Approach to Abdominal Pain in the Emergency Department

Approach to Abdominal Pain in the Emergency Department Sezgin Sarıkaya, Assoc. Prof. MD, MBA Department of Emergency Medicine Yeditepe University

Introduction n At the end of this lecture you should: Understand the generation and presentation of types of abdominal pain l Develop critical elements of the history and physical for AP l Apply knowledge of utility of testing to diagnostic approach l Apply management principles to patient care in the ED l

The Epidemiology of Acute Abdominal Pain n n 5 -10% of all ED visits. Among them, 14 -40% patients need surgical intervention. n Most common diagnosis is NONSPECIFIC (ie, “I dunno”) n Challenge for emergency physician (EP): l l About 1/3 have an atypical presentation. If misdiagnosis, mortality rate 2. 5 times higher than correct diagnosis in the elderly.

Three Subgroups of Patients with Abdominal Pain Who deserve Particular Focus Elderly/ nursing home patients n Immunocompromised (e. g. HIV) n n Women of childbearing age. Post operative patients n Infants n

The Most Important Concept for EP in Approaching Abdominal Pain n To Differentiate l Who is the patient of acute abdomen? l What are the probable diagnoses you have in mind? l Why do you consider such diagnosis? l How do you prove it? l When will you consult surgeon for operation?

Causes of Acute Abdominal Pain in the ED Cause Percentage of Cases Nonspecific abdominal pain 41 -46 Appendicitis 4 -24 Cholecystitis 2. 5 -9 Gastroenteritis 7 Salpingitis 2 -7 UTI 3 -5 Small-bowel obstruction 2. 5 -4 Renal colic 1. 5 -4 Constipation 2 Pancreatitis 1 -2 Diverticulitis 1 -2 Abdominal aneurysm, ectopic pregnancy (Brewer et al. , 1979; Scand J Gastroenterol) <1

Abdominal Pain Across the Ages n n Ages 0 -2 l Colic, GE, viral illness, constipation Ages 2 -12 l Functional, appendicitis, GE, toxins Teens to adults l Addition of genitourinary problems Elderly l Beware of what seems like everything!

Important Extra-abdominal Causes of Abdominal Pain n Systemic l DKA l Alcoholic ketoacidosis l Uremia l Sickle cell disease l Porphyria l SLE l Vasculitis l Glaucoma l Hyperthyroidism Toxic l Methanol poisoning l Heavy metal toxicity l Scorpion bite l Black widow spider bite Thoracic l Myocardial infarction/ Unstable angina

Important Extra-abdominal Causes of Abdominal Pain l l l n Genitourinary l l n Testicular torsion Renal colic Infectious l l l n Pneumonia Pulmonary embolism Herniated thoracic disc (neuralgia) Strep pharyngitis (more often in children) Rocky Mountain Spotted Fever Mononucleosis Abdominal wall l Muscle spasm Muscle hematoma Herpes zoster Emerg Med Clin North Am 1989; 7: 21 -740

Abdominal Pain in the Elderly n n n Diminished sensation of pain in the elderly Comorbid diseases Polypharmacy Combinations of above result in many more vague, nonspecific presentations Twice as likely to require surgery with presentation over age 65

What’s the Problem Imprecise pain generation and transmission to the central nervous system n Comorbid diseases n Developmental stage n Medications n Social factors n

Understanding the Types of Abdominal Pain n Visceral l n Somatic l n Stretch fibers in capsules or walls of hollow viscus that enter both sides of spinal cord Fibers dermatomally distributed and enter unilaterally in the spinal cord Referred l Overlap of fibers from other locations

Understanding the Types of Abdominal Pain n Visceral Crampy, achy, diffuse, l Poorly localized l n Somatic Sharp, lancinating l Well localized l n Referred Distant from site of generation l Symptoms, but no signs l

Understanding the Types of Abdominal Pain n n Location, location Organs and their corresponding fiber entry to the spinal cord l C 3 -5 – liver, spleen, diaphragm l T 5 -9 – gallbladder, stomach, pancreas, small intestine l T 10 -11– colon, appendix, pelvic viscerat 11 -l 1 – sigmoid, renal capsules, ureters, gonads l S 2 -4 - bladder

Visceral

Somatic

History Taking in Abdominal Pain Presentations n “OLD CARS” l l l l O- onset L- location D- duration C- character A-alleviating/aggravating factors associated symptoms R- radiation S- severity

History Taking for Abdominal Pain Presentations n n n PMH l Similar episodes in past l Other medical problems that increase disease likelihood of problems (ex: DM and gastroparesis) PSH l Adhesions, hernias, tumors MEDS l Abx, NSAIDS, acid blockers, etc GYN/URO l LMP, bleeding, discharge Social l Tob/Eto. H/drugs/home situation/agenda

n

n

Physical Exam in Abdominal Pain Presentations n n n Inspection l Distention, scars, bruises Auscultation l Present, hyper, or absent l Actually not that helpful! Palpation l Often the most helpful part of exam l Tenderness versus pain l Start away from painful area first l Guarding, rebound, masses

Physical Exam in Abdominal Pain Presentations n n n Signs l Mc burney l Murphy’s Extra-abdominal exam l Pelvic or scrotal exams l Lungs, heart l Remember it’s a patient, not a part Rectal l Adds very little (despite the angst) beyond gross blood or melena

Laboratory Testing n Everybody likes a CBC, but… Lacks sensitivity, no specificity l Little to no change in diagnostic probabilities l Should not dramatically alter approach (tender is still tender) l

Laboratory Testing Directed approach to lab studies n There are no “standard belly labs” n Pregnancy test in women of child bearing age n Urine dipsticks n

Imaging n n n Plain films l Free air, obstruction, air-fluid, FBs Ultrasound l Rapid “yes or no” ED evaluations l Formal studies l May add doppler Computed Tomography l Revolutionized acute care l Often better than we are!

Common Diagnoses by Quadrant n RUQ l l l l l Cholecystitis Biliary colic Hepatitis Pancreatitis Renal stones PUD Pneumonia PE MI n LUQ l l l l l Gastritis Gastric ulcer Pancreatitis Splenomegaly Splenic rupture Renal stone Pneumonia PE MI

Common Diagnoses by Quadrants n RLQ l l l l l Appendicitis Renal stone Ovarian cyst Torsion Epididymitis Ectopic IBD AAA UTI n LLQ l l l l l Diverticulitis Renal stone Ovarian cyst Torsion Epididymitis Ectopic IBD AAA UTI

Dangerous Mimics True Diagnosis Appendicitis Ruptured abdominal aortic aneurysm Ectopic pregnancy Diverticulitis Perforated viscus Bowel obstruction Mesenteric ischemia Incarcerated or strangulated hernia Shock or sepsis from perforation, bleed, abdominal infection Initial Misdiagnosis Gastroenteritis, PID, UTI Renal colic, diverticulitis, lumbar strain PID, UTI, corpus luteum cyst Constipation, GE , pyelonephritis PUD, pancreatitis, nsp abdominal pain Constipation, gastroenteritis, nonspecific abdominal pain GE, constipation, ileus small bowel obstruction Ileus or small bowel obstruction Urosepsis or pneumonia (in elderly)

Five Major Categories of Acute Abdomen (BIOPI) n Bleeding or rupture of vessels or tumor n Ischemia or Infarction n Obstruction n Perforation n Inflammation

Common Pitfalls in Acute Appendicitis n n n Abdominal pain and tenderness are present in nearly 100% of patients with appendicitis; other clinical features are less reliable. Fever occurs in only 16% of patients with acute appendicitis; its presence is more suggestive of appendiceal perforation. Murphy sequence appears in only 22% elderly. l Perforation rate about 60% (age > 60 Y/O)

Management of Abdominal Pain n n n n Always right to start with ABC’s IV access Fluid administration Antiemetics Analgesics Directed testing and imaging Re-evaluations Antibiotics Consultants l Surgeons, OB/GYN, urologists, cardiologists, etc

Disposition of Abdominal Pain Patients Operating Room n Hospital bed/observation n Serial labs l Serial exams l n Home with abdominal warnings The art of emergency medicine l 3 components of discharge plan l Document, document l

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