Abdominal Pain. Luke Donnelly, MD Emergency Medicine
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1 Abdominal Pain Luke Donnelly, MD Emergency Medicine
2 Objectives Approach to abdominal pain Evaluation Critical diagnoses and treatments
3 Abdominal Pain Most Common ER Complaint Broad Differential Can often be indicative of illness involving other systems (MI, PNA, sepsis) Focus on intrinsic causes of abd pain
4 Causes of abdominal pain?
5 Causes of abdominal pain
6 Critical diagnoses Appendicitis AAA Small Bowel Obstruction Cholycystitis Ectopic Pregnancy Ovarian Torsion Pancreatitis
7 Initial assessment Primary survey ABC, IV, O2, Monitor Abnormal vitals General appearance Urine HCG
8 History Provocation/Palliation Quality Region/radiation Severity Timing Associated Symptoms Last BM/LMP/Last Meal
9 History PMH PSH Meds/All Fam Hx Soc Hx
10 Physical exam General Vitals Lungs Abdomen by quadrant Check for rebound/guarding/distention Check for pulsatile masses Pelvic Exam
11 EMS brings in patient
12 Minute 1 Initial assessment/abcs Vital signs IV, O2, Monitor EMS history
13 Minute 5 What kind of history do you want? Any tests? Any medications?
14 Minute 5 SAMPLE history If female under 50-urine HCG ECG, US of aorta Belly labs-(cbc, CMP, Lipase,VBG, UA) Medications: Vomiting-Zofran Indigestion/Heartburn-Pepcid Pain-Morphine
15 Be very worried if OR
16 Minute 15 Pt is stabilized, initial data gathered, labs and imaging ordered. Meds ordered to address symptoms Begin refining differential -Use EKG, US, Urine HCG, Vitals
17 Case 1 33 y/o F with no PMH presents with RLQ pain. Exam reveals TTP in RLQ with guarding.
18 Differential Appendicitis Ovarian Torsion Ectopic Pregnancy Kidney Stone AAA
19 Findings Gradual Onset, +nausea, +anorexia WBC 12, Hb-14, Lipase-nml, Alk Phos-nml HCG--Negative US: normal Aorta Other Imaging?
20 CT
21 Appendicitis Symptoms Right lower quadrant pain/periumbilical Pain Loss of appetite Vomiting Exam RLQ tenderness Fever +/- rebound
22
23 Appendicitis Test of Choice Management Surgery Consult NPO Fluids Morphine Abx
24 Case 2 33 y/o F with no PMH presents with RLQ pain. Exam reveals TTP in RLQ with guarding.
25 Differential Appendicitis Ovarian Torsion Ectopic Pregnancy Kidney Stone AAA
26 Findings Gradual Onset, +nausea, +anorexia WBC 12, Hb-14, Lipase-nml, Alk Phos-nml Urine HCG--POSITIVE Quant Beta HCG-5,000 Next Step?
27 Ectopic Pregnancy-Likelihood Ratios CMT-4.9 Adnexal mass-2.4 Adnexal tenderness 1.9 Ultrasound-111 No IUP on US in pregant patient is ectopic until proven otherwise
28 IUP
29 IUP
30 NO IUP
31 Ectopic
32 Ectopic Pregnancy Symptoms Abdominal Pain Syncope Vaginal Bleeding Vomiting Exam Lower abdominal tenderness Adnexal TTP CMT Peritoneal Abdomen
33 Ectopic Pregnancy Labs Quant B-HCG, CBC, Coags, Type and Screen -very low B-HCG cannot rule out ectopic Management -STAT GYN consult -NPO -Medical vs Surgical Management
34 Case 3 72 y/o M presents with abdominal pain, and back pain. Exam shows BP of 90/60 and a pulsatile mass in the abdomen. Next Step???
35
36 >3cm-abnormal
37 AAA Risk Factors Smoking Male Gender Age over 65 HTN HLD Symptoms Abd, Flank or Back Pain-can mimic renal colic Syncope or Dizziness-due to low BP
38 AAA Risk Factors Smoking Male Gender Age over 65 HTN HLD Symptoms Abd, Flank or Back Pain-can mimic renal colic Syncope or Dizziness-due to low BP
39 AAA Tests US is test of choice CT is useful for surgeons to plan procedure CBC Type and Screen-transfuse if ruptured Pre op labs Management-Rupture Surgical Repair Volume resuscitation Target Systolic
40 Case 4 72 y/o M h/o appendectomy presents with diffuse abdominal pain and vomiting. Vitals: 156/ %
41 Differential Pancreatitis SBO MI Sepsis Gastritis Gastroenteritis Colitis Cholangitis SBP AAA UTI Perforated Viscous GI bleed
42 Findings Last BM 3 days ago Vomiting green liquid Exam: -Belly distended, diffusely ttp -Tympanic Labs: -lactate 4.6 -WBC 13, Hb 15, Lipase nml
43 Diagnosis Small Bowel Obstruction
44 SBO Test of Choice?
45 SBO Management -Gastric Decompression (NG Tube) -IV fluids -Anti emetics -Pain Control -NPO -Surgery consult
46 Case 5 48 y/o F no pmh, presents with epigastric and RUQ pain, fever and vomiting Vitals: 150/ %
47 DDX Cholecystitis Cholangitis Hepatitis Pancreatitis Gastritis Pyelonephritis Perforated Ulcer
48 Findings Symptoms for 10 hours, began after eating Exam: - RUQ TTP - +Murphy's sign Labs: -WBC 14, Lipase nml, lactate 2.4, Alk Phos-274 -AST 224 ALT 198
49 Next Step?
50
51 Cholecystitis Risk Factors -gallstones -female gender -obesity Symptoms/Exam -RUQ pain and tenderness -no one finding can make diagnosis
52
53 Cholecystitis Management -infection so if septic treat accordingly -Iv abx (zosyn) -Fluids -NPO -STAT surgery consult
54 Pearls -Have a high index of suspicion in old patients -Every female under 50 with abd pain is ectopic until proven otherwise -Remember ovarian, testicular torsion as alternate causes of RLQ pain -The ultrasound is the test of choice to evaluate for AAA and cholecystitis -All patients with suspected serious causes of abdominal pain will need imaging
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