1. Abdominal Pain

2. Case 1
A 19 year old male presents with a two day history of abdominal pain. He states that at onset, his pain was in the middle of his abdomen, and has since moved to the right lower side. He notes nausea, emesis, anorexia, and a low grade fever. On exam, he has rebound tenderness to the RLQ, pain with leg movement, hip rotation, and pain in the RLQ on LLQ palpation. How often do perfect clinical cases like this present to the ED?

3. Introduction 6.7% of ED visits are for abdominal pain
History, physical, labs often not as helpful as Cope would have you believe.
Goal is to detect life-threatening causes of abdominal pain, if not to make a solid diagnosis.
The Elderly, the Young, and those who cannot get follow-up are high risk groups that may require further study and admission even in the absence of abnormal findings.

4. Pain Visceral Parietal
Stretching of unmyelinated fibers that innervate walls or capsules of organs.
Crampy, dull, achey pain.
Localized to a sensory level, but often midline
Parietal
Irritaion of myelinated fibers in the parietal peritoneum
Localizable, causing guarding, rebound
Patients like to stay still
Visceral fibers from appendix T10 – periumbilical pain

5. Pain Referred pain Pain that is remote from the source
Caused by developmental embryology
Normally ipsilateral
Boaz Sign?
Kehr’s Sign?
Where might renal pain get referred to?

6. Priorites Finding critical illness and stabilizing
Normal vitals signs are not excluding for critical illness
Resuscitate and diagnose at the same time
2 LB IV’s, O2, monitor
CBC, BMP, Coag, T&S
Don’t neglect to do a thorough exam.
Intensity of pain bears no relation to severity of illness.

7. Priorities Finding critical illness Red Flags
Extremes of age
Rapid onset of severe pain
Abnormal vitals
Dehydration
Pallor, vomiting, diaphoresis
Shock most likely hemorrhagic if of rapid onset
Temperature least helpful of vitals

8. History OPQRST What has been done Last oral intake Onset
Provocations/palliations
Quality
Radiation
Severity
Timing
What has been done
Last oral intake

9. History Pertinent illnesses DM HTN, CAD, PVD Liver or Renal disease
Surgical history
Sexual history
Meds/IUDs
Any trauma
Any similar episodes?

10. Physical Exam Uncover as much as necessary First, inspect
Check for that perirectal abscess and Fournier’s
First, inspect
Distended, stigmata of liver disease, surgical scars? Masses?
Then, auscultate
Low sensitivity!

11. Physical exam Finally palpate Have the patient point to where it hurts
Hit that area last
May have patient bend knees if they cannot otherwise relax abdominal wall muscles
Interrater reliability 60-92% for abdominal tenderness (Yen, K, et al, Arch Ped Adol Med, 2005, Apr, 159(4):373-6)
Consider early use of Ultrasound at the time of palpation.

12. Labs Should be diagnosis specific Consider pattern of pain
How likely is it that an LFT will help someone with LLQ pain?
Preg test – always necessary for women of childbearing age and capability

13. Labs CBC BMP WBC least useful in the panel
Hemoglobin – anemia from what?
Can be useful for trending
Platelet counts – liver disease, ITP, HEELP
BMP
Renal function most important
Calcium
CO2 level as a flag for metabolic acidosis

15. Imaging Ultrasound Many choose to use ultrasound like a stethoscope
Modality of choice for RUQ pain
Recommended as first line for flank pain, RLQ pain in kids – operator dependent
Modality of choice for pelvic pain

16. Imaging Plain films Useful only for Overall, low value Free air
Obstruction/volvulus
Pneumonia
Overall, low value

17. Imaging CT
High sensitivity
High specificity
High radiation risk
High cost
Elderly, immune compromised, those who you are uncertain, but look ill.
PO contrast – bowel obstruction, bowel mass
No contrast – renal stone, renal insufficiency
IV contrast – AAA, dissection

18. Name that Story!
Dull RUQ pain in a 16 year old male, worse with eating, associated with nausea and diarrhea?
The four F’s are still most common, but many males are getting into the game

19. Name that Story!
Low grade fever, LLQ tenderness, and rectal bleeding in a 55 year old male.

20. Name that Story!
Epigastric pain which is boring and cramping, which radiates to back, and is associated with eating cheese and alchohol. Amylase and lipase are normal. This is the 6th visit for this in a year.
What level of bilirubin is needed to produce scleral icterus?
19 patients in a large study had normal amylase and Lipase levels on presentation, 14 had elevations on hospital day one.
2-3 mg/dL

21. Name that Story
55 year old diabetic with epigastric pain, weakness, nausea and vomiting. Some SOA, no diarrhea. Hx of HTN. Pain is off and on for the past week.
ECG showed anteroseptal MI

22. Name that Story
Post parandial pain in a 65 year old female who has nausea, emesis, appears to be in pain, but a benign abdominal exam, trace blood on rectal exam.
How many patients with mesenteric ischemia have a normal first lactate? 25%

23. Name that Story
65 year old male who presents with left flank pain that is gnawing, kept him up at night, and is not associated with syncope or hypotension. His last US showed a 3.5cm AAA.
US was several years ago, now has a 6cm AAA with inflammation around it… no renal stone on CT.

24. Name that Story
20 year old male sharp flank pain after backing into something. Has a 1 inch laceration to left flank. Vitals signs are stable. 30 minutes later, he is dead.
Type of knife – bayonet to the aorta.

25. Name that Story!
16 year old virgin presents with vaginal bleeding, RLQ abdominal pain and weakness. She is tachycardic, and her rosary-holding mother (who has been in the room) is concerned about fibroids.
Sexual hx with parents out of the room – HCG.

28. High Risk Groups

29. Treatment TRUE OR FALSE?
Pain should not be treated until a surgeon has laid hands on the patient?

30. Treatment Fluids Symptom management
NPO status until you know a surgeon won’t be needed anytime soon
Antibiotics
Gram negative for gut (flagyl, AG)
E.coli for gut and urine (Cipro)
Gram positives for SBP
STD guidelines for PID

31. Disposition Discharge Otherwise admit Surgical consults as needed.
Pain better
Nasuea better
Tolerates PO
Negative eval, or no critical findings
Adequate follow-up
Otherwise admit
Surgical consults as needed.

32. Gastric Bypass High risk for leak Dumping Syndrome Internal hernia
Septic, abdominal pain, fever
Dumping Syndrome
Dietary changes
Octreotide SQ drips for severe cases
Internal hernia
Immediate bowel obstruction may cause gastric rupture.
Dumping Syndrome – nausea, vomiting, diaphoresis minutes after eating – rapid gastric emptying