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Evaluation of Abdominal Pain

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Assistant Professor of Medicine. Division of Gastroenterology Georgetown University Hospital ... Plain ABD film (free air) CT (free air) Key... Exam and ... – PowerPoint PPT presentation

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Title: Evaluation of Abdominal Pain


1
Evaluation of Abdominal Pain
John E. Carroll, M.D.
Assistant Professor of Medicine
Division of Gastroenterology
Georgetown University Hospital
2
24 Causes of Abdominal Pain
3
Causes 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

4
Causes 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

5
Causes 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

6
Causes 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

7
Causes 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

8
Causes 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

9
Causes 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

10
Causes 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

11
Causes 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

12
Causes 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

13
Causes 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

14
Causes 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

15
Causes 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

16
Causes 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

17
Causes 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

18
Causes 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

19
Causes 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

20
Causes of Abdominal Pain
16. Choledochal cyst
  • Hx ABD pain Moderate RUQ
  • PE Unremarkable
  • Labs Normal
  • Imaging CT ERCP U/S EUS
  • Key Imaging studies

21
Causes 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

22
Causes 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

23
Causes 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

24
Causes 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

25
Causes 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

26
Causes 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

27
Causes 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

28
Causes 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

29
The Acute Abdomen
Problem perforated viscus uncontrolled ABD
infection/inflammation Evaluation Rigid
ABD Peritoneal signs Culprits bowel
perforation progressive peritonitis acute
appendicitis
30
24 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
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