ABDOMINAL PAIN THE GREAT CLINIC FRONTIER

Size: px

Start display at page:

Download "ABDOMINAL PAIN THE GREAT CLINIC FRONTIER"

Merry McCarthy
6 years ago
Views:

THE GREAT CLINIC FRONTIER 2017 MONA ADVANCED

FACP, FASGE, FACG, AGAF Associate Professor of

Missouri Columbia 4/28/17 DEFINITION: Pain in

No exact definition of acute or chronic ACUTE

1 THE GREAT CLINIC FRONTIER 2017 MONA ADVANCED PRACTICE NURSING CONFERENCE Matthew Bechtold MD, FACP, FASGE, FACG, AGAF Associate Professor of Medicine Division of Gastroenterology University of Missouri Columbia 4/28/17 DEFINITION: Pain in abdominal area Extremely common in everyday practice No exact definition of acute or chronic ACUTE PERSISTENT CHRONIC 0 14ish 30ish DAYS Fleischer AB, et al. Am J Manag Care

PHYSICAL EXAMINATION DIAGNOSTIC TESTING/EVALUATION TREATMENT & : Overall poor sensitivity and specificity for cause Worse for benign conditions

2 PHYSICAL EXAMINATION DIAGNOSTIC TESTING/EVALUATION TREATMENT & : Overall poor sensitivity and specificity for cause Worse for benign conditions Better for acute serious abdominal pain Like acute appendicitis Bohner H, et al. Eur J Surg 1998 Thomson AB, et al. Aliment Pharmacol Ther

3 PRIMARY GOALS: ACUTE VS CHRONIC EMERGENT VS NON-EMERGENT ACUTE VS CHRONIC: ACUTE < FEW DAYS WORSENED PROGRESSIVELY CHRONIC UNCHANGED OVER MONTHS BEWARE OF ACUTE EXACERATIONS PAIN DESCRIPTION: LOCATION & RADIATION TIMING QUALITY SEVERITY HELP OR HURT OTHER SYMPTOMS 3

LOCATION & RADIATION: Significantly helps identify etiology Remember anatomy: Pick an organ and add itis Certain types of pain radiates: Pancreatitis Front to back Renal colic Back to groin LOCATION:

4 LOCATION & RADIATION: Significantly helps identify etiology Remember anatomy: Pick an organ and add itis Certain types of pain radiates: Pancreatitis Front to back Renal colic Back to groin LOCATION: Patient. TIMING: Pancreatitis may be slow and steady Peritonitis is sudden QUALITY: PUD may be burning or gnawing Colicky (cramping) may be gastroenteritis 4

CHARACTERITIC BURNING CRAMPING COLIC ACHING KNIFELIKE GRADUAL ONSET SUDDEN ONSET POSSIBLE CONDITION PEPTIC ULCER BILIARY COLIC GASTROENTERITIS APPENDICITIS WITH IMPACTED FECES RENAL STONE APPENDICEAL

jpg SEVERITY: Depends on: Etiology Age General Health May be less severe in older patients and those taking corticosteroids HELP OR HURT: Factors may narrow etiology Fleischer AB, et al.

5 CHARACTERITIC BURNING CRAMPING COLIC ACHING KNIFELIKE GRADUAL ONSET SUDDEN ONSET POSSIBLE CONDITION PEPTIC ULCER BILIARY COLIC GASTROENTERITIS APPENDICITIS WITH IMPACTED FECES RENAL STONE APPENDICEAL IRRITATION PANCREATITIS INFECTION DUODENAL ULCER ACUTE PANCREATITIS OBSTRUCTION PERFORATION Clinical Gate. SEVERITY: Depends on: Etiology Age General Health May be less severe in older patients and those taking corticosteroids HELP OR HURT: Factors may narrow etiology Fleischer AB, et al. Am J Manag Care 2001 FACTOR POSSIBLE CONDITION 1 HOUR AFTER EATING MESENTERIC ISCHEMIA RELIEVED BY EATING PUD WORSENED WITH EATING PANCREATITIS RELIEVED BY SITTING UP PANCREATITIS AND LEANDING FORWARD LIE MOTIONLESS PERITONITIS Fleischer AB, et al. Am J Manag Care

SICK CONTACTS QUESTIONS MENSTRUAL USE OF CONTRACEPTION VAGINAL DISCHARGE OR BLEEDING CAD SURGERIES NSAIDs CORTICOSTEROIDS LIVER DISEASE

6 ASSOCIATE SYMPTOMS: GI Symptoms: N/V, diarrhea, constipation, bleeding GU Symptoms: Dysuria, increased frequency, hematuria CP Symptoms: Cough, SOB, dyspnea, shock Constitutional Symptoms: F/C, weight loss, anorexia OTHER FEMALES PAST MEDICAL MEDICATIONS ALCOHOL FAMILY TRAVEL SICK CONTACTS QUESTIONS MENSTRUAL USE OF CONTRACEPTION VAGINAL DISCHARGE OR BLEEDING CAD SURGERIES NSAIDs CORTICOSTEROIDS LIVER DISEASE INFLAMMATORY BOWEL DISEASE GASTROENTERITIS GASTROENTERITIS Clinical Gate. 6

7 VITAL SIGNS ABDOMINAL EXAM: Inspection Auscultation Percussion Palpation INSPECTION OF ABDOMEN: Scars Ascites Signs of Trauma 7

8 AUSCULTATION OF ABDOMEN: Timing: Before percussion since percussion alters frequency and intensity of bowel sounds Procedure: Procedure: Warm up Stethoscope Gently listen in all 4 quadrants and over liver and spleen with diaphragm (bowel sounds, friction rubs) Switch to bell Gently listen again in all 4 quadrants and over vessels (bruits) Bowel Sounds: Clicks & Gurgles: Irregular 5 35 times/minute Borborygmi = Loud & Prolonged bowel sounds Increased Bowel Sounds: Gastroenteritis Early Intestinal Obstruction Hunger Decreased Bowel Sounds: Paralytic Ileus Peritonitis Absent Bowel Sounds (> 5 minutes) High-Pitch Tinkling: Intestinal fluid and air under pressure Early Obstruction Vascular & Other Sounds: Bruits: Low-pitched Possible vascular stenosis Listen over Aortic, Renal, Iliac, Femoral Arteries bilaterally with bell Friction Rubs: High-pitched Possible inflammation of peritoneal surface (tumor, infection, infarct) Listen over Liver and Spleen with diaphragm Venous Hum: Increased collateral circulation between portal and systemic venous system Low-pitched, continuous, soft Listen over epigastric region with bell PERCUSSION OF ABDOMEN: Assesses organs, fluid, air, masses. Tympany = Air in small intestine and stomach Dullness = Organs and solid masses PALPATION OF ABDOMEN: Assesses organs and detects muscle spasms, masses, fluid, and tenderness Light Palpation Moderate Palpation Deep Palpation 8

9 PALPATION OF ABDOMEN: Monitor facial responses during exam Localize pain during exam Rebound Tenderness: Determines peritoneal irritation Perform at end of exam Procedure: Pt supine Place hand with fingers extended at 90 o to pt s abdomen on area of discomfort Rapidly withdraw hand Monitor for response Positive: Increased pain with removal of hand McBurney s Sign: Rebound TTP over McBurney s point (RLQ) Suggests acute appendicitis ORGAN-SPECIFIC PALPATION: Gallbladder: Should not be palpable in healthy patients Murphy s Sign: Suggestive of acute cholecystitis Procedure:» Pt supine Place R hand on liver along mid-clavicular line Apply deep palpation pressure Instruct pt to take deep breath Monitor pt s response» Positive = Abrupt end of inspiration before full cycle due to inflammed gallbladder contacting fingers ORGAN-SPECIFIC PALPATION: Spleen: Usually not palpable in healthy patients Procedure: Pt supine Assume position on R side of pt Place L hand over pt and beneath the pt at the L costovertebral angle Apply pressure upward Place gentle pressure with R hand and fingers extended on splenic region Instruct pt to breath deep Feel for spleen edge Repeat procedure with pt on R side 9

10 ORGAN-SPECIFIC PALPATION: Kidneys: Tenderness: Procedure A:» Pt sitting upright Place palm of hand over R costovertebral angle Strike hand with ulnar side of fisted other hand Monitor for response Repeat on other side Procedure B:» Repeat above using on fisted hand Palpation: Usually not palpable in healthy patients Procedure:» Similar to splenic palpation with initiation point at costal margins ORGAN-SPECIFIC PALPATION: Aorta: Importance: Detects abdominal aortic aneurysms Procedure: Pt supine Palpate deeply and feel for pulsation Repeat from other side Measure distance OR Pt supine Palpate deeply with one hand and feel pulsation against thumb and index finger Measure distance RECTAL EXAM PELVIC EXAM (FEMALES) 10

11 DIAGNOSIS ACUTE ABDOMINAL PAIN ACUTE LIFE-THREATENING: Go to ER UNSTABLE VITALS SIGNS OF PERITONITIS (ABDOMINAL RIGIDITY, REBOUND) CONCERN OVER SERIOUS CONDITION (ACUTE BOWEL OBSTRUCTION, ACUTE MESENTERIC ISCHEMIA, PEFORATION, ACUTE MI, ECTOPIC PREGNANCY) FEVER, RUQ PAIN, JAUNDICE 11

12 ACUTE NON-URGENT EVALUATION: Guided by location of pain ACUTE RUQ, EPIGASTRIC, LUQ PAIN: CBC CMP AMYLASE LIPASE ABDOMINAL ULTRASOUND/CT ABDOMEN ACUTE LOWER ABDOMEN: CBC CMP PREGNANCY TEST URINALYSIS CT ABDOMEN 12

ACUTE DIFFUSE : CBC CMP AMYLASE LIPASE PREGNANCY TEST URINALYSIS CT ABDOMEN CHRONIC ABDOMINAL PAIN CHRONIC Most with functional disorder: Irritable bowel syndrome:

13 ACUTE DIFFUSE : CBC CMP AMYLASE LIPASE PREGNANCY TEST URINALYSIS CT ABDOMEN CHRONIC ABDOMINAL PAIN CHRONIC Most with functional disorder: Irritable bowel syndrome: Abdominal pain + change in bowel habits Initial Evaluation: CBC CMP with CA AMYLASE LIPASE IRON, TIBC, FERRITIN CELIAC PANEL (TTG) Drossman DA, et al. Dig Dis Sci

CHRONIC Further Evaluation: Depends on differential diagnosis: FINDING FE-DEFICIENCY CHRONIC ETOH RECURRENT PANCREATITIS CONSTIPATION ILEUS ETIOLOGIES CELIAC DISEASE IBD COLORECTAL CANCER CHRONIC

14 CHRONIC Further Evaluation: Depends on differential diagnosis: FINDING FE-DEFICIENCY CHRONIC ETOH RECURRENT PANCREATITIS CONSTIPATION ILEUS ETIOLOGIES CELIAC DISEASE IBD COLORECTAL CANCER CHRONIC PANCREATITIS HYPOTHYROIDISM CHRONIC Further Work-Up: Young with no evidence of organic disease may be treated symptomatically New-onset pain in > 50 yo need to rule-out malignancy Rare: SOD Chronic choledocholithiasis Chronic small bowel obstruction CHRONIC Special Populations: Women: Evaluate etiologies for pelvic pain Elderly: May not have fever or abnormal lab values Peritonitis is subtle Immunosuppressed: May have severe pathology Sickle Cell: RUQ pain with liver involvement HIV: May have severe pathology Opportunistic infections de Dombal FT. J Clin Gastroenterol 1994 Thuluvath PJ, et al. Q J Med 1991 Lyon C, et al. Am Fam Physician

15 TREATMENT CHRONIC TREAT UNDERLYING ETIOLOGY IRRITABLE BOWEL SYNDROME 15

DEFINITION: Recurrent abdominal pain or discomfort 3 day/month in last 3 months with 2 of the following: Improvement with defecation Change in frequency of stool Change in form (appearance) of

Am J Gastroenterol 2009 SUBTYPES: with Constipation (-C) Type 1 and 2 with Diarrhea (-D) Type 6 and 7 Mixed (-M) At least ¼ of both Unclassified Cannot categorize ACG Task Force.

16 DEFINITION: Recurrent abdominal pain or discomfort 3 day/month in last 3 months with 2 of the following: Improvement with defecation Change in frequency of stool Change in form (appearance) of stool Estimated in 10-15% of adults and adolescents Mearin F, et al. Gastroenterology 2016 ACG Task Force. Am J Gastroenterol 2009 SUBTYPES: with Constipation (-C) Type 1 and 2 with Diarrhea (-D) Type 6 and 7 Mixed (-M) At least ¼ of both Unclassified Cannot categorize ACG Task Force. Am J Gastroenterol 2009 Mearin F, et al. Gastroenterology 2016 Heaton KW, et al. Gut 1992 INITIAL TREATMENT CLOSE PATIENT-PHYSICIAN RELATIONSHIP FREQUENT FOLLOW-UP VISITS DIETARY MODIFICATION Mearin F, et al. Gastroenterology 2016 Owens DM, et al. Ann Intern Med 1995 ACG Task Force. Am J Gastroenterol

DIETARY MODIFICATION LOW FODMAP DIET: Decreases fermentable oligo-, di-, and monosaccharides and polyols Decrease gas-producing foods May try for 6-8 weeks then may reintroduce 1 food at a time

17 DIETARY MODIFICATION LOW FODMAP DIET: Decreases fermentable oligo-, di-, and monosaccharides and polyols Decrease gas-producing foods May try for 6-8 weeks then may reintroduce 1 food at a time AVOID: Alcohol Caffeine Consider if no response to low FODMAP: Lactose free Gluten free Especially with -D due to nonceliac gluten sensitivity ACG Task Force. Am J Gastroenterol 2009 Mearin F, et al. Gastroenterology 2016 Bohn L, et al. Gastroenterology 2015 Hasler WL, et al. Textbook of Gastroenterology 2003 MORE MODIFICATION FIBER: Controversial in May be beneficial in -C May cause increased gas/bloating FOOD ALLERGY TESTING: Unclear at this time if any benefit PHYSICAL ACTIVITY: minutes of moderate-vigorous activity 3-5 days/week are less likely to have worsening symptoms ACG Task Force. Am J Gastroenterol 2009 Mearin F, et al. Gastroenterology 2016 Bohn L, et al. Gastroenterology 2015 Hasler WL, et al. Textbook of Gastroenterology 2003 Johannesson E, et al. Am J Gastroenterol 2011 Ford AC, et al. BMJ 2008 ADJUNCTIVE PHARMACOLOGY RESERVED FOR MODERATE-TO- SEVERE SYMPTOMS CHANGES AT 2-4 WEEKS INTERVALS DIRECT TOWARD PREDOMINANT SYMPTOM Mearin F, et al. Gastroenterology 2016 ACG Task Force. Am J Gastroenterol

CONSTIPATION OSMOTIC LAXATIVES: Polyethylene glycol (PEG) Improves stools but may not improve abdominal pain LUBIPROSTONE (Amitiza): Chloride-channel activator Use if PEG failed in women ( 18 yo)

18 CONSTIPATION OSMOTIC LAXATIVES: Polyethylene glycol (PEG) Improves stools but may not improve abdominal pain LUBIPROSTONE (Amitiza): Chloride-channel activator Use if PEG failed in women ( 18 yo) with -C LINACLOTIDE (Linzess): Guanylate cyclase agonist Limited to failed PEG in -C ACG Task Force. Am J Gastroenterol 2009 Chapman RW, et al. Am J Gastroenterol 2013 Khoshoo V, et al. Aliment Pharmacol Ther 2006 Drossman DA, et al. Aliment Pharmacol Ther 2009 Rao S, et al. Am J Gastroenterol 2012 DIARRHEA ANTIDIARRHEAL AGENTS: Loperamide (Imodium) 2 mg 45 minutes before meals Eluxadoline (Viberzi) Needs more research for benefit in subpopulations BILE ACID SEQUESTRANTS: Up to 50% of -D have bile acid malabsorption Limited after failure of antidiarrheals May cause side effects of bloating, discomfort, flatulence ALOSETRON (Lotronex): 5-hydroxytryptamine (serotonin) 3 receptor antagonist Reserved for -D women failing all other treatment Cann PA, et al. Dig Dis Sci 1984 May induce ischemic colitis ACG Task Force. Am J Gastroenterol 2009 Efskind PS, et al. Scand J Gastroenterol 1996 Dove LS, et al. Gastroenterology 2013 Lembo AJ, et al. Gastroenterology 2016 Wedlake L, et al. Aliment Pharmacol Ther 2009 Andresen V, et al. Clin Gastroenterol Hepatol 2008 & BLOATING ANTISPASMODIC AGENTS: Dicyclomine (Bentyl) Hyoscyamine (Levbid/Levsin) Mebeverine (Colofac) Peppermint Oil ANTIDEPRESSANTS: Better in adults Tricyclic antidepressants help in -D in low doses Amitriptyline (Elavil) Imipramine (Tofranil) Selective serotonin reuptake inhibitors (SSRIs) data inconsistent ANTIBIOTICS: Failure to other modalities in -D Rifaximin (Xifaxan) 2 weeks trial PROBIOTICS: Not routinely recommended but may help some ACG Task Force. Am J Gastroenterol 2009 Lynn RB, et al. NEJM 1993 Gorard DA, et al. Dig Dis Sci 1995 Menees SB, et al. Am J Gastroenterol 2012 Moayyedi P, et al. Gut

REFRACTORY SYMPTOMS BEHAVIOR MODIFICATION: Psychiatric referral ANXIOLYTICS: Only for short-term use (< 2 weeks) OTHERS: Role is uncertain HERBS ACUPUNCTURE ENZYME SUPPLEMENTS MAST CELL STABILIZERS

19 REFRACTORY SYMPTOMS BEHAVIOR MODIFICATION: Psychiatric referral ANXIOLYTICS: Only for short-term use (< 2 weeks) OTHERS: Role is uncertain HERBS ACUPUNCTURE ENZYME SUPPLEMENTS MAST CELL STABILIZERS (KETOTIFEN) ACG Task Force. Am J Gastroenterol 2009 Labus J, et al. Aliment Pharmacol Ther 2013 Drossman DA, et al. Ann Intern Med 1992 Spanier JA, et al. Arch Intern Med 2003 SUMMARY DIETARY & LIFESTYLE MODIFICATIONS LOW FODMAP DIET EXERCISE PROGRAM ADJUNCT PHARMALOGIC AGENT(S) -C LAXATIVES PEG LUBIPROSTONE LINACLOTIDE -D ANTIDIARRHEALS (LOPERAMIDE) BILE ACID BINDER ALOSETRON (FEMALES ONLY) ABD PAIN/BLOATING ANTIBIOTIC TRIAL ANTISPASMOTIC AGENT ANTIDEPRESSANT SUMMARY DIETARY & LIFESTYLE MODIFICATIONS LOW FODMAP DIET EXERCISE PROGRAM FREQUENT CLINIC ADJUNCT FOLLOW-UP PHARMALOGIC AGENT(S) TO BUILD RELATIONSHIP -C LAXATIVES PEG LUBIPROSTONE LINACLOTIDE -D ANTIDIARRHEALS (LOPERAMIDE) BILE ACID BINDER ALOSETRON (FEMALES ONLY) ABD PAIN/BLOATING ANTIBIOTIC TRIAL ANTISPASMOTIC AGENT ANTIDEPRESSANT 19

MUSCULOSKETETAL GENITOURINARY PULMONARY PSYCHIATRIC SUMMARY IS VERY COMMON & IS

20 WRAP-UP CHEST PAIN GASTROINTESTINAL CARDIOVASCULAR MUSCULOSKETETAL PULMONARY PSYCHIATRIC WRAP-UP ABDOMINAL PAIN GASTROINTESTINAL CARDIOVASCULAR MUSCULOSKETETAL GENITOURINARY PULMONARY PSYCHIATRIC SUMMARY IS VERY COMMON & IS IMPORTANT TRIAGE CRUCIAL DIAGNOSIS IS CLINICAL-BASED TREATMENT DIRECTED AT ETIOLOGY IS MOST COMMON 20

Abdominal Examination Benchmarks

Abdominal Examination Benchmarks Preparation and Positioning: Stand on the right side of the patient. The patient should be supine and double draped so only the abdomen is exposed o To relax the abdominal