Abdominal Pain Flashcards
If patient is actively bleeding (eg, abdominal aortic aneurysm [AAA] rupture or ruptured ectopic pregnancy)
1=> Transfuse packed red blood cells:fresh frozen plasma in a ≤2:1 ratio.
2=> Utilize massive transfusion protocol as needed.
If patient appears septic (based on vital signs or exam)
Consider early=>
Broad-spectrum antibiotics:
For example, piperacillin-tazobactam 4.5 g IV q8h
Consider early consultation if suspecting
AAA -
Vascular/General Surgery
Consider early consultation if suspecting
Ectopic pregnancy -
Obstetrics/Gynecology
Consider early consultation if suspecting
Mesenteric ischemia -
General Surgery
Consider early consultation if suspecting
Perforated viscus -
General Surgery
Consider early consultation if suspecting
Intestinal obstruction -
General Surgery
what is the study of choice for undifferentiated patients.
Computed tomography (CT) abdomen/pelvis with IV contrast
what is indicated in patients with UPPER abdominal pain (especially those without tenderness) to assess for acute coronary syndromes.
ECG
Do not forget to control pain even in unstable patients:
Morphine 0.1 mg/kg IV push
Fentanyl 0.35-0.5 µg/kg IV push
Do not forget to perform a _______in women and a testicular exam in men with lower abdominal pain.
pelvic exam
Do not forget to perform a pelvic exam in women and a _________ in men with lower abdominal pain.
testicular exam
Perform a _________, especially in patients who are homeless, have diabetes, or have other risks of necrotizing skin infections.
skin exam
Table: Top 6 “Can’t Miss” Causes of Abdominal Pain
1=> Ruptured AAA
2=>Mesenteric ischemia
3=> Intestinal obstruction
4=> Perforated viscus
5=> Ectopic pregnancy
6=> Extra-abdominal diseases
Be especially WARY of patients with a complicated surgical history; surgery begets ____. Adhesions cause small bowel obstructions, perforated appendicitis causes abscesses, gastric bypasses cause internal hernias; the list goes on.
surgery
Be especially WARY of patients with a complicated surgical history; surgery begets surgery. Adhesions cause small bowel obstructions, perforated appendicitis causes _______, gastric bypasses cause internal hernias; the list goes on.
abscesses
Be especially WARY of patients with a complicated surgical history; surgery begets surgery. Adhesions cause __________, perforated appendicitis causes abscesses, gastric bypasses cause internal hernias; the list goes on.
small bowel obstructions
Be especially WARY of patients with a complicated surgical history; surgery begets surgery. Adhesions cause small bowel obstructions, perforated appendicitis causes abscesses, gastric bypasses cause _______; the list goes on.
internal hernias
After an appropriate evaluation that does not reveal emergent causes of abdominal pain, a trial of ______, repeat exam, and clear timeline for primary care follow up and appropriate return precautions should be discussed. Some causes of abdominal pathology will only reveal themselves in time, and re-evaluation is critical.
PO
Do not forget to appropriately treat pain. _________does not prevent successful diagnosis or observation of patients with abdominal pain.
Pain control
Differential Diagnosis
Diffuse Pain
1- AAA 2-Bowel obstruction 3-Mesenteric ischemia 4-perforated viscus 5-Appendicitis (early) 6-gastroenteritis 7-metabolic disorder, DKA, porphyria, uremia 8-pancreatitis
Differential Diagnosis
Epigastric pain
1-ACS 2-Thoracic Aortic Dissection 3-gastritis 4-pancreatitis 5-pericarditis 6-peptic ulcer disease
Differential Diagnosis
RUQ
1-cholangitis 2-Retrocecal appendicitis 3-appendicitis in pregnancy 4-biliary colic 5-fitz-Hugh-curtis syndrome 6-CHF (liver engorgement) 7-cholecystitis 8-hepatitis 9-pneumonia
Differential Diagnosis
RLQ
1-Ectopic Pregnancy 2-Ovarian torsion 3-testicular torsion 4-Appendicitis 5-Diverticulitis (cecal) 6-Meckel's diverticulum 7-Inguinal Hernia (strangulation/incarceration) 8-Ovarian cyst rupture 9-PID 10-psoas abscess 11-TOA 12-uretal calculi
Differential Diagnosis
LUQ
1-MI 2-splenic rupture/dissection/infarct 3-Diaphragmatic hernia 4-gastritis/ulcer 5-pancreatis 6-pneumonia 7-splenic abscess
Differential Diagnosis
LLQ
1-ovarian torsion 2-testicular torsion 3-DIverticulitis (sigmoid) 4-inguinal hernia (strangulation/incarceration) 5-ovarian cyst rupture 6-psoas abscess 7-PID 8-TOA 9- Ureteral Calculi
Biliary tract disorders
Risk Factors/ General Info
- Female > Male
* Risk factors: Obesity, multiparity, family history of gallstones, drugs (eg, oral contraceptive pills)
Biliary tract disorders
Presentation
- RUQ/epigastric pain, may radiate to the right shoulder/back
- Nausea/ vomiting, anorexia
- Consider cholecystitis if associated with fever or constant pain
RUQ/epigastric pain, may radiate to the right shoulder/back
Biliary tract disorders
- RUQ tenderness to palpation
- Rebound/ guarding in cholecystitis
- Febrile in cholecystitis
- Murphy’s sign
Biliary tract disorders
Biliary tract disorders
Work-up
WBC elevation (cholecystitis/cholangitis)
Ultrasound of the abdomenDiverticulitis
Risk Factors/ General Info
- Male > Female
- Age: Older population
- Risk factors: Diverticulosis, low-fiber diet, obesity, smoking
- *FEVER**
- LLQ pain (usually for days prior to presentation)
- Nausea/ vomiting
- Change in stool characteristics
Diverticulitis
Febrile
LLQ tenderness +/-
Guaiac-positive stool
Diverticulitis
Diverticulitis
DX
WBC elevation
CT scan
Ovarian Torsion
Risk Factors/ General Info
- Females 20-39 y old (70%)
* Risk factors: Tubal ligation, polycystic ovary syndrome, fertility treatment, enlarged ovary >5 cm
Sudden onset, sharp, unilateral lower abdominal pain
Nausea/ vomiting (70%)
Ovarian Torsion
Unilateral lower abdominal tenderness
Palpable adnexal mass (25%)
Ovarian Torsion
Ovarian Torsion
DX
Leukocytosis is not reliable
Pelvic ultrasound
Pancreatitis
Risk Factors/ General Info
- Female > Male
- Age: 40s
- Risk factors: Alcohol use, biliary disease, hypertriglyceridemia, drugs (NSAIDs, thiazides, furosemide), hypercalcemia
- Children: Trauma, infection, or drugs
Severe, constant, progressive epigastric pain radiating to the back
Nausea/ vomiting
Pancreatitis
Low-grade fever, possible hypotension, tachypnea
Epigastric pain, possible peritonitis
Pancreatitis
Pancreatitis
DX
- Lipase is the test of choice
- Ultrasound to assess for biliary etiology
- CT of the abdomen/pelvis to rule-out complications (abscess, cyst, hemorrhage)
Testicular Torsion
Risk Factors/ General Info
- 12-18 y old, neonatal
* Risk factors: Cryptorchism, family history of testicular torsion, recent trauma
- Sudden onset, severe scrotal pain (can be after vigorous activity)
- Swollen testicle
- Nausea/vomiting (90%)
- Chief complaint can be abdominal pain
- Can be intermittent
Testicular Torsion
- High-riding, transverse lie of the testicle
* Loss of cremasteric testicle
Testicular Torsion
Testicular Torsion
DX
- Scrotum ultrasound (sensitivity 85%-95%)
* MRI is less used; consider if ultrasound is indeterminate
Ureteral Colic
Risk Factors/ General Info
- Male > Female
- Age: 20-50 y old (70%)
- Risk factors: Family history of kidney stones, obesity, UTI
- Sudden onset, severe pain that can radiate to the flank/groin
- Nausea/vomiting
- Gross hematuria (33%)
- “Can’t get comfortable”
Ureteral Colic
- Abdomen generally not tender
* CVA tenderness
Ureteral Colic
Ureteral Colic
DX
- BUN/Creatinine
- UA: Hematuria (80%)
- Renal ultrasound: Can see hydronephrosis (sensitivity 85%-95%, specificity 100%)
- CT of the abdomen: Sensitivity 98%, specificity 100%)
Be sure to ask female patients about pregnancy and vaginal bleeding or discharge.
If a patient is pregnant, add _______, _______, and ________ to the differential.
ectopic pregnancy
preeclampsia
placental abruption
_________does not decrease until 30%-40% blood loss has occurred.※
Systolic blood pressure
_______ may develop late in the disease course.
Tachycardia
________: Be aware of patient populations that may not mount a fever (elderly, immunocompromised). Older patients are more likely to present with hypothermia.※ When in doubt, check a rectal temperature.
Temperature
A good abdominal exam can help to decipher the cause of a patient’s abdominal pain. This consists of:
Inspection _________
Auscultation (Decreased bowel sounds?)
Palpation (Guarding? Rigidity? Rebound? Palpate the aorta)
(Any distention? Skin lesions? Ecchymoses?)
A good abdominal exam can help to decipher the cause of a patient’s abdominal pain. This consists of:
Inspection (Any distention? Skin lesions? Ecchymoses?)
Auscultation___________
Palpation (Guarding? Rigidity? Rebound? Palpate the aorta)
(Decreased bowel sounds?)
A good abdominal exam can help to decipher the cause of a patient’s abdominal pain. This consists of:
Inspection (Any distention? Skin lesions? Ecchymoses?)
Auscultation (Decreased bowel sounds?)
Palpation (____________
Guarding? Rigidity? Rebound? Palpate the aorta)
abdominal/flank pain
hypotension
pulsatile abdominal mass.
AAA
in AAA Pain may be present in the _____, abdomen, or even the flank or groin.
back
In one study, the accuracy of _________ for detecting AAA was found to be 68% sensitive and 75% specific (in patients with known AAA on ultrasound vs. cross-matched controls). The sensitivity increased to 82% for AAAs ≥5.0 cm, and reached 100% for AAAs ≥5.0 cm with an abdominal girth <100 cm.
abdominal palpation
In other words, a large aneurysm should be felt in a skinny patient, and sensitivity predictably decreases with larger patients and smaller aneurysms. If an _________ is felt, it is likely a large one, but do not rely solely on the exam
aneurysm
A large meta-analysis showed that a description of pain “migration to the RLQ” had a positive likelihood ratio of 1.75
Acute appendicitis
In acute appendicitis _________, or pain in the RLQ upon palpation of the LLQ, had a positive likelihood ratio for acute appendicitis of 3.52. RLQ pain also had a positive likelihood ratio.※
Rovsing’s sign
_________, classically defined as halted inspiration due to pain upon palpation of the right upper quadrant (RUQ), had moderate test characteristics for acute cholecystitis, with 62% sensitivity and 96% specificity
Murphy’s sign
One study found that the clinical diagnosis of acute diverticulitis was relatively accurate, especially in patients <65 y old with acute pain in the ______, as well as those with an elevated C-reactive protein
LLQ
Beware of diagnosing diverticulitis without the use of imaging in patients >____65 y old.※
65 y old.※
16% of patients with ________ and abdominal pain who come to the ED will have an ectopic pregnancy.
first-trimester bleeding
Intestinal obstruction
Key historical elements include previous _______ and_______
abdominal surgery and constipation.
Physical exam findings that predict small bowel obstruction are _________ (most specific), abdominal pain, and abnormal bowel sounds
abdominal distention
This is a difficult disease to clinically diagnose.
Increase suspicion based on the following risk factors: Atrial fibrillation, coronary artery disease, heart failure, and hypercoagulable state.
High-risk characteristics include acute onset of abdominal pain, nausea and vomiting, and pain out of proportion to physical exam findings.
Physical exam may show diffuse tenderness or peritoneal signs later in the course.※
Mesenteric ischemia
The majority of patients have acute onset, severe epigastric pain or RUQ abdominal pain.
Pancreatitis
In the United States, the major causes of _______ are gallstones or alcohol consumption.
pancreatitis
3% of patients may present with Grey Turner’s sign (ecchymosis over the flank) or Cullen’s sign (ecchymosis in the periumbilical region).
pancreatitis
________ is one of the first tests in patients who are critically ill or with known diabetes.
DKA can present as abdominal pain.
Fingerstick glucose
_______ can alert to sepsis, chronic alcohol use, or platelet disorders.
Thrombocytopenia
_________is often normal but can alert to electrolyte abnormalities in patients with vomiting/diarrhea, endocrine/metabolic disorders, and DKA.
Basic metabolic panel
______should be obtained in patients with abdominal pain at or above the umbilicus.
LFTs
Most often, there is no elevation in alkaline phosphatase or total bilirubin in uncomplicated cholelithiasis, but these findings can be very specific for acute _______
cholecystitis.
_______: Order coagulation studies in patients with end-stage liver disease, a history of coagulopathy, or those with a suspected GI bleed.
Coagulation studies
Lipase can be elevated in a number of diseases. It is more sensitive and specific than amylase.
In________, lipase should be elevated to at least twice the normal value.
pancreatitis
Venous blood gas/Lactate: Lactate can be very helpful in determining whether there is ________. It is often elevated in sepsis and bowel ischemia/mesenteric ischemia.
adequate tissue perfusion
Venous blood gas/Lactate: Lactate can be very helpful in determining whether there is adequate tissue perfusion. It is often elevated in ______ and ______
sepsis and bowel ischemia/mesenteric ischemia.
25% of mesenteric ischemia patients can have a normal ________on initial presentation.
lactate
_______can help to detect an extra-abdominal cause of abdominal pain. An ECG should also be performed if there is concern for myocardial ischemia.
Troponin
_______ should be obtained if there is concern for sepsis.
Blood cultures
______ is often associated with nephrolithiasis but can be seen in cystitis, renal vein occlusion, and AAA.
Hematuria
87% of patients with AAA have ______, leading to a potential misdiagnosis of kidney stones.※
hematuria
____________: Free air can be seen in 33%-66% of cases, depending on the location of the perforation. An upright CXR can detect as little as 1-2 mL air (the patient must have been sitting upright for 5-10 min), whereas an abdominal X-ray can only detect ≥5 mL
Bowel perforation on upright CXR
______can diagnose AAA, appendicitis, diverticular disease, obstructions, colitis, ischemia, and traumatic injuries (although blunt abdominal injuries may not be initially apparent).
CT
CT of the abdomen/pelvis for ________ is becoming more accepted as a method to rule out ovarian torsion if performed before a Doppler pelvic ultrasound.
ovarian torsion
IV contrast is generally contraindicated (except for patients in extremis) in patients with creatinine >_____or glomerular filtration rate
creatinine >1.5
glomerular filtration rate <60.
CTA in patients with___________is a good alternative to angiography (and is more realistically obtained in the ED). CTA allows visualization of the mesenteric vasculature and has the ability to check for bowel infarction.
mesenteric ischemia
______ provides excellent images with less ionizing radiation.
MRI
In pregnant patients, _______ may be the diagnostic modality of choice to diagnose appendicitis, given its superior sensitivity to ultrasound.
MRI
_______ is generally first-line, followed by metoclopramide, promethazine, and prochlorperazine.
Ondansetron
Ondansetron 4 mg IV causes a reliable increase in ______of ~20 ms, which has a questionable clinical impact, especially in an otherwise healthy patient.※
QTc
_________ should be dosed at 10 mg IV, which can be repeated after 4-6 h as needed.
Consider administering with diphenhydramine 25-50 mg IV to prevent extrapyramidal side effects. Avoid metoclopramide if obstruction is a consideration.
Metoclopramide
Metoclopramide should be dosed at 10 mg IV, which can be repeated after 4-6 h as needed.
Consider administering with \_\_\_\_\_\_\_\_\_25-50 mg IV to prevent extrapyramidal side effects. Avoid metoclopramide if obstruction is a consideration.
diphenhydramine
Metoclopramide should be dosed at 10 mg IV, which can be repeated after 4-6 h as needed.
Consider administering with diphenhydramine 25-50 mg IV to prevent extrapyramidal side effects. Avoid metoclopramide if \_\_\_\_\_\_\_\_ is a consideration.
obstruction
Morphine is dosed at 0.1 mg/kg IV
Morphine is often given as an initial dose of \_\_\_\_\_\_, especially in cases of uncertain opioid tolerance or exposure. Be sure to reassess frequently and consider writing for as needed dosing. Side effects include nausea (can worsen pain or nausea) and itching (consider co-administration or as needed diphenhydramine).
4 mg
_______ is dosed in increments of 0.5-1 mg IV and is approximately 8 times more potent than morphine. The onset of action is around 5 min, with a duration of 2-3 h.
Hydromorphone
________is dosed 0.35-0.5 µg/kg IV; usually, 25-50 µg is given, which can be given every 5 min until the pain is controlled.
It has near-immediate onset but must be redosed every 30-60 min.
Analgesic effects precede respiratory depression. Consider co-administration with an antiemetic, because nausea is common.
Fentanyl
Adult dose is 10-30 mg intramuscular (IM)/IV. A high-quality trial showed that ketorolac, at the analgesic ceiling of 10 mg, was equally effective in treating severe pain as 15 mg or 30 mg.※
In patients >65 y or <50 kg, dose at no more than _______mg IM/IV.
15
______ is not recommended as a general therapy for undifferentiated abdominal pain, because it is contraindicated in patients who may undergo surgery or have GI bleeding.
Ketorolac
GI “cocktail”
Maalox or Mylanta
viscous lidocaine,
and (historically) Donnatal® containing hyoscamine, atropine, scopolamine, phenobarbital,
GI cocktail
However, the_______ by itself is likely as effective as any of the above combinations, with fewer concerning side effects for the patient, such as numbness and possible blunting of protective airway reflexes (as from lidocaine).※
liquid antacid
Antibiotics should be given when an intra-abdominal infection is suspected. If the patient is toxic or ill-appearing, consider broad-spectrum antibiotics. Given that intra-abdominal infections are polymicrobial, coverage for enteric gram-negative, gram-positive, and anaerobic bacteria is needed.
Single agent
Piperacillin-tazobactam:
Piperacillin-tazobactam: 4.5 g IV q8h or
Has been associated with acute kidney injury
Antibiotics should be given when an intra-abdominal infection is suspected. If the patient is toxic or ill-appearing, consider broad-spectrum antibiotics. Given that intra-abdominal infections are polymicrobial, coverage for enteric gram-negative, gram-positive, and anaerobic bacteria is needed.
Single agent
Ampicillin-sulbactam
Ampicillin-sulbactam 3 g IV q6h
Antibiotics should be given when an intra-abdominal infection is suspected. If the patient is toxic or ill-appearing, consider broad-spectrum antibiotics. Given that intra-abdominal infections are polymicrobial, coverage for enteric gram-negative, gram-positive, and anaerobic bacteria is needed.
Single agent
Meropenem 1 g IV q8h
Meropenem 1 g IV q8h
Antibiotics should be given when an intra-abdominal infection is suspected. If the patient is toxic or ill-appearing, consider broad-spectrum antibiotics. Given that intra-abdominal infections are polymicrobial, coverage for enteric gram-negative, gram-positive, and anaerobic bacteria is needed.
Single agent
Imipenem-cilastatin: 500 mg IV q6h
Imipenem-cilastatin: 500 mg IV q6h
Preferable in patients who have recently received other antibiotics.
Antibiotics should be given when an intra-abdominal infection is suspected. If the patient is toxic or ill-appearing, consider broad-spectrum antibiotics. Given that intra-abdominal infections are polymicrobial, coverage for enteric gram-negative, gram-positive, and anaerobic bacteria is needed.
Combination regimen
Cefepime 2 g IV q8h and metronidazole 500 mg IV q8h
Consider IV/IM ___________for gastroparesis-induced nausea, vomiting, and abdominal pain. Haloperidol 5 mg IM has been shown to reduce morphine equivalent requirements and admissions to the hospital. It did not decrease ED or hospital length of stay, but there were no significant complications noted
haloperidol
