Abdominal Pain OUWB School Of - PowerPoint Presentation

1. Abdominal PainOUWB School Of MedicineBeaumont Health SystemDepartment of Emergency Medicine

2. Abdominal PainObjectivesState the differential diagnosis for… RLQ pain LLQ pain RUQ/epigastric painRecognize the etiologies, signs, symptoms, and radiographic findings compatible with small bowel obstruction vs. large bowel obstruction. Recognize the risk factors, signs, and symptoms compatible with mesenteric ischemia. Name the 2 most common initial misdiagnosis in patients presenting with a leaking abdominal aortic aneurysm. List the most common life threatening extra abdominal diseases presenting as abdominal pain. Understand the appropriate use and limitations of plain films, ultrasound, and CT in a patient with abdominal pain. List the common etiologies of upper vs. lower GI bleeding. List admission criteria for GI hemorrhage

3. Abdominal PainOne of the most common presenting complaints to the ED.GI and Non-GI etiologiesHave a wide differential!Focus in by a good HPI, ROS and Physical Exam

4. Abdominal PainHPIOnsetPalliative/ProvocativeQualityRegionSeverityTemporalAssociated sx’sAttribution

5. HPIKey Words:Sudden onset: perforationTearing/Ripping: aneurysm or dissectionBurning: GERD/PUDColicky: Biliary or kidney stonesCramping: intestinal

6. ROSAsk broadly to focus your differential!Remember many Non-GI causes to abd painRenalPelvicCardiovascularpulmonaryMetabolic/EndocrineHematologic

7. Physical ExamInspectionShape, skin changes, surgical scars, movementAuscultationFrequency, quality of bowel soundsPalpationLight and deepStart away from stated area of painNote areas of tendernessRebound/guarding?Acute Abdomen

8. Physical ExamGroin/Pelvic examsCheck for herniasAny female with lower abd pain (and some upper) requires a pelvic exam to help differentiate pelvic etiologiesRectal Exam?ImpactedStool colorStool guiac

9. Physical ExamDon’t forget your full exam!HENTDehydrationIcterusCardiac/Pulm SkinJaundice, rashes, telangictasiasExtremPerfusionedema

10. Diagnostic TestingCommon LabsCBC w/diffDon’t be misled by absence of leukocytosis!Poor sensitivity and specificityBMP LFTsLipaseUALactic acidAdditional per ROSHCG

11. Diagnostic TestingCommon ImagingAASEval for obstruction, constipation, or free airCan also just do portable upright CXR for free airUltrasoundBiliary dzFree FluidAAARenalPelvic

12. Diagnostic TestingCommon ImagingCTIV, po, or non-contrast CT; based on what you are looking forInstitution specific policies Non-contrastKidney stone protocolIV contrastWill show most inflammatory conditionsAAAIV and po contrastSpecifically for obstruction

13. Common ImagingUnstable patients do not leave the department for imagingCan use bedside ultrasound ourselves or call for formal bedside study

14. Upper Abdominal Pain

15. Upper Abdominal PainDifferential Dx:PUD/Gastritis/EsophagitisPancreatitisBiliary/HepatitisACSPneumonia/PEPyelonephritisFitz-Hugh Curtis SynAppendicitis (early)

16. Upper Abdominal Pain Case #143 yo F with epigastric and RUQ pain for 3 hours. Per pt it is a “deep” pain, radiating to her back. Increased with po intake. Has had similar, but less severe, pain like this before that seemed to resolve with antacids. (+) N/V. Denies hematemesis. Today pain was worse and did not improve with regular meds.PMH: DMSxHx: c-sectionSH: Denies tobacco, drugs. (+) EtOH weekly

17. Upper Abdominal PainCase #1ROSDenies CP, SOB, coughDenies Urinary Sx’s, flank painNo fevers but feels hot then coldDenies wt loss

18. Upper Abdominal PainCase #1Physical ExamMildly dry mucous membranesNo icterusLCTA, heart RRRAbd not distended, (+) csection scar, (+) bowel sounds. (+) tenderness to epigastrum, RUQ. Mild voluntary guarding. (+) murphys sign. Guiac (-) on rectal exam

19. Upper Abdominal PainCase #1LabsCBC:WBC 13.2 w/ L shiftHgb 12.2LFTSElevated Alk Phos, biliRemaining normalEKG NSR, no ischemic changesImagingRUQ U/S(+) stones with thickened GB wall, pericholecystic fluid, ductal dilitationStudy of choice

20. RUQ Ultrasound

21. Upper Abdominal PainCase #1Acute CholecystitisGallbladder inflammation, infectionMurphy’s sign may or may not be present, low sensitivityUsually have leukocytosisLFT elevationMay have Pancreatitis as well depending on location of obstructing stoneCharcot’s Triad: RUQ pain, fever, jaundice

22. Acute CholecystitisManagementIVFsNPOPain, nausea controlAbx:Cipro/flagyl, unasyn or zosynSurgical consultation and cholecystectomyMay have ERCP with stone retrieval prior to chole to allow decompression depending on stone location

23. Upper Abdominal PainCase #1Gallstone locations

24. Acute CholecystitisComplications:Ascending CholangitisInfection up biliary tree from obstruction to normal flowEnteric bacteriaReynolds Pentad: Charcot’s Triad + sepsis, MS changeEmphysematous/Gangrenous CholecystitisAir in biliary treePancreatitis Obstruction of pancreatic duct by gallstone

25. Emphysematous Cholecystitis

26. Biliary ColicSymptomatic cholelithiasisAbd pain, N/VOften following meals, fattyPain usually resolves on ownLabs often normalSymptomatic txIf recurrent, sx consult in ED vs outpt f/uIf frequently recurrent, elective chole

27. Upper Abdominal PainCase #2Same Initial Presentation43 yo F with epigastric and RUQ pain for 3 hours. Per pt it is a “deep” pain, radiating to her back. Increased with po intake. Has had similar, but less severe pain like this before that seemed to resolve with antacids. (+) N/V. Denies hematemesis. Today pain was worse and did not improve with regular meds.PMH: DMSxHx: c-sectionSH: Denies tobacco, drugs. (+) EtOH weekly

28. Upper Abdominal PainROS:Denies CP, SOB, fever. Denies urinary sx’s, flank painDenies BRBPR, melenaPEDry mucous membranesNo icterusLCTA, heart tachyAbd soft, (+) tenderness to epigastrum, LUQ(+) guardingDecreased bowel soundsGuiac (-)

29. Upper Abdominal PainCase #2LabsWBC 16 BUN 52, Cr 1.98AST 42, ALT 65Lipase 842Lactic acid 2.8Labs otherwise nlImaging:U/S: no evidence of gallstones, cholecystitisCT: (+) acute pancreatitis** Imaging is not always necessary in pancreatitis. Recommended if concern for gallstones, episode without clear cause, or toxic appearing as may have ruptured pseudocyst or hemorrhagic pancreatitis

30. Acute Pancreatitis

31. Acute PancreatitisEtiologyAutodigestion of pancreatic tissueEtOH, GallstonesThese 2 vast majority of cases, 80-90%HLDDrugs (many!)Viruses (ie mumps)Pregnancy

32. Acute PancreatitisTreatmentAdmit, ICU if necessaryNPO, bowel restIVFs, aggressiveSymptomatic controlID and treat underlying cause if possibleIf biliary in origin, ERCP followed by choleRanson’s Criteria to help determine severity, mortality risk

33. Ranson’s CriteriaAt AdmissionAge >55 yr WBC >16,000/mL LDH >350 IU/L AST >250 IU/L Glucose >200 mg/dL Score 0 to 2 : 2% mortalityScore 3 to 4 : 15% mortalityScore 5 to 6 : 40% mortalityScore 7 to 8 : 100% mortalityAt 48 Hours Hematocrit decrease >10% BUN increase >5 mg/dL Calcium <8 mg/dL Pao2 <60 mm Hg Base deficit >4 mg/dL Fluid sequestration >6 L

34. Acute PancreatitisCan be severe with necrotizing, hemorrhagic PancreatitisGrey-Turners Sign (any intraperitoneal hemorrhage can cause)Cullens Sign

35. HepatitisViralHep ARNAFecal/oralHep BDNASTD/parenteralHep CRNA, parenteralHep DRNCCo-infection with BAlcoholicBacterialAutoimmuneDrug Induced

36. HepatitisPresentationMalaiseN/V/DAbd painJaundiceAMSPhysical ExamVaries based on severityDehydrationJaundiceAbd distention (ascites), tendernessBruising (coagulopathy)AMSHyperammonemiaAsterixis

37. HepatitisTestingGuided by differentialViral panelImaging to r/o biliary causeBMP, CBCLFTsCoagsPT/INR best indicator of liver functionLactic acidammoniaTylenol level

38. HepatitisTreatmentID etiologyIVFsElectrolyte replacementCorrection of CoagulopathyLactulose for hyperammonemiaRemove/antidote for toxins; ie tylenol ODAdmit forCoagulopathyAMSIf fulminent Hepatic FailureTransfer to transplant site

39. Generalized Abdominal Pain

40. Next case43 yo F with severe abd pain for 3 hours. Per pt it started suddenly, while she was cleaning. Pain is generalized, worse to her upper abd. Has had intermittent upper abd pain for the last few months, worsening recently. Prev pain was a more burning in quality, improved with antacids. (+) N/V. (+) hematemesis. No palliative factors currently. Worse with any movement. PMH: DM, arthritisSxHx: c-sectionSH: Denies drug use. (+) EtOH weekly, (+) ½ PPD tobacco

41. ROSDenies CP, (+) SOB, inspiration makes abd pain worseDenis dysuria, hematuria(+) lightheaded, no numbness, focal weaknessDenies BRBPR, melena(+) arthritis painDenies fever, (+) chills

42. ExamPhysical Exam:HR 114, BP 110/64, RR 30, T 99.5(+) distress, diaphoresisHeart tachy, regularLungs clear, shallow respAbd with absent BS, (+) sig tenderness diffusely, (+) rebound, guarding. Guiac (+)Extrem: no edema

43. Orders?IV, O2, MonitorCBCBMPLFTS, lipaseType and screenPT/PTTPortable CXR, upright abdUAHCG

44. Perforated ViscousPerforated ulcer with free air

45. Perforated ViscousCausesPerforated gastric/duodenal ulcerBowel obstruction with perforationDiverticulitis/ColitisTraumaCAForeign bodiesIatrogenicTreatmentIVFsNPO, NGTAbxHemodynamic stabilizationEmergent Sx consult, OR

46. Generalized Abdominal Pain56 yo M with h/o CAD, HTN, presents with abd pain for 2-3 days, increasing. (+) N/V, multiple episodes, now of dark material. States he must be constipated as he hasn’t had a BM in 3 days. Denies flatus. States his abd feels full. Pain is constant, but increases in waves.PMH: CAD, HTN, HLDSxHx: chole, ventral hernia repairSH: Denies x3

47. Generalized Abdominal PainROSDenies fever, chills, CP, SOBNo dysuria, hematuriaDenies hematemesis(+) constipation, denies BRBPR, melena

48. Generalized Abdominal PainPhysical Exam(+) mild distressDry mucous membranesLCTA, heart tachy, regularAbd distended, midline scar from hernia repair, port scars from chole; increased high pitched BS(+) generalized tendernessRectal with empty vault and guiac (-)Groin without herniasOrders?CBCCMPUAType and screenLactic acidAASIVFs, pain, nausea meds

49. Bowel Obstruction

50. Bowel ObstructionSBOABCAdhesionsBulge (hernia)CancerIntussecptionIBDIleusPost-opElectrolyte/metabolicMedsinfectionLBOMass (most common)Colitis/diverticulitisVolvulusCecal vs sigmoidForeign bodyStool impactionIBD

51. Bowel ObstructionDx:Hx, PEAASAir/fluid levelsDilated bowel:Small bowel >3cmLg bowel >10 cmSx consultCT scanBetter delineate cause, site of obstructionTxAdmitNPONGTIVFsCorrection of electrolyte abnAbx if peritoneal signsSymptomatic controlSx may watch for spontaneous resolution, may go to OR

52. Bowel ObstructionComplications/Progression of dzBowel wall IschemiaPerforationPeritonitisShock

53. Bowel ObstructionSBOLBO

54. Bowel ObstructionCecal VolvulusRotation/torsion of cecum/ascending colonYounger ptsObstruction presentationXR with “coffee bean” Dilated loop of colonTX: NGT, NPO, OR

55. Bowel ObstructionSigmoid VolvulusMore common in elderly, bedridden ptsMore common than cecal volvulusTypically have chronic constipation“Bent Inner Tube” on AASSame Tx:Surgical consult, NPO, NGT, IVFs, OR, abx

56. Case83 yo F with h/o HTN, CAD, DM, afib, CHF, frequent falls, presents with increasing abd pain. Began few hours prior to presentation. Pain is diffuse. (+) N/V. No hematemesis, BRBPR. (+) multiple loose stools after onset of pain as well. Denies anticoagulation due to recurrent falls.PMH: HTN, CAD, DM, afib, CHFSxHx: chole, appy, hysterectomy

57. Physical examMild distressDry mucous membranesHeart irreg, irregLCTAAbd ND, (+) generalized tenderness, (+) guardingGuiac (-)Extrem with 2+ edema B/L

58. Mesenteric IschemiaTypically elderlyH/o afib, low flow states, CADPain is usually acute, severe“pain out of proportion of physical exam findings”Can be due to embolic phenomenon (afib) or luminal thrombosis from vascular dzGuiac +/-(+) lactic acidosisProgresses to peritonitis/shock from necrotic bowel

59. Mesenteric IschemiaDxAngiography is the gold standard CT can show signs assoc with ischemia: wall edema/gasTx:IVFsNGTAbxEmergent sx consultIR consultangiography

60. Lower abdominal Pain

61. Lower Abdominal PainDifferential DiagnosisAppendicitisDiverticulitisIBDPelvic etiologiesPID, ovarian/testicular torsion, ectopicHerniaUrinary

62. Lower Abdominal Pain29 yo F without sig PMH, presents with c/o lower abd pain for 1 day. Pain is constant, increasing. (+) nausea, no emesis. Denies BRBPR, melena. Sexually active with one partner. Is on oral contraceptives, no barrier contraceptives used. (+) vaginal d/c, slightly increased from baseline. Has never been pregnant. LMP 2 weeks ago, normal.PMH: noneSxHx: none

63. Lower Abdominal PainFurther ROS:(+) anorexiaDenies dysuria, hematuria, flank pain.No fever, chillsNo diarrhea, constipation, last BM yesterdayDenies vaginal bleeding

64. Lower Abdominal PainPhysical ExamNAD, well appearingMoist mucous membranesLCTA, heart RRRAbd ND, BS (+). Soft, (+) tenderness to periumbilical and RLQ areas, no guardingNo hernias notedGuiac (-)Pelvic with (+) clear/white d/c, no CMT, (+) R adnexal tenderness

65. Lower Abdominal PainDifferential DxAppendicitisEctopicOvarian torsionPID with TOAOvarian Cyst…….OrdersCBCBMPUAGC/ChlamHCGType and screenImaging?

66. Lower Abdominal PainImaging? U/S vs CTIf this was a male would it change your go-to test?Use your clinical suspicion to guide which is most urgent/likely based on presentationOk to wait for labs before ordering imaging, ie HCG to eliminate ectopic, safety of testCan utilize bedside u/s as well to r/o free fluid if pt unstable

67. AppendicitisUsual presentation of abdominal pain to RLQ. May start L sided or periumbilical and migrate to RLQMajority have anorexia, N/VTypically Pain prior to vomitingCommonly misdiagnosed as gastroenteritisHighlights importance of good return instructions in gastro pts.

68. AppendicitisObturator SignPain on flexion, rotation of hipPsoas SignPain on extension of R hipMost common with a retrocecal appendix as it will lay on the right psoas mslRovsing SignPain to RLQ with palp of the LLQ

69. AppendicitisLabsMost, approx 80%, will have leukocytosis with L shiftDon’t let a normal WBC r/o the diagnosis! Can still be an appyMay have a sterile pyuriaCT scanDilated appendixThickened wallPeriappendiceal fat strandingAppendicolithU/SEsp useful in childrenCan be used in thinner adultsAppendiceal dilation, appendicolith, wall thickening

70. AppendicitisTx:AbxSx consultation for appendectomyComplicationsRuptureAbscess formationSepsis/septic shock

71. DiverticulitisInflammation/Infection of a diverticulumMajority of cases in those >40 yrs of ageMost in sigmoid colonTypical presentation is LLQ pain, N/VMay c/o constipation or diarrheaPain may increase with BMsOften clinical dx, esp in outpt setting CT will demonstrate location as well as r/o complication

72. DiverticulitisComplicationsAbscessPerforationObstructionTreatmentAbxSymptomatic controlIR or sx drainage of abscessSigmoid resection for recurrent diverticulitis

73. DiverticulitisInpatient vs outpatient txAdmission for:Fever, signs of sepsisAbscessInability to tol po intakePain not well controlledD/C home with po Abx, pain meds if:Well appearingHave easy access to return for worsening sx’sAble to tol po intakeGood follow up

74. Flank pain

75. Flank PainCan be a difficult diagnosis!!DifferentialRenal: stones, pyeloAAAPulmonary: pneumonia, PEMSKGI

76. Flank Pain65 yo M with h/o HTN, DM, CAD, nephrolithiasis, presents with c/o L flank pain. Began abruptly while watching a hockey game on TV. Pain radiates to his groin. Denies dysuria, hematuria, numbness, weakness. (+) lightheaded. VS: T 98.9 HR 115, BP 110/55, RR 28, SpO2 98%PE: (+) mod distress, diaphoresis. Heart tachy, regular, LCTA. Abd soft, obese, generalized tenderness. Guiac (-). No LE edema.

77. Flank PainOrders? What can you do at bedside to make the diagnosis? Will you send him out of the department for imaging?

78. AAA

79. AAANormal aorta 2cmTypically do not rupture <5cmRecc repair when >4cm, electiveMost are infrarenal in locationEnlarging/Rupture most commonly misdiagnosed as renal colic, lumbar strainDifficult to palpate pulsatile mass with obese abdBleeding can be retroperitoneal or intraperitoneal

80. AAANeed to clinically suspect ruptureDo not send an unstable pt out of the department for imaging!Can do a bedside u/s to visualize AAA, though does not always illustrate rupture/leakageStable pts can go to CT Call vascular sx for a STAT consultOrdersNPO2 lg bore IVsType and cross 8 units PRBCsCBCCoagsBMPUA (can show hematuria)Emergent vascular consult

81. AAAMortality

82. GI BleedCommon chief complaintAttempt to differentiate Upper vs Lower GIBLarge spectrum of presentation from asymptomatic to shock

83. GI BleedHematemesisUpper GIBGastric, duodenal ulcersMelenaDark tarry stool, digested bloodCan be upper or slow lower GIBHematocheziaLower GIB or rapid upperConfoundersIron supplements, pepto-bismol can give dark stools, though guiac (-)

84. GIBRisk FactorsASANSAIDsEtoh use/abuseanticoagulationPresentation VariesAsymptomatic Weak, dizzy, lightheadedSyncopeCP, SOB

85. GIBOrdersNGT2 IVsType and screen/crossmatch, CBC, CMP, coagsProtonix gtt for UGIBOctreotide for UGIB/varicies, PUDDilates splanchnic vasculature, decreases portal HTN, bleedingEKG

86. GIBIf rapid GIB/ HD unstableGI and Sx consult in EDEmergent endoscopyEnsure appropriate vascular accessReversal of any anticoagulationBlood product transfusion as neededICU admission

87. GIBUpperPUD most commonVariciesMallory-Weiss tearSwallowed blood; ie epistaxisGastritisAortoenteric fistulas/p AAA repairNeoplasmAVMLowerHemorrhoids: most common minorDiverticulosis: most common large bleeding, painlessIBDAVMPolyps/CA

88. The end