Transcript Slide 1
Abdominal Pain Scenario You are called by a nurse to evaluate a patient on the inpatient medicine service with abdominal pain (cross-cover) “Worst case scenario” DDx “Surgical abdomen” – condition with rapidly worsening prognosis without surgical intervention • Obstruction • Peritonitis – – – – Viscus perforation (e.g., intestine, pelvic organ) Intraperitoneal hemorrhage (e.g., ruptured AAA) Intraabdominal abscess (SBP is medically managed) Location, location, location RUQ: • • • • Biliary colic Cholecystitis Cholangitis Hepatitis DDx Epigastric: • • • • • Pancreatitis Dyspepsia/PUD Gastroparesis Cardiac ischemia Pulmonary pathology affecting lower lungs/pleura (PNA, PE, pulmonary infarct, empyema) DDx Lower abdominal: • • • • • • Colitis/enteritis (infectious, ischemic, IBD) Diverticulitis Appendicitis Cystitis Renal colic (flank), pyelonephritis (CVA tenderness) Gynecologic: PID, adnexal cysts/masses (bleeding, torsion, rupture), fibroids, ectopic DDx Generalized: • Intestinal ischemia/infarction • Endocrinopathies: DKA, hypercalcemia, adrenal insufficiency • Constipation • Pain syndromes: functional abdominal pain, IBS, fibromyalgia, somatoform disorder, narcotic-seeking behavior First steps Is the patient unstable (phone)? Is the patient sick (bedside)? If yes to above ABCs, consider ICU Xfer History All about the pain • Onset, what patient was doing/had recently done (e.g. just finished a meal, ERCP yesterday) • Ever had this pain before? • Location, radiation • Character: – Dull/achy/vague (visceral) – Sharp/well-localized : parietal (2/2 peritoneal irritation) – Colicky • Severity History Aggravating/alleviating factors – Food : aggravates intestinal ischemia, alleviates some cases of PUD – Position : peritonitis aggravated by any movement, pancreatitis alleviated by sitting up and leaning forward Associated symptoms – N/V (bloody, bilious, feculent), diarrhea/constipation, melena/hematochezia, vaginal discharge/bleeding History STD risk/symptoms Possibility of pregnancy Medical history: diabetes, chronic liver disease, IBD, rheumatologic disease, immunocompromised, prior abdominal surgeries Abdominal Exam General appearance, level of discomfort Vitals: fever, HoTN Inspection • Bulging (ascites, mass) • Signs of chronic liver disease (jaundice, dilated superficial veins, spider angiomata) • Scars Auscultation: • Absent bowel sounds (adynamic ileus, advanced peritonitis) • Hyperactive, high-pitched bowel sounds (early bowel obstruction) Abdominal Exam Palpation/Percussion • Gently assess for peritonitis – Muscle rigidity (guarding) – may be focal or diffuse – Rebound tenderness – “Shake tenderness” – bump the bed • Start away from the pain • Tympany (distended bowel) • Pain out of proportion to exam (intestinal ischemia/infarction) • Murphy’s sign, hepatomegaly • Ascites (SBP) • Pulsatile mass (AAA) Exam Rectal exam • Have to justify not doing it • Impaction, tenderness, check stool for occult blood Pelvic exam • If suspect pelvic pathology (e.g., woman with lower abdominal pain) • Bleeding, discharge • CMT • Adnexal/uterine pathology Don’t forget the heart, lungs, eyes/skin (jaundice), pulses (AAA) Whole exam can be done rapidly Labs • • • • • • • • • • • CBC: leukocytosis, anemia CMP: hepatic/renal function, electrolytes, anion gap Lipase UA Lactate (ischemia/infarction) Urine hcg Blood Cultures: if febrile or unstable Stool Cx/O+P/C. Diff Wet mount of vaginal discharge/GC/Chlamydia Troponin, EKG ABG Imaging Abdominal X-ray: • • • • • “bones, stones, mass, and gas” Different from KUB which is centered lower in the abdomen Supine and upright/L lateral decubitus views Obstruction proximally dilated bowel loops, air-fluid levels Viscus rupture intraperitoneal free air (see under diaphragm, over liver) • Toxic megacolon (C. Diff) markedly dilated bowel +/perforation • Ileus, intestinal pseudoobstruction dilated bowel extending to rectum • Constipation Imaging CT Abdomen/Pelvis (with contrast): • • • • • • • • Higher diagnostic accuracy than plain radiographs Intraperitoneal free air Obstruction (may see transition point) Intestinal ischemia Viscus inflammation Abscess AAA leak/rupture Pancreatitis Imaging Ultrasound: • RUQ : cholecystitis, gallstones, biliary dilation, cholangitis • Pelvic: fibroids, adnexal masses, IUP, ectopic pregnancy, free pelvic fluid • Renal • Pregnancy CXR: • If pulmonary pathology suspected • May need follow-up chest CT Therapy/Management Consultation: • Emergent surgical consult if acute abdomen • Biliary consult if biliary dilation, choledocholithiasis ERCP/MRCP • GI consult if dyspepsia with red flag symptoms (e.g., dysphagia, wt. loss, persistent vomiting) EGD +/Bx • GYN consult if complex pelvic disease Therapy/Management Some therapeutic examples: • Ileus: – Decompression with NGT to suction, NPO • Constipation/fecal impaction: – Manual disimpaction, stool softeners, laxatives • Enterocolitis, diverticulitis, cholangitis, PID: – ABx Therapy/Management Diagnosis is often unclear after initial assessment • Serial assessments, watchful waiting If you didn’t document, you didn’t do it • Initial assessment, f/u assessments • If cross-covering, give appropriate sign-out Take-Home Points Is the patient sick? (phone, prompt bedside assessment) R/o surgical abdomen Very focused history and exam Relevant labs and imaging (think before you order) Use your consultants Watchful waiting – good medicine when used correctly Documentation