utah Medical Center Division of Emergency Medicine Medical Student Orientation

A Common Complaint 4-8% of all ED Visits Most Common Diagnoses pts > 50 Cholecystitis (21%) Nonspecific abdominal pain (16%) Appendicitis (15%) SBO (12%) Everything else (diverticulitis, hernia, cancer, vascular) Most Common Diagnoses pts < 50: Nonspecific Abdominal Pain ( ~40% ) Appendicits (32%) Cholecystitis (6%) SBO and Pancreatitis (each ~ 2%)

Key Consideration! Extensive differential Multiple Life-threatening causes AAA Perforation Obstruction Ischemia Ectopic pregnancy

Other Common Diagnoses Gastroenteritis* GERD Cholecystitis Appendicitis Obstruction Constipation* UTI* PID* *often misdiagnoses in patients w/significant abdominal pathology

H&P are key (as usual)-they help guide your workup and whittle down the large ddx Labs and Imaging are used to either support/refute your suspected diagnosis Occasionally, the labs and imaging will help come up with a diagnosis when the history and exam are not particularly helpful (altered, confused pt)

Abdominal Pain History HPI Onset Palliates/Provokes Quality Radiation Severity Time course Undo (what have they done to “undo” their pain) PMH PMHx Surgical Hx Allergies Meds Social Hx EtOH

High-Yield Historical Questions. How old are you? (Advanced age means increased risk) Which came first—pain or vomiting? (Pain first is worse [i.e., more likely to be caused by surgical disease]) How long have you had the pain? (Pain for less than 48 hours is worse) Have you ever had abdominal surgery? (Consider obstruction in patients who report previous abdominal surgery) Is the pain constant or intermittent? (Constant pain is worse) Have you ever had this before? (A report of no prior episodes is worse) Do you have a history of cancer, diverticulosis, pancreatitis, kidney failure, gallstones, or inflammatory bowel disease? (All are bad)

High-Yield Historical Questions. Do you have HIV? (Consider occult infection or drug- related pancreatitis) How much alcohol do you drink per day? (Consider pancreatitis, hepatitis, or cirrhosis) Are you pregnant?( Test for pregnancy—consider ectopic pregnancy) Are you taking antibiotics or steroids? (These may mask infection) Did the pain start centrally and migrate to the right lower quadrant? (High specificity for appendicitis) Do you have a history of vascular or heart disease, hypertension, or atrial fibrillation? (Consider mesenteric ischemia and abdominal aneurysm)

Physical Exam Vitals Look Listen Percussion Palpation- where tender, rebound or guarding? Rectal and Pelvic-as indicated by history and exam Rebound tenderness 81% sensitive, 50% specific for peritonitis 63-76% sensitive, 56-69% specific for appendicitis

Rectal Exam Generally indicated only in those with symptoms referable to the rectal/anal area or suspected GI bleeding, otherwise rarely useful in generalized abdominal pain workup Prostatitis GI bleeding: upper or lower Hemorrhoids Constipation: possible impaction? Bloody diarrhea (enteritis)

Causes of Abdominal Pain by Quadrants RUQ LUQ Gastric/Peptic Ulcer Biliary Disease Hepatitis Pancreatitis Retrocecal Appendicitis Renal Stone Pyelonephritis MI Pulmonary Embolus Pneumonia Gastric Ulcer Gastritis Splenic injury RLQ LLQ Appendicitis Ovarian Cyst Mittelschmerz Pregnancy Tubo-ovarian abscess PID Ovarian Torsion Cystitis Prostatitis Ureteral Stone Testicular Torsion Epididymitis Diverticulitis AAA

Stop and Think Differential Diagnosis Knowing that labs and radiographic studies will only aid what you already suspect, identify needed treatments and start them empirically as dictated by pt condition

Laboratory Studies These will rarely clinch diagnosis CBC Anywhere from 10-60% of patients with surgically proven appendicitis have an initially normal white count An elevated white count detects a mere 53% of severe abdominal pathology. Electrolyte, Lipase, UA, LFTs Pregnancy Test! ECG (especially in elderly)

Radiographic Studies- Plain Film Really only helpful in ED for: Free air (suspected perforation) Dilated loops of bowel with air fluid levels (obstruction) Foreign body Free air seen in only 30-50% of bowel perforation

Sigmoid Volvulus

Sigmoid Volvulus

Sigmoid Volvulus

What’s wrong with this picture??

Radiology- Ultrasound Excellent for Biliary Tract Disease (very sensitive for Gallstones (90+%) AAA- can rapidly assess size at bedside Ectopic Pregnancy- look for intrauterine yolk sac, assess adnexa, assess for free fluid Appendicitis- 75%-90% sensitive (in experienced hands, best in thin patients) Not routinely done in this country. May change. Pelvic structures, testicles

Gallstones

AAA

Radiology- CT Scan Detect Leaking AAA ( in stable patient ) Excellent for Renal Calculi Evaluate for appendicitis, perforation (free air), diverticulitis, abscess, mesenteric ischemia, masses, obstruction The sensitivity and specificity for these vary. Nothing is 100% accurate Not a place for unstable patients

Kidney Stones- CT Style

Sigmoid Tumor/Intussusception

Psoas Abscess

Retroperitoneal Abscess

TOA

Abdominal Pain in the Elderly “An M&M waiting to happen” Mortality & misdiagnosis rise exponentially w/each decade >50 yrs. Elderly generally considered 65 and older Approximately 60-70% get admitted, 40-50% go to the OR and 10% die (this is higher than mortality of acute MI at 6-8%) These patients frequently get, and deserve, a full complement of imaging and labs

Case #1- Presentation 23 yo female acute onset LLQ pain 2 hours ago Constant, no radiation, no N/V/D No exacerbating, alleviating factors No vaginal discharge

Case #1 -PMH No medical problems No medications, No allergies Surg Hx: S/P Elective Abortion 1 year ago No history of STDs, Sexually Active LMP 4 weeks ago

Case #1- Exam Vitals: P105 R20 T37.7 BP 103/58 Abd: soft, tender LLQ with guarding, no rebound pain detected Pelvic: No cervical motion tenderness, L adnexal tenderness/fullness Rectal: No masses, guaiac negative

Case #1- Differential Diagnosis Ectopic Pregnancy Ovarian Cyst Tubo-ovarian abscess Ovarian Torsion

Case#1- Intervention/Diagnosis Pregnancy Test - Negative IV Fluids - 500 cc bolus ( repeat P 90, BP110/65 ) U/S- L ovary with absent blood flow, multiple cysts Diagnosis: Ovarian Torsion Disposition: To OR by GYN

Case #2- Presentation 47 yo male with sudden onset abd pain Epigastric pain, vomited x2 Pain 10/10 Better if holds still, worse on car ride into hospital Never had pain like this before

Case #2- Past Medical History Medical Hx: Arthritis, Chronic Low Back Pain Surgical Hx: L knee meniscus repair Meds: No prescribed meds, OTC ibuprofen Allergies: NKDA SH: 2 beers/night

Case #2- Exam Vitals: P95 R22 T37.4 BP 124/75 O2 100% Gen: Anxious, Mild distress/diaphoretic, Remaining still Abd: Decreased BS, Severe epigastric tenderness with guarding and rebound Rectal: Guaiac positive

Case #2- Actions Large bore IV x2, Type and Screen, CBC, CMP, Lipase, Fluid bolus,ECG Acute Abdominal Series Orthostatic Vitals

Case #2 - Interventions/Diagnosis CXR reveals intra-abdominal free air Diagnosis: Perforation, likely duodenal or gastric ulcer Disposition: To OR for identification and repair

Multiple Life Threatening Causes of Abdominal Pain Identify the potential life threatening cause of the following cases. Differential diagnosis is large but consider an acute event and test your intuition

Rapid Cases #1 25 yo female Recurrent vomiting, diffuse mild pain Febrile, dehydrated, tachycardic H/O Diabetes Mellitus Diagnosis: DKA

Rapid Cases #2 Healthy 17 yo male, football player L shoulder pain, not reproducible on exam lightheaded, weak U/S with free intraperitoneal fluid Diagnosis: Splenic Lac

Rapid Cases #3 16 yo female Nausea, diffuse discomfort starting yesterday Now worse RLQ Abd exam: pain RLQ, +guarding Diagnosis: Appendicitis

31 yo appy

73 yo appy

Rapid Case #4 65 yo male Hx of HTN, Renal Colic x3 episodes Low back pain- ?new pain Abd: obese, soft, no masses palpated U/S shows 7cm AAA

Rapid Case #5 56 yo female H/O Alcoholic Cirrhosis Diffuse abd pain, gradual onset Distended abdomen, febrile U/S: ascites Peritoneal tap >500 WBC/cc Spontaneous Bacterial Peritonitis

Rapid Case #6 32 yo female, S/P Tubal ligation 2 weeks ago Gradual onset diffuse pain N/V/D, fever Diffusely tender, guarding, + rebound CXR with free air Bowel perforation

Free Air

Rapid Case #7 82 yo male S/P distant chole, appy Gradual onset vomiting, nausea, distension Distended abdomen, increased bowel sounds KUB: multiple air fluid levels, dilated loops of small bowel Small Bowel Obstruction

Small Bowel Obstruction

Rapid Case #8 16 yo male sudden onset lower abd, scrotal pain No hx of trauma Tender L testicle to exam U/S: No vascular flow to L testicle Acute Testicular Torsion

Rapid Case #9 30 yo female, G3P3 IUD in place LLQ pain, gradually worsening today No fever, Tender L Adnexa + UPT U/S with L Adnexal Gestational Sac Ectopic Pregnancy

Rapid Case #10 4 yo male Crampy abdominal pain- crying Tender diffusely to exam, afebrile Guaiac positive stool Complete relief with enema Intussusception

Intussusception

Rapid Case #11 23 yo healthy female Severe lower abdominal pain Gradual onset, no N/V/D Abd Tender Bilateral Lower Quadrants Cervix tender with movement, UPT - Dx: PID

Rapid Case #12 82 yo Female H/O HTN, A. Fib, CAD, COPD Acute severe diffuse abd pain Exam: Soft, minimal tenderness to palpation Angiography reveals occluded SMA DX: Mesenteric Ischemia

Rapid Case #13 46 yo female, G3P3 Post Prandial Epigastric pain Exam: Obese, RUQ tender to palpation U/S: Multiple Gallstones with GB wall thickening DX: Acute Cholecystitis

Acute Cholecystitis

Rapid Case #14 78 yo male H/O HTN, DM Acute onset nausea, diaphoresis, epigastric discomfort, Exam: Mild epigastric discomfort to palpation ECG ST elevation 3mm leads II, III aVF Dx: Inferior MI

Inferior STEMI

Rapid Case # 15 65 yo female LLQ pain, gradually worsening Exam: Febrile, Tender LLQ to palpation Guaiac + stool CT: Diverticulitis with multiple microperforations Dx: Acute Diverticulitis

Do you see the free air?

Rapid Case #16 52 yo alcoholic male Diffuse abd pain, gradually worsening, vomiting recurrently Exam: soft abdomen, minimal tenderness Labs: Increased lipase Dx: Pancreatitis

Rapid Case #17 14 yo healthy male Acute crampy abd pain past day Vomiting, Diaphoretic Exam: Diffuse mildly tender abdomen with palpable firm mass in R groin Dx: Incarcerated inguinal hernia

Incarcerated Hernia

Rapid Case #18 28 yo post-partum healthy female Acute R flank pain radiating to groin Exam: Abd soft, non-tender without CVA tenderness UA with 2+ RBC, no WBCs CT with R Ureteral Calculi Dx: Renal Colic

Hydronephrosis

Renal Calculus

Hydro-ureter

UVJ Stone

Rapid Case #19 72 yo female c/o RUQ pain & cough PMHx: HTN, COPD on home O2 Vitals: T38.5 HR 105 RR 26 BP 140/90 SpO2 88% on 2L Physical: dry mucous membranes, decreased breath sounds, non-tender abdomen CXR: RLL infiltrate Diagnosis: RLL pneumonia

Summary The Differential Diagnosis of Abdominal Pain is extensive. Large. Massive even. You need to identify patterns that place a person at risk for serious causes of their pain and rule out/in those causes History and Physical are the key to narrowing the ddx Labs and Radiology support/refute your diagnosis

Summary Continued Always get Pregnancy Test (doesn’t matter if they are on OCP’s, had a tubal ligation, or swear they can’t be pregnant due to saintly behavior-OK, no, if hysterectomy or elderly) If discharging a patient, always alert patient of symptoms they should watch for and when to return If dx is “abdominal pain NOS” (unknown etiology), consider f/u, even in ED, for re-evaluation