Title: Evaluation of Abdominal Pain
1Evaluation of Abdominal Pain
John E. Carroll, M.D.
Assistant Professor of Medicine
Division of Gastroenterology
Georgetown University Hospital
224 Causes of Abdominal Pain
3Causes of Abdominal Pain
1. Adhesions
- Hx Intermittent pain. Non-localized No sig.
aggravating/alleviating Factors Hx of ABD
surgery or ABD infection - PE Unimpressive Normal BS
- Labs None (all normal)
- Imaging None (all normal)
- Key.. Clinical Suspicion
4Causes of Abdominal Pain
2. Small Bowel Obstruction
- Hx Sudden onset. Severe pain Mid abdominal
location Significant vomiting Hx of prior
surgery - PE Distended. Diffusely tender High Pitched
BS - Labs None (hypokalemic alkalosis)
- Imaging Plain ABD film (air fluid levels)
- Key Exam and ABD film
5Causes of Abdominal Pain
3. Partial SBO
- Hx Intermittent pain Diffuse - mid
abdomen Hx of prior surgery More
nausealess vomiting - PE Non-specific Less distended . Less
tender High pitched - normal BS - Labs None (normal)
- Imaging Plain ABD film (sparse AFLs)
- Key. Hx, Exam and ABD film
6Causes of Abdominal Pain
4. Ileus
- Hx Non specific ABD pain Mid-abdominal
location Nausealess vomiting No need for
prior surgery Debillitated state. Certain
medications. - PE Absent BS
- Labs None (normal)
- Imaging Plain ABD film (distended bowel)
- Key Exam and ABD film
7Causes of Abdominal Pain
5. Colonic Obstruction
- Hx Severe, unremitting ABD pain Fairly sudden
onset Decreased stool output - PE Unremarkable Slightly
distended Tympanic - Labs None (normal)
- Imaging Plain ABD film (no air in rectal
vault) CT (mass with proximal bowel dilation) - Key Clinical Suspicion and imaging studies
8Causes of Abdominal Pain
6.
- Hx Severe epigastric pain Risk factors
(ETOH, gallstones) - PE Severe epigastric tenderness
- Labs Amylase, Lipase
- Imaging CT
- Key Labs and CT
9Causes of Abdominal Pain
6. Acute Pancreatitis
- Hx Severe epigastric pain Risk factors
(ETOH, gallstones) - PE Severe epigastric tenderness
- Labs Amylase, Lipase
- Imaging CT
- Key Labs and CT
10Causes of Abdominal Pain
7.
- Hx Known pancreatitis ETOH, idiopathic,
medications - PE Moderate epigastric tenderness Less tender
than in acute pancreatitis - Labs Amylase, Lipase Less elevated than in
acute pancreatitis - Imaging CT (calcifications, atrophic
gland) ERCP (ductal changes) MRCP (ductal
changes) EUS (parenchyma and ductalchanges) - Key Imaging studies
11Causes of Abdominal Pain
7. Chronic Pancreatitis
- Hx Known pancreatitis ETOH, idiopathic,
medications - PE Moderate epigastric tenderness Less tender
than in acute pancreatitis - Labs Amylase, Lipase Less elevated than in
acute pancreatitis - Imaging CT (calcifications, atrophic
gland) ERCP (ductal changes) MRCP (ductal
changes) EUS (parenchyma and ductalchanges) - Key Imaging studies
12Causes of Abdominal Pain
8. Pancreatic Pseudocyst
- Hx Known pancreatitis ABD pain in chronic
pancreatitis unresolving acute pancreatitis - PE Non-specific
- Labs Non-specific
- Imaging CT (pseudocyst size) (pseudocyst
wall) (internal cyst texture) - Key CT
13Causes of Abdominal Pain
9. Pancreatic Cancer (body)
- Hx Persistent, gradual pain May have
fatigue, anorexia, wt. loss - PE Unremarkable
- Labs CA 19-9 otherwise normal
- Imaging CT (mass) ERCP (pancreatic duct
narrowing) EUS (mass, vascular, ductal changes) - Key Imaging studies and CA 19-9
14Causes of Abdominal Pain
10. Peptic Ulcer Disease
- Hx Gradual moderate epigastric pain NSAID use
- PE Unremarkable Slight epigastric
tenderness - Labs None (normal)
- Imaging UGI series Upper endoscopy
- Key Upper endoscopy
15Causes of Abdominal Pain
11. Perforated PUD
- Hx Sudden onset severe epigastric pain
- PE Rigid ABD Severe diffuse tenderness
- Labs None
- Imaging Plain ABD film (free air) CT (free
air) - Key Exam and Imaging studies
16Causes of Abdominal Pain
12. Cholangitis
- Hx Vague ABD pain Recent biliary
manipulation Known hepatobiliary malignancy - PE Toxic appearing. Fever. Tachycardia. Jaund
iced Epigastric/RUQ tenderness - Labs WBC, bilirubin, bicarb
- Imaging Non-specific
- Key Clinical history, exam and labs
17Causes of Abdominal Pain
13. Cholecystitis
- Hx Sudden onset RUQ pain May be a pleuritic
component - PE RUQ tenderness Murphys sign
- Labs WBC, bilirubin, alk phos
- Imaging RUQ U/S (peri-cholecystic
fluid) (thickened GB wall) - Key Exam and U/S
18Causes of Abdominal Pain
14. Biliary Colic
- Hx Intermittent epigastric pain Moderate to
severe in intensity Occurs spontaneously Sel
f limiting after 2-3 hours Risk factors for
lithogenic bile - PE Normal
- Labs None (normal)
- Imaging RUQ U/S (cholelithiasis)
- Key Clinical history and RUQ U/S
19Causes of Abdominal Pain
15. Biliary Dyskinesia
- Hx Postprandial component nausea RUQ
pain - PE Unremarkable
- Labs None (normal)
- Imaging HIDA scan
- Key Clinical history and HIDA scan
20Causes of Abdominal Pain
16. Choledochal cyst
- Hx ABD pain Moderate RUQ
- PE Unremarkable
- Labs Normal
- Imaging CT ERCP U/S EUS
- Key Imaging studies
21Causes of Abdominal Pain
17. Appendicitis
- Hx Sudden onset Severe pain RLQ
- PE Fever Localized RLQ tenderness
- Labs WBC
- Imaging CT (appendiceal thickening)
- Key History, exam, labs, CT
22Causes of Abdominal Pain
18. Diverticulitis
- Hx Sudden onset Severe pain LLQ
- PE Fever Severe tenderness LLQ
- Labs WBC
- Imaging CT (peri-colonic stranding)
- Key CT
23Causes of Abdominal Pain
19. Ischemic Bowel
- Hx Poorly localized Non-specific nausea and
pain Followed by bloody diarrhea Elderly
patient Known atherosclerotic disease - PE Unremarkable
- Labs None (normal)
- Imaging None (normal)
- Key Clinical history
24Causes of Abdominal Pain
20. Celiac Artery Compression Syndrome (median
arcuate ligament syndrome)
- Hx Intermittent ABD pain Epigastric
location Weight loss No
aggravating/alleviating factors - PE Unremarkable
- Labs None (normal)
- Imaging Angiography (breathing sequences)
- Key Clinical suspicion and angiography
25Causes of Abdominal Pain
21. Peritonitis
- Hx Severe, diffuse ABD pain Recent
interventional procedure Ascites - PE Diffusely tender Rebound
tenderness Guarding - Labs WBC, bicarb
- Imaging None
- Key Physical exam
26Causes of Abdominal Pain
22. Perforated Viscus
- Hx Recent interventional procedure Inflammator
y bowel disease Known intra-abdominal
malignancy - PE Rigid abdomen Diffusely
tender Rebound tenderness - Labs WBC, bicarb
- Imaging Plain ABD film (free air) CT (free
air) - Key Clinical history, exam and imaging
27Causes of Abdominal Pain
23. Crohns Disease
- Hx Sudden onset severe pain Mid-abdomen
location Associated with nausea - PE Non-specific tendeness Rebound
tenderness Guarding - Labs WBC
- Imaging CT (stranding, inflammatory
mass) SBFT (fibrostenotic disease) - Key Imaging studies
28Causes of Abdominal Pain
24. Ulcerative Colitis
- Hx Progressive diarrhea Blood and
mucous Diffuse, non-localized pain - PE Toxic appearing Fever.
Tachycardia Severe diffuse tenderness Rebou
nd tenderness. Guarding - Labs WBC, bicarb
- Imaging Plain ABD film (toxic
megacolon) CT (diffusely thickened wall) - Key Clinical history, exam, imaging studies
29The Acute Abdomen
Problem perforated viscus uncontrolled ABD
infection/inflammation Evaluation Rigid
ABD Peritoneal signs Culprits bowel
perforation progressive peritonitis acute
appendicitis
3024 Causes of Abdominal Pain
-Adhesions -Cholecystits -Small Bowel
Obstruction -Biliary Colic -Partial
SBO -Biliary Dyskinesia -Ileus -Choledochal
cyst -Colonic Obstruction -Appendicitis -Acute
Pancreatitis -Diverticulitis -Chronic
Pancreatitis -Ischemic Bowel -Pancreatic
Pseudocyst -Celiac Comp. Synd. -Pancreatic
Cancer -Peritonitis -Peptic Ulcer
Disease -Perforated Viscus -Perforated
PUD -Crohns Disease -Cholangitis -Ulcerative
Colitis