Case #1 24 yo healthy M with one day hx of abdominal pain. Pain was generalized at first, now worse in right lower abd & radiates to his right groin. He has vomited twice today. Denies any diarrhea, fevers, dysuria or other complaints. No appetite today. ROS otherwise negative. PMHx: negative PSurgHx: negative Meds: none NKDA Social hx: no alcohol, tobacco or drug use Family hx: non-contributory Basic cases to go through the most common abd pain complaints we see in the ED

Abdominal pain What else do you want to know? What is on your differential diagnosis so far? (healthy male with RLQ abd pain….) How do you approach the complaint of abdominal pain in general? Let’s review in this lecture: Types of pain History and physical examination Labs and imaging Abdominal pain in special populations (Elderly, HIV) Clinical pearls to help you in the ED

“Tell me more about your pain….” Location Quality Severity Onset Duration Modifying factors Change over time

What kind of pain is it? Visceral Parietal Referred Involves hollow or solid organs; midline pain due to bilateral innvervation Steady ache or vague discomfort to excruciating or colicky pain Poorly localized Epigastric region: stomach, duodenum, biliary tract Periumbilical: small bowel, appendix, cecum Suprapubic: colon, sigmoid, GU tract Parietal Involves parietal peritoneum Localized pain Causes tenderness and guarding which progress to rigidity and rebound as peritonitis develops Referred Produces symptoms not signs Based on developmental embryology Ureteral obstruction → testicular pain Subdiaphragmatic irritation → ipsilateral shoulder or supraclavicular pain Gynecologic pathology → back or proximal lower extremity Biliary disease → right infrascapular pain MI → epigastric, neck, jaw or upper extremity pain

GI symptoms GU symptoms Gyn symptoms General Nausea, vomiting, hematemesis, anorexia, diarrhea, constipation, bloody stools, melena stools GU symptoms Dysuria, frequency, urgency, hematuria, incontinence Gyn symptoms Vaginal discharge, vaginal bleeding General Fever, lightheadedness

And don’t forget the history GI Past abdominal surgeries, h/o GB disease, ulcers; FamHx IBD GU Past surgeries, h/o kidney stones, pyelonephritis, UTI Gyn Last menses, sexual activity, contraception, h/o PID or STDs, h/o ovarian cysts, past gynecological surgeries, pregnancies Vascular h/o MI, heart disease, a-fib, anticoagulation, CHF, PVD, Fam Hx of AAA Other medical history DM, organ transplant, HIV/AIDS, cancer Social Tobacco, drugs – Especially cocaine, alcohol Medications NSAIDs, H2 blockers, PPIs, immunosuppression, coumadin

Physical Examination General Vital Signs Cardiac Lungs Abdomen Back Pallor, diaphoresis, general appearance, level of distress or discomfort, is the patient lying still or moving around in the bed Vital Signs Orthostatic VS when volume depletion is suspected Cardiac Arrhythmias Lungs Pneumonia Abdomen Look for distention, scars, masses Auscultate – hyperactive or obstructive BS increase likelihood of SBO fivefold – otherwise not very helpful Palpate for tenderness, masses, aortic aneurysm, organomegaly, rebound, guarding, rigidity Percuss for tympany Look for hernias! rectal exam Back CVA tenderness Pelvic exam CMT Vaginal discharge – Culture Adenexal mass or fullness Orthostatic VS are less reliable in the diabetic, elderly, those on beta-blocker. Pulse increase of 30 or presyncope on standing are highly sensitive for loss of 1 L of blood or 3L of fluid. BP changes are less reliable. Patient must be standing at least one minute before measurements are taken.

Abdominal Findings Guarding Rebound Voluntary Contraction of abdominal musculature in anticipation of palpation Diminish by having patient flex knees Involuntary Reflex spasm of abdominal muscles aka: rigidity Suggests peritoneal irritation Rebound Present in 1 of 4 patients without peritonitis Pain referred to the point of maximum tenderness when palpating an adjacent quadrant is suggestive of peritonitis Rovsing’s sign in appendicitis Rectal exam Little evidence that tenderness adds any useful information beyond abdominal examination Gross blood or melena indicates a GIB Heme positive stool – 10% of people over the age of 50 sent home with diagnosis of NSAP and heme positive stools were found to have cancer within a year. Heme positive stool in the setting of suspected PUD should elicit more urgent referral for further evaluation

Appendicitis: Psoas Sign

Appendicitis Diagnosis Treatment WBC Clinical appendicitis – call your surgeon Maybe appendicitis - CT scan Not likely appendicitis – observe for 6-12 hours or re-examination in 12 hours Treatment NPO IVFs Preoperative antibiotics – decrease the incidence of postoperative wound infections

Case #2 68 yo F with 2 days of LLQ abd pain, diarrhea, fevers/chills, nausea; vomited once at home. PMHx: HTN, diverticulosis PSurgHx: negative Meds: HCTZ NKDA Social hx: no alcohol, tobacco or drug use Family hx: non-contributory11

Case #2 Exam T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99% room air Gen: uncomfortable appearing, slightly pale Pulmonary: normal heart and lung exam, no LE edema, normal pulses Abd: soft, moderately tender in LLQ What is your differential diagnosis & what next?

Diverticulitis Risk factors Clinical features Physical Exam Diverticula Increasing age Clinical features Steady, deep discomfort in LLQ Change in bowel habits Urinary symptoms Tenesmus Paralytic ileus SBO Physical Exam Low-grade fever Localized tenderness Rebound and guarding Left-sided pain on rectal exam Occult blood Peritoneal signs Suggest perforation or abscess rupture

Diverticulitis Diagnosis Treatment CT scan (IV and oral contrast) Pericolic fat stranding Diverticula Thickened bowel wall Peridiverticular abscess Leukocytosis present in only 36% of patients Treatment Fluids Correct electrolyte abnormalities NPO Abx: gentamicin AND metronidazole OR clindamycin OR levaquin/flagyl For outpatients (non-toxic) liquid diet x 48 hours cipro and flagyl

Case #3 46 yo M with hx of alcohol abuse with 3 days of severe upper abd pain, vomiting, subjective fevers. Med Hx: negative Surg Hx: negative Meds: none; Allergies: NKDA Social hx: homeless, heavy alcohol use, smokes 2ppd, no drug use

Case #3 Exam Vital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat: 95% room air General: ill-appearing, appears in pain CV: tachycardic, normal heart sounds, pulses normal Lungs: clear Abdomen: mildly distended, moderately TTP epigastric, +voluntary guarding Rectal: heme neg stool What is your differential diagnosis & what next?