Acute Abdominal Pain A Practical Work-up Guide

Transcription

1 Acute Abdominal Pain A Practical Work-up Guide Robert Baldor, MD. AAFP Professor, Family Medicine & Community Health University of Massachusetts Medical School

2 Robert Baldor, MD, FAAFP Professor and Vice Chair, Department of Family Medicine and Community Health/Director, Community-Based Education, Office of Undergraduate Medical Education/Director of Health Policy Education, Meyers Primary Care Institute/Medical Director, Center for Developmental Disabilities Evaluation and Research at the Eunice Kennedy Shriver Center, University of Massachusetts (UMass) Medical School, Worcester Dr. Baldor has been teaching for 30 years and practices family medicine at the UMass Memorial Medical Center, Worcester. A member of the Massachusetts Governor s Commission on Intellectual Disability, he has been recognized in The Best Doctors in America: Northeast Region and is a past-president of the Massachusetts Academy of Family Physicians. He publishes and presents regularly on a variety of family medicine topics and is an associate editor for The 5-Minute Clinical Consult. Dr. Baldor practices family medicine with a special interest in developmental and intellectual disabilities. Throughout the years, he has spoken on a variety of primary care topics at the AAFP's annual meeting.

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4 Learning Objectives 1. Narrow the differential diagnosis of acute abdominal pain based on location of the pain, age and sex of the patient. 2. Perform specialized maneuvers (e.g. Carnett s sign, Murphy s sign, psoas sign) to evaluate for signs associated with causes of abdominal pain. 3. Order appropriate diagnostic and imaging studies based on the location of the pain and the presentation of the patient. 4. Identify red flag symptoms in patients with acute abdominal pain that indicate emergent or urgent conditions that require surgical consult. 4

5 Acute Abdominal Pain Acute, severe abdominal pain is almost always a symptom of intra-abdominal disease Textbook descriptions have limitations because people react to pain differently 10% presenting to the ED for abdominal pain may require surgery

6 Acute Abdominal Pain Common in all groups Peak incidence years Non-specific abdominal pain (40%) No definite diagnosis is made 30% with surgical indication Appendicitis most common cause of acute surgical abdomen

7 Visceral pain Pathophysiology from abdominal organs autonomic nerves respond to distention and contractions Somatic pain from ligaments, tendons, bones, blood vessels, fascia,muscles stimulation of nociceptors dull, aching, poorly-localized Peritonitis

8 Referred Pain Pain arising from organs but pain not in the abdomen Organs involved (typically) Lower lungs/diaphragm Trapezius Kidney Flank Gall bladder scapula Pancreas mid-back

9 Etiology of Acute Abdominal Pain Inflammation Distention Ischemic or Vascular Other

10 Etiology of Acute Abdominal Pain Inflammation Distention Ischemic or Vascular Other Appendicitis Diverticulitis Colitis Dyspepsia (PUD); gastritis, esophagitis Acute pancreatitis Acute cholecystitis

11 Etiology of Acute Abdominal Pain Inflammation Distention Ischemic or Vascular Other Appendicitis Diverticulitis Colitis Dyspepsia (PUD); gastritis, esophagitis Acute pancreatitis Acute cholecystitis SBO Cholelithiasis (Biliary colic)

12 Etiology of Acute Abdominal Pain Inflammation Distention Ischemic or Vascular Other Appendicitis SBO Abdominal angina Diverticulitis Colitis Dyspepsia (PUD); gastritis, esophagitis Acute pancreatitis Acute cholecystitis Cholelithiasis (Biliary colic) SMA occlusion (thromboembolic) Ischemic colitis Mesenteric venous thrombosis

13 Etiology of Acute Abdominal Pain Inflammation Distention Ischemic or Vascular Other Appendicitis SBO Abdominal angina IBS Diverticulitis Cholelithiasis (Biliary colic) SMA occlusion (thromboembolic) AAA Colitis Ischemic colitis Ovarian Dyspepsia (PUD); gastritis, esophagitis Acute pancreatitis Acute cholecystitis Mesenteric venous thrombosis Uterine: fibroids endometriosis, PID Kidney stones

14 A thorough history usually suggests the diagnosis Location Previous encounters Character of onset Severity Radiation Exacerbating/Relieving factors Other symptoms (fever, NVD, etc.)

15 Acute RUQ Abdominal Pain Cholecystitis and biliary colic Congestive Hepatitis/and or abscess Perforated ulcer Retro-cecal appendicitis (rarely)

16 43 yo Caucasian female with 3 months of intermittent epigastric & RUQ discomfort, postprandial nausea with occasional vomiting presents in acute discomfort Bowel sounds hypoactive Pain is 8/10 with diffuse tenderness, more so in RUQ and epigastrium No rebound Pain worsened when the hands are placed beneath the rib cage and the patient asked to inhale

17 Palpation under the Rib Cage is what sign? A. Cullen s sign B. Grey-Turners Sign C. Murphy s sign D. Hall sign

18 What Lab Tests Would You Order? A. Electrolytes, BUN, creatinine, glucose (BMP) B. Aminotransferases, alkaline phosphatase, bilirubin (LFTs) C.Complete blood count with differential (CBC) D.Lipase and Amylase E. All of the above

19 The Most Useful Diagnostic Study to Order in this Circumstance? A. An abdominal plain film (KUB) B. Abdominal Ultrasound C.Abdominal CT scan D. Magnetic resonance cholangiopancreatography (MRCP)

20 Abdominal Studies in Acute Abdomen Consideration. Cholelithiasis, Abscess, Palpable mass, AAA Pelvic pain in women AAA, Pancreatic disease, Urethral colic Consider when diagnosis is not obvious Pyelonephritis, stones, obstruction, polycystic kidneys, horseshoe kidney Ischemia and/or Hemorrhage Investigation Ultrasound CT Scan Intravenous pyelogram (IVP) Mesenteric angiography

21 Most Useful Studies by Pain Location Location RUQ LUQ RLQ LLQ Suprapubic Imaging Study Ultrasound CT Scan CTScan with IV contrast CT with oral AND IV contrast Ultrasound

22 Our RUQ Patient... Initial labs reflect a rise in serum ALT/AST A slight rise in total bilirubin US shows stone in gall bladder w/ surrounding fluid

23 Gall Bladder Disease Risk Factors. Hereditary 25% w/first-degree relative (a dozen genes may contribute) Obesity Metabolic syndrome, HTN, DM, hyperlipidemia Drugs Estrogens, fibrates Hemolytic Diseases Sickle cell anemia, heredity spherocytosis, beta thalassemia Pregnancy Higher progesterone levels reduce GB contractility Gall bladder stasis Spinal cord injuries, prolonged fasting, TPN, short bowel syndrome

24 Complications of GB Disease Biliary colic (Murphy s sign) Localized pain, guarding. Rebound may be present Acute cholecystitis (Obstructions at the GB neck) RUQ pain. +/- fever, WBC, tachycardia BS may be hypoactive or absent Ascending cholangitis (Charcot's Triad: RUQ pain, fever, jaundice) Purulent inflammation of the liver and biliary tree WBC, tachycardia Jaundice/scleral icterus ( LFT s) Reynolds Pentad Charcot s + confusion & shock Pancreatitis Epigastric pain. BS may be hypoactive or absent

25 Right AND Left Upper Quadrant Pain Acute Pancreatitis Lower Lobe Pneumonia Myocardial Ischemia Herpes Zoster Radiculitis

26 48 yo Caucasian male who is brought to the ED with sudden onset of epigastric pain with nausea, occasional vomiting, & radiation to the back for the past 5 hours Pain has been sharp and tearing with increasing intensity 8/10 He has a history of chronic alcohol abuse 5-6 beers almost nightly over the past 20 years. He decided to take a break for 3 days No history of similar episodes

27 On Exam His Vital signs are WNL Chest and heart auscultation are unremarkable Hypoactive bowel sounds Exquisite tenderness when palpating the epigastric area Ecchymosis in the left flank & periumbilical regions

28 Cullen & Grey Turner Exam Signs Cullen sign is the ecchymotic discoloration in the periumbilical region. Grey Turner sign is the ecchymotic discoloration in the flank

29 What Lab Tests You Would Order now? A. Electrolytes, BUN, creatinine, glucose (BMP) B. Aminotransferases, alkaline phosphatase, bilirubin (LFTs) C.Complete blood count with differential (CBC) D.Lipase and Amylase E. All of the above

30 The Most Sensitive Diagnostic Study You Would Order in this Circumstance is A.MRI of abdomen B.Ultrasound C.CT scan of abdomen D.Flat Plate/Acute Abdominal Series

31 62 yo African American male has intermittent (1-2/month) epigastric pain for last year Dull and now occurring 3/week No exacerbating or relieving factors Omeprazole and ranitidine unsuccessful over the past month PMH: CAD s/p L main carotid artery stent, HTN, PVD Meds: amlodipine, enalapril, aspirin, simvastatin Social: Occasional alcohol; 50 year 2ppd cigarette use

32 Physical Exam concerns Coarse and reduced breath sounds 2/6 murmur in LSB Soft, obese, non-tender abdominal exam with pulsatile sensation on deep palpation elicits some tenderness, but not similar to the pain patient has been experiencing

33 The Most Sensitive Diagnostic Study You Would Order in this Circumstance is? A.Ultrasound B.MRI C.CT scan D.All of the above

34 Abdominal Aortic Aneurysms (AAA) rupture risk Aneurysm size is the strongest predictor of rupture AAA < 5 cm not likely to rupture Risk increases markedly at diameters > 5.5 cm This patient had a 6.8 cm AAA and was referred for therapeutic intervention Endovascular stent versus surgical approach

35 Left Upper Quadrant Pain Gastritis Splenic Injury (abscess/rupture) Intestinal Obstruction Ischemic Intestinal Disease

36 Gastritis Gnawing or burning epigastric distress +/- nausea or vomiting Pain may improve or worsen with eating NSAID use/helicobacter pylori infection Examination often normal with occasional mild epigastric tenderness 36

37 Splenic concerns... Enlarged or tender on palpation CT scan US to assess splenomegaly CBC, platelet count, blood smear 37

38 Bowel Obstruction.. Small Bowel (85%) Nausea/often times vomiting Distention/Crampy pain Diarrhea (early finding) Constipation (late finding) H/O abdominal surgery Hyper-tympanic, high-pitch BS +/- tenderness Fever/tachycardia/Peritoneal signs(if strangulation occurs) Large Bowel (15%) Nausea/often times vomiting Distention/Crampy pain Constipation Hyper-tympanic to percussion Tenderness to palpation Peritoneal signs suggest strangulation or perforation Guaiac positive stools if cancer Cecum most likely to perforate

39 Bowel Obstruction - Plain x-ray findings SBO Dilated loops of small bowel Air fluid levels Absent or minimal colonic gas LBO Intra-luminal air (colonic ischemia) Free air (present in only ½ of perforations) Kidney bean sign (sigmoid or cecal volvulus)

40 Small Bowel Obstruction Partial (simple) 60% Wait and watch Complete (strangulated) 40% SBOs make up ~20% of all acute surgical admissions Most commonly associated with Surgical emergency Surgery < 36hrs, mortality ~ 8% Surgery > 36hrs, mortality > 25% 40

41 Acute Mesenteric Ischemia Superior mesenteric artery embolism/thrombosis Mortality: 70-90% Nausea/vomiting common Forceful bowel evacuation Non-occlusive mesenteric ischemia (NOMI) (20-30%) Tobacco abuse (70-80%) Mean age 60 Women > Men 3:1 Food avoidance lb wt loss Dull/crampy pain 41

42 Acute Mesenteric Ischemia Findings Abdominal exam initially non-specific Abdominal bruit (60-90%) Guaiac positive (10%) As ischemia progresses peritonitis shock Lab non-specific metabolic acidosis with progression Abdominal pain & Metabolic Acidosis = Ischemia until ruled out! 42

43 Chronic Mesenteric Ischemia Intestinal/Abdominal angina Atherosclerotic disease Episodic or constant intestinal hypo-perfusion o Mid-abdominal, colicky pain o Nausea, vomiting, anorexia and diarrhea common 43

44 Right LOWER Quadrant Pain Appendicitis Cecal Diverticulitis Meckel s Diverticulitis Mesenteric Adenitis Mesenteric Ischemia/Thrombosis

45 9 yo Asian male presents for abdominal pain. Will not eat/last meal was 24 hrs ago/vomited x 1 History Pain escalated from a 2 to 9 on a scale of 10 over the day He finds it difficult to move Pain is constant, periumbilical Described as sharp, colicky Noted mild diarrhea Past Hx unremarkable Exam Temp 101 Lying flat on exam table with knees flexed and shallow breathing Hypoactive bowel sounds Abdomen tender, worse at a point 1/3 of the distance between a line from the iliac crest to the umbilicus (McBurney s point) Rebound tenderness (Blumberg sign) 45

46 Deep palpation from L iliac fossa upwards may cause pain in the R iliac fossa, by pushing bowel contents towards the ileocaecal valve and thus increasing pressure around the appendix. This maneuver is called? A. Obturator sign B. Rovsing s sign C. Psoas sign D. Kosher s sign E. Blumberg sign

47 RLQ pain produced with passive extension of the patient s right hip (patient lying on left side, with knee in flexion) or by the patient s active flexion of the right hip while supine is called? A. Obturator s sign B. Rovsing s sign C.Psoas sign D.Kosher s sign E. Blumberg sign

48 Spasm of this muscle can be demonstrated by flexing and internal rotation of the hip. This will cause pain in the vagina or hypogastrium. This maneuver is called? A. Obturator sign B. Rovsing s sign C.Psoas sign D.Kosher s sign E. Blumberg sign

49 Increased pain in the RLQ with coughing, is what sign? A. Obturator sign B. Rovsing s sign C.Psoas sign D.Kocher s sign E. Dunphy s sign

50 From the history given, the appearance of pain in the epigastric region or around the stomach at the beginning of disease with subsequent shift to the right iliac region, is known as which sign? A. Obturator sign B. Rovsing s sign C.Psoas sign D.Kocher s sign E. Dunphy s sign

51 Our patient WBC count of 14,000 with left shift Pediatric Appendicitis Score of 8 CT scan & ultrasound diagnostic of acute appendicitis 51

52 The Pediatric Appendicitis Score (PAS) Points scored: RLQ pain w/cough, percussion or hopping - 2 RLQ tenderness on light palpation - 2 Anorexia - 1 Low grade fever over 38 C (100.4 F) - 1 Nausea or Vomiting - 1 Leukocytosis (>10,000/mm3) - 1 Left Shift (>75% Neutrophilia) - 1 Migration of pain to RLQ - 1 Interpretation/Score 1-3: Low risk of Appendicitis 4-7: Intermediate risk 8-10: High risk 52

53 Appendicitis Exam Most specific finding Rebound tenderness Guarding Pain on percussion Rigidity RLQ pain is most discriminating feature Present in 96% of patients Sensitivity and Specificity of -80% Vomiting usually always follows pain Rectal exam?? Helpful or not

54 Appendicitis predictors WBC >10K in 80-85% of pts Neutrophilia > 75% in 80% of pts CRP elevates within 6-12 hrs If Sxs > 24 hr and nl CRP, NPV~100% If WBC < 10.5, Neutrophilia < 75% and nl CRP, NPV % 54

55 Appendicitis Imaging CT Scan Gold standard study A decrease in negative laparotomy and perforation rates when used in selected patients with suspected appendicitis US When (+) go to surgery, when (-) go to CT scan Plain film X-ray Appendicolith is highly suggestive but seen in only 10% 55

56 Left Lower Quadrant Pain Sigmoid Diverticulitis

57 71 year old white female seen for a UTI LLQ pain with radiation to the left flank Pain sharp with bloating; aggravated by meals; occasional nausea Pt had intermittent loose BM and constipation x 10 days Seen 4 days prior for possible Renal Stones. Amoxil administered No improvement prompted recheck

58 Exam Findings Temp: 100.2, BP 131/70, Respirations 19; Pulse:120 Chest clear CV: RRR no murmur Abdomen: Soft tender in the left lower quadrant, CVA tenderness. No rebound. Bowel sounds hypoactive WBC: 17.9 w/l shift

59 Diagnostic Test of Choice in this situation? A. Abdominal Ultrasound B. Air-contrast barium enema C. Water soluble contrast enema D. CT scan of abdomen

60 Chest X-ray negative Our Patient Renal ultrasound negative CT scan w/ air fluid filled collection in the mid abdomen & communication with sigmoid colon Then directly admitted from radiology and surgical consult was obtained

61 Right AND Left Lower Quadrant Pain Abdominal or Psoas abscess Abdominal wall hematoma Cystitis Endometriosis Incarcerated or strangulated hernia Acute Mesenteric Ischemia Acute Mesenteric Venous Thrombosis/embolism Inflammatory Bowel Disease Mittleschmerz PID Renal stone Rupture of Aortic Aneurysm Ruptured Ectopic Torsion of ovary/testes Carcinoid

62 Extra-Abdominal Causes of Abdominal Pain Abdominal wall: Rectus hematoma Thoracic: MI, Pneumonia, PE, Radiculitis GU: Testicular torsion Infectious: Herpes Zoster Metabolic: Alcoholic, DK acidosis, Porphyria, Sickle Cell Toxic: Heavy metal poisoning, Opioid withdrawal

63 Vomiting Pearls. Pain first followed by vomiting is usually surgical Vomiting is due to reflex pylorospasm Nausea and vomiting first, followed by pain is usually due to a medical condition Not always 100% but helpful

64 Practice Recommendations A normal WBC does not rule out appendicitis (SOR-C) Simultaneous amylase & lipase measurements recommended in patients with epigastric pain (SOR-C) Acute abdominal pain & metabolic acidosis = ischemia until R/O (SOR-C) US is the imaging study of choice for acute RUQ pain (SOR-C) CT is the imaging study of choice for acute RLQ or LLQ pain (SOR-C)

65 Summary The presentation of the patient can narrow the differential diagnosis. Consider age, sex, and type of pain under consideration Specialized maneuvers can evaluate for signs associated with specific entities The location of the abdominal pain should guide the evaluation Laboratory tests should be performed based on suspected diagnosis and location of pain Imaging studies are based on the location of the pain

66 Most Useful Studies by Pain Location Location RUQ LUQ RLQ LLQ Suprapubic Imaging Study Ultrasound CT Scan CTScan with IV contrast CT with oral AND IV contrast Ultrasound

67 Abdominal Studies in Acute Abdomen Consideration. Cholelithiasis, Abscess, Palpable mass, AAA Pelvic pain in women AAA, Pancreatic disease, Urethral colic Consider when diagnosis is not obvious Pyelonephritis, stones, obstruction, polycystic kidneys, horseshoe kidney Ischemia and/or Hemorrhage Investigation Ultrasound CT Scan Intravenous pyelogram (IVP) Mesenteric angiography

68 References 1. Cope's Early Diagnosis of the Acute Abdomen 22nd Edition William Silen (Editor) 2. Reust CE, Williams A. Acute Abdominal Pain in Children. Am Fam Physician May 15;93(10): Cartwright SL, Knudson MP. Diagnostic imaging of acute abdominal pain in adults. Am Fam Physician Apr 1;91(7): Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician Apr 1;77(7):971-8.