1. Evaluation of the ED Patient with Abdominal Pain
University of Utah Medical Center
Division of Emergency Medicine
Medical Student Orientation

2. A Common Complaint 4-8% of all ED Visits
Most Common Diagnoses pts > 50
Cholecystitis (21%)
Nonspecific abdominal pain (16%)
Appendicitis (15%)
SBO (12%)
Everything else (diverticulitis, hernia, cancer, vascular)
Most Common Diagnoses pts < 50:
Nonspecific Abdominal Pain ( ~40% )
Appendicits (32%)
Cholecystitis (6%)
SBO and Pancreatitis (each ~ 2%)

3. Key Consideration! Extensive differential
Multiple Life-threatening causes
AAA
Perforation
Obstruction
Ischemia
Ectopic pregnancy

4. Other Common Diagnoses
Gastroenteritis*
GERD
Cholecystitis
Appendicitis
Obstruction
Constipation*
UTI*
PID*
*often misdiagnoses in patients w/significant abdominal pathology

5. H&P are key (as usual)-they help guide your workup and whittle down the large ddx
Labs and Imaging are used to either support/refute your suspected diagnosis
Occasionally, the labs and imaging will help come up with a diagnosis when the history and exam are not particularly helpful (altered, confused pt)

6. Abdominal Pain History
HPI
Onset
Palliates/Provokes
Quality
Radiation
Severity
Time course
Undo (what have they done to “undo” their pain)
PMH
PMHx
Surgical Hx
Allergies
Meds
Social Hx
EtOH

7. High-Yield Historical Questions.
How old are you? (Advanced age means increased risk)
Which came first—pain or vomiting? (Pain first is worse [i.e., more likely to be caused by surgical disease])
How long have you had the pain? (Pain for less than 48 hours is worse)
Have you ever had abdominal surgery? (Consider obstruction in patients who report previous abdominal surgery)
Is the pain constant or intermittent? (Constant pain is worse)
Have you ever had this before? (A report of no prior episodes is worse)
Do you have a history of cancer, diverticulosis, pancreatitis, kidney failure, gallstones, or inflammatory bowel disease? (All are bad)

8. High-Yield Historical Questions.
Do you have HIV? (Consider occult infection or drug- related pancreatitis)
How much alcohol do you drink per day? (Consider pancreatitis, hepatitis, or cirrhosis)
Are you pregnant?( Test for pregnancy—consider ectopic pregnancy)
Are you taking antibiotics or steroids? (These may mask infection)
Did the pain start centrally and migrate to the right lower quadrant? (High specificity for appendicitis)
Do you have a history of vascular or heart disease, hypertension, or atrial fibrillation? (Consider mesenteric ischemia and abdominal aneurysm)

9. Physical Exam Vitals Look Listen Percussion
Palpation- where tender, rebound or guarding?
Rectal and Pelvic-as indicated by history and exam
Rebound tenderness
81% sensitive, 50% specific for peritonitis
63-76% sensitive, 56-69% specific for appendicitis

10. Rectal Exam
Generally indicated only in those with symptoms referable to the rectal/anal area or suspected GI bleeding, otherwise rarely useful in generalized abdominal pain workup
Prostatitis
GI bleeding: upper or lower
Hemorrhoids
Constipation: possible impaction?
Bloody diarrhea (enteritis)

11. Causes of Abdominal Pain by Quadrants
RUQ
LUQ
Gastric/Peptic Ulcer
Biliary Disease
Hepatitis
Pancreatitis
Retrocecal Appendicitis
Renal Stone
Pyelonephritis MI
Pulmonary Embolus
Pneumonia
Gastric Ulcer
Gastritis
Splenic injury
RLQ
LLQ
Appendicitis
Ovarian Cyst
Mittelschmerz
Pregnancy
Tubo-ovarian abscess
PID
Ovarian Torsion
Cystitis
Prostatitis
Ureteral Stone
Testicular Torsion
Epididymitis
Diverticulitis
AAA

12. Stop and Think Differential Diagnosis
Knowing that labs and radiographic studies will only aid what you already suspect, identify needed treatments and start them empirically as dictated by pt condition

13. Laboratory Studies These will rarely clinch diagnosis CBC
Anywhere from 10-60% of patients with surgically proven appendicitis have an initially normal white count
An elevated white count detects a mere 53% of severe abdominal pathology.
Electrolyte, Lipase, UA, LFTs
Pregnancy Test!
ECG (especially in elderly)

14. Radiographic Studies- Plain Film
Really only helpful in ED for:
Free air (suspected perforation)
Dilated loops of bowel with air fluid levels (obstruction)
Foreign body
Free air seen in only 30-50% of bowel perforation

15. Sigmoid Volvulus

16. Sigmoid Volvulus

17. Sigmoid Volvulus

18. What’s wrong with this picture??

19. Radiology- Ultrasound
Excellent for Biliary Tract Disease (very sensitive for Gallstones (90+%)
AAA- can rapidly assess size at bedside
Ectopic Pregnancy- look for intrauterine yolk sac, assess adnexa, assess for free fluid
Appendicitis- 75%-90% sensitive (in experienced hands, best in thin patients)
Not routinely done in this country. May change.
Pelvic structures, testicles

20. Gallstones

21. AAA

22. Radiology- CT Scan Detect Leaking AAA ( in stable patient )
Excellent for Renal Calculi
Evaluate for appendicitis, perforation
(free air), diverticulitis, abscess, mesenteric ischemia, masses, obstruction
The sensitivity and specificity for these vary. Nothing is 100% accurate
Not a place for unstable patients

23. Kidney Stones- CT Style

24. Sigmoid Tumor/Intussusception

25. Psoas Abscess

26. Retroperitoneal Abscess

27. TOA

28. Abdominal Pain in the Elderly
“An M&M waiting to happen”
Mortality & misdiagnosis rise exponentially w/each decade >50 yrs.
Elderly generally considered 65 and older
Approximately 60-70% get admitted, 40-50% go to the OR and 10% die (this is higher than mortality of acute MI at 6-8%)
These patients frequently get, and deserve, a full complement of imaging and labs

29. Case #1- Presentation 23 yo female acute onset LLQ pain 2 hours ago
Constant, no radiation, no N/V/D
No exacerbating, alleviating factors
No vaginal discharge

30. Case #1 -PMH No medical problems No medications, No allergies
Surg Hx: S/P Elective Abortion 1 year ago
No history of STDs, Sexually Active
LMP 4 weeks ago

31. Case #1- Exam Vitals: P105 R20 T37.7 BP 103/58
Abd: soft, tender LLQ with guarding, no rebound pain detected
Pelvic: No cervical motion tenderness, L adnexal tenderness/fullness
Rectal: No masses, guaiac negative

32. Case #1- Differential Diagnosis
Ectopic Pregnancy
Ovarian Cyst
Tubo-ovarian abscess
Ovarian Torsion

33. Case#1- Intervention/Diagnosis
Pregnancy Test - Negative
IV Fluids cc bolus ( repeat P 90, BP110/65 )
U/S- L ovary with absent blood flow, multiple cysts
Diagnosis: Ovarian Torsion
Disposition: To OR by GYN

34. Case #2- Presentation 47 yo male with sudden onset abd pain
Epigastric pain, vomited x2
Pain 10/10
Better if holds still, worse on car ride into hospital
Never had pain like this before

35. Case #2- Past Medical History
Medical Hx: Arthritis, Chronic Low Back Pain
Surgical Hx: L knee meniscus repair
Meds: No prescribed meds, OTC ibuprofen
Allergies: NKDA
SH: 2 beers/night

36. Case #2- Exam Vitals: P95 R22 T37.4 BP 124/75 O2 100%
Gen: Anxious, Mild distress/diaphoretic, Remaining still
Abd: Decreased BS, Severe epigastric tenderness with guarding and rebound
Rectal: Guaiac positive

37. Case #2- Actions
Large bore IV x2, Type and Screen, CBC, CMP, Lipase, Fluid bolus,ECG
Acute Abdominal Series
Orthostatic Vitals

39. Case #2 - Interventions/Diagnosis
CXR reveals intra-abdominal free air
Diagnosis: Perforation, likely duodenal or gastric ulcer
Disposition: To OR for identification and repair

40. Multiple Life Threatening Causes of Abdominal Pain
Identify the potential life threatening cause of the following cases.
Differential diagnosis is large but consider an acute event and test your intuition

41. Rapid Cases #1 25 yo female Recurrent vomiting, diffuse mild pain
Febrile, dehydrated, tachycardic
H/O Diabetes Mellitus
Diagnosis: DKA

42. Rapid Cases #2 Healthy 17 yo male, football player
L shoulder pain, not reproducible on exam
lightheaded, weak
U/S with free intraperitoneal fluid
Diagnosis: Splenic Lac

43. Rapid Cases #3
16 yo female
Nausea, diffuse discomfort starting yesterday
Now worse RLQ
Abd exam: pain RLQ, +guarding
Diagnosis: Appendicitis

45. 31 yo appy

46. 73 yo appy

47. Rapid Case #4 65 yo male Hx of HTN, Renal Colic x3 episodes
Low back pain- ?new pain
Abd: obese, soft, no masses palpated
U/S shows 7cm AAA

49. Rapid Case #5 56 yo female H/O Alcoholic Cirrhosis
Diffuse abd pain, gradual onset
Distended abdomen, febrile
U/S: ascites
Peritoneal tap >500 WBC/cc
Spontaneous Bacterial Peritonitis

50. Rapid Case #6 32 yo female, S/P Tubal ligation 2 weeks ago
Gradual onset diffuse pain
N/V/D, fever
Diffusely tender, guarding, + rebound
CXR with free air
Bowel perforation

51. Free Air

52. Rapid Case #7 82 yo male S/P distant chole, appy
Gradual onset vomiting, nausea, distension
Distended abdomen, increased bowel sounds
KUB: multiple air fluid levels, dilated loops of small bowel
Small Bowel Obstruction

53. Small Bowel Obstruction

54. Rapid Case #8 16 yo male sudden onset lower abd, scrotal pain
No hx of trauma
Tender L testicle to exam
U/S: No vascular flow to L testicle
Acute Testicular Torsion

55. Rapid Case #9 30 yo female, G3P3 IUD in place
LLQ pain, gradually worsening today
No fever, Tender L Adnexa
+ UPT
U/S with L Adnexal Gestational Sac
Ectopic Pregnancy

56. Rapid Case #10 4 yo male Crampy abdominal pain- crying
Tender diffusely to exam, afebrile
Guaiac positive stool
Complete relief with enema
Intussusception

57. Intussusception

58. Rapid Case #11 23 yo healthy female Severe lower abdominal pain
Gradual onset, no N/V/D
Abd Tender Bilateral Lower Quadrants
Cervix tender with movement, UPT -
Dx: PID

59. Rapid Case #12 82 yo Female H/O HTN, A. Fib, CAD, COPD
Acute severe diffuse abd pain
Exam: Soft, minimal tenderness to palpation
Angiography reveals occluded SMA
DX: Mesenteric Ischemia

60. Rapid Case #13 46 yo female, G3P3 Post Prandial Epigastric pain
Exam: Obese, RUQ tender to palpation
U/S: Multiple Gallstones with GB wall thickening
DX: Acute Cholecystitis

61. Acute Cholecystitis

62. Rapid Case #14 78 yo male H/O HTN, DM
Acute onset nausea, diaphoresis, epigastric discomfort,
Exam: Mild epigastric discomfort to palpation
ECG ST elevation 3mm leads II, III aVF
Dx: Inferior MI

63. Inferior STEMI

64. Rapid Case # 15 65 yo female LLQ pain, gradually worsening
Exam: Febrile, Tender LLQ to palpation
Guaiac + stool
CT: Diverticulitis with multiple microperforations
Dx: Acute Diverticulitis

65. Do you see the free air?

67. Rapid Case #16 52 yo alcoholic male
Diffuse abd pain, gradually worsening, vomiting recurrently
Exam: soft abdomen, minimal tenderness
Labs: Increased lipase
Dx: Pancreatitis

68. Rapid Case #17 14 yo healthy male Acute crampy abd pain past day
Vomiting, Diaphoretic
Exam: Diffuse mildly tender abdomen with palpable firm mass in R groin
Dx: Incarcerated inguinal hernia

69. Incarcerated Hernia

70. Rapid Case #18 28 yo post-partum healthy female
Acute R flank pain radiating to groin
Exam: Abd soft, non-tender without CVA tenderness
UA with 2+ RBC, no WBCs
CT with R Ureteral Calculi
Dx: Renal Colic

71. Hydronephrosis

72. Renal Calculus

73. Hydro-ureter

74. UVJ Stone

75. Rapid Case #19 72 yo female c/o RUQ pain & cough
PMHx: HTN, COPD on home O2
Vitals: T38.5 HR 105 RR 26 BP 140/90 SpO2 88% on 2L
Physical: dry mucous membranes, decreased breath sounds, non-tender abdomen
CXR: RLL infiltrate
Diagnosis: RLL pneumonia

78. Summary
The Differential Diagnosis of Abdominal Pain is extensive. Large. Massive even.
You need to identify patterns that place a person at risk for serious causes of their pain and rule out/in those causes
History and Physical are the key to narrowing the ddx
Labs and Radiology support/refute your diagnosis

79. Summary Continued
Always get Pregnancy Test (doesn’t matter if they are on OCP’s, had a tubal ligation, or swear they can’t be pregnant due to saintly behavior-OK, no, if hysterectomy or elderly)
If discharging a patient, always alert patient of symptoms they should watch for and when to return
If dx is “abdominal pain NOS” (unknown etiology), consider f/u, even in ED, for re-evaluation