1. Vishal Bhella, MD, CCFP PGY3, Academic Family Medicine
Acute Abdominal Pain
Vishal Bhella, MD, CCFP
PGY3, Academic Family Medicine

2. Objectives Review relevant history for abdominal pain presentations
Review differentials for various abdominal pain presentations
Review some common and important presentations

3. History
Onset – What was the patient doing when the symptoms started? Acute versus Gradual?
Provoking/Palliative factors – Factors that exacerbate or improve symptoms for example food, antacids, exertion, defecation?
Quality – Characteristics of pain/symptoms – Is it sharp or dull? Is it constant or it comes and goes?

4. History continued
Region/Radiation – Can you point with one finger where it hurts the most? Does the pain radiate or move anywhere else?
Severity - On a scale of 1 to 10, how would you rate your level of discomfort right now? Using the same scale, how would you rate your discomfort when it first began?
Timing - When did the symptoms first begin? Have you ever experienced these symptoms before? If so, when?

5. History continued
Associated symptoms: fevers, chills, weight loss/gain, nausea, vomiting, diarrhea, constipation, melena, jaundice, change of colour of urine or stool
Past medical and surgical history
Family history
Alcohol intake/Smoking
Medications including NSAIDS
Women: Menstrual history, ?Pregnancy

6. Is this a surgical abdomen?
The 'surgical abdomen' can be usefully defined as a condition with a rapidly worsening prognosis in the absence of surgical intervention
Two syndromes that constitute urgent surgical referrals are complete obstruction and peritonitis.
Patients with peritonitis tend to lie very still to minimize discomfort
Peritonitis manifests on physical examination as rebound tenderness, or pain upon removal of pressure rather than application of pressure to the abdomen.
Rigidity and tenderness with percussion
Often patients will be guarding during physical examination .

7. Obstruction
Obstruction presents as pain with anorexia, bloating, nausea and vomiting along with constipation and obstipation
Patients who have evolved from partial to complete bowel obstruction may present with weeks of vague abdominal pain, followed by a sudden deterioration
Typically in cases of surgical abdomen – pain is severe and it can be associated with unstable vital signs, fever, and dehydration.

8. Investigations
Patients with a surgical abdomen – consider the following laboratory measurements:
CBC, Electrolytes, BUN, creatinine, and glucose
LFTs: Aminotransferases, alkaline phosphatase, and bilirubin
Lipase
Urinalysis, Pregnancy test in women of childbearing potential
In the presence of fever or unstable vital signs, blood and urine cultures should be performed.
Abdominal radiograph: proximally dilated loops of bowel are the hallmark of intestinal obstruction, and free intra-peritoneal air can confirm a suspicion of hollow organ perforation
In the case of suspected partial or complete intestinal obstruction, a CT scan of the abdomen is more sensitive than plain abdominal radiographs
Ultrasound a good initial test to assess - ?Appendicitis/Intra-pelvic pathology/Abdominal abscess

9. Case 1 Mr. D is a 46 year old man complaining of stomach pain
Subacute onset of epigastric pain, stable vitals, mild to moderate discomfort

10. Dyspepsia
Dyspepsia is a group of symptoms which alerts physicians to consider diseases of the upper gastrointestinal tract including - upper abdominal discomfort, nausea, bloating, fullness and early satiety amongst others

11. Dyspepsia Eliminate precipitating agents – NSAIDS, Alcohol
Consider trial of PPI or H2 receptor antagonist for 4 weeks
H. Pylori treatment - HP-PAC-(lansoprazole, amoxicillin, clarithromycin package)
Timely investigations including endoscopy is indicated for
New onset symptoms over age 50
Alarm features
Failure to respond to pharmacotherapy

12. Case 2 Mr. P is a 50 year old man complaining of nausea and vomiting
Relatively sudden onset, no appetite, history of alcohol use

13. Pancreatitis
Sudden onset epigastric pain associated with nausea, vomiting, anorexia – think pancreatitis
Risk factors for pancreatitis
Gallstones
Alcohol use
Recent ERCP
Trauma
Lab findings: High amylase/lipase
Treatment: NPO/hydration/analgesia/antibiotics
May need urgent ERCP

14. Epigastric pain Biliary: cholecystitis, cholelithiasis, cholangitis
Cardiac: myocardial infarction, pericarditis
Gastric: esophagitis, gastritis, peptic ulcer
Pancreatic: mass, pancreatitis
Vascular: aortic dissection, mesenteric ischemia

15. Case 3
Mrs. C is a 40 year old woman complaining of off/on sharp pains after eating
Slightly obese lady, severe pain episodes, right upper quadrant, worse with heavy meals

16. Cholecystitis

17. Cholecystitis
The patient with acute cholecystitis usually presents with unremitting and intensifying pain at the right side of the abdomen, often associated with fever and vomiting.
Indicators such as right upper quadrant pain and Murphy’s sign (i.e., inspiratory arrest with palpation of the right upper quadrant) are present in about one half of older patients
Complications include acute ascending cholangitis, gallbladder perforation, emphysematous cholecystitis, bile peritonitis, and gallstone ileus.
Acute ascending cholangitis :Charcot’s triad (i.e., fever, jaundice, and right upper quadrant pain). The majority of patients have an elevated alkaline phosphatase level, 50 percent have positive blood cultures, and approximately 40 percent have hyperbilirubinemia.
Reynold’s pentad (i.e., Charcot’s triad plus shock and mental status changes.

18. Right upper quadrant pain
Biliary: cholecystitis, cholelithiasis, cholangitis
Colonic: colitis, diverticulitis
Hepatic: abscess, hepatitis, mass
Pulmonary: pneumonia, embolus
Renal: nephrolithiasis, pyelonephritis

19. Case 4
Mrs. P is a 35 year old female with left sided pain, fever, nausea.
Pain is worst in left flank, having nausea, with a couple of episodes of emesis, decreased appetite

20. Pyelonephritis
Typical microorganisms: E.coli, Klebsiella, Proteus, Enterococcus, S. Saprophyticus
Symptoms – Fever, chills, nausea, vomiting, myalgia, malaise, CVA tenderness or exquisite flank pain, lower urinary tract symptoms (urgency, frequency, dysuria)
Tx with day course of Septra. Ciprofloxacin x 7 days has activity against Pseudomonas
IV antibiotics in severe cases. Switch to oral when tolerating po intake

21. Left upper quadrant pain
Cardiac: angina, myocardial infarction, pericarditis
Gastric: esophagitis, gastritis, peptic ulcer
Pancreatic: mass, pancreatitis
Renal: nephrolithiasis, pyelonephritis
Vascular: aortic dissection, mesenteric ischemia

22. Case 5
Mr. A is a 67 year old gentleman with sudden onset severe abdominal pain.
Pain severe, sharp, mid to upper abdominal pain. Mr. A looks very unwell, is hypotensive and exhibits signs of shock and peritonitis. A pulsatile abdominal mass is noted.

23. AAA AAA dissection is a life threatening emergency
Some other differentials in such a presentation include
Perforated PUD
Appendicitis/diverticulitis with perforation
Mesenteric ischemia
Always remember to r/o AAA and mesenteric ischemia in an elderly presenting with moderate- severe abdominal pain

24. Periumbilical Pain Colonic: early appendicitis
Gastric: esophagitis, gastritis, peptic ulcer, small-bowel mass or obstruction
Vascular: aortic dissection, mesenteric ischemia

25. Case 6
Ms. A is an 18 year old female presenting with nausea, vomiting and abdominal pain
Acute onset, slight fever, significant right lower quadrant pain

26. Appendicitis Abdominal pain with anorexia, nausea and vomiting
Classic pattern is pain initially periumbilical, constant, dull, poorly localized and then localized over McBurney’s point
CBC may show leukocytosis
β-hCG in women to rule out ectopic pregnancy
Management: Hydrate, correct electrolyte abnormalities, appendectomy

27. Right lower quadrant pain
Colonic: appendicitis, colitis, diverticulitis, IBD, IBS
Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID
Renal: nephrolithiasis, pyelonephritis

28. Case 7 Mrs. D is a 60 year old woman presenting with LLQ pain.
Elderly woman with subacute onset of abdominal pain, localized peritoneal signs, lack of severe systemic symptoms

29. Diverticulitis Key learning points: Some differentials to consider:
Generally a disease of the elderly, 20% < 50
Distinguish between complicated vs. uncomplicated diverticulitis, complicated is characterized by:
Large abscess > 4cm (requires CT-guided drainage generally)
Generalized peritoneal signs
Fistula formations: colovesical (male), colovaginal, colocutaneous
Some differentials to consider:
Intra-abdominal abscess
Mesenteric ischemia
Ovarian cysts (consider malignancy in post-menopausal women)
Renal colic, pyelonephritis/UTI

30. Diverticulitis Require broad-spectrum antibiotics 7-10d:
Outpatient: ciprofloxacin + metronidazole
Inpatient: 3rd generation cephalosporin/fluoroquinolne + metronidazole
CT is best imaging modality
Recurrence rate for 1st-timers ~ 60-70%; ~20% of initial presentations require surgical intervention

31. Left lower quadrant pain
Colonic: colitis, diverticulitis, IBD, IBS
Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID
Renal: nephrolithiasis, pyelonephritis

32. Case 8
Ms. P is a 19 year old female complaining of not feeling well and having lower abdominal pain.
LMP 1 week ago, is sexually active – uses OCP for birth control but no other protection. Cervical motion tenderness on pelvic exam

33. PID
Case presents woman of child bearing age with lower abdo pain and risk factors for STI.
Consider Pelvic Inflammatory Disease in this setting.
Note that 1 out of 3 women with PID have a fever. As well, difficult to rule in or out PID based on history, physical or lab work.
Should rule out ectopic pregnancy, ovarian abscess and appendicitis. Some other considerations include:
Ovarian torsion
Cystitis
Large bowel: constipation, mesenteric adenitis, inflammatory bowel disease
Urinary stone – bladder stone (uncommon)

34. PID Diagnostic Considerations: Only 1/3 women with PID have fever
No history/physical/lab test can definitively rule in/out PID
Minimal criteria:
Lower abdo pain
Adnexal tenderness
Cervical motion tenderness
Additional criteria:
Fever > 38.3
 ESR, CRP
Swabs/urine confirm Gonorrhea/Chlamydia
Transvaginal U/S – fluid filled tubes, tubo-ovarian complex
Endometritis from endometrial biopsy / laparoscopy

35. PID Management: Determine if needs admission:
Surgical emergencies such as appendicitis cannot be excluded.
Pregnant
No response to oral antimicrobial therapy
Unable to follow or tolerate an outpatient oral regimen
Severe illness, nausea and vomiting, or high fever
Tubo-ovarian abscess
Think of Gonorrhea, Chlamydia, and anerobes
Outpatient therapy:
1st: Ceftriaxone 250 mg IM X1, doxycycline 100 mg po bid 14d +/- metronidazole 500 mg po bid 14d
2nd: Ofloxacin 400 mg po bid 14d +/- metronidazole 500 mg po bid 14d, OR Levofloxacin 500 mg po od 14 d +/- metronidazole 500 mg po bid 14d

36. Suprapubic pain
Colonic: appendicitis, colitis, diverticulitis, IBD, IBS
Gynecologic: ectopic pregnancy, fibroids, ovarian mass, torsion, PID
Renal: cystitis, nephrolithiasis, pyelonephritis

37. Case 9
Ms I is a 70 year old female who presents with rapid onset of severe periumbilical abdominal pain, which is out of proportion to findings on physical examination. Nausea and vomiting are present.

38. Intestinal Ischemia
Acute abdomen with metabolic acidosis = Ischemic bowel until proven otherwise.
Risk factors: Atrial Fibrillation, CHF, Peripheral Vascular Disease, or a history of hypercoagulability, Atherosclerotic disease
Common sites: Superior Mesenteric Artery supplied territory “watershed” areas of colon - splenic flexure, left colon, sigmoid colon
Lab investigations: Leukocytosis. Serum lactate elevation. Amylase, LDH, CK, ALP
Contrast CT
CT angiography is gold standard for acute arterial ischemia
Treatment: Fluid resuscitation, NPO, antibiotics, Laparotomy

39. Case 10
Mr. M is a 55 year old man with vague, constant, upper abdominal discomfort
Sudden onset while doing errands, some SOB, worse with continued exertion, settles slightly at complete rest. Physical exam - no palpable abdominal pain.

40. Cardiac pain
MYCARDIAL INFARCTION – Topic for another lecture.

41. Differential Diagnosis Should Include Extra-Abdominal Sources
Toxic, MSK, Trauma, Psych
Cardiac, Respiratory
Metabolic, Vascular
Specific diseases
Gynecological, GI,
Genitourinary,
Vascular
Organs within each
system