1. Approach to Abdominal Pain in the Emergency Department
Sezgin Sarıkaya, Assoc. Prof. MD, MBA
Department of Emergency Medicine Yeditepe University

2. Introduction At the end of this lecture you should:
Understand the generation and presentation of types of abdominal pain
Develop critical elements of the history and physical for AP
Apply knowledge of utility of testing to diagnostic approach
Apply management principles to patient care in the ED

3. The Epidemiology of Acute Abdominal Pain
5-10% of all ED visits.
Among them, 14-40% patients need surgical intervention.
Most common diagnosis is NONSPECIFIC (ie, “I dunno”)
Challenge for emergency physician (EP):
About 1/3 have an atypical presentation.
If misdiagnosis, mortality rate 2.5 times higher than correct diagnosis in the elderly.

4. Elderly/ nursing home patients Immunocompromised (e.g. HIV)
Three Subgroups of Patients with Abdominal Pain Who deserve Particular Focus
Elderly/ nursing home patients
Immunocompromised (e.g. HIV)
Women of childbearing age.
Post operative patients
Infants

5. The Most Important Concept for EP in Approaching Abdominal Pain
To Differentiate
Who is the patient of acute abdomen?
What are the probable diagnoses you have in mind?
Why do you consider such diagnosis?
How do you prove it?
When will you consult surgeon for operation?

6. Causes of Acute Abdominal Pain in the ED
Cause Percentage of Cases
Nonspecific abdominal pain
Appendicitis
Cholecystitis
Gastroenteritis 7
Salpingitis
UTI
Small-bowel obstruction
Renal colic
Constipation
Pancreatitis
Diverticulitis
Abdominal aneurysm, ectopic pregnancy <1
(Brewer et al., 1979; Scand J Gastroenterol)

7. Abdominal Pain Across the Ages
Colic, GE, viral illness, constipation
Ages 2-12
Functional, appendicitis, GE, toxins
Teens to adults
Addition of genitourinary problems
Elderly
Beware of what seems like everything!

8. Important Extra-abdominal Causes of Abdominal Pain
Systemic
DKA
Alcoholic ketoacidosis
Uremia
Sickle cell disease
Porphyria
SLE
Vasculitis
Glaucoma
Hyperthyroidism
Toxic
Methanol poisoning
Heavy metal toxicity
Scorpion bite
Black widow spider bite
Thoracic
Myocardial infarction/ Unstable angina

9. Important Extra-abdominal Causes of Abdominal Pain
Pneumonia
Pulmonary embolism
Herniated thoracic disc (neuralgia)
Genitourinary
Testicular torsion
Renal colic
Infectious
Strep pharyngitis (more often in children)
Rocky Mountain Spotted Fever
Mononucleosis
Abdominal wall
Muscle spasm
Muscle hematoma
Herpes zoster
Emerg Med Clin North Am 1989; 7:

10. Abdominal Pain in the Elderly
Diminished sensation of pain in the elderly
Comorbid diseases
Polypharmacy
Combinations of above result in many more vague, nonspecific presentations
Twice as likely to require surgery with presentation over age 65

11. What’s the Problem
Imprecise pain generation and transmission to the central nervous system
Comorbid diseases
Developmental stage
Medications
Social factors

12. Understanding the Types of Abdominal Pain
Visceral
Stretch fibers in capsules or walls of hollow viscus that enter both sides of spinal cord
Somatic
Fibers dermatomally distributed and enter unilaterally in the spinal cord
Referred
Overlap of fibers from other locations

13. Understanding the Types of Abdominal Pain
Visceral
Crampy, achy, diffuse,
Poorly localized
Somatic
Sharp, lancinating
Well localized
Referred
Distant from site of generation
Symptoms, but no signs

14. Understanding the Types of Abdominal Pain
Location, location, location
Organs and their corresponding fiber entry to the spinal cord
C3-5 – liver, spleen, diaphragm
T5-9 – gallbladder, stomach, pancreas, small intestine
T10-11– colon, appendix, pelvic viscerat11-l1 – sigmoid, renal capsules, ureters, gonads
S2-4 - bladder

16. Visceral

17. Somatic

18. History Taking in Abdominal Pain Presentations
“OLD CARS”
O- onset
L- location
D- duration
C- character
A-alleviating/aggravating factors
associated symptoms
R- radiation
S- severity

19. History Taking for Abdominal Pain Presentations
PMH
Similar episodes in past
Other medical problems that increase disease likelihood of problems (ex: DM and gastroparesis)
PSH
Adhesions, hernias, tumors
MEDS
Abx, NSAIDS, acid blockers, etc
GYN/URO
LMP, bleeding, discharge
Social
Tob/EtoH/drugs/home situation/agenda

20. Karın boşluğunun (abdominal kavitenin)
·        Üst sınırı diyafram
·        Alt sınırı pelvis
·        Arka sınırı lumbal omurlar
·        Ön sınırı karın duvarı kasları

21. PERİTON Karın boşluğunu çevreler · Çift katlıdır : Visseral periton
PERİTON
Karın boşluğunu çevreler
·        Çift katlıdır :
 Visseral periton
 Pariyetal periton
·        Karın boşluğunu ikiye böler:
 Peritoneal boşluk
 Retroperitoneal aralık

22. karın ağrısı olan hastanın tanı ve tedavisi hekimler için hala önemli klinik sorunların başında gelmektedir

23. Physical Exam in Abdominal Pain Presentations
Inspection
Distention, scars, bruises
Auscultation
Present, hyper, or absent
Actually not that helpful!
Palpation
Often the most helpful part of exam
Tenderness versus pain
Start away from painful area first
Guarding, rebound, masses

24. Physical Exam in Abdominal Pain Presentations
Signs
Mc burney
Murphy’s
Extra-abdominal exam
Pelvic or scrotal exams
Lungs, heart
Remember it’s a patient, not a part
Rectal
Adds very little (despite the angst) beyond gross blood or melena

25. Laboratory Testing Everybody likes a CBC, but…
Lacks sensitivity, no specificity
Little to no change in diagnostic probabilities
Should not dramatically alter approach (tender is still tender)

26. Laboratory Testing Directed approach to lab studies
There are no “standard belly labs”
Pregnancy test in women of child bearing age
Urine dipsticks

27. Imaging Plain films Free air, obstruction, air-fluid, FBs Ultrasound
Rapid “yes or no” ED evaluations
Formal studies
May add doppler
Computed Tomography
Revolutionized acute care
Often better than we are!

30. Common Diagnoses by Quadrant
RUQ
Cholecystitis
Biliary colic
Hepatitis
Pancreatitis
Renal stones
PUD
Pneumonia
P E
M I
LUQ
Gastritis
Gastric ulcer
Pancreatitis
Splenomegaly
Splenic rupture
Renal stone
Pneumonia
P E
M I

31. Common Diagnoses by Quadrants
RLQ
Appendicitis
Renal stone
Ovarian cyst
Torsion
Epididymitis
Ectopic
IBD
AAA
UTI
LLQ
Diverticulitis
Renal stone
Ovarian cyst
Torsion
Epididymitis
Ectopic
IBD
AAA
UTI

32. Dangerous Mimics True Diagnosis Initial Misdiagnosis
Appendicitis Gastroenteritis, PID, UTI
Ruptured abdominal Renal colic, diverticulitis, lumbar strain
aortic aneurysm
Ectopic pregnancy PID, UTI, corpus luteum cyst
Diverticulitis Constipation,GE ,pyelonephritis
Perforated viscus PUD, pancreatitis, nsp abdominal pain
Bowel obstruction Constipation, gastroenteritis,nonspecific abdominal pain
Mesenteric ischemia GE, constipation, ileus small bowel obstruction
Incarcerated or Ileus or small bowel obstruction
strangulated hernia
Shock or sepsis from Urosepsis or pneumonia (in elderly)
perforation, bleed,
abdominal infection

33. Five Major Categories of Acute Abdomen (BIOPI)
Bleeding or rupture of vessels or tumor
Ischemia or Infarction
Obstruction
Perforation
Inflammation

34. Common Pitfalls in Acute Appendicitis
Abdominal pain and tenderness are present in nearly 100% of patients with appendicitis; other clinical features are less reliable.
Fever occurs in only 16% of patients with acute appendicitis; its presence is more suggestive of appendiceal perforation.
Murphy sequence appears in only 22% elderly.
Perforation rate about 60% (age > 60 Y/O)

35. Management of Abdominal Pain
Always right to start with ABC’s
IV access
Fluid administration
Antiemetics
Analgesics
Directed testing and imaging
Re-evaluations
Antibiotics
Consultants
Surgeons, OB/GYN, urologists, cardiologists, etc

36. Disposition of Abdominal Pain Patients
Operating Room
Hospital bed/observation
Serial labs
Serial exams
Home with abdominal warnings
The art of emergency medicine
3 components of discharge plan
Document, document, document

37. TEŞEKKÜRLER
SORU VE KATKI