Approach to Abdominal Pain in the Emergency Department

Approach to Abdominal Pain in the Emergency Department Richard Stair, MD, FACEP Department of Emergency Medicine Introduction  At the end of this lecture you should: Understand the generation and presentation of types of abdominal pain  Develop critical elements of the history and physical for AP  Apply knowledge of utility of testing to diagnostic approach  Apply management principles to patient care in the ED  What Do They Have?  As you go through this presentation, think about each of these cases: An 18 mo old that suddenly became inconsoleable from AP while playing  A 20 yo man with 12 hours of diffuse crampy AP that migrated to RLQ that became sharp  78 yo woman with h/o chronic steroid use with sudden sharp AP and a rigid exam  Acute Abdominal Pain      Approximately 6% of ED visits Admission rates vary by population, up to about to 65% in high risk elderly populations Most common diagnosis is NONSPECIFIC (ie, “I dunno”) Use H+P, risk factors, and directed studies to arrive at diagnosis MUST rule out emergency conditions Abdominal Pain Across the Ages  Ages 0-2  Colic, GE, viral illness, constipation Functional, appendicitis, GE, toxins Addition of genitourinary problems Beware of what seems like everything!  Ages 2-12   Teens to adults   Elderly  Special Populations     Elderly/ nursing home patients Immunocompromised Post operative patients Infants Abdominal Pain in the Elderly      Diminished sensation of pain in the elderly Comorbid diseases Polypharmacy Combinations of above result in many more vague, nonspecific presentations Twice as likely to require surgery with presentation over age 65 What’s the Problem      Imprecise pain generation and transmission to the central nervous system Comorbid diseases Developmental stage Medications Social factors Understanding the Types of Abdominal Pain  Visceral  Stretch fibers in capsules or walls of hollow viscus that enter both sides of spinal cord Fibers dermatomally distributed and enter unilaterally in the spinal cord Overlap of fibers from other locations  Somatic   Referred  Understanding the Types of Abdominal Pain  Visceral Crampy, achy, diffuse,  Poorly localized   Somatic Sharp, lancinating  Well localized   Referred Distant from site of generation  Symptoms, but no signs  Understanding the Types of Abdominal Pain   Location, location, location Organs and their corresponding fiber entry to the spinal cord C3-5 – liver, spleen, diaphragm  T5-9 – gallbladder, stomach, pancreas, small intestine  T10-11– colon, appendix, pelvic viscerat11-l1 – sigmoid, renal capsules, ureters, gonads  S2-4 - bladder  History Taking in Abdominal Pain Presentations  “OLD CARS” O- onset  L- location  D- duration  C- character  A-alleviating/aggravating factors associated symptoms  R- radiation  S- severity  History Taking for Abdominal Pain Presentations  PMH   Similar episodes in past Other medical problems that increase disease likelihood of problems (ex: DM and gastroparesis)  PSH  Adhesions, hernias, tumors Abx, NSAIDS, acid blockers, etc LMP, bleeding, discharge Tob/EtoH/drugs/home situation/agenda  MEDS   GYN/URO   Social  Physical Exam in Abdominal Pain Presentations  General appearance “Sick versus not sick”  Mobile versus still  Obvious pain or discomfort  “Doorway” impression   Vital signs  “That’s why they’re called vital” Physical Exam in Abdominal Pain Presentations  Inspection  Distention, scars, bruises  Auscultation Present, hyper, or absent  Actually not that helpful!   Palpation Often the most helpful part of exam  Tenderness versus pain  Start away from painful area first  Guarding, rebound, masses  Physical Exam in Abdominal Pain Presentations  Signs      Iliopsoas Obturator Rovsing’s Murphy’s Extra-abdominal exam    Pelvic or scrotal exams Lungs, heart Remember it’s a patient, not a part Adds very little (despite the angst) beyond gross blood or melena  Rectal  Laboratory Testing  Everybody likes a CBC, but… Lacks sensitivity, no specificity  Little to no change in diagnostic probabilities  Should not dramatically alter approach (tender is still tender)  Laboratory Testing     Directed approach to lab studies There are no “standard belly labs” Pregnancy test in women of child bearing age Urine dipsticks Imaging  Plain films  Free air, obstruction, air-fluid, FBs  Ultrasound Rapid “yes or no” ED evaluations  Formal studies  May add doppler   Computed Tomography Revolutionized acute care  Often better than we are!  Common Diagnoses by Quadrant  RUQ           LUQ          Cholecystitis Biliary colic Hepatitis Pancreatitis Renal stones PUD Pneumonia PE MI Gastritis Gastric ulcer Pancreatitis Splenomegaly Splenic rupture Renal stone Pneumonia PE MI Common Diagnoses by Quadrants  RLQ           LLQ          Appendicitis Renal stone Ovarian cyst Torsion Epididymitis Ectopic IBD AAA UTI Diverticulitis Renal stone Ovarian cyst Torsion Epididymitis Ectopic IBD AAA UTI Management of Abdominal Pain          Always right to start with ABC’s IV access Fluid administration Antiemetics Analgesics Directed testing and imaging Re-evaluations Antibiotics Consultants  Surgeons, OB/GYN, urologists, cardiologists, etc Disposition of Abdominal Pain Patients   Operating Room Hospital bed/observation Serial labs  Serial exams   Home with abdominal warnings The art of emergency medicine  3 components of discharge plan  Document, document, document  Now How About Those Cases  18 mo old had classic presentation of intussusception, and symptoms may wax and wane; rectal would be to look for current jelly stool. Air enema for diagnosis and reduction. Involve consultants early in the course. Now How About Those Cases  20 year old with classic presentation of appendicits, which likely does not need CT scan. Most do not present so simply, quite a wide array of presentations. General surgery consultation, pain meds, IVF, and an operation would all be good, but don’t be shocked if CT requested. Now How About Those Cases  78 yo has perforated abdomen, with age, multiple problems, and chronic steroids risks for perforation. Rapid resuscitation, plain films to confirm free air, antibiotics, pain medicine, and a surgeon as fast as you can would be good practice. Take Home Points      Perform a good history and physical to guide assessment Lab studies have limitations…..and costs Imaging studies also need to be selected wisely Early involvement of consultants for sick patients Treatment initiation, not just diagnostics