Approach to Abdominal Pain in the Emergency Department Sezgin Sarıkaya, Assoc. Prof. MD, MBA Department of Emergency Medicine Yeditepe University

Introduction At the end of this lecture you should: Understand the generation and presentation of types of abdominal pain Develop critical elements of the history and physical for AP Apply knowledge of utility of testing to diagnostic approach Apply management principles to patient care in the ED

The Epidemiology of Acute Abdominal Pain 5-10% of all ED visits. Among them, 14-40% patients need surgical intervention. Most common diagnosis is NONSPECIFIC (ie, “I dunno”) Challenge for emergency physician (EP): About 1/3 have an atypical presentation. If misdiagnosis, mortality rate 2.5 times higher than correct diagnosis in the elderly.

Elderly/ nursing home patients Immunocompromised (e.g. HIV) Three Subgroups of Patients with Abdominal Pain Who deserve Particular Focus Elderly/ nursing home patients Immunocompromised (e.g. HIV) Women of childbearing age. Post operative patients Infants

The Most Important Concept for EP in Approaching Abdominal Pain To Differentiate Who is the patient of acute abdomen? What are the probable diagnoses you have in mind? Why do you consider such diagnosis? How do you prove it? When will you consult surgeon for operation?

Causes of Acute Abdominal Pain in the ED Cause Percentage of Cases Nonspecific abdominal pain 41-46 Appendicitis 4-24 Cholecystitis 2.5-9 Gastroenteritis 7 Salpingitis 2-7 UTI 3-5 Small-bowel obstruction 2.5-4 Renal colic 1.5-4 Constipation 2 Pancreatitis 1-2 Diverticulitis 1-2 Abdominal aneurysm, ectopic pregnancy <1 (Brewer et al., 1979; Scand J Gastroenterol)

Abdominal Pain Across the Ages Colic, GE, viral illness, constipation Ages 2-12 Functional, appendicitis, GE, toxins Teens to adults Addition of genitourinary problems Elderly Beware of what seems like everything!

Important Extra-abdominal Causes of Abdominal Pain Systemic DKA Alcoholic ketoacidosis Uremia Sickle cell disease Porphyria SLE Vasculitis Glaucoma Hyperthyroidism Toxic Methanol poisoning Heavy metal toxicity Scorpion bite Black widow spider bite Thoracic Myocardial infarction/ Unstable angina

Important Extra-abdominal Causes of Abdominal Pain Pneumonia Pulmonary embolism Herniated thoracic disc (neuralgia) Genitourinary Testicular torsion Renal colic Infectious Strep pharyngitis (more often in children) Rocky Mountain Spotted Fever Mononucleosis Abdominal wall Muscle spasm Muscle hematoma Herpes zoster Emerg Med Clin North Am 1989; 7: 21-740

Abdominal Pain in the Elderly 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

What’s the Problem Imprecise pain generation and transmission to the central nervous system Comorbid diseases Developmental stage Medications Social factors

Understanding the Types of Abdominal Pain Visceral Stretch fibers in capsules or walls of hollow viscus that enter both sides of spinal cord Somatic Fibers dermatomally distributed and enter unilaterally in the spinal cord Referred Overlap of fibers from other locations

Understanding the Types of Abdominal Pain Visceral Crampy, achy, diffuse, Poorly localized Somatic Sharp, lancinating Well localized Referred Distant from site of generation Symptoms, but no signs

Understanding the Types of Abdominal Pain 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

Visceral

Somatic

History Taking in Abdominal Pain Presentations “OLD CARS” O- onset L- location D- duration C- character A-alleviating/aggravating factors associated symptoms R- radiation S- severity

History Taking for Abdominal Pain Presentations PMH Similar episodes in past Other medical problems that increase disease likelihood of problems (ex: DM and gastroparesis) PSH Adhesions, hernias, tumors MEDS Abx, NSAIDS, acid blockers, etc GYN/URO LMP, bleeding, discharge Social Tob/EtoH/drugs/home situation/agenda

Karın boşluğunun (abdominal kavitenin) ·        Üst sınırı diyafram ·        Alt sınırı pelvis ·        Arka sınırı lumbal omurlar ·        Ön sınırı karın duvarı kasları  

PERİTON Karın boşluğunu çevreler · Çift katlıdır : Visseral periton   PERİTON Karın boşluğunu çevreler ·        Çift katlıdır :  Visseral periton  Pariyetal periton ·        Karın boşluğunu ikiye böler:  Peritoneal boşluk  Retroperitoneal aralık

karın ağrısı olan hastanın tanı ve tedavisi hekimler için hala önemli klinik sorunların başında gelmektedir

Physical Exam in Abdominal Pain Presentations Inspection Distention, scars, bruises Auscultation Present, hyper, or absent Actually not that helpful! Palpation Often the most helpful part of exam Tenderness versus pain Start away from painful area first Guarding, rebound, masses

Physical Exam in Abdominal Pain Presentations Signs Mc burney Murphy’s Extra-abdominal exam Pelvic or scrotal exams Lungs, heart Remember it’s a patient, not a part Rectal Adds very little (despite the angst) beyond gross blood or melena

Laboratory Testing 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)

Laboratory Testing Directed approach to lab studies There are no “standard belly labs” Pregnancy test in women of child bearing age Urine dipsticks

Imaging Plain films Free air, obstruction, air-fluid, FBs Ultrasound Rapid “yes or no” ED evaluations Formal studies May add doppler Computed Tomography Revolutionized acute care Often better than we are!

Common Diagnoses by Quadrant RUQ Cholecystitis Biliary colic Hepatitis Pancreatitis Renal stones PUD Pneumonia P E M I LUQ Gastritis Gastric ulcer Pancreatitis Splenomegaly Splenic rupture Renal stone Pneumonia P E M I

Common Diagnoses by Quadrants RLQ Appendicitis Renal stone Ovarian cyst Torsion Epididymitis Ectopic IBD AAA UTI LLQ Diverticulitis Renal stone Ovarian cyst Torsion Epididymitis Ectopic IBD AAA UTI

Dangerous Mimics True Diagnosis Initial Misdiagnosis Appendicitis Gastroenteritis, PID, UTI Ruptured abdominal Renal colic, diverticulitis, lumbar strain aortic aneurysm Ectopic pregnancy PID, UTI, corpus luteum cyst Diverticulitis Constipation,GE ,pyelonephritis Perforated viscus PUD, pancreatitis, nsp abdominal pain Bowel obstruction Constipation, gastroenteritis,nonspecific abdominal pain Mesenteric ischemia GE, constipation, ileus small bowel obstruction Incarcerated or Ileus or small bowel obstruction strangulated hernia Shock or sepsis from Urosepsis or pneumonia (in elderly) perforation, bleed, abdominal infection

Five Major Categories of Acute Abdomen (BIOPI) Bleeding or rupture of vessels or tumor Ischemia or Infarction Obstruction Perforation Inflammation

Common Pitfalls in Acute Appendicitis Abdominal pain and tenderness are present in nearly 100% of patients with appendicitis; other clinical features are less reliable. Fever occurs in only 16% of patients with acute appendicitis; its presence is more suggestive of appendiceal perforation. Murphy sequence appears in only 22% elderly. Perforation rate about 60% (age > 60 Y/O)

Management of Abdominal Pain Always right to start with ABC’s IV access Fluid administration Antiemetics Analgesics Directed testing and imaging Re-evaluations Antibiotics Consultants Surgeons, OB/GYN, urologists, cardiologists, etc

Disposition of Abdominal Pain Patients Operating Room Hospital bed/observation Serial labs Serial exams Home with abdominal warnings The art of emergency medicine 3 components of discharge plan Document, document, document

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