Systematic Approach to Abdominal Pain Dr Devinder Singh Bansi BM DM FRCP Consultant Gastroenterologist Imperial College Healthcare NHS Trust

What Do They Have? As you go through this presentation, think about each of these cases: An 18 mo old that suddenly became inconsoleable from AP while playing A 20 yo man with 12 hours of diffuse crampy AP that migrated to RLQ that became sharp 78 yo woman with h/o chronic steroid use with sudden sharp AP and a rigid exam

Scale of the Problem GI symptoms in primary care 7.1-9.6% of all primary consultations are with regard to GI complaints Gastric pain: 5.0 per 1000/yr Regurgitation: 2.0 Abdominal pain: 6.1 Nausea: 2.9 Diarrhoea: 6.7 Constipation: 8.1 Thompson WG, Gut 2000: 46: 78-82

Scale of the Problem: Abdominal pain in the general population Community prevalence 15-20% 75% of these abdominal complaints non-consulting 25% consulting 23.5% stay in primary care 1-2% referred to secondary care

Scale of the Problem: Abdominal pain in general practice 578 cases of non-acute abdominal pain presenting to 11 general practices Follow up 15 months Females predominated in the younger age groups 80% visited GP <3 times during F/U 83% managed entirely in the practices 64% received a prescription Only 20% were additionally investigated in anyway by the GP Hardly any differences in dx between patients who had complaints less than 1 week or more than 1 week before presenting to their GP Family Practice Vol 10: 4. 387-400

Scale of the Problem: Prevalence of GI disease Peptic ulcer: 1.9 per 1000/yr Oesophagitis: 2.9 IBD: 1.5 GI cancer: 1.6 Functional dyspepsia: 12 GORD: 5.8 IBS: 10.5 80% of chronic GI disease has a functional background Thompson WG . Gut 2000: 46: 78-82

Scale of the problem; Acute abdominal pain Acute abdominal pain is not uncommon. Approximately 5 admissions to the MRI/day with acute abdominal pain from a population base of 500,000. 1 case per GP per month for an average list size of 2,000.

Acute Abdominal Pain Approximately 6% of ED visits Admission rates vary by population, up to about 65% in high risk elderly populations Most common diagnosis is NONSPECIFIC (ie, “I dunno”) Use H+P, risk factors, and directed studies to arrive at diagnosis MUST rule out emergency conditions

Acute Abdominal Pain Causes in 10320 patients Appendicitis 28% Cholecystitis 10% Small bowel obstruction 4% Gynaecological 4% Pancreatitis 3% Renal colic 3% Peptic ulcer 2% Cancer 2% No clinical diagnosis 34% De Dombal, Scand J Gastroenterol 1988

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!

Special Populations Elderly/ nursing home patients Immunocompromised Post operative patients Infants

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 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

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

Physical Exam in Abdominal Pain Presentations General appearance “Sick versus not sick” Mobile versus still Obvious pain or discomfort “Doorway” impression Vital signs “That’s why they’re called vital”

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 Iliopsoas 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 Ultrasound Computed Tomography 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

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

Now How About Those Cases 18 mo old had classic presentation of intussusception, and symptoms may wax and wane; rectal would be to look for current jelly stool. Air enema for diagnosis and reduction. Involve consultants early in the course.

Now How About Those Cases 20 year old with classic presentation of appendicitis, which likely does not need CT scan. Most do not present so simply, quite a wide array of presentations. General surgery consultation, pain meds, IVF, and an operation would all be good, but don’t be shocked if CT requested.

Now How About Those Cases 78 yo has perforated abdomen, with age, multiple problems, and chronic steroids risks for perforation. Rapid resuscitation, plain films to confirm free air, antibiotics, pain medicine, and a surgeon as fast as you can would be good practice.

Pearls, Pitfalls and Myths Do not restrict the diagnosis solely by the location of the pain. Consider appendicitis in all patients with abdominal pain and an appendix, especially in patients with the presumed diagnosis of gastroenteritis, PID or UTI. Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain. The WBC count is of little clinical value in the patient with possible appendicitis. Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative. Pain medications reduce pain and suffering without compromising diagnostic accuracy. An elderly patient with abdominal pain has a high likelihood of surgical disease. Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain. A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis; they need an operation. The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA.

Simplified rules for the diagnosis of acute abdominal pain. Think in terms of the area of the pain. Common conditions are common. Disease prevalence changes with age. Different patterns of disease between men and women.