Approach to Abdominal Pain in the Emergency Department Sezgin Sarıkaya, Assoc. Prof. MD, MBA...

Approach to Abdominal Approach to Abdominal Pain in the Emergency Pain in the Emergency

DepartmentDepartment

Sezgin Sarıkaya, Assoc. Sezgin Sarıkaya, Assoc. Prof. MD, MBAProf. MD, MBA

Department of Emergency Department of Emergency MedicineMedicine Yeditepe Yeditepe

UniversityUniversity

IntroductionIntroduction At the end of this lecture you At the end of this lecture you

should:should: Understand the generation and Understand the generation and

presentation of types of presentation of types of abdominal painabdominal pain

Develop critical elements of the Develop critical elements of the history and physical for APhistory and physical for AP

Apply knowledge of utility of Apply knowledge of utility of testing to diagnostic approachtesting to diagnostic approach

Apply management principles to Apply management principles to patient care in the EDpatient care in the ED

The Epidemiology of Acute The Epidemiology of Acute Abdominal PainAbdominal Pain

5-10%5-10% of all ED visits. of all ED visits. Among them, Among them, 14-40%14-40% patients need patients need

surgical intervention. surgical intervention. Most common diagnosis is NONSPECIFIC Most common diagnosis is NONSPECIFIC

(ie, “I dunno”)(ie, “I dunno”) Challenge for emergency Challenge for emergency

physician (EP)physician (EP):: About About 1/31/3 have an atypical have an atypical

presentation.presentation. If misdiagnosis, mortality rate If misdiagnosis, mortality rate 2.52.5 times times

higher than correct diagnosis in the higher than correct diagnosis in the elderly.elderly.

Three Subgroups of Patients with Three Subgroups of Patients with Abdominal Pain Who deserve Abdominal Pain Who deserve Particular FocusParticular Focus

Elderly/ nursing home patientsElderly/ nursing home patients Immunocompromised Immunocompromised (e.g. HIV)(e.g. HIV) Women of childbearing age.Women of childbearing age. Post operative patientsPost operative patients InfantsInfants

The Most Important Concept The Most Important Concept for EP in Approaching for EP in Approaching Abdominal PainAbdominal Pain

To Differentiate To Differentiate

WhoWho is the patient of acute abdomen? is the patient of acute abdomen?

What What are the probable diagnoses you are the probable diagnoses you

have in mind?have in mind?

WhyWhy do you consider such diagnosis? do you consider such diagnosis?

HowHow do you prove it? do you prove it?

WhenWhen will you consult surgeon for will you consult surgeon for

operation?operation?

Causes of Acute Abdominal Causes of Acute Abdominal Pain in the EDPain in the ED

CauseCause Percentage of CasesPercentage of Cases

Nonspecific abdominal painNonspecific abdominal pain 441-461-46AppendicitisAppendicitis 4-244-24CholecystitisCholecystitis 2.5-92.5-9GastroenteritisGastroenteritis 7 7SalpingitisSalpingitis 2-72-7UTIUTI 3-53-5Small-bowel obstructionSmall-bowel obstruction 2.5-42.5-4

Renal colicRenal colic 1.5-41.5-4

ConstipationConstipation 2 2

PancreatitisPancreatitis 1-21-2

DiverticulitisDiverticulitis 1-21-2

Abdominal aneurysm, ectopic pregnancyAbdominal aneurysm, ectopic pregnancy <1 <1

(Brewer et al., 1979; Scand J Gastroenterol)

Abdominal Pain Across the Abdominal Pain Across the AgesAges

Ages 0-2Ages 0-2 Colic, GE, viral illness, constipationColic, GE, viral illness, constipation

Ages 2-12Ages 2-12 Functional, appendicitis, GE, toxinsFunctional, appendicitis, GE, toxins

Teens to adultsTeens to adults Addition of genitourinary problemsAddition of genitourinary problems

ElderlyElderly Beware of what seems like everything!Beware of what seems like everything!

Important Extra-abdominal Important Extra-abdominal Causes of Abdominal PainCauses of Abdominal Pain

SystemicSystemic DKADKA Alcoholic ketoacidosisAlcoholic ketoacidosis UremiaUremia Sickle cell diseaseSickle cell disease PorphyriaPorphyria SLESLE VasculitisVasculitis GlaucomaGlaucoma HyperthyroidismHyperthyroidism

ToxicToxic Methanol poisoningMethanol poisoning Heavy metal toxicityHeavy metal toxicity Scorpion biteScorpion bite Black widow spider biteBlack widow spider bite

ThoracicThoracic Myocardial infarction/ Unstable anginaMyocardial infarction/ Unstable angina

Important Extra-abdominal Causes of Important Extra-abdominal Causes of Abdominal PainAbdominal Pain

PneumoniaPneumonia Pulmonary embolismPulmonary embolism Herniated thoracic disc (neuralgia)Herniated thoracic disc (neuralgia)

GenitourinaryGenitourinary Testicular torsTesticular torsiionon Renal colicRenal colic

Infectious Infectious Strep pharyngitis (more often in children)Strep pharyngitis (more often in children) Rocky Mountain Spotted FeverRocky Mountain Spotted Fever MonoMononnucleosisucleosis

Abdominal wallAbdominal wall Muscle spasmMuscle spasm Muscle hematomaMuscle hematoma Herpes zosterHerpes zoster

Emerg Med Clin North Am 1989; 7: 21-740

Abdominal Pain in the ElderlyAbdominal Pain in the Elderly

Diminished sensation of pain in the Diminished sensation of pain in the elderly elderly

Comorbid diseasesComorbid diseases PolypharmacyPolypharmacy Combinations of above result in Combinations of above result in

many more vague, nonspecific many more vague, nonspecific presentationspresentations

Twice as likely to require surgery Twice as likely to require surgery with presentation over age 65with presentation over age 65

What’s the ProblemWhat’s the Problem

Imprecise pain generation and Imprecise pain generation and transmission to the central transmission to the central nervous systemnervous system

Comorbid diseasesComorbid diseases Developmental stageDevelopmental stage MedicationsMedications Social factorsSocial factors

Understanding the Types of Understanding the Types of Abdominal Pain Abdominal Pain

VisceralVisceral Stretch fibers in capsules or Stretch fibers in capsules or

walls of hollow viscus that enter walls of hollow viscus that enter both sides of spinal cordboth sides of spinal cord

SomaticSomatic Fibers dermatomally distributed Fibers dermatomally distributed

and enter unilaterally in the and enter unilaterally in the spinal cordspinal cord

ReferredReferred Overlap of fibers from other Overlap of fibers from other

locationslocations

Understanding the Types of Understanding the Types of Abdominal PainAbdominal Pain

VisceralVisceral Crampy, achy, diffuse, Crampy, achy, diffuse, Poorly localizedPoorly localized

SomaticSomatic Sharp, lancinatingSharp, lancinating Well localizedWell localized

ReferredReferred Distant from site of generationDistant from site of generation Symptoms, but no signsSymptoms, but no signs

Understanding the Types of Understanding the Types of Abdominal PainAbdominal Pain

Location, location, locationLocation, location, location Organs and their corresponding fiber Organs and their corresponding fiber

entry to the spinal cordentry to the spinal cord C3-5 – liver, spleen, diaphragmC3-5 – liver, spleen, diaphragm T5-9 – gallbladder, stomach, T5-9 – gallbladder, stomach,

pancreas, small intestinepancreas, small intestine T10-11– colon, appendix, pelvic T10-11– colon, appendix, pelvic

viscerat11-l1 – sigmoid, renal viscerat11-l1 – sigmoid, renal capsules, ureters, gonadscapsules, ureters, gonads

S2-4 - bladderS2-4 - bladder

VisceralVisceral

SomaticSomatic

History Taking in Abdominal Pain History Taking in Abdominal Pain PresentationsPresentations

““OLD CARS”OLD CARS”

O- onsetO- onset L- locationL- location D- durationD- duration C- characterC- character A-alleviating/aggravating factorsA-alleviating/aggravating factors

associated symptomsassociated symptoms R- radiationR- radiation S- severityS- severity

History Taking for Abdominal Pain History Taking for Abdominal Pain PresentationsPresentations

PMHPMH Similar episodes in pastSimilar episodes in past Other medical problems that increase disease Other medical problems that increase disease

likelihood of problems (ex: DM and likelihood of problems (ex: DM and gastroparesis)gastroparesis)

PSHPSH Adhesions, hernias, tumorsAdhesions, hernias, tumors

MEDSMEDS Abx, NSAIDS, acid blockers, etcAbx, NSAIDS, acid blockers, etc

GYN/UROGYN/URO LMP, bleeding, dischargeLMP, bleeding, discharge

SocialSocial Tob/EtoH/drugs/home situation/agendaTob/EtoH/drugs/home situation/agenda

Physical Exam in Abdominal Physical Exam in Abdominal Pain PresentationsPain Presentations InspectionInspection

Distention, scars, Distention, scars, bruisesbruises

AuscultationAuscultation Present, hyper, or Present, hyper, or

absentabsent Actually not that helpful!Actually not that helpful!

PalpationPalpation Often the most helpful Often the most helpful

part of exampart of exam Tenderness versus painTenderness versus pain Start away from painful Start away from painful

area firstarea first Guarding, rebound, Guarding, rebound,

massesmasses

Physical Exam in Abdominal Pain Physical Exam in Abdominal Pain PresentationsPresentations

SignsSigns Mc burneyMc burney Murphy’sMurphy’s

Extra-abdominal examExtra-abdominal exam Pelvic or scrotal examsPelvic or scrotal exams Lungs, heartLungs, heart Remember it’s a patient, not a partRemember it’s a patient, not a part

RectalRectal Adds very little (despite the angst) beyond Adds very little (despite the angst) beyond

gross blood or melenagross blood or melena

Laboratory Testing Laboratory Testing

Everybody likes a CBC, but…Everybody likes a CBC, but…

Lacks sensitivity, no specificityLacks sensitivity, no specificity Little to no change in diagnostic Little to no change in diagnostic

probabilitiesprobabilities Should not dramatically alter Should not dramatically alter

approach (tender is still tender)approach (tender is still tender)

Laboratory TestingLaboratory Testing

Directed approach to lab studiesDirected approach to lab studies There are no “standard belly There are no “standard belly

labs”labs” Pregnancy test in women of Pregnancy test in women of

child bearing agechild bearing age Urine dipsticksUrine dipsticks

ImagingImaging

Plain filmsPlain films Free air, obstruction, air-fluid, FBsFree air, obstruction, air-fluid, FBs

UltrasoundUltrasound Rapid “yes or no” ED evaluationsRapid “yes or no” ED evaluations Formal studiesFormal studies May add dopplerMay add doppler

Computed TomographyComputed Tomography Revolutionized acute careRevolutionized acute care Often better than we are!Often better than we are!

Common Diagnoses by QuadrantCommon Diagnoses by Quadrant

RUQRUQ CholecystitisCholecystitis Biliary colicBiliary colic HepatitisHepatitis PancreatitisPancreatitis Renal stonesRenal stones PUDPUD PneumoniaPneumonia P EP E M IM I

LUQLUQ GastritisGastritis Gastric ulcerGastric ulcer PancreatitisPancreatitis SplenomegalySplenomegaly Splenic ruptureSplenic rupture Renal stoneRenal stone PneumoniaPneumonia P EP E M IM I

Common Diagnoses by Common Diagnoses by QuadrantsQuadrants

RLQRLQ AppendicitisAppendicitis Renal stoneRenal stone Ovarian cystOvarian cyst TorsionTorsion EpididymitisEpididymitis Ectopic Ectopic IBDIBD AAAAAA UTIUTI

LLQLLQ DiverticulitisDiverticulitis Renal stoneRenal stone Ovarian cystOvarian cyst TorsionTorsion EpididymitisEpididymitis Ectopic Ectopic IBDIBD AAAAAA UTIUTI

Dangerous MimicsDangerous Mimics

True DiagnosisTrue Diagnosis Initial MisdiagnosisInitial MisdiagnosisAppendicitisAppendicitis Gastroenteritis, PID, UTIGastroenteritis, PID, UTIRuptured abdominalRuptured abdominal Renal colic, diverticulitis, lumbar Renal colic, diverticulitis, lumbar

strainstrainaortic aneurysmaortic aneurysmEctopic pregnancyEctopic pregnancy PID, UTI, corpus luteum cystPID, UTI, corpus luteum cystDiverticulitisDiverticulitis Constipation,Constipation,GEGE ,pyelonephritis ,pyelonephritisPerforated viscusPerforated viscus PUD, pancreatitis, nspPUD, pancreatitis, nsp a abdominal bdominal

painpainBowel obstructionBowel obstruction Constipation, Constipation,

gastroenteritis,gastroenteritis,nnonspecific onspecific abdominal painabdominal painMesenteric ischemiaMesenteric ischemia GGEE, constipation, ileus small , constipation, ileus small bowel bowel

obstructionobstructionIncarcerated or Incarcerated or Ileus or small bowel obstructionIleus or small bowel obstructionstrangulated herniastrangulated herniaShock or sepsis fromShock or sepsis from Urosepsis or pneumonia (in elderly)Urosepsis or pneumonia (in elderly)perforation, bleed, perforation, bleed, abdominal infectionabdominal infection

Five Major Categories of Five Major Categories of Acute Abdomen (BIOPI)Acute Abdomen (BIOPI)

Bleeding or rupture of Bleeding or rupture of vessels or tumorvessels or tumor

Ischemia or InfarctionIschemia or Infarction ObstructionObstruction PerforationPerforation InflammationInflammation

Common Pitfalls in Acute Common Pitfalls in Acute AppendicitisAppendicitis Abdominal painAbdominal pain and and tendernesstenderness are are

present in nearly 100% of patients with present in nearly 100% of patients with appendicitis; other clinical features are less appendicitis; other clinical features are less reliable.reliable.

FeverFever occurs in only occurs in only 16%16% of patients with of patients with acute appendicitis; its presence is more acute appendicitis; its presence is more suggestive of appendiceal perforation.suggestive of appendiceal perforation.

Murphy sequenceMurphy sequence appears in only appears in only 22%22% elderly.elderly. Perforation rate about 60% (age > 60 Perforation rate about 60% (age > 60

Y/O)Y/O)

Management of Abdominal Management of Abdominal PainPain

Always right to start with ABC’sAlways right to start with ABC’s IV accessIV access Fluid administrationFluid administration AntiemeticsAntiemetics AnalgesicsAnalgesics Directed testing and imagingDirected testing and imaging Re-evaluationsRe-evaluations AntibioticsAntibiotics ConsultantsConsultants

Surgeons, OB/GYN, urologists, cardiologists, Surgeons, OB/GYN, urologists, cardiologists, etcetc

Disposition of Abdominal Pain Disposition of Abdominal Pain PatientsPatients

Operating RoomOperating Room Hospital bed/observationHospital bed/observation

Serial labsSerial labs Serial examsSerial exams

Home with abdominal warningsHome with abdominal warnings The art of emergency medicineThe art of emergency medicine 3 components of discharge plan3 components of discharge plan Document, document, documentDocument, document, document

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