1. Abdominal Pain I – Upper Abdominal pains
EMC SDMH 2015

2. Objectives
Understand the nature of visceral abdominal pain and radiation patterns
Be able to develop differentials for pain affecting Epigastrium, Right upper, Left upper quadrants and Flanks
To briefly review the nature and management of Biliary disorders
Briefly review Pancreatitis
Briefly review ED approach to dyspepsia
Briefly review Aortic aneurysm rupture

3. Pain modalities in the abdomen
Visceral
‘aching, cramping, dull’
Poorly localised – typically midline
 ‘Colicky’
Parietal
Somatic, sharp, well localised
 ‘Peritonitic’
Referred
Ureteric  teste/vulva
Cardiac  epigastrium, arm, back
Diaphragmatic  shoulder tip

4. Differentials for upper abdominal pain
Always consider renal/ureteric pathology in R+L UQ
AAA rupture may be peri umbilical or epigastric in nature

5. Biliary Disorders Cholelithiaisis Cholecystitis Cholangitis
(Pancreatitis)

6. Biliary Disorders – ‘Biliary colic’
Attack of colicky RUQ pain lasting <6 hrs
No associated systemic involvement
Most commonly due to stones
No defining lab features. Abnormalities can be absent even with obstructed GB
Inpatient surgical referral necessary if persistent pain
Outpatient referral if pain resolves and tolerant of diet

7. Biliary disorders – Cholecystitis
Unremitting RUQ pain > 6 hrs
Almost always associated with stones
Fever 40% Nausea 70%
RUQ tenderness/‘Murphys +ve’ 80%
Labs –
Leukocytosis – 63%
Abnormal LFT – 70% (specificity 42%)
CRP – 97% specificity 76%...but only if..
Combined with USS(94% and 78% by itself!)
Inpatient surgical referral
IV a/b, analgesia, IVF hydration
Beware gangrenous GB/perforation in elderly

8. Cholangitis
Fever, abdominal pain, jaundice (90%, 70%, 60% presence) – Charcot triad
+ Altered mental state , sepsis = Reynold pentad
Consider in altered mental state/sepsis differential
May rapidly progress to septic shock
Biliary stasis key pathology
Stones 50%, malignancy 10-20%, stricture/stent 30-40%
Labs –
FBC - WCC elevation; thrombocytopaenia
UEC - Renal impairment
LFT – Obstructive picture – bilirubin elevation diagnostic
Imaging – Abdominal USS
CBD dilation +/- stone, obstruction
ED – IV fluids, IV Tazocin
Definitive treatment = Early CBD decompression (ERCP) – transfer out

9. Pancreatitis Sudden onset epigastric pain, boring, constant nature
Dx – 2 of 3;
Clinical picture
Biomarker elevation – Lipase or Amylase
Imaging evaluation +ve
Gallstones/Alcohol 90% cases
Labs – Lipase dx if >2 x ULN, Amylase 3 x
Imaging not routinely required
Severity – no useful ED scoring system
Age, Shock, Hypoxia, Renal failure, DIC, Acidosis. APACHE > 7, Ransons >3 often used
Management– Fluids, analgesia, NBM. No role for antibiotics.
Surgical admission +/- ICU if moderate/severe

10. Dyspepsia + Reflux
Epigastric burning, dull ache, colicky pain or fullness. Associated with nausea +/- vomiting
Avoid accepting ‘heartburn’ ‘indigestion’ as patient descriptions
Usually few ‘hard’ physical signs; beware abnormal vital signs
Aim to exclude serious differentials
Biliary pathology Small bowel obstruction
Pancreatitis Perforation
Myocardial ischaemia AAA
No specifically useful labs or imaging for ‘rule-in’
Clinical diagnosis and therefore higher risk.
Dyspepsia – 10-20% PU; 10-20% gastritis; 50-60% nil endoscopic findings
Dyspepsia with Reflux – 33% esophagitis at endoscopy (but 80% response rate to therapy)
ED management – Analgesia/Antacids. Trial PPI +/- H2 Antagonist
Discharge for outpatient GP follow up for empirical treatment or ‘test and treat’ approach once symptomatically controlled

11. Abdominal Aortic Aneurysm
Older individual >60 yrs age
Sudden onset epigastric, abdominal back or flank pains – severe
Beware ‘renal colic’ in over 65 yr old
Fall or syncope
Vitals may be normal to start
Will generally appear ‘unwell’
Pulsatile mass present only 60% time
Labs – Massive transfusion protocol
Imaging – Bedside USS
ED management – IV access x 2
Minimal volume resuscitation
Emergency transport to TWH Vascular OT via ambulance

12. Questions?

13. Summary
Consider pain character to decide if pain is visceral or parietal
Localise to quadrant to narrow diagnosis, but be aware of variation
Be aware of ability to be led astray by labs in RUQ pathology – get an USS (bedside)
Keep cholangitis in mind in your septic screen; appreciate it’s ability to deteriorate
Don’t get too concerned about pancreatitis scores in ED; if marked clinical or biochemical abnormality consider ICU
Dyspepsia is challenging! Be careful not to label too early.
AAA at SDMH requires rapid diagnosis and emergency transport