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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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