approach to abdominal pain in the emergency department
TRANSCRIPT
Approach to Abdominal Pain in the Emergency Department
Richard Stair, MD, FACEP
Department of Emergency Medicine
Introduction At the end of this lecture you
should: Understand the generation and
presentation of types of abdominal pain
Develop critical elements of the history and physical for AP
Apply knowledge of utility of testing to diagnostic approach
Apply management principles to patient care in the ED
What Do They Have? As you go through this
presentation, think about each of these cases: An 18 mo old that suddenly
became inconsoleable from AP while playing
A 20 yo man with 12 hours of diffuse crampy AP that migrated to RLQ that became sharp
78 yo woman with h/o chronic steroid use with sudden sharp AP and a rigid exam
Acute Abdominal Pain Approximately 6% of ED visits Admission rates vary by
population, up to about to 65% in high risk elderly populations
Most common diagnosis is NONSPECIFIC (ie, “I dunno”)
Use H+P, risk factors, and directed studies to arrive at diagnosis
MUST rule out emergency conditions
Abdominal Pain Across the Ages
Ages 0-2 Colic, GE, viral illness, constipation
Ages 2-12 Functional, appendicitis, GE, toxins
Teens to adults Addition of genitourinary problems
Elderly Beware of what seems like
everything!
Special Populations
Elderly/ nursing home patients Immunocompromised Post operative patients Infants
Abdominal Pain in the Elderly
Diminished sensation of pain in the elderly
Comorbid diseases Polypharmacy Combinations of above result in
many more vague, nonspecific presentations
Twice as likely to require surgery with presentation over age 65
What’s the Problem
Imprecise pain generation and transmission to the central nervous system
Comorbid diseases Developmental stage Medications Social factors
Understanding the Types of Abdominal Pain
Visceral Stretch fibers in capsules or walls
of hollow viscus that enter both sides of spinal cord
Somatic Fibers dermatomally distributed
and enter unilaterally in the spinal cord
Referred Overlap of fibers from other
locations
Understanding the Types of Abdominal Pain
Visceral Crampy, achy, diffuse, Poorly localized
Somatic Sharp, lancinating Well localized
Referred Distant from site of generation Symptoms, but no signs
Understanding the Types of Abdominal Pain
Location, location, location Organs and their corresponding
fiber entry to the spinal cord C3-5 – liver, spleen, diaphragm T5-9 – gallbladder, stomach,
pancreas, small intestine T10-11– colon, appendix, pelvic
viscerat11-l1 – sigmoid, renal capsules, ureters, gonads
S2-4 - bladder
History Taking in Abdominal Pain Presentations
“OLD CARS”
O- onset L- location D- duration C- character A-alleviating/aggravating factors
associated symptoms R- radiation S- severity
History Taking for Abdominal Pain Presentations
PMH Similar episodes in past Other medical problems that increase disease
likelihood of problems (ex: DM and gastroparesis)
PSH Adhesions, hernias, tumors
MEDS Abx, NSAIDS, acid blockers, etc
GYN/URO LMP, bleeding, discharge
Social Tob/EtoH/drugs/home situation/agenda
Physical Exam in Abdominal Pain Presentations
General appearance “Sick versus not sick” Mobile versus still Obvious pain or discomfort “Doorway” impression
Vital signs “That’s why they’re called vital”
Physical Exam in Abdominal Pain Presentations
Inspection Distention, scars, bruises
Auscultation Present, hyper, or absent Actually not that helpful!
Palpation Often the most helpful part of exam Tenderness versus pain Start away from painful area first Guarding, rebound, masses
Physical Exam in Abdominal Pain Presentations
Signs Iliopsoas Obturator Rovsing’s Murphy’s
Extra-abdominal exam Pelvic or scrotal exams Lungs, heart Remember it’s a patient, not a part
Rectal Adds very little (despite the angst)
beyond gross blood or melena
Laboratory Testing
Everybody likes a CBC, but…
Lacks sensitivity, no specificity Little to no change in diagnostic
probabilities Should not dramatically alter
approach (tender is still tender)
Laboratory Testing
Directed approach to lab studies There are no “standard belly labs” Pregnancy test in women of child
bearing age Urine dipsticks
Imaging Plain films
Free air, obstruction, air-fluid, FBs Ultrasound
Rapid “yes or no” ED evaluations Formal studies May add doppler
Computed Tomography Revolutionized acute care Often better than we are!
Common Diagnoses by Quadrant
RUQ Cholecystitis Biliary colic Hepatitis Pancreatitis Renal stones PUD Pneumonia P E M I
LUQ Gastritis Gastric ulcer Pancreatitis Splenomegaly Splenic rupture Renal stone Pneumonia P E M I
Common Diagnoses by Quadrants
RLQ Appendicitis Renal stone Ovarian cyst Torsion Epididymitis Ectopic IBD AAA UTI
LLQ Diverticulitis Renal stone Ovarian cyst Torsion Epididymitis Ectopic IBD AAA UTI
Management of Abdominal Pain
Always right to start with ABC’s IV access Fluid administration Antiemetics Analgesics Directed testing and imaging Re-evaluations Antibiotics Consultants
Surgeons, OB/GYN, urologists, cardiologists, etc
Disposition of Abdominal Pain Patients
Operating Room Hospital bed/observation
Serial labs Serial exams
Home with abdominal warnings The art of emergency medicine 3 components of discharge plan Document, document, document
Now How About Those Cases
18 mo old had classic presentation of intussusception, and symptoms may wax and wane; rectal would be to look for current jelly stool. Air enema for diagnosis and reduction. Involve consultants early in the course.
Now How About Those Cases
20 year old with classic presentation of appendicits, which likely does not need CT scan. Most do not present so simply, quite a wide array of presentations. General surgery consultation, pain meds, IVF, and an operation would all be good, but don’t be shocked if CT requested.
Now How About Those Cases
78 yo has perforated abdomen, with age, multiple problems, and chronic steroids risks for perforation. Rapid resuscitation, plain films to confirm free air, antibiotics, pain medicine, and a surgeon as fast as you can would be good practice.
Take Home Points Perform a good history and
physical to guide assessment Lab studies have limitations…..and
costs Imaging studies also need to be
selected wisely Early involvement of consultants
for sick patients Treatment initiation, not just
diagnostics