Approach to Acute Abdominal Pain

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Approach to Acute Abdominal Pain

• Richard W. Stair, MD

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Acute Abdominal Pain

• Approximately 5-10 of ED visits
• 5 million visits annually
• Most common diagnosis is nonspecific abdominal
  pain ( ie, I dunno!)
• Sex and age shift the likelihood of certain
  diagnoses

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Abdominal Pain for the AgesCommon Etiologies

• 0-2 years - colic, gastroenteritis, viral
  illness, constipation
• 2-12 years - appendicitis, functional disorders,
  gastroenteritis, constipation, viral illness,
  toxins, UTI
• Teens - as in 2-12 plus dysmenorrhea, PID,
  Mittleshmerz, pregnancy, ovarian cyst

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Abdominal Pain for the AgesUncommon Etiologies

• 0-2 years - Hirschsprungs disease, incarcerated
  hernia, intussusception, malabsorption,
  appendicitis, volvulus, milk allergy
• 2-12 - CF, DM, IBD, Meckels diverticulum,
  ovarian/testicular torsions
• Teens - colitis, DM, endometriosis, epidydimitis,
  cholecystitis, IBD, torsion

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BEWARE - Abdominal Pain in the Elderly

• Many more vague presentations
• Comorbid diseases
• Morbidity and mortality rise EXPONENTIALLY after
  age 50
• Twice as likely to need surgery after age 65
• Diminished pain sensation

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Acute Abdominal Pain and Sex

• Men more frequently seen in the ED, and more
  likely to have a perforated viscus
• Women are more likely to have cholecystitis,
  diverticulitis, and be D/Cd with nonspecific AP

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Whats the Problem

• Imprecise pain generation and transmission to the
  CNS
• Comorbid diseases, developmental stage of
  patient, medications, social factors
• The key is understanding types of pain
• visceral
• somatic
• referred

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Visceral Pain

• Generated by stretch receptors in the walls of
  hollow viscus and the capsules of solid organs
• Fibers return to various levels of the
  sympathetic trunk on BOTH sides of the spinal
  cord
• Poorly described, achy, crampy, diffuse

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Visceral Pain

• Levels of visceral innervation
• C3-5 - liver, spleen, diaphragm, pericardium
• T5-9 - gallbladder, stomach, pancreas, small
  intestine
• T10-11 - colon, appendix, pelvic viscera
• T11-L1 - sigmoid colon, renal capsules, ureters,
  testes
• S2-4 - urinary bladder

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Somatic Pain

• Fibers arise from the parietal peritoneum, the
  rrot of the mesentery, and the anterior abdominal
  wall
• Innervation corresponds to dermatomes entering
  cord unilaterally
• Usually sharp, well localized

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Referred pain

• Caused by overlap of nerve fibers from different
  locations returning to the spinal cord at the
  same area
• Pain sensed distal to site of problem
• Example - L shoulder pain with ruptured spleen,
  remember spleens capsular fibers enter cord at
  C3-5

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Abdominal Pain - HistoryThink OLD CARS

• O - onset
• L - location
• D - duration
• C - character
• A - aggravating/alleviating factors,
  - associated symptoms
• R - radiation
• S - severity

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History - More Info

• PMH - prior episodes prior medical conditions
  making some diagnoses more common
• PSH - adhesions 1 cause SBO
• Medications - NSAIDS, Abx
• Social - drugs, withdrawal, foreign bodies
• Gyn/Urol - timing of periods, bleeding,
  testicular pain, bloody urine

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Physical Exam

• VITALS
• General - appears sick or in obvious pain
• Inspection - bruises, scars, distension
• Auscultation - hyper, normal, none
• Palpation - pain vs. tenderness
• start away from painful area, guarding, etc
• Extra-abdominal exam

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Physical Exam Signs

• Murphys
• Rovsings
• Iliopsoas
• Obturator

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Ancillary Tests

• CBC - lacks sensitivity and specificity
• Labs should be DIRECTED
• Urine dipsticks
• Urine hCG

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Imaging

• Plain films - obstruction, free air, air-fluid
  levels, foreign bodies
• CT scanning
• Ultrasound
• Nuclear medicine scans (HIDA)
• Endoscopy

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DDx - RUQ pain

• Pneumonia
• PE
• hepatitis
• cholecystitis
• biliary colic
• PUD

• Pancreatitis
• renal stone
• pyelonephritis
• retrocecal appendix
• heart failure
• MI

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DDx - LUQ pain

• Gastritis
• gastric ulcer
• pancreatitis
• renal stone
• pyelonephritis

• Pneumonia
• PE
• splenic rupture
• splenic enlargement
• diverticulitis

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DDx - RLQ pain

• Appendicitis
• cholecystitis
• diverticulitis
• renal stone
• AAA
• mesenteric adenitis
• regional enteritis
• Meckels diverticulum

• Testicular torsion
• epidydimitis
• salpingitis
• ectopic pregnancy
• ovarian cyst
• Mittleschmertz
• TOA
• cystitis
• prostatitis

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DDx - LLQ pain

• AAA
• renal stone
• diverticulitis
• perforation
• volvulus
• salpingitis
• ectopic pregnancy

• Ovarian cyst
• Mittleschmertz
• TOA
• cystitis
• prostatitis
• testicular torsion
• epidydimitis

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Management of Acute Abdominal Pain

• IV access
• Fluids
• Emesis Control
• Analgesia
• Antibiotics
• Consultants

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ACEP Clinical Policy on Acute Abdominal Pain -
Oct 2000

• Evidence based guidelines and options for many
  Emergency Department presentation

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Abdominal Pain - Disposition

• Operating Room
• Hospital Bed
• Home with abdominal warnings
• Remember to beware of the extremes of age