Approach to Abdominal Pain

Approach to Abdominal Pain Mike Heavey GI Fellow 7/6/07 Why is this important? • Abdominal pain is one of the most common reasons for outpatient and ER visits • Variation in degree of pathology is vast, some of which needs immediate attention • A lot can happen in the abdomen and you need an organized approach Just a few diagnoses to ponder… • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Esophagitis GERD Gastric ulcer Gastritis Duodenal ulcer Duodenitis Gastric outlet obstruction Bowel obstruction Intussusception Bowel perforation Cancer Hepatitis Splenic infarct Splenic abscess Mesenteric ischemia Somatization IBS Crohn’s disease Ulcerative colitis Gastroenteritis Familial Mediterranean fever Acute intermittent porphyria Appendicitis AAA rupture Esophageal spasm Diverticulitis Ectopic pregnancy Pelvic inflammatory disease Fitz-Hugh-Curtis HSV Abdominal epilepsy • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Endometriosis Vitamin D deficiency Adrenal insufficiency Pancreatitis Cholangitis Cholecystitis Choledocholithiasis Incarcerated hernia UTI Nephrolithiasis Abdominal migraine Celiac artery compression syndrome Uterine pathology HIV Hemophilia Sickle cell disease Trauma Pneumonia Subdiaphragmatic abscess Myocardial infarction Pericarditis Prostatitis Idiopathic inflammatory disorders Epiploic appendagitis Hereditary angioedema Painful rib syndrome Wandering spleen syndrome Abdominal wall pain Leukemia HSP Lead poisoning So how do we organize this? • Location • Acute v. chronic – Surgical v. nonsurgical Localizing pain -- RUQ • • • • • Hepatitis Cholecystitis Cholangitis RLL pneumonia Subdiaphragmatic abscess Localizing pain -- LUQ • Splenic infarct • Splenic abscess • Gastritis/PUD Localizing pain -- RLQ • • • • • • • Appendicitis Inguinal hernia Nephrolithiasis IBD Salpingitis Ectopic pregnancy Ovarian pathology Localizing pain -- LLQ • • • • • • • Diverticulitis Inguinal hernia Nephrolithiasis IBD Salpingitis Ectopic pregnancy Ovarian pathology Localizing pain -- epigastric • • • • • PUD Gastritis Pancreatitis GERD Cardiac (MI, pericarditis, etc) Localizing pain -- periumbilical • • • • Pancreatitis Obstruction Early appendicitis Small bowel pathology • Gastroenteritis Localizing pain -- pelvic • UTI • Prostatitis • Bladder outlet obstruction • PID • Uterine pathology Localizing pain -- diffuse • • • • • • Gastroenteritis Ischemia Obstruction DKA IBS Others – – – – FMF AIP Vitamin D deficiency Adrenal insufficiency Acute abdominal pain • Generally present for less than a couple weeks – Usually days to hours old – Don’t forget about the chronic pain that has acutely worsened • More immediate attention is required Acute abdominal pain • Surgical – – – – Appendicitis Cholecystitis Bowel obstruction Acute mesenteric ischemia – Perforation – Trauma – Peritonitis • Nonsurgical – – – – – – – Cholangitis Pancreatitis Nonabdominal causes Choledocholithiasis Diverticulitis PUD/-itis gastroenteritis Surgical abdomen • This is the first thing to be considered in acute abdominal pain – Early identification is a must as prognosis worsens rapidly with delay in treatment • Important to get surgeons involved early if this is even mildly suspected • This is a clinical diagnosis Surgical abdomen • Presentation is usually bad – Fevers, tachycardia, hypotension – VERY tender abdomen, possibly rigid • Presentation can vary with other demographic and medical factors – Advanced age – Immunosuppression Surgical abdomen • Peritonitis – Often signals an intraabdominal catastrophe • Perforation, big abscess, severe bleeding – Patient usually appears ill – Exam findings • Rebound, rigidity, tender to percussion or light palpation, pain with shaking bed Surgical abdomen • Obstruction – May be acute or acute on chronic – Symptoms include persistent vomiting, abdominal distention (or not), pain – Exam findings depend on level of obstruction (proximal v. distal) • Distal – distention, tympany, absent or highpitched bowel sounds • Proximal – similar, but may not see distention and tympany Surgical abdomen • Ischemia – Mesenteric ischemia usually seen in patients with CAD risk factors, but anyone can infarct bowel for a variety of reasons – Symptoms include pain OUT OF PROPORTION TO EXAM – Exam findings • Severe tenderness to minimal palpation, unstable vital signs, and a very uncomfortable patient Surgical abdomen • Work-up – Start with stat labs – Surgical abdominal series (plain films) – Consider stat CT if readily available • Sometimes patients go straight to surgery as initial step • Again, get surgeons involved early for guidance and early intervention Chronic abdominal pain • Generally present for months to years • Generally not immediately life threatening • Outpatient work-up is prudent Approach to the patient • History is THE MOST IMPORTANT part of the diagnostic process – Location, quality, severity, radiation, exacerbating or alleviating factors, associated symptoms • Visceral v. peritoneal – A good thorough medical history – A good thorough social history, including alcohol, drugs, domestic abuse, stressors, etc. – Family history is important (IBD, cancers, etc) – MEDICATION INVENTORY Approach to the patient • Physical exam – Vitals – A good thorough medical exam • Jaundice, signs of chronic liver disease, signs of vitamin deficiency, etc. – Abdominal exam • Look, listen, feel • Know a few tricks Approach to the patient • Labs – CMP, CBC, coags – Amylase and lipase – UA – bHCG – Lactate Approach to the patient • Imaging – – – – – Plain films (KUB, UGI) CT Ultrasound MRI Angiography • Endoscopy – EGD – Colonoscopy – ERCP/EUS What to do on call • • • • Get out of bed and assess patient Review the patient’s history Ask the nurse what happened that day Consider stat testing – Blood – Imaging • If questions, call your senior • Consider surgical eval and/or advice from GI fellow if it seems bad and you have no idea what is going on Biliary pathology • Cholangitis – Fever, RUQ tenderness, jaundice, mental status changes, hypotension – Labs show leukocytosis with elevated AP and bilirubin – Imaging may show ductal dilation from stone – Treatment is antibiotics (GN), ERCP Biliary pathology • Cholecystitis – Fever, RUQ pain, Murphy’s sign, rebound tenderness – Labs with leukocytosis and left shift, often NORMAL LFTs – Imaging with GB wall thickening, maybe gallstones pericholecystic fluid, sonographic Murphy’s • HIDA may also be helpful – Treatment is antibiotics, surgery, percutaneous cholecystostomy if critically ill or poor surgical candidate Biliary pathology • Choledocholithiasis (biliary colic) – Intermittent RUQ pain associated with fatty meal • Starts 30-40 minutes after starting eating, spikes early, then tapers over a few hours – Labs normal – Imaging with cholelithiasis (possibly intraductal stone during attack) – Treatment is cholecystectomy Diverticulitis • Pain is LLQ, constant, associated with fever, mainly obstipation, maybe some blood with small amount of stool • Labs show leukocytosis • Imaging shows colon thickening with diverticuli, pericolonic fat stranding, possible abscess • Treatment is antibiotics