Approach to the ED Patient With Abdominal Pain

Approach to the ED Patient With Abdominal Pain EMPA Residency UTHSCSA Overview • • • • • • • • • General remarks & epidemiology Anatomy - not Neuroanatomy and pain perception - not History Physical Laboratory Imaging Management Disposition Abdominal Pain in the ED • • • • Hard to evaluate Hard to diagnose Can be hard to treat Disposition often difficult Causes of Abdominal Pain in ED patients of all ages r Othe ) (22% n (41 kno w Un %) 2%) UD ( P (2%) atio n stip Co n 3%) ion ( tru ct Ob s 3%) itis ( st lecy Ch o 4%) itis ( c en di ) Ap p e (4% Ston eral Uret 7%) GE ( A 5%) UT I ( (7%) PID Abdominal Pain in ED • Factors affecting your differential diagnosis, evaluation, treatment, and disposition – Age – Sex Causes of Abdominal Pain in patients > 70 y/o 5%) tis (2 i cyst hole C ) (13% ncy gna Mali r Othe ) (13% on (1 ructi t Obs ) %) n (10 ow Unkn %) tis (7 ( PUD 8%) 1%) % is (4 dicit en App 4%) itis ( reat Panc d ... erate c Incar iculi ivert D Causes of Abdominal pain in children of all ages ) (63% wn nk no U r (5 Othe %) App 2 is ( 3 dicit en %) Causes of Acute Abdominal Pain in Children Infants (age 0 to 2 years) Colic Gastroenteritis Viral illness Constipation Preadolescents (2 – 12) Adolescents (teens) Appendicitis Functional disorder Nonspecific constipation Gastroenteritis Dysmenorrhea Urinary infection Pelvic infection Mittelschmerz Pregnancy Ovarian cyst Colitis Diabetes Ectopic pregnancy Endometriosis Epididymitis Gallbladder disease Gastritis Inflammatory bowel disease Occult trauma Ovarian torsion Sickling syndromes Testicular torsion Common Appendicitis Functional disorder Gastroenteritis Nonspecific constipation Viral illness Toxic ingestions Urinary infection Uncommon Appendicitis Congenital anomalies Cystic fibrosis Hirschsprung disease Incarcerated hernia Intussusception Malabsorption Milk allergy Neoplasms Sepsis Volvulus Asthma Cystic fibrosis Diabetes Inflammatory bowel disease Hematologic Meckel’s diverticulum Occult trauma Ovarian torsion Pancreatitis Pharyngitis Pneumonia Sickling syndromes Testicular torsion History • Characterize the nature and course of the pain • Associated symptoms • Past medical history • Build relationship with patient Onset and Duration of Pain • Abrupt and severe – Vascular occlusion – Perforation of hollow organ – Renal colic • Gradual over hours to days – Inflammatory conditions • Cholecystitis • Appendicitis • Diverticulitis Physical Examination • • • • Localize the area of disease Look for extra-abdominal causes of pain Often difficult 2° to patient’s pain Re-examine, re-examine and then reexamine • Phenergan® Physical Examination General Appearance &Vital Signs • Pale, distressed, still, diaphoretic & sick • Vital signs are VITAL Physical Examination General Appearance &Vital Signs • Hypotension and tachycardia in the face of abd pain is bad – Ruptured AAA or ectopic until proven otherwise – Remember β-blockers and vagal response • Respirations rate and depth – Compensate for met acidosis, DKA, AKA, pulm source of pain or toxin Physical Examination • Inspection – Scars, distention, masses • Auscultation – Silent in patients with perf – High-pitched in SBO’s • Percussion – Distention • Generally these are of little value Physical Examination • Palpation – Pain vs. Tenderness – RLQ tenderness 65% of appys and 28% of non-specific abdominal pain – Peritoneal signs Physical Examination • Specific sings – Iliopsoas sign – Obturator sign – Murphy’s sign – Rovsing’s sign Physical Examination • Rectal exam – Masses, blood, prostate, tenderness • Pelvic examination – PID, Fitz-Hugh and Curtis syndrome, masses – Just do it! Physical Examination • • • • Heart Lungs Back Genitalia Case #1 • 17 y/o with abdominal pain – 135/70, 95, 18, 101 – 18 hours of pain – mid abdomen  RLQ – Nausea last 3-4 hours – Anorexia – TTP RLQ – (+) rebound, heel tap, Rovsings Case #1 Discussion • 17 y/o with abdominal pain – 135/70, 95, 18, 101 – 18 hours of pain – mid abdomen  RLQ – Nausea last 3-4 hours – Anorexia – TTP RLQ – (+) rebound, heel tap, Rovsings  Fever  20%  Duration  >72 hours negative predictor  Location and migration  Other than RLQ negative predictor Case #1 Discussion  Associated symptoms • 17 y/o with abdominal pain – 135/70, 95, 18, 101 – 18 hours of pain – mid abdomen  RLQ – Nausea last 3-4 hours – Anorexia – TTP RLQ – (+) rebound, heel tap, Rovsings  N/V 67%, anorexia 70%, diarrhea 11%  Tenderness  95% tender  65-94% RLQ  Peritoneal signs  68% rebound  13% psoas, 8% obturator Case #1 Discussion • Testing – WBC count – poor sensitivity and specificity – CRP – ditto – Plain films – not helpful 2% with appendicolith Case #1 Discussion • Testing – Contrast CT – sens ~ 100%, spec ~ 95% – Non con CT – sens ~ 90%, spec ~ 97% – Ultrasound – sens ~ 93%, spec ~ 91% – Bottom Line • Depends upon your radiologist Case # 2 • 63 y/o M with HTN with abd and flank pain radiating to the groin • 110/51, 105, 20, 98.6 • Started abruptly 4 hours ago • Severe pain • Abd – flat no masses, nl auscultation • No CVA tenderness • GU – nl • Peripheral vascular exam normal Case # 2 - Discussion • 63 y/o M with HTN with abd and flank pain radiating to the groin 110/51, 105, 20, 98.6 Started abruptly 4 hours ago Severe pain Abd – flat no masses, nl auscultation No CVA tenderness GU – nl Peripheral vascular exam normal  Age  65-70, rare <50  Pulsatile mass, bruit  Most elective with mass, 5% bruit • • • • • • •  Peripheral vascular exam  Usually normal  Lab tests  None helpful, some needed Case # 2 - Discussion • 63 y/o M with HTN with abd and flank pain radiating to the groin 110/51, 105, 20, 98.6 Started abruptly 4 hours ago - severe pain Abd – flat no masses, nl auscultation No CVA tenderness GU – nl Peripheral vascular exam normal • • • • • •  Plain films – no help  CT & Ultrasound - ~ 100% sensitive for presence of AAA, to identify leak must get CT  MRI – very accurate, difficult logistically  Angiography – less sensitive Case #3 • • • • 40 y/o obese F with RUQ pain 139/75, 88, 18, 99 Pain off and on for 2 wks after eating 1 hour after double whopper pain started has not resolved, (+) N/V • TTP RUQ with Murphy’s sign • No peritoneal signs Case #3 - Discussion • • • • 40 y/o obese F with RUQ pain 139/75, 88, 18, 99 Pain off and on for 2 wks after eating 1 hour after double whopper pain started has not resolved, (+) N/V TTP RUQ with Murphy’s sign No peritoneal signs  Risk factors  F,F,F,F,F  Fever  Normal cholelithiasis  32% of cholecystitis  History of similar pain  71% •  Murphy’s  Specific not sensitive • Case #3 - Discussion • • • • • • 40 y/o obese F with RUQ pain 139/75, 88, 18, 99 Pain off and on for 2 wks after eating 1 hour after double whopper pain started has not resolved, (+) N/V TTP RUQ with Murphy’s sign No peritoneal signs  Ultrasound  98%/98% for stone  90-95%/78-80% for “itis”  Radionuclide scanning  97%/90% for cholecystitis  CT/MR  Better for common duct pathology  LFT/WBC  50%/60% sens respectively Case #4 • 70 y/o M with prior abd surgery N/V, abd pain x 8 hours • 125/75, 85, 18, 99 • Crampy pain then n/v • PO intolerant • Distended, tympanitic abdomen • High pitched bowel sounds • Diffusely tender Case #4 - Discussion • 70 y/o M with prior abd surgery N/V, abd pain x 8 hours 125/75, 85, 18, 99 Crampy pain then n/v PO intolerant Distended, tympanitic abdomen High pitched bowel sounds Diffusely tender  Colicky pain  80% colicky • • • • • •  Prior surgery  70%  High pitched bowel sounds  50% Case #4 - Discussion • 70 y/o M with prior abd surgery N/V, abd pain x 8 hours 125/75, 85, 18, 99 Crampy pain then n/v PO intolerant Distended, tympanitic abdomen High pitched bowel sounds Diffusely tender  Plain films  70%/80% • • • • • •  CT  94-100%/83-96%  Etiology ~ 90%  Ultrasound  88%/96% Case #5 • • • • 60 y/o female with LLQ abd pain, diarrhea 125/75, 95, 20, 101 TTP LLQ without peritoneal signs Heme neg Case #5 - Discussion • • • • 60 y/o female with LLQ abd pain, diarrhea 125/75, 95, 20, 101 TTP LLQ without peritoneal signs Heme neg  Location  Nearly all LLQ, Asian RLQ  Change in stools  most  Peritoneal signs  Early rare, late highly variable  Blood in stool  50% Case #5 - Discussion • • • • 60 y/o female with LLQ abd pain, diarrhea 125/75, 95, 20, 101 TTP LLQ without peritoneal signs Heme neg  CT  ?~100%/100%  Ultrasound  84-98%/93-97%  Barium enema radiographs  80%/100% Case #6 • 17 y/o female with LLQ pain • 95/45, 125, 25, 99 • LLQ abd/pelvic pain X 12 hours acutely worse last hour • LMP – 2 wks, denies pregnancy • TTP LLQ • GU -scant blood, L adnexal fullness Case #6 - Discussion • • • 17 y/o female with LLQ pain 95/45, 125, 25, 99 LLQ abd/pelvic pain X 12 hours acutely worse last hour LMP – 2 wks, denies pregnancy TTP LLQ GU -scant blood, L adnexal fullness  LMP  NL menses, denies pregnancy  7% pregnant  Risk Factors  50% without any • • •  Vaginal bleeding  Only occasionally without, mild  Adnexal mass  60% Case #6 - Discussion • • • 17 y/o female with LLQ pain 95/45, 125, 25, 99 LLQ abd/pelvic pain X 12 hours acutely worse last hour LMP – 2wks, denies pregnancy TTP LLQ GU -scant blood, L adnexal fullness  Urine ß-HCG  <3% false negative  Endovaginal US  ß-HCG 1K-2K  (+) sac  <1K US 17% sens • • •  Transabdominal US  Occasionally locates ectopic Case #7 • 80 y/o with A-fib, presents with 1 day of severe abdominal pain • 115/60, 105, 26, 99 • Very uncomfortable • Flat abdomen with mild tenderness and normal BS • Heme (+) Case #7 - Discussion • 80 y/o with A-fib, presents with 1 day of severe abdominal pain 115/60, 105, 26, 99 Very uncomfortable Flat abdomen with mild tenderness and normal BS Heme (+)  Risk factors  Almost all have some • • •  Pain out of proportion to exam  Most if early  Heme (+)  50% • Case #7 - Discussion  Plain films • 80 y/o with A-fib, presents with 1 day of severe abdominal pain 115/60, 105, 26, 99 Very uncomfortable Flat abdomen with mild tenderness and normal BS Heme (+)  Typically normal, thumbprinting, pneumatosis • • •  Angiography  88% sens  CT  82%/93% •  Phosphate  26-85% sens Case 8 • • • • • • • 28 y/o F with LLQ abdominal/pelvic pain 135/75, 95, 18, 99 LMP – 1 year on Depo-Provera® Abrupt onset TTP LLQ (+) adnexal tenderness L adnexal mass Case #8 - Discussion • • • • • • • 28 y/o F with LLQ abdominal/pelvic pain 135/75, 95, 18, 99 LMP – 1 year on DepoProvera® Abrupt onset TTP LLQ (+) adnexal tenderness L adnexal mass  Incidence  ??  extremely rare (3% of emergency GYN surg)  Depo-Provera ®  99.7% effective  Onset  Almost always sudden  Mass  90% Case #8 - Discussion • • • • • • • 28 y/o F with LLQ abdominal/pelvic pain 135/75, 95, 18, 99 LMP – 1 year on DepoProvera® Abrupt onset TTP LLQ (+) adnexal tenderness L adnexal mass  Doppler Ultrasound  100% sens Case #9 • 40 y/o male with midepigastric pain radiating to the back • 135/75, 90, 18, 99 • Hx of ETOH, Gallstones • Pain x 18 hours steady, (+) n/v • TTP midepigastrium without peritoneal signs Case #9 - Discussion • 40 y/o male with midepigastric pain radiating to the back 135/75, 90, 18, 99 Hx of ETOH, Gallstones Pain x 18 hours steady, (+) n/v TTP midepigastrium without peritoneal signs  Radiation  50% • •  Risk factors  ETOH & gallstones  N/V  Usually • • Case #9 - Discussion • 40 y/o male with midepigastric pain radiating to the back 135/75, 90, 18, 99 Hx of ETOH, Gallstones Pain x 18 hours steady, (+) n/v TTP midepigastrium without peritoneal signs  Amylase  80%/90% (x3 100%) • •  Lipase  97-100%/83-98%  CT/MR/US  OK, good for fluid collections, prognosis • • Case #10 • 30 y/o M with L flank pain radiating to groin • 165/85, 110, 24, 99 • Very uncomfortable, won’t stay on gurney • Outside all day today without po intake • Exam unremarkable Case #10 - Discussion • • • • • • 30 y/o M with L flank pain radiating to groin 165/85, 110, 24, 99 Father with Hx of kidney stones Very uncomfortable, won’t stay on gurney Outside all day today without po intake Exam unremarkable  Family Hx  3x more likely to have stone if (+) family hx  Dehydration  Increased K, Ca, animal protein more important  Exam  Flank tenderness, abd nearly always non-tender Case #10 - Discussion • • • • • • 30 y/o M with L flank pain radiating to groin 165/85, 110, 24, 99 Father with Hx of kidney stones Very uncomfortable, won’t stay on gurney Outside all day today without po intake Exam unremarkable  Plain films  60%/77%  Non-con CT  98%/96%  IVP  85-90%/95-100% Case #11 • • • • • 13 y/o M with L testicular pain x 2 hours 150/85, 105, 20, 99 Uncomfortable Abd – benign L testicle: swollen, tender, high-riding, horizontal lye, no cremasteric reflex Case #11 - Discussion  Age • 13 y/o M with L testicular pain x 2 hours 150/85, 105, 20, 99 Uncomfortable Abd – benign L testicle: swollen, tender, high-riding, horizontal lye, no cremasteric reflex  Average 16.2 yrs  Swollen, tender  Nearly always early • • • •  High-riding, horizontal position  Most often  Cremasteric reflex  Lack of >90% sens, poor spec Case #11 - Discussion •  Doppler US 13 y/o M with L testicular pain x 2 hours 150/85, 105, 20, 99 Uncomfortable Abd – benign L testicle: swollen, tender, high-riding, horizontal lye, no cremasteric reflex  100%/100%  Radionuclide Scanning  85-98%/100% • • • • Case #12 • 38 y/o female with suprapubic abdominal pain, back pain • 135/75, 75, 16, 99 • 3-4 hours ago aching in back • Dysuria, frequency, urgency Case #12 - Discussion • 38 y/o female with suprapubic abdominal pain, back pain 135/75, 75, 16, 99 3-4 hours ago aching in back Dysuria, frequency, urgency  Abdominal pain  Suggests something else • •  LUT symptoms  Abrupt onset, dysuria, frequency, urgency, small volumes  External vs. internal  Vaginal discharge • Case #12 - Discussion • 38 y/o female with suprapubic abdominal pain, back pain 135/75, 75, 16, 99 3-4 hours ago aching in back Dysuria, frequency, urgency  Urine WBC  >10 WBC’S/HPF 82%/80% • •  Leukocyte esterase  72-89%/68-92%  Nitrite  40-75%/93-98% • Case #13 • • • • • • • 19 y/o F with L Pelvic pain x 3 days 135/75, 105, 20, 101 Gradually increasing pain since menses Multiple sexual partners Abdominal tenderness (+) CMT Purulent discharge Case #13 - Discussion • • • • • • • 19 y/o F with L Pelvic pain x 3 days 135/75, 105, 20, 101 Gradually increasing pain since menses Multiple sexual partners Abdominal tenderness (+) CMT Purulent discharge  Menstrual cycle  3-5 days post menses  Risk factors  Multiple partners  IUD  menses or abortion  trauma Case #13 - Discussion • • • • • • • 19 y/o F with L Pelvic pain x 3 days 135/75, 105, 20, 101 Gradually increasing pain since menses Multiple sexual partners Abdominal tenderness (+) CMT Purulent discharge  WBC  66% sens  ESR  60-81%/53-57%  CRP  50-74%/59-80%  Ultrasound  63-85%/100%