1. Case #1
24 yo healthy M with one day hx of abdominal pain. Pain was generalized at first, now worse in right lower abd & radiates to his right groin. He has vomited twice today. Denies any diarrhea, fevers, dysuria or other complaints. No appetite today. ROS otherwise negative.
PMHx: negative
PSurgHx: negative
Meds: none
NKDA
Social hx: no alcohol, tobacco or drug use
Family hx: non-contributory
Basic cases to go through the most common abd pain complaints we see in the ED

2. Abdominal pain What else do you want to know?
What is on your differential diagnosis so far?
(healthy male with RLQ abd pain….)
How do you approach the complaint of abdominal pain in general?
Let’s review in this lecture:
Types of pain
History and physical examination
Labs and imaging
Abdominal pain in special populations (Elderly, HIV)
Clinical pearls to help you in the ED

3. “Tell me more about your pain….”
Location
Quality
Severity
Onset
Duration
Modifying factors
Change over time

4. What kind of pain is it? Visceral Parietal Referred
Involves hollow or solid organs; midline pain due to bilateral innvervation
Steady ache or vague discomfort to excruciating or colicky pain
Poorly localized
Epigastric region: stomach, duodenum, biliary tract
Periumbilical: small bowel, appendix, cecum
Suprapubic: colon, sigmoid, GU tract
Parietal
Involves parietal peritoneum
Localized pain
Causes tenderness and guarding which progress to rigidity and rebound as peritonitis develops
Referred
Produces symptoms not signs
Based on developmental embryology
Ureteral obstruction → testicular pain
Subdiaphragmatic irritation → ipsilateral shoulder or supraclavicular pain
Gynecologic pathology → back or proximal lower extremity
Biliary disease → right infrascapular pain
MI → epigastric, neck, jaw or upper extremity pain

5. GI symptoms GU symptoms Gyn symptoms General
Nausea, vomiting, hematemesis, anorexia, diarrhea, constipation, bloody stools, melena stools
GU symptoms
Dysuria, frequency, urgency, hematuria, incontinence
Gyn symptoms
Vaginal discharge, vaginal bleeding
General
Fever, lightheadedness

6. And don’t forget the historyGI
Past abdominal surgeries, h/o GB disease, ulcers; FamHx IBD GU
Past surgeries, h/o kidney stones, pyelonephritis, UTI
Gyn
Last menses, sexual activity, contraception, h/o PID or STDs, h/o ovarian cysts, past gynecological surgeries, pregnancies
Vascular
h/o MI, heart disease, a-fib, anticoagulation, CHF, PVD, Fam Hx of AAA
Other medical history
DM, organ transplant, HIV/AIDS, cancer
Social
Tobacco, drugs – Especially cocaine, alcohol
Medications
NSAIDs, H2 blockers, PPIs, immunosuppression, coumadin

7. Physical Examination General Vital Signs Cardiac Lungs Abdomen Back
Pallor, diaphoresis, general appearance, level of distress or discomfort, is the patient lying still or moving around in the bed
Vital Signs
Orthostatic VS when volume depletion is suspected
Cardiac
Arrhythmias
Lungs
Pneumonia
Abdomen
Look for distention, scars, masses
Auscultate – hyperactive or obstructive BS increase likelihood of SBO fivefold – otherwise not very helpful
Palpate for tenderness, masses, aortic aneurysm, organomegaly, rebound, guarding, rigidity
Percuss for tympany
Look for hernias!
rectal exam
Back
CVA tenderness
Pelvic exam
CMT
Vaginal discharge – Culture
Adenexal mass or fullness
Orthostatic VS are less reliable in the diabetic, elderly, those on beta-blocker. Pulse increase of 30 or presyncope on standing are highly sensitive for loss of 1 L of blood or 3L of fluid. BP changes are less reliable. Patient must be standing at least one minute before measurements are taken.

8. Abdominal Findings Guarding Rebound
Voluntary
Contraction of abdominal musculature in anticipation of palpation
Diminish by having patient flex knees
Involuntary
Reflex spasm of abdominal muscles
aka: rigidity
Suggests peritoneal irritation
Rebound
Present in 1 of 4 patients without peritonitis
Pain referred to the point of maximum tenderness when palpating an adjacent quadrant is suggestive of peritonitis
Rovsing’s sign in appendicitis
Rectal exam
Little evidence that tenderness adds any useful information beyond abdominal examination
Gross blood or melena indicates a GIB
Heme positive stool – 10% of people over the age of 50 sent home with diagnosis of NSAP and heme positive stools were found to have cancer within a year.
Heme positive stool in the setting of suspected PUD should elicit more urgent referral for further evaluation

9. Appendicitis: Psoas Sign

10. Appendicitis Diagnosis Treatment WBC
Clinical appendicitis – call your surgeon
Maybe appendicitis - CT scan
Not likely appendicitis – observe for 6-12 hours or re-examination in 12 hours
Treatment
NPO
IVFs
Preoperative antibiotics – decrease the incidence of postoperative wound infections

11. Case #2
68 yo F with 2 days of LLQ abd pain, diarrhea, fevers/chills, nausea; vomited once at home.
PMHx: HTN, diverticulosis
PSurgHx: negative
Meds: HCTZ
NKDA
Social hx: no alcohol, tobacco or drug use
Family hx: non-contributory11

12. Case #2 Exam T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99% room air
Gen: uncomfortable appearing, slightly pale
Pulmonary: normal heart and lung exam, no LE edema, normal pulses
Abd: soft, moderately tender in LLQ
What is your differential diagnosis & what next?

13. Diverticulitis Risk factors Clinical features Physical Exam
Diverticula
Increasing age
Clinical features
Steady, deep discomfort in LLQ
Change in bowel habits
Urinary symptoms
Tenesmus
Paralytic ileus
SBO
Physical Exam
Low-grade fever
Localized tenderness
Rebound and guarding
Left-sided pain on rectal exam
Occult blood
Peritoneal signs
Suggest perforation or abscess rupture

14. Diverticulitis Diagnosis Treatment CT scan (IV and oral contrast)
Pericolic fat stranding
Diverticula
Thickened bowel wall
Peridiverticular abscess
Leukocytosis present in only 36% of patients
Treatment
Fluids
Correct electrolyte abnormalities
NPO
Abx: gentamicin AND metronidazole OR clindamycin OR levaquin/flagyl
For outpatients (non-toxic)
liquid diet x 48 hours
cipro and flagyl

15. Case #3
46 yo M with hx of alcohol abuse with 3 days of severe upper abd pain, vomiting, subjective fevers.
Med Hx: negative
Surg Hx: negative
Meds: none; Allergies: NKDA
Social hx: homeless, heavy alcohol use, smokes 2ppd, no drug use

16. Case #3 Exam
Vital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat: 95% room air
General: ill-appearing, appears in pain
CV: tachycardic, normal heart sounds, pulses normal
Lungs: clear
Abdomen: mildly distended, moderately TTP epigastric, +voluntary guarding
Rectal: heme neg stool
What is your differential diagnosis & what next?