Evaluation of Abdominal Pain by acm31250


									                                                                                Evaluation of Abdominal Pain   1

Evaluation of Abdominal Pain

Pathophysiology and clinical presentation
 Acute obstruction: pain is severe and “colicky” or wavelike; makes pt restless
Small Bowel
 70% caused by adhesions or external hernias
 Pain greatest when obstruction is jejunal; vomiting common
 Sx: restless during bouts of pain, comfortable b/t bouts of pain, vomiting common, temp normal or mildly
 PEX: abdomen distended; high-pitched, hyperactive bowel sounds, stool usually negative for occult
 Plain radiographs (supine and upright): distention of loops of small bowel with high air-fluid levels,
  absence of gas in large bowel distal to obstruction
 Severity decreases w/ time as bowel motility diminishes
 Complete strangulation assoc. w/ steady pain from secondary vascular insufficiency or peritoneal
Large Bowel
 90% caused by diverticular disease and carcinoma
 Sx: less vomiting and less painful than small bowel obstruction, constipation or change in bowel habits
  often precedes complete obstruction
 PEX: distention greater than SBO, stools frequently positive for occult blood
 Plain radiograph (supine and upright): varies with competency of ileocecal valve; if valve competent,
  less small bowel dilation occurs
Cystic Duct
 Sx: acute pain, biliary “colic”, pain mostly steady lasting over one hour after sudden onset
 Acute cholecystitis: localized peritonitis in addition to obstruction, pain maximal in RUQ or epigastrium,
  radiation to scapular region, nausea, vomiting, fever w/o jaundice
              o +Murphy’s sign (inspiratory arrest in response to RUQ palpation)
              o Leukocytosis, modest alk phos elevation
Common Duct
  Sx: pain more likely epigastric and less severe than in cystic duct obstruction, jaundice noted soon after
   onset, emesis
  PEX: tender RUQ, but less focal and deep than acute cholecystitis
  Alk phos and serum bili markedly elevated
 Urinary Tract
  Sx: can present as abdominal pain, sudden onset, cramping, pain begins in back and flank and
   radiates into lower abdomen and groin
  Acute pyelonephritis: upper abdominal pain, fever, and chills
  Acute bladder outflow obstruction: lower abdominal distention and suprapubic pain

 Sx: Involuntary guarding, rebound tenderness prominent; palpation, coughing, or movement may
  increase the pain, causing pt to lie still
Focal peritonitis
 Characteristic of acute appendicitis
 Test with psoas sign: pt lies on left side and extends right knee
 Bowel sounds often reduced or absent, esp when irritation is generalized
 Origin of peritoneal irritant does not need to be intra-abdominal
Familial Mediterranean Fever
 Autosomal recessive, occurs among Armenians and Sephardic Jews, presents in childhood or early
 Recurrent, severe attacks of peritoneal irritation
 Brief but severe attacks of fever, peritoneal irritation, pleuritis, and synovitis
 Marked elevations in ESR and acute phase reactants
 Amyloidosis is severe consequence, can result in renal impairment
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 Tx: colchicine  provides relief of pain and prevents amyloid deposition and renal impairment

Acute Arterial Insufficiency
 Etiology: artherosclerosis or embolus; most often from systemic embolization from Afib, severe
  atherosclerotic occlusive disease, and hypoperfusion states
 Sx: severe abdominal pain, but often early presentation is more subtle with mild constant pain
 Diagnosis may not be apparent until signs of peritonitis and shock from bowel perforation occurs
Chronic Mesenteric Insufficiency
 Sx: dull or cramping postprandial pain (“abdominal angina”) localized to epigastrium or mid-abdomen,
  can persist for 2-3 hrs
 Ischemia in celiac territory: nausea, vomiting, bloating
 Ischemia to midgut: pain and weight loss
 Inferior mesenteric artery insufficiency: constipation accompanied by occult blood loss
 Abdominal bruits in 20-60%
Aortic Dissection
 Rupture of abdominal aortic aneurysm
 Sx: severe abdominal pain that often radiates to back or genitalia
Mesenteric Venous Thrombosis
 Less common cause of intestinal ischemia than arterial occlusion
 Pain complaints are in excess of those elicited by physical exam
 May present similar to arterial occlusion, but often has a more slowly progressive course

Peptic Ulcer Disease
 Sx: pain mostly confined to epigastrium unless perforation or penetration into pancreas is present, pain
  described as gnawing, aching, and burning
 Radiation of pain into the back suggests perforation
 Sx: fever, nausea, vomiting
 PEX: bowel sounds hyperactive

Irritable Bowel Syndrome
 Spasmodic, nonpropulsive, segmental contractions of large bowel  high intraluminal pressures
 Manifests as cramping lower abdominal pain and bloating
 Constipation alternating with diarrhea and mucous stools
 Pain relieved with defecation, more frequent and loose stools w/ onset of pain, feeling of incomplete
 Altered motility and chronically increased intraluminal pressures may lead to diverticular disease
 Rome diagnostic criteria
             o At least 3 months of continuous or recurrent sx of abdom pain or discomfort associated
                  w/ any or all of the following: relief with defecation, change in stool frequency, change in
                  stool consistency
             o 2 or more of the following: altered stool frequency (>3 BM/day or <3 BM/wk), altered stool
                  form, altered stool passage, passage of mucus, bloating or feeling of abdominal
Functional Dyspepsia
 Chronic or recurrent upper abdominal discomfort or pain, often in conjunction w/ food-related dysmotility
  sx (bloating, fullness, nausea, early satiety)
 Many pts have concurrent GERD and irritable bowel syndrome
 Rome criteria (for ulcer-like variant)
             o Abdominal pain predominates, 3 months or more of upper abdom pain w/ no e/o organic
                  disease pluse 3 or more of the following:
             o Very well localized pain, pain relieved with food, pain relieved by antacids or H2 blockers,
                  pain that awakens pt from sleep, periods of remission and relapse
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Psychiatric Disturbances
 Common in pts with irritable bowel syndrome, esp. anxiety and mood d/o
Acute Ileus
 Causes: peritonitis, systemic infections, bowel ischemia, abdominal surgery, abdominal trauma,
  pharmacologic agents (anticholinergics and narcotics), and metabolic disturbances (esp. hypokalemia)
Intestinal Pseudo-obstuction
 Clinical features mimic those of intestinal obstruction
 Sx may be chronic (recurrent or persistent) or occur acutely (acute ileus)
 Sx: vomiting, abdominal distention, diarrhea or constipation
 Chronic: often idiopathic, may occur in setting of scleroderma, Parkinson’s, drug use (opiates,
  phenothiazines, TCAs, or antiparkinsonian meds), hypercalcemia, diabetes, myxedema, amyloidosis,
  radiation enteritis, and chronic laxative abuse

 Severe abdominal pain accompanied by emesis and elevated wbc
 Acute intermittent porphyria: moderate to severe colicky abdom pain, localized or general
 Sx: vomiting and diarrhea are common complaints, proximal muscle pain and range of neuropsychiatric
 Fever and leukocytosis
 PEX: soft abdomen
Lead Poisoning
 Pain is wandering, poorly localized, colicky, and accompanied by rigid abdomen
 Encephalopathy, peripheral neuropathy, and anemia are associated features
 Diagnostic test: urine coproporphyrin test more reliable indicator than serum lead level
Angioneurotic Edema
 Caused by C esterase inhibitor deficiency
 Episodic and severe abdominal pain
 Diagnostic test: serum level of C4 low
Nerve Injury
 Herpes zoster: pain of herpes infection often precedes rash by several days and may persist after skin
  clears, severe lancinating pain
Abdominal Wall Pathology
 Traumatic injury to musculature of wall
 Pain is constant, aching, and exacerbated by movement or pressure on abdomen
Referred Pain
 Pulmonary infarction, pneumonia of lower lobe  upper abdom pain
 Inferior MI  upper abdom pain, nausea, vomiting

 Hx and PEX
 Labs: CBC, stool examination for wbc for pts with diarrhea, pregnancy test (b-hCG)
 Plain films of abdomen
             o Complete SBO: multiple air-fluid levels, distention of small bowel, absence of gas in large
             o Partial SBO: some loops of bowel with air-fluid levels, +gas in colon
             o Colonic obstruction w/ competent ileocecal valve: only large bowel appears distended
             o Colonic obstruction w/ incompetent ileocecal valve: both large and small bowel have
                  distention and gas, mimicking the findings of adynamic ileus
             o Suspected large bowel obstruction  indication for Ba enema
             o Perforation of viscus: free air under diaphragm
             o Retroperitoneal bleeding, abscess, or mass: absent psoas shadows
             o Compression from tumor: displaced stomach or bowel
 UA, chem, and LFTs
 Other imaging/tests
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 Paracentesis: for ascites or abdom trauma
 CT abdomen: for suspected diverticulitis esp if concerned for abscess formation, aortic aneurysm
 Helical CT of appendix: for suspected appendicitis
 U/S: for acute cholecystitis and choledocholithiasis, hydronephrosis from urterolithiasis, suspected
  pancreatic cancer

Functional GI Disease
 Two common types: irritable bowel syndrome and non-ulcer dyspepsia

 large bowel discomfort or pain, disturbed defecation, distention, often predominated by constipation,
  diarrhea, or gaseousness
 strongly influenced by emotional factors
 functional disturbance in motor activity and visceral perception; abnormal motor function, producing both
  constipation and diarrhea
 increased prevalence of somatization, personality disturbances, anxiety, depression
 increased sx associated with greater prevalence of serious situational stresses, psychopathology, and
  learned visceral responses to bowel discomfort and threatening situations
 Intraluminal factors: malabsorption of certain sugars (lactose, fructose, sorbitol)
 Chronic relapsing condition w/ no e/o significant morbidity or mortality
 Management: establish strong patient-doctor relationship, treat important underlying psychopathology,
  modify diet, judicious use of meds
 Psychopathology: depression, chronic anxiety, somatization d/o; use behavioral methods,
  psychotherapy, relaxation techniques, hypnosis; use multi-faceted approach
 Dietery modifications: avoid caffeine, alcohol, sorbitol, fructose, lactose, poorly digestable
  carbohydrates; increase dietary fiber
 Drug therapy: treat for diarrhea (loperamide), constipation, abdom pain/distention (anticholinergics)
 Herbal therapy
 Patient education

Non-ulcer dyspepsia (“bad digestion”)
 upper abdom discomfort, bloating, distention, nausea, early satiety, anorexia, often but not always
  exacerbated or triggered by eating
 Pathophysiology: dysmotility, delayed gastric emptying, altered visceral perception, psychological
  factors, excessive acid production, H. pylori infection, maldigestion/malabsorption of carbohydrates
 Not considered part of presentation: acid reflux, biliary colic, painful or altered defecation, chronic pain
 DDx: gastric carcinoma, complicated peptic ulcer disease, erosive esophagitis, low-grade chronic
  pancreatitis, biliary tract disease
 W/u: upper GI endoscopy, guiaic stool test, H. pylori serology
 Management: little consensus on how to best treat this condition; eradicate H. pylori, chronic acid
  suppression, prokinetic therapy (enhance gastric motility; metoclopramide, cisapride), dietary
  manipulations, psychotherapy
 Diet, alcohol, smoking, stress: no data to indicate that a low-fat diet, alcohol restriction, smoking
  cessation, or stress reduction have positive effect on non-ulcer dyspepsia
 Refer pts to GI when there is increased risk of malignancy and other serious GI pathology

Examination of Anorectum and Sigmoid Colon

Anorectal exam
 Men – examine prostate and if possible, seminal vesicles
 Check for tenderness, induration, fluctuance, or masses
 Test for occult blood unless gross blood is seen
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 Evaluation of bright red rectal bleeding, perianal pain, or suspected hemorrhoids
 Normal rectal mucosa – pink w/ visible delicate network of submucosal vessels
 Proctitis – vascular pattern typically obliterated and mucosa may be friable
 Hemorrhoids – appear as purple bulges into the lumen
 Fissures may be identified at the anal verge
 For colorectal cancer screening
 About ¼ of CRCs are w/in reachof rigid sig, about 50% w/in reach of flex sig
 Cost-effective in combination with FOBT
 Can remove polyps before they undergo malignant transformation
 High risk polyps - >1 cm in diameter
 Permits direct visualization of colonic mucosa
 Evaluate pts w/ problems referable to large bowel
 Can monitor disease activity and response to therapy for pts with known inflam bowel disease
Contraindications – acute peritonitis, suspected bowel perforation or infarction, severely uncooperative pt,
refusal of pt to give consent. Not contraindicated in pregnancy.

Somatoform Disorders, Factitious Disorders, and Malingering

Somatoform Disorders
 4th most common problem in FM
 Pts “doctor shop”, receiving multiple medical evaluations and possibly surgical procedures
 Present with physical complaints and sx but have no objective findings or complaints far exceed the
  demonstratable physical disease
 Convinced that they have a definite physical illness
 Subsyndromal somatization – do not meet full diagnostic criteria for specific somatoform d/o

Types                           Characteristics
Somatization d/o (SD), SD        Many unexplained sx over time that impair functioning (social,
NOS, undifferentiated SD        occupational)
                                 Undifferentiated – 6 months or longer; chronic fatigue, loss of appetite,
                                GI complaints, GU complaints
Pain d/o                         All encompassing focus of pain, which is inexplicably severe or
Hypochondriasis                  Persistent and possibly debilitating fear that he/she has a serious
                                disease in spite of evidence to the contrary
Conversion d/o                   Sudden onset of sx or deficits in voluntary motor or sensory fx that
                                cannot be explained by medical condition or effects of a substance
                                 Onset is sudden and transient
                                 Paralysis of extremity, areas of anesthesia, pseudoseizures, hysterical
                                blindness, falling, aphonia
Body dysmorphic d/o              Excessive concern, preoccupation, or loathing about some aspect of
                                his/her appearance
Factitious d/o                   Complaints and other physical findings that are self-inflicted
                                 No apparent secondary gain
                                 Factitious d/o by proxy – complaints and physical findings induced in a
                                child by dependent adult or caregiver
Malingering                      Complaints and possibly physical signs and lab findings of medical or
                                psychological illness, with secondary gain usually evident

 Best medicine is patient-physician relationship
 Consultation PRN to help FP in management
 Management includes: thorough history taking, complete PEX, obtain labs, review previous medical
  records and test results
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                                     Screening for Colorectal Cancer

 Cancers detected and removed while still localized are associated with a 5-year survival rate >80%
 Incidence greater in economically developed societies
 Risk factors: high-fat low-fiber diet, advancing age, FH (1 st degree relative raises risk 2x-3x), FAP,
  HNPCC, UC (increase 5-10x)
 Use of aspirin or NSAIDs associated with lower risk
 Sporadic polyps: common lesions, no malignant potential
 Adenomas: truly neoplastic, may include malignant foci, risk for malignancy increases with size of
  adenoma, histology contributes
 Villous adenomas: highest malignant potential
             o Tubular or mixed tubulovillous adenomas: associated with less risk
             o Duration of asymptomatic detectable period estimated to be several years
 When cancers found after symptomatic period, 60% have already disseminated to regional LNs or
  distant organs
 Dukes stage A (confined locally to bowel wall) or Dukes stage B (pericolic fat) – 80% 5 yr survival
 Dukes C (regional LN mets) – 46% 5 yr survival
 Dukes D (distant mets) – 5% 5 yr survival

Screening Tests
 Digital Exam – only 10% of CRCs are w/in reach of examining finger; little evidence to support this
  screening test
 Fecal Occult Blood Testing – best performed serially due to intermittent nature of the bleeding
             o Sensitivity of 30-70%
             o +FOBT  require thorough evaluation for colorectal neoplasia; colonoscopy or
                 sigmoidoscopy w/ air-contrast Ba enema
 Sigmoidoscopy – 25% of colon cancers are w/in range of rigid sigmoidoscope, 50% with flexible
 Low risk of bowel perforation (1-2 in 10,000)
 Guidelines from ACS:
             o Annual FOBT
             o Flexible sigmoidoscopy q5 yrs beginning at age 50 for pts at average risk
             o Start screening at age 40 for those at higher risk (or 10 yrs before the earliest cancer in a
                 family with strong hx of colorectal cancer)
 Adenomatous polyps >0.5 cm, multiple lesions, or lesions w/ villous or tubulovillous histology found w/
  sigmoidoscopy screening  refer for colonoscopy to search for more proximal synchronous disease;
  remove polyp for histologic examination

 Annual FOBT + periodic sigmoidoscopy or colonoscopy, depending on estimated risk for CRC
 Reassess pt’s CRC risk by reviewing FH for CRC and larger (>1 cm) adenomas in 1 degree relatives,
  PMH for CRC, larger adenomas, UC w/ pancolonic involvement
 High risk (ulcerative pancolitis >10 yrs, FAP, or HNPCC) – refer to gastroenterologist for surveillance
 Intermediate-high risk pts (personal hx of CRC or larger adenomatous polyps) – obtain f/u colonoscopy
  about q3 yrs
 High-intermediate risk (strong FH of CRC, larger adenomas in 1 st degree relative <60 yo, or >1 affected
  1st degree relative) – begin screening at age 40 w/ colonoscopy about q5 yrs
 Intermediate risk (1st degree relative w/ CRC or polyps diagnosed after age 60, personal hx of smaller
  (<1 cm) adenomatous polyp) – begin screening at age 40 w/ annual FOBT and flex sig q5 yrs
 Avg-risk (no risk factors other than age) – annual FOBT at age 50 and flex sig q5 yrs
Test Performance
 FOBT – 2 samples on each of 3 days, restrict dietary peroxidases and red meat
 +FOBT  colonoscopy or sigmoidoscopy w/ air-contrast Ba enema
 larger polyp, multiple smaller polyps, or polyp w/ tubulovillous or villous histology on screening
  sigmoidoscopy  get colonoscopy
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Irritable Bowel Syndrome
 Intestinal d/o characterized by abnormal movement and sensitivity of the bowel
 Can cause irregularity of bowel movements (constipation, diarrhea, or both) and abdominal pain
 Not a serious condition
 Unknown cause; believed that muscles in wall of colon contract abnormally
 Muscular contraction too strong  result in painful spasm (“spastic colon”)
 May have genetic factors

Factors worsening the condition
 Sensitivity to certain foods; depends on the individual
 Emotional stress
 Caffeine
 Alcohol
 Excessive gas
 Large, fatty meals
 Menstrual periods

Risk factors
 Female (2:1 vs. males)
 Other family members with IBS
 Domestic violence
 Sexual abuse
 Depression and/or anxiety

 Abdom pain or discomfort for at least 12 wks out of the previous 12 months; 12 weeks don’t need to be
  continuous; sx come and go, range in severity from mild to severe
 Pain relieved by having a bowel movement
 Constipation, diarrhea, or both
 Change in form of stool (more liquid or more solid)
 Less specific sx: gas, bloating, urge to move bowel but unable to, mucus in stool

 Clinical diagnosis and r/o other diseases

 No cure, but can reduce frequency and duration of sx
 Dietary sx: high fiber diet (fresh fruits and veggies, whole grains), avoid foods that trigger sx, eat smaller
  more frequent meals, eat slowly to reduce gas production, drink lots of water
 Stress management
 Meds – fiber supplements (Metamucil or Citrucel), meds for abdom cramps or spasms, meds to treat
  diarrhea and/or constipation, antidepressants and/or meds for anxiety

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