1. Abdominal Pain

2. Scenario
You are called by a nurse to evaluate a patient on the inpatient medicine service with abdominal pain (cross-cover)

3. “Worst case scenario” DDx
“Surgical abdomen” – condition with rapidly worsening prognosis without surgical intervention
Obstruction
Peritonitis
Viscus perforation (e.g., intestine, pelvic organ)
Intraperitoneal hemorrhage (e.g., ruptured AAA)
Intraabdominal abscess
(SBP is medically managed)

4. Location, location, location
RUQ:
Biliary colic
Cholecystitis
Cholangitis
Hepatitis

5. DDx Epigastric: Pancreatitis Dyspepsia/PUD Gastroparesis
Cardiac ischemia
Pulmonary pathology affecting lower lungs/pleura (PNA, PE, pulmonary infarct, empyema)

6. DDx Lower abdominal: Colitis/enteritis (infectious, ischemic, IBD)
Diverticulitis
Appendicitis
Cystitis
Renal colic (flank), pyelonephritis (CVA tenderness)
Gynecologic: PID, adnexal cysts/masses (bleeding, torsion, rupture), fibroids, ectopic

7. DDx Generalized: Intestinal ischemia/infarction
Endocrinopathies: DKA, hypercalcemia, adrenal insufficiency
Constipation
Pain syndromes: functional abdominal pain, IBS, fibromyalgia, somatoform disorder, narcotic-seeking behavior

8. First steps Is the patient unstable (phone)?
Is the patient sick (bedside)?
If yes to above  ABCs, consider ICU Xfer

9. History All about the pain
Onset, what patient was doing/had recently done (e.g. just finished a meal, ERCP yesterday)
Ever had this pain before?
Location, radiation
Character:
Dull/achy/vague (visceral)
Sharp/well-localized : parietal (2/2 peritoneal irritation)
Colicky
Severity

10. History Aggravating/alleviating factors Associated symptoms
Food : aggravates intestinal ischemia, alleviates some cases of PUD
Position : peritonitis aggravated by any movement, pancreatitis alleviated by sitting up and leaning forward
Associated symptoms
N/V (bloody, bilious, feculent), diarrhea/constipation, melena/hematochezia, vaginal discharge/bleeding

11. History STD risk/symptoms Possibility of pregnancy
Medical history: diabetes, chronic liver disease, IBD, rheumatologic disease, immunocompromised, prior abdominal surgeries

12. Abdominal Exam General appearance, level of discomfort
Vitals: fever, HoTN
Inspection
Bulging (ascites, mass)
Signs of chronic liver disease (jaundice, dilated superficial veins, spider angiomata)
Scars
Auscultation:
Absent bowel sounds (adynamic ileus, advanced peritonitis)
Hyperactive, high-pitched bowel sounds (early bowel obstruction)

13. Abdominal Exam Palpation/Percussion Gently assess for peritonitis
Muscle rigidity (guarding) – may be focal or diffuse
Rebound tenderness
“Shake tenderness” – bump the bed
Start away from the pain
Tympany (distended bowel)
Pain out of proportion to exam (intestinal ischemia/infarction)
Murphy’s sign, hepatomegaly
Ascites (SBP)
Pulsatile mass (AAA)

14. Exam Rectal exam Pelvic exam
Have to justify not doing it
Impaction, tenderness, check stool for occult blood
Pelvic exam
If suspect pelvic pathology (e.g., woman with lower abdominal pain)
Bleeding, discharge
CMT
Adnexal/uterine pathology
Don’t forget the heart, lungs, eyes/skin (jaundice), pulses (AAA)
Whole exam can be done rapidly

15. Labs CBC: leukocytosis, anemia
CMP: hepatic/renal function, electrolytes, anion gap
Lipase UA
Lactate (ischemia/infarction)
Urine hcg
Blood Cultures: if febrile or unstable
Stool Cx/O+P/C. Diff
Wet mount of vaginal discharge/GC/Chlamydia
Troponin, EKG
ABG

16. Imaging Abdominal X-ray: “bones, stones, mass, and gas”
Different from KUB which is centered lower in the abdomen
Supine and upright/L lateral decubitus views
Obstruction  proximally dilated bowel loops, air-fluid levels
Viscus rupture  intraperitoneal free air (see under diaphragm, over liver)
Toxic megacolon (C. Diff)  markedly dilated bowel +/- perforation
Ileus, intestinal pseudoobstruction  dilated bowel extending to rectum
Constipation

17. SBO. Centrally-located, dilated bowel with no bowel gas in “outer box” where colon normally is.

18. Gastric perforation from lymphoma
Gastric perforation from lymphoma. Free air over liver, “Riggler’s sign” on supine film (able to see both sides of bowel wall due to presence of gas on either side of the bowel).

19. Imaging CT Abdomen/Pelvis (with contrast):
Higher diagnostic accuracy than plain radiographs
Intraperitoneal free air
Obstruction (may see transition point)
Intestinal ischemia
Viscus inflammation
Abscess
AAA leak/rupture
Pancreatitis

20. 65 M c abdominal pain, lactate 9. 4
65 M c abdominal pain, lactate Clot in aorta, SMA, bowel wall thickening (descending, transverse, ascending colon) with surrounding fluid.

21. Imaging Ultrasound: CXR:
RUQ : cholecystitis, gallstones, biliary dilation, cholangitis
Pelvic: fibroids, adnexal masses, IUP, ectopic pregnancy, free pelvic fluid
Renal
Pregnancy
CXR:
If pulmonary pathology suspected
May need follow-up chest CT

22. Therapy/Management Consultation:
Emergent surgical consult if acute abdomen
Biliary consult if biliary dilation, choledocholithiasis  ERCP/MRCP
GI consult if dyspepsia with red flag symptoms (e.g., dysphagia, wt. loss, persistent vomiting)  EGD +/- Bx
GYN consult if complex pelvic disease

23. Therapy/Management Some therapeutic examples: Ileus:
Decompression with NGT to suction, NPO
Constipation/fecal impaction:
Manual disimpaction, stool softeners, laxatives
Enterocolitis, diverticulitis, cholangitis, PID:
ABx

24. Therapy/Management Diagnosis is often unclear after initial assessment
Serial assessments, watchful waiting
If you didn’t document, you didn’t do it
Initial assessment, f/u assessments
If cross-covering, give appropriate sign-out

25. Take-Home Points
Is the patient sick? (phone, prompt bedside assessment)
R/o surgical abdomen
Very focused history and exam
Relevant labs and imaging (think before you order)
Use your consultants
Watchful waiting – good medicine when used correctly
Documentation