Abdominal Pain - Beaumont Emergency Medicine
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Transcript Abdominal Pain - Beaumont Emergency Medicine
Ob Gyn and Male GU
William Beaumont Hospital
Department of Emergency Medicine
Cases…
26 y/o F presents with RLQ pain and
vaginal spotting. Abdominal and pelvic
exams are normal.
26 y/o F presents with RLQ pain, R
shoulder pain, no spotting. Pelvic with
R adnexal fullness and tenderness.
What are you thinking about?
Causes of Pelvic Pain
Ectopic pregnancy
Ovarian torsion
PID
Ruptured ovarian cyst
– Simple vs. hemorrhagic
Fibroids
Endometriosis
Renal stone
Appendicitis
Ectopic Pregnancy
How do they present?
Signs and Symptoms
Abdominal pain 95%
Abdominal tenderness 70%
Vaginal bleeding – slight spotting
Tenesmus
3 S’s
– Syncope, shoulder pain, shock
– Suggests rupture
Ectopic Pregnancy
2% incidence
Leading cause of first trimester
maternal death
Risk factors?
Ectopic Pregnancy
Duration of the pregnancy
– Is their LMP reliable?
Site of implantation
– Ampulla – most common
– Isthmus – 10% – rupture common
– Cornual – massive hemorrhage
Extent of intraperitoneal hemorrhage
– Slow leakage (65% non ruptured)
– Frank rupture
Diagnosis
Physical exam – not always helpful
High index of suspicion
BhCG – all women with vaginal bleeding or
abdominal pain in reproductive years
Pelvic ultrasound – Suggestive of ectopic
pregnancy
– No IUP, BhCG >1200
– Complex adnexal mass
– Moderate-large amount cul-de-sac fluid
Treatment
ABCs
Rhogam if Rh negative and bleeding
Gynecology consult for surgical
removal or Methotrexate
Next Case…
18 y/o F presents with low abdominal
pain, fever, and last period about one
week ago.
This is her pelvic.
What is this?
PID
Cervicitis that ascends to become a
polymicrobial endometritis, salpingitis,
oophoritis
Common cause of pelvic pain
Most common serious infection in
reproductive aged women
PID
Risk Factors
– Prior PID
– Multiple partners
– IUD use
– Instrumentation of uterine cavity
Symptoms
Bilateral lower quadrant pain
Purulent vaginal discharge >50%
Abnormal vaginal bleeding
Symptoms begin shortly after menses
PE
Vital signs?
CMT
Bilateral adnexal tenderness
Purulent cervical discharge
Diagnosis:
– Wait for cultures?
PID
Work-up
– HCG (duh!)
– CBC
– UA
– Pelvic:
Gram neg intracellular diplococci
C & S, DNA probe
– Ultrasound?
Indications for Admission
Suspected TOA or Fitz-Hugh-Curtis syndrome
Patient unable to tolerate PO
Peritonitis, septic appearing
Prepubertal children
Indwelling IUD
Pregnancy
Inpatient Treatment
Look it up, it changes… BUT…
– Cefoxitin 2 g IV q 6 or
– Cefotetan 2 g IV q 12 or
– Unasyn 3 g IV q or
– AND all above with Doxycycline 100 mg
PO/IV q 12 – or - Clindamycin 900 mg
IV q 8 with Gentamycin alone
Outpatient Treatment
Changes more, look it up…BUT…
– Ceftriaxone 250 mg IM PLUS
– Cefoxitin 2 gm IM with Probenecid 1 gm
po PLUS
– Doxycycline 100 mg BID x 14 d
– +/-Metronidazole 500 mg BID x 14 d
Cervicitis
Cervical infection – discharge without
abdominal pain or constitutional symptoms
Gonorrhea or Chlamydia
Outpatient treatment
– Ceftriaxone 125 mg IM with Doxycycline 100 mg
BID x 7 days
– Alternatives for GC: Cefixime 400 mg PO x 1
– Alternative for Chlamydia: Azithromycin 1 g PO
– Alternative for both: Azithromycin 2 g PO
Next Case…
26 y/o F presents with L flank pain, LLQ
pain, and pain that radiates to the
vagina. She also has urinary
frequency. She has L CVA and LLQ
tenderness on exam.
What could this be?
What was missed?
Ovarian Pain
Ruptured cyst
– Sudden, severe, sharp unilateral pain
– Self resolving unless hemorrhagic or
dermoid
– Treatment – observe in ED
Ovarian Torsion
Intermittent colicky pain or acute
abdomen
Adnexal fullness/tenderness
BhCG, doppler ultrasound is diagnostic
Treatment – OR
Kidney Stones
Common – 10% incidence
Flank pain, radiating to groin or
abdomen
Writhing pain, nausea, vomiting
CVA tenderness
GU exam (radiating pain)
Abdomen soft, nontender, BS – ileus
Kidney Stone Work Up
Urinalysis
– Hematuria (unless complete obstruction)
What percentage of stones have no blood in the urine?
– Infection = surgical emergency
Non-contrast CT scan abd/pelvis
Ultrasound
IVP
90% radiopaque – visible on KUB
– 75% Calcium, 15% struvite (Mg)
– Others: uric acid, cystine, drug induced
Helical CT Scan
Perinephric
stranding of fat
surrounding the left
kidney and proximal
left ureter
Left kidney is
enlarged, with
dilatation of the
intrarenal collecting
system
Treatment
IV fluids
Strain urine
Analgesics – ketorolac, narcotics
Antiemetics if vomiting
Tamsulosin – Flomax – alpha blocker
Depending on the location of the stone:
– < 5mm – usually pass spontaneously
– > 8mm – often require surgery
Admission (Observation)
Intractable pain
Intractable vomiting
Stone > 6mm
Extravasation of dye on CT
Solitary kidney
Infected stone is a surgical emergency
– Stone plus UA with bacteria and WBCs
– Why is this so bad?
Male GU
Testicular torsion
Epididymitis
Fourniere’s gangrene
Next Case…
18 y/o male c/o of pain in his right
testicle that was sudden onset 2 hours
ago with nausea and vomiting. It
began while he was running. Exam
shows a diffusely tender swollen right
testicle, with loss of cremasteric reflex.
What are you thinking?
What tests do you want to order?
Testicular Torsion
Sudden severe testicular or lower abd pain
Often preceded by trauma/physical activity
Most common in pre and pubescent males,
but can occur at any age
PE – diffusely tender, swollen testicle
Diagnosis – no flow on testicular ultrasound
When do you call urology?
Epididymitis
Gradual pain
Posterior epididymal tenderness and edema
(later swollen scrotum obscures)
Usually occurs in sexually active males
UA – pyuria
Testicular ultrasound – to rule out torsion
– Not always necessary!
Epididymitis
Treatment
– Antibiotics
GC and Chlamydia if <35 yo
E Coli if >35 yo
– Analgesics
– Scrotal support
Fourniere’s Gangrene
Elderly or immunocompromised men
Sudden onset of edematous, necrotic
scrotum/perineum
Patients appear toxic
Plain films – scrotal gangrene and
intrascrotal gas
Fourniere’s Gangrene
Treatment:
– Urologic/general surgery consult for surgical
debridement
– IVF
– Broad spectrum IV antibiotics
Fournier’s Gangrene
The End
Any Questions??