Abdominal Pain

Scenario You are called by a nurse to evaluate a patient on the inpatient medicine service with abdominal pain (cross-cover)

“Worst case scenario” DDx “Surgical abdomen” – condition with rapidly worsening prognosis without surgical intervention Obstruction Peritonitis Viscus perforation (e.g., intestine, pelvic organ) Intraperitoneal hemorrhage (e.g., ruptured AAA) Intraabdominal abscess (SBP is medically managed)

Location, location, location RUQ: Biliary colic Cholecystitis Cholangitis Hepatitis

DDx Epigastric: Pancreatitis Dyspepsia/PUD Gastroparesis Cardiac ischemia Pulmonary pathology affecting lower lungs/pleura (PNA, PE, pulmonary infarct, empyema)

DDx Lower abdominal: Colitis/enteritis (infectious, ischemic, IBD) Diverticulitis Appendicitis Cystitis Renal colic (flank), pyelonephritis (CVA tenderness) Gynecologic: PID, adnexal cysts/masses (bleeding, torsion, rupture), fibroids, ectopic

DDx Generalized: Intestinal ischemia/infarction Endocrinopathies: DKA, hypercalcemia, adrenal insufficiency Constipation Pain syndromes: functional abdominal pain, IBS, fibromyalgia, somatoform disorder, narcotic-seeking behavior

First steps Is the patient unstable (phone)? Is the patient sick (bedside)? If yes to above  ABCs, consider ICU Xfer

History All about the pain Onset, what patient was doing/had recently done (e.g. just finished a meal, ERCP yesterday) Ever had this pain before? Location, radiation Character: Dull/achy/vague (visceral) Sharp/well-localized : parietal (2/2 peritoneal irritation) Colicky Severity

History Aggravating/alleviating factors Associated symptoms Food : aggravates intestinal ischemia, alleviates some cases of PUD Position : peritonitis aggravated by any movement, pancreatitis alleviated by sitting up and leaning forward Associated symptoms N/V (bloody, bilious, feculent), diarrhea/constipation, melena/hematochezia, vaginal discharge/bleeding

History STD risk/symptoms Possibility of pregnancy Medical history: diabetes, chronic liver disease, IBD, rheumatologic disease, immunocompromised, prior abdominal surgeries

Abdominal Exam General appearance, level of discomfort Vitals: fever, HoTN Inspection Bulging (ascites, mass) Signs of chronic liver disease (jaundice, dilated superficial veins, spider angiomata) Scars Auscultation: Absent bowel sounds (adynamic ileus, advanced peritonitis) Hyperactive, high-pitched bowel sounds (early bowel obstruction)

Abdominal Exam Palpation/Percussion Gently assess for peritonitis Muscle rigidity (guarding) – may be focal or diffuse Rebound tenderness “Shake tenderness” – bump the bed Start away from the pain Tympany (distended bowel) Pain out of proportion to exam (intestinal ischemia/infarction) Murphy’s sign, hepatomegaly Ascites (SBP) Pulsatile mass (AAA)

Exam Rectal exam Pelvic exam Have to justify not doing it Impaction, tenderness, check stool for occult blood Pelvic exam If suspect pelvic pathology (e.g., woman with lower abdominal pain) Bleeding, discharge CMT Adnexal/uterine pathology Don’t forget the heart, lungs, eyes/skin (jaundice), pulses (AAA) Whole exam can be done rapidly

Labs CBC: leukocytosis, anemia CMP: hepatic/renal function, electrolytes, anion gap Lipase UA Lactate (ischemia/infarction) Urine hcg Blood Cultures: if febrile or unstable Stool Cx/O+P/C. Diff Wet mount of vaginal discharge/GC/Chlamydia Troponin, EKG ABG

Imaging Abdominal X-ray: “bones, stones, mass, and gas” Different from KUB which is centered lower in the abdomen Supine and upright/L lateral decubitus views Obstruction  proximally dilated bowel loops, air-fluid levels Viscus rupture  intraperitoneal free air (see under diaphragm, over liver) Toxic megacolon (C. Diff)  markedly dilated bowel +/- perforation Ileus, intestinal pseudoobstruction  dilated bowel extending to rectum Constipation

SBO. Centrally-located, dilated bowel with no bowel gas in “outer box” where colon normally is.

Gastric perforation from lymphoma Gastric perforation from lymphoma. Free air over liver, “Riggler’s sign” on supine film (able to see both sides of bowel wall due to presence of gas on either side of the bowel).

Imaging CT Abdomen/Pelvis (with contrast): Higher diagnostic accuracy than plain radiographs Intraperitoneal free air Obstruction (may see transition point) Intestinal ischemia Viscus inflammation Abscess AAA leak/rupture Pancreatitis

65 M c abdominal pain, lactate 9. 4 65 M c abdominal pain, lactate 9.4. Clot in aorta, SMA, bowel wall thickening (descending, transverse, ascending colon) with surrounding fluid.

Imaging Ultrasound: CXR: RUQ : cholecystitis, gallstones, biliary dilation, cholangitis Pelvic: fibroids, adnexal masses, IUP, ectopic pregnancy, free pelvic fluid Renal Pregnancy CXR: If pulmonary pathology suspected May need follow-up chest CT

Therapy/Management Consultation: Emergent surgical consult if acute abdomen Biliary consult if biliary dilation, choledocholithiasis  ERCP/MRCP GI consult if dyspepsia with red flag symptoms (e.g., dysphagia, wt. loss, persistent vomiting)  EGD +/- Bx GYN consult if complex pelvic disease

Therapy/Management Some therapeutic examples: Ileus: Decompression with NGT to suction, NPO Constipation/fecal impaction: Manual disimpaction, stool softeners, laxatives Enterocolitis, diverticulitis, cholangitis, PID: ABx

Therapy/Management Diagnosis is often unclear after initial assessment Serial assessments, watchful waiting If you didn’t document, you didn’t do it Initial assessment, f/u assessments If cross-covering, give appropriate sign-out

Take-Home Points Is the patient sick? (phone, prompt bedside assessment) R/o surgical abdomen Very focused history and exam Relevant labs and imaging (think before you order) Use your consultants Watchful waiting – good medicine when used correctly Documentation