Transcript Abdominal Pain

Abdominal Pain
William Beaumont Hospital
Department of Emergency Medicine
Abdominal Pain
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One of the most common CC
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Confounders making dx difficult
– Age
– Corticosteroids
– Diabetics
– Recent antibiotics
Abdominal Pain: Pitfalls
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Consider non-GI causes
– Acute MI (inferior), ectopic pregnancy,
DKA, sickle cell anemia, porphyria, HSP,
acute adrenal insufficiency
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History
– Location, quality, severity, onset,
duration, aggravating and alleviating
factors, prior symptoms
Abdominal Pain: History
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Sudden onset – perforated viscus
Crushing – esophageal or cardiac dz
Burning – peptic ulcer dz
Colicky – biliary or renal dz
Cramping – intestinal
Ripping – aneurysmal rupture
Abdominal Pain: Physical
Exam
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Abdomen
– Inspection
– Bowel sounds
– Tenderness (rebound, guarding)
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Extra-abdomen exam
– Lung, cardiac, pelvic, GU and rectal
Work up: Labs
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Beta-hCG
WBC – poor sensitivity and specificity
LFTs – hepatobiliary
Lipase – pancreatic
Electrolytes – CO2
Lactic acid
Urinalysis – BEWARE
Work up: Imaging
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Acute Abdominal Series
– Free air and bowel gas
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KUB
– Poor screening test
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Ultrasound –
– Biliary dz, AAA, free fluid or air, pelvic
pathology
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CT – appendicitis, diverticulitis
Case: Upper Abdominal
Pain
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79 yo female presents with aching
sharp pain in the epigastrium and right
upper quadrant ½ hour after eating.
Pain radiates to the back. +N, –V
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Differential diagnosis?
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Testing?
RUQ/midepigastric pain
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Biliary disease
PUD/gastritis
Pancreatitis
AAA
Pneumonia (RLL)
Pyelonephritis
Acute MI
Hepatitis
Appendicitis
Fitz-Hugh Curtis syndrome
Gallstones: Risk Factors
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Female 4:1
Fertile
Forty
Fat
Family history
Crohns, UC, SCA, thalassemia
Rapid weight loss, starvation, TPN
Elevated TGs, cholesterol
Cholelithiasis
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History:
– RUQ/epigastric pain
– Nausea/vomiting with fatty meals
– Similar episodes in past
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PE: RUQ tenderness
Labs: may be normal
ECG: consider in older patients
Imaging: test of choice = US
Cholelithiasis: Treatment
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Symptomatic gallstones
– Pain control
– Anti-emetics
– Consult general surgery
90% with recurrent symptoms
 50% develop acute cholecystitis
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Cholelithiasis: Treatment
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Asymptomatic gallstones
– Incidental finding
– 15-20% become symptomatic
– Outpatient elective surgery if
Frequent, severe attacks
 Diabetic
 Large calculi
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Acute Cholecystitis
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Sudden GB inflammation
Bacterial infection in 50-80%
– E. coli, Klebsiella, Enterococci
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History/PE:
– Fever, tachycardia, RUQ tenderness
– Murphy’s sign – low sensitivity
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Labs:
– Elevated WBC with left shift
– LFTs – large elevation  CBD stone
Acute Cholecystitis:
Imaging
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KUB – stones only seen @ 10%
– Air in biliary tree  gangrenous
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Ultrasound – sensitivity 90-95%
– Gallstones (absent in biliary stasis)
– Thickened GB wall
– Pericholecystic fluid
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CT scan – sensitivity 50%
HIDA scan – negative scan rules out dx
– Positive = no visualization of the GB
Acute Cholecystitis
Acute Cholecystits:
Treatment
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Admit
NPO, IVF
Pain control
Anti-emetics
Antibiotics
Surgical consult
Pancreatitis
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Autodigestion of pancreatic tissue
B – Biliary
A – Alcohol
D – Drugs
S – Scorpion bite
H – HyperTG, HyperCa
I – Idiopathic, Infection
T – Trauma
Pancreatitis: History and
Physical
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History:
– Boring pain in LUQ or epigastrium
– Constant
– Radiates to midback
– Nausea, vomiting
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PE:
– Epigastric or LUQ tenderness
– Grey-Turner or Cullen sign
Gray-Turner sign
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Flank ecchymosis
Intraperitoneal bleeding
Hemorrhagic
pancreatitis, ruptured
abdominal aorta, or
ruptured ectopic
pregnancy
Cullen's Sign
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Periumbilical hemorrhage
Pancreatitis: Diagnosis
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Lipase – most specific
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Ranson’s criteria – predicts outcome
– Acutely: >55 yo, glucose > 200, WBC >16k,
SGOT (ALT) > 250, LDH > 350
– 48 hrs: HCT decreases > 10%, BUN rises > 5,
Ca < 8, pO2 < 60, base deficit >4, fluid
sequestration > 6L
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3-4 criteria – 15% mortality
5-6 criteria – 40% mortality
7-8 criteria – 100% mortality
Pancreatitis: Imaging
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Plain films – sentinel loop (local ileus)
Ultrasound – poor (biliary tree)
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*CT scan with contrast*
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Pancreatitis: Treatment
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NPO, IVF, pain control, antiemetics
Antibiotics if gallstones or septic
Surgical consult
– If gallstones, abscess, hemorrhage or
pseudocyst
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ERCP if CBD stone
Gastritis/PUD
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Duodenal 80%; gastric 20%
Etiology: H pylori, NSAIDS, zollingerellison syndrome, smoking, ETOH, FHx,
male, stress
H pylori – 95% duodenal; 85% gastric
History:
– Epigastric constant, gnawing pain
– Food lessens – duodenal
– Food worsens - gastric
PUD: Workup/Treatment
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Workup:
– Hemoglobin
– PT/PTT – if bleeding
– Lipase – rule out pancreatitis
– Hemoccult stool – rule out GI bleed
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Treatment:
– Antacids (GI cocktail), PPI, outpatient
endoscopy and H. pylori testing
Perforated Viscus
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Rare in small bowel and mid-gut
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History: abrupt onset pain
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Diagnosis: upright CXR
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Tx: IVF, IV abx, NGT, OR
Questions on
Upper Abdominal Pain?
Let’s Move On Down
Case: Lower Abdominal
Pain
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History: 35 y/o female c/o 1 day of
periumbilical aching pain. +N,+V, +D, +F,
+C, +anorexia. Today, she has crampy lower
abdominal pain. No urinary sx.
Exam: afebrile, bilateral lower quadrant
tenderness (R > L), no rebound or guarding.
Other questions?
Differential diagnosis? Testing?
Appendicitis
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Incidence – 6%
Mortality – 0.1%
– Perforation 2-6% (9% elderly)
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All ages – peak 10 – 30 yo
Difficult dx: young, old, pregnant
(RUQ), immunocompromised
Appendicitis
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Abdominal pain (98%)
– Periumbilical migrating to RLQ < 48 hrs
– Anorexia 70%
– Nausea, vomiting 67%
– Common misdiagnosis – gastroenteritis,
UTI
Appendicitis
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PE: RLQ tenderness 95%
–Rovsing: RLQ pain palpating
LLQ
–Psoas: R hip elevation,extension
–Obturator: flexion, internal
rotation
Appendicitis: Diagnosis
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Labs:
– WBC > 10k – 75%
– UA – sterile pyuria
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Imaging:
– Ultrasound
– CT scan
Appendicitis: Treatment
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IV fluids, NPO, analgesia
Antibiotics
Surgery consult
Diverticulitis
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Inflammation of a diverticulum (herniation
of mucosa through defects in bowel wall);
sigmoid colon is the most common site
History:
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L>R
3% under 40
LLQ pain with BMs
N/V/constipation
PE: LLQ tenderness
Diagnosis: clinical, CT
Diverticulitis: Treatment
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Admit if fever, abscess
– NPO, IV fluids, IV antibiotics
– Surgical consultation
Case: Generalized Abdomen
Pain
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History: 80 y/o male c/o nausea and
crampy abdominal pain x 1 day. Emesis
which was bilious and is now malodorous
and brown.
PE: Diffusely tender, distended, with
hyperactive bowel sounds.
Differential Diagnosis?
Workup?
SBO
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Etiology
– Adhesions (>50%)
– Incarcerated hernia
– Neoplasms
– Adynamic ileus – non mechanical
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Abd trauma (post op), infection, hypokalemia,
opiates, MI, scleroderma, hypothyroidism
– Rare: intusseception, bezoar, Crohn’s ds,
abscess, radiation enteritis
LBO
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Etiology
– Tumor  left = obstruct; right =
bleeding
– Diverticulitis
– Volvulus
– Fecal impaction
– Foreign body
Bowel Obstruction
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Pathophysiology: 3rd spacing  bowel wall ischemia
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History: crampy, colicky diffuse abd pain,
vomiting (feculent), no flatus or BMs
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PE: abdominal distension, high pitched BS,
diffuse tenderness
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Diagnosis: AAS shows A/F levels with dilated
bowel (SB > 3cm; LB > 10cm)
 perforates, peritonitis  sepsis  shock
SBO: Imaging
SBO: Treatment
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IV fluids!
Correct electrolyte abnormalities
NPO/NGT
Broad spectrum abx if peritonitis
Surgery consult
Sigmoid Volvulus
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History:
– Elderly, bedridden, psychiatric pts
– Crampy lower abd pain, vomiting,
dehydration, obstipation
– Prior h/o constipation
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PE:
– Diffuse abd tenderness
– Distension
Sigmoid Volvulus
Sigmoid Volvulus: Imaging
and Treatment
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AAS: dilated loop of colon on left
Barium enema: “bird’s beak”
WBC > 20k: suggests strangulation
CT scan
Treatment: IVF, surgical consult, abx if
suspect perforation
Cecal volvulus
Most common in 25-35 year olds
 No underlying chronic constipation
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History: Severe, colicky abd pain,
vomiting
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PE: Diffusely tender abdomen,
distension
Cecal Volvulus
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KUB: coffee bean –
large dilated loop colon
in midabdomen, empty
distal bowel
Tx: surgery
– Mortality: 10-15% if
bowel viable; 30-40% if
gangrene
Hernias
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Inguinal (most common) 75%
– Indirect 50% vs direct 25% men > women,
high risk incarceration in kids
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Femoral 5% - women > men
Incisional 10%
Umbilical – newborns, women > men
Incarcerated – unable to reduce
Strangulated – incarcerated with vascular
compromise
Hernias
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Clinical presentation:
– Most are asymptomatic
– Leads to SBO sxs
– Peritonitis and shock – if strangulation
Treatment:
– Reduce if non-tender – trendelenberg,
sedation, warm compresses
– Do not reduce if possible dead bowel
– Admit via OR if strangulation
Mesenteric Ischemia
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Etiology
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50% arterial emboli
20% non-occlusive dz (CHF, sepsis, shock)
15% arterial thrombi
5% venous occlusion
Mortality rates 70-90% - delayed dx
Mesenteric Ischemia
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Pathophysiology: impaired blood supply
from SMA, IMA, celiac trunk  adynamic
ileus  mucosal infarction & 3rd spacing
 bacterial invasion  sepsis  shock
History: Acute, severe, colicky, poorly
localized pain, postprandial pain, N/V/D
Mesenteric Ischemia:
Diagnosis
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Pain out of proportion to exam!
Heme positive stools (>50%) – may
present as LGIB
Peritonitis and shock – late findings
WBC > 15k
Metabolic acidosis (lactic acid) – high
sensitivity, not specific
Mesenteric Ischemia:
Diagnosis and Treatment
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CT scan
– Bowel wall edema/gas, +/- mesenteric
thrombus, normal CT does NOT rule out
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Plain films – late findings
– Portal venous gas or pneumatosis intestinalis
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Treatment: IVF, NGT, IV abx,
surgical and IR consult
GI hemorrhage: UGIB vs.
LGIB
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History:
– Hematemesis seen in 50% UGIB
– Melena seen in 70% UGIB; 30% LGIB
– Hematochezia – LGIB vs rapid UGIB
– Ask about:
NSAID, ASA, ETOH, plavix, coumadin
 Night sweats, wt loss, bowel changes –
malignancy
 Iron, Bismuth – guaic neg, black stools
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GI Hemorrhage
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Consider with CC: weakness, SOB,
dizzy, abdominal pain
PE: orthostatics, abdomen, rectal
– Conjunctival pallor
– Cool, clammy skin
– Spider angiomata, palmer erythema,
jaundice, bruises – liver dz
GIB: Diagnosis
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Hemoccult – iodide, methylene blue,
red meat  false positive
Labs – CBC (Hg < 8), PT, T & S,
increased BUN (blood, hypovolemia)
ECG – rule out silent MI (anemia)
NGT – rule out UGI bleed
UGI Hemorrhage: Etiology
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PUD 60%
Gastritis/esophagitis 15%
Varices – portal HTN, liver disease
Mallory-Weiss
Aortoenteric fistula – H/O AAA repair
Other: Stress ulcers, malignancy, AVM,
ENT bleeds, hemoptysis
LGI Hemorrhage: Etiology
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Hemorrhoids – most common overall
Diverticulosis – most common severe
cause LGIB
Angiodysplasia
Polyps/cancer
Rectal disease
IBD
GIB: Treatment
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Unstable:
– IV x 2, O2, monitor
– Blood products – FFP, pRBCs, platlets
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GI (UGI) and surgery (LGI) consults
Tagged red blood cell study – need
0.1 – 0.2 ml/min of hemorrhage
GIB: Treatment
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Colonscopy – ligate or sclerose
diverticulosis, AVM bleeds
EGD – band ligation or sclerose varices
Octreotide – varices, PUD
Vasopressin – varices
Sengstaken-Blakemore tube – varices
GIB: Surgical Indications
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Hemodynamically unstable
Unresponsive to endoscopy, IV fluids,
and correction of coagulopathy
Transfused > 5 U in 4-6 hrs
Mortality 23% if emergent surgery
GIB: Disposition
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Admit
– Any UGIB
– Any hemodynamic instability
– Significant LGIB
Observation
– LGIB with stable VS and HgB
Discharge home
– Hemorrhoid bleed, rectal neg with nl HgB
Case: Flank pain
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70 y/o male w HTN, DM c/o acute onset
right flank pain. Pain is sharp and
crampy, radiates to the groin. He is
pale, diaphoretic. Abdomen is soft,
diffusely tender, no rebound or
guarding.
What are you thinking and what are
you going to do?
Differential Diagnosis
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AAA
Renal colic
LBP
Mesenteric ischemia
Diverticulitis, cholecystitis, pancreatitis
PUD with perforation
GI bleed (r/o aortoenteric fistula)
AAA
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4 male: 1 female
Peak incidence 70 yo
98% infrarenal (50% involve iliacs)
33% of cases initially misdiagnosed
– Renal colic, low back pain
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Risk factors: HTN*, smoking, COPD,
diabetes, hyperlipidemia, connective
tissue dz (Marfan’s, Ehlers-danlos)
AAA: Pathophysiology
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Atherosclerosis causes loss of elastin
and collagen in aortic wall
Normal aorta diameter = 2 cm
Uncommon to rupture if < 5 cm
(elective repair)
30% of aneurysms >5 cm rupture
within 5 years
AAA: History & Physical
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History:
– Sudden onset severe constant mid-abdomen or
back pain
– Pain may radiate to the thigh or testes
– Back/flank pain – retroperitoneal ureteral
irritation
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PE:
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Pulsatile mass 50-90%
Abdominal distension – due to RP or IP blood
Abdominal bruit 3-8%
Blue toe syndrome – 5% - emboli
AAA: Diagnosis
ECG
 Plain films – r/o free air or SBO
 US – does not delineate rupture or
leak
 CT – evaluates size and leakage
and extent
 Angiography – may miss AAA if
mural thrombus
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AAA: Treatment
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Asymtomatic patient
– Incidental finding
– <4 cm – repeat US q 6 months
– >4 cm – elective repair
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Symptomatic patient
– CT to confirm dx (if stable)
– 2 large bore IVs, T&C x 8uPRBC
– Admit via OR (vascular surgery consult)
AAA: Mortality
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Elective repair – 4%
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Post rupture – 45%
– Normal BP – 20%
– Hypotensive, responds to volume – 40%
– Hypotensive, incomplete response 60%
– Hypotensive, no urinary output – 80%
THE END
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Questions?