1. Yi-Sheng Kam, D.O. CPT MC USA Dept. of Family Medicine Eisenhower Army Medical Center

2.  Abdominal pain is a common presentation in outpatient and ER visit.  Is a challenging diagnose  Most are benign but as many as 10% have sever life- threatening cause or require surgery.  Necessary for a thorough and system approach

3.  Stable vs. unstable  Unstable sign and symptoms  Severe  Rapidly worsening  Rigidity  Guarding  Rebound tenderness  Absence bowel sounds  Tachycardia and hypotension  Acute vs. chronic  Assessment of their airway, breathing, and circulation, followed by appropriate resuscitation  Once stable, the differential diagnosis can be considered in terms of symptom clusters in order to guide further management and investigation.

4.  History  Location pain, radiation, factors, nausea, vomiting, associated symptoms, duration, previous abd pain  Signs and symptoms are predictive of certain causes of abdominal pain and can narrow the differential diagnose  Alcohol intake  OTC medications  Duration  Bloody stool or melena

5.  Sign and symptoms that require urgent surgical intervention or care  Rapidly worsening condition  Unstable vitals  Pain is severe  Obstruction  anorexia, bloating, nausea, vomiting (may be bilious or feculent), distension and high-pitched or absent bowel sound  Peritonitis  Ill appearing, lie still, rigid abd, rebound tenderness

6. Key focus  Vitals  Eye and skin jaundice  Lung  Rectal and pelvic exam recommended for lower abd pain and pelvic pain  Including testing stool for occult blood

7.  Abd exam  Palpation of abdomen for masses, tenderness, and peritoneal signs  E.g  Murphy’s sign with cholecystitis  Less reliable in older patients  Psoas, Obturator, Rovsing’s sign for appendicitis  Psoas sign--pain on extension of right thigh (retroperitoneal retrocecal appendix)  Obturator sign--pain on internal rotation of right thigh (pelvic appendix)  Rovsing's sign--pain in right lower quadrant with palpation of left lower quadrant  Fullness and tenderness on right side of rectum suggest may retrocecal appendix

8.  CBC, renal, hepatic, lipase, UA, pregnancy test  Important but not sufficient to r/o surgical abdomen  Three out of four appendicitis have elevated WBC  Surgical abd is a clinic diagnosis  Cultures in presence of fever or unstable vital signs

9. Small bowelLarge bowel Diameter>3 and <5cm>5cm Position of loopsCentralPeripheral Number of loopsMany (step-ladder)Few Fluid levelsManyFew MarkingsValvaulaeHaustra Large bowel gasNoYes - Should have basic understanding and approach to reading plain abd films - Plain upright and lateral decubitus radiograph are crucial -Dilated loops of bowel hallmark of intestinal obstruction

10.  Perforation with free air  Upright chest film is best for identifying free air in the abdomen  If etiology unclear for peritonitis in stable patient  Abd u/s is test of choice (effective assessing for appendicitis, abd abscess, AA and intrapelvic pathology).

11.  If stable, CT scan more sensitive and yield better diagnosis  best film for abdomen free air, CT more sensitive  Barium avoided in suspected obstruction because may result in retention of barium and interfere with diagnostic tests.  Consider direct surgical intervention  Pulsatile abd mass, suspect ruptured AA

12.  Location of abd pain can guide initial imaging studies  RUQ and suprapubic consider Ultrasound  LUQ consider CT  RUQ consider CT with IV contrast  LLQ consider CT with oral and IV contrast  Sigmoid diverticulitis is the most common cause of left lower quadrant pain in adults, and CT has a reported sensitivity of 79 to 99 percent for detecting the condition.

13.  Common right upper quadrant pain  Obtain History and physical exam  Pulmonary symptoms consider PE (pulmonary embolism) and pneumonia  Signs/symptoms; tachypnea, hypoxia orcrackles decrease air sound  Consider chest x-ray, D-dimer and helical CT to r/o PE  Urinary symptoms  UTI vs. nephrolitiasis  CVA tenderness or suprapubic tenderness  Obtain UA; if pyuria consider UTI or pyelonephritis  Hematuria consider nephrolithiasis and consider obtain CT  Colic consider hepatobiliary cause or nephrolithiasis  Perform U/S of abd, if nondiagnostic consider nephrolithiasis

14.  Right lower quadrant pain is guided by the patient’s history of pain or signs (e.g., psoas sign, rigidity, rebound, guarding) suggestive of appendicitis should receive CT and urgent surgical consultation.  Normal CT findings should trigger additional urine, colon, or pelvic examination.

15.  Consider diverticulitis if fever and history of diverticular disease  CT with oral and IV contrast or consider empiric treatment  If no fever and diverticular disease  Consider UTI or GYN evaluation  Consider CT if abd distension, tenderness and consider rectal bleeding

16.  Certain populations in which the spectrum of disease is significantly different than the majority of patients.  Extra attention is warranted when evaluating women and older persons with abdominal pain  Female patient is challenging  Perform a pregnancy test for childbearing age  Positive pregnancy test consider transvaginal u/s to evaluate for ectopic pregnancy or pregnancy related complications  Negative pregnancy teset consider genitourinary infection with general work up for abd pain including pelvic exam.  Older patients with abdominal pain present a particular diagnostic challenge.  Disease frequency and severity may be exaggerated in this population (e.g., a higher incidence of diverticular disease or sepsis in those with urinary tract infection).  General abd pain work-up if low risk (stable vital signs, limited comorbidities) and consider UTI and diverticulitis  Perform CT and consider hospitalization if unstable vital signs or significant comorbidities and consider sepsis, perforated viscus or ischemic bowel

17.  AAA (abd aortic aneurysm)  Over 60, rapid onset of severe periumbilical pain and out of proportion findings  Risk factors include advance age, COPD, PVD, HTN, smoking and FHX  6cm is considered a threshold for surgical intervention  Mesenteric ischemia  Often out of proportion to findings on physical examination  Risk factors include advance age, atherosclerosis, cardiac arrhythmias, severe cardiac valvular disease, recent MI and intraabdominal malignancy

18.  Bowel perforation  peptic ulcer disease is the most common etiology  Sudden severe abd pain with initially local then rapidly diffuse  Tympanitic is drum like resonance obtained by percussing over a large space filled with air  Acute bowel obstruction  majority of bowel obstructions involve the small intestine  Common symptoms of SBO (small bowl obstruction) are abdominal distention, vomiting, crampy abdominal pain, and inability to pass flatus.  Most common cause of SBO is adhesions, other common causes are hernia and neoplasm

19.  Volvulus  Cecal  similar presentation to SBO  Pain usually steady with superimposed colicky component  Sigmoid  Accounts for majority of volvulus  vomiting less common  abdomen is usually distended and tympanitic  Risk factor includes excessive use of laxatives and anticholinergic medications

20.  Ectopic pregnancy  consider the diagnosis of ectopic pregnancy in any female of childbearing age with abdominal pain and should obtain hCG test  Risk factors include a history of PID, previous tubal pregnancy and surgery, endometriosis, and IUD.  Symptoms classically include amenorrhea, abdominal pain, and vaginal bleeding  Placental abruption  painful vaginal bleeding, abdominal or back pain, and uterine contractions.  uterus may be rigid and tender  acute disseminated intravascular coagulation (DIC) can develop

21.  Appendicitis  Pancreatitis  Peptic ulcer disease  Gastroenteritis  Irritable bowel syndrome (IBS)  Pyelpnephritis  Inflammatory bowel disease  cholecystitis, cholelithiasis  Ectopic pregnancy  Ovarian torison  nephrolithiasis  PID  Hepatitis  Spontaneous bacterial peritonitis (SBP)  Colitis