Abdominal pain Flashcards
Three types of abdominal pain
1) Visceral
2) Somatoparietal or peritoneal
3) Referred
Visceral
- Poorly localized but site roughly corresponds to dermatome that innervates the affected organ
- Characteristics may vary (dull, cramping, burning)
- Frequently accompanied by secondary autonomic effects (nausea, vomiting, pallow, diaphoresis, restlessness)
- Patient moves around in an attempt to alleviate discomfort
Somatoparietal or peritoneal pain
- More localized and more intense than visceral pain
- Arises from peritoneal irritation
- Aggravated by movement (patient attempts to lie still)
Referred pain
- Usually well localized but felt in areas remote to affected organ
- May be felt in skin or in deeper tissues
- Results from convergence of visceral afferent neurons with somatic neurons from different anatomic regions
Important history items in abdominal pain
- Associated symptoms (constitutional, GI, cardiac, pulmonary, renal, pelvic)
- History of similar symptoms
- Hx of gallstones, renal stones, atherosclerotic vascular disease
- Previous abdominal or pelvic surgeries
- Chronic medical conditions
- Sexual activity
- Medications, alcohol and drug use
- Family history
- Domestic violence
Physical exam of abdomen in abdominal pain
- Inspection for scars, distension, asymmetry, cutaneous abnormalities (dilated veins, ecchymoses)
- Auscultation for abnormal BS and bruits
- Percussion for detection of hepatomegaly, splenomegaly, abdominal masses, or ascites
- Palpation for tenderness, signs of peritoneal inflammation (guarding, rebound), murphy sign, psoas and obturator signs, hepatomegaly, splenomegaly, abnormal masses, pulsations, or hernias
- CVA palpation
- Rectal/pelvic exam
Possible DDx in abdominal pain
- Appendicitis
- Cholecystitis (biliary colic)
- Pancreatitis
- Diverticulitis
- PUD including perforation
- Gastroenteritis
- Hepatitis
- IBS
- SBO
- Acute mesenteric ischemia
- IBD
- Ruptured AAA
- Ureteral stones
- PID
- Ruptured ectopic
- Abdominal wall pain
- Referred pain
Labs to consider in abdominal pain
- CBC with diff
- UA
- Pregnancy test
- Stool for occult blood
- Hepatic function panel
- Amylase and lipase
- Abdominal obstructive series
- Abdominal US
- Abdominal CT
- Paracentesis fluid studies
- Upper GI endoscopy
- Sigmiodoscopy/colonoscopy
- Barium contrast studies
- HIDA radionucleotide scan of hepatobiliary system
45 M with sudden onset colicky R-side flank pain that radiates to testes, associated N/V, hematuria, and CVA tenderness
DDx:
- Nephrolithiasis
- RCC
- Pyleonephritis
- GI eti (e.g., appendicitis)
Workup
- Rectal
- UA
- UCx and sensitivity
- BUN/Cr
- CT-abdomen
- US-renal
- IVP
60 M with dull epigastric pain that radiates to back, associated weight loss, dark urine, clay-colored stool. He is heavy drinker and smoker
DDx:
- Pancreatic CA
- Acute viral hepatitis
- Chronic pancreatitis
- Cholecystitis/choledocholithiasis
- Abdominal aortic aneurysm
- PUD
Workup
- Rectal exam
- CBC/electrolytes
- Amylase and lipase
- AST/ALT/bili/Alkaline phosphatase
- US-abdomen
- CT-abdomen
56 M with severe midepigastric abdominal pain that radiates to back and improves when leans forward. Also anorexia, n/v. He is alcoholic and spent last 3 days binge drinking
DDx
- Acute pancreatitis
- PUD
- Cholecystitis/choledocholithiasis
- Gastritis
- AAA
- Mesenteric ischemia
- Alcoholic hepatitis
- Mallory-Weiss tear
Workup
- Rectal
- CBC, electrolytes, BUN/Cr, amylase, lipase, AST/ALT/bili/alk phos
- US-abdomen
- CT-abdomen
- Upper endoscopy
- ECG
41 F obese, RUQ pain that radiates to R scapula, associated n/v, fever 101.5, pain started after fatty food, has had similar but less intense episodes that lasted a few hours, exam reveals positive Murphy sign
DDx
- Acute cholecystitis
- Hepatitis
- Choledocholithiasis
- Ascending cholangitis
- PUD
- Fitz-Hugh-Curtis syndrome
Workup
- Rectal
- CBC
- LFTs
- US-abdomen
- CT-abdomen
- HIDA
43 F, obese, RUQ pain, fever, jaundice. Diagnosed with asymptomatic gallstones 1 yr ago.
DDx
- Ascending cholangitis
- Acute cholecystitis
- Hepatitis
- Choledocholithiasis
- Sclerosing cholangitis
- Fitz-Hugh-Curtis syndrome
Workup
- Rectal
- CBC
- LFTs
- Viral hepatitis serologies
- US abdomen
- MRCP
- ERCP
25 M, RUQ pain, fever, anorexia, n/v, dark urine, clay-colored stool
DDx
- Acute hepatitis
- Acute cholecystitis
- Ascending cholangitis
- Choledocholithiasis
- Pancreatitis
- Acute glomerulonephritis
Workup
- Rectal
- CBC, amylase, lipase, LFTs
- UA
- Viral hepatitis serologies
- US-abdomen
35 M burning epigastric pain starts 2-3 hrs after meals, relieved by food and antacids
DDx
- PUD
- Gastritis
- GERD
- Cholecystitis
- Chronic pancreatitis
- Mesenteric ischemia
Workup
- Rectal
- Amylase, lipase, lactate, LFTs
- Endoscopy (including H. pylori testing)
- Upper GI series
37 M severe epigastric pain, n/v, mild fever, appears toxic, Hx of intermittent epigastric pain relieved by food and antacids, smokes heavily and takes aspirin on regular basis
DDx
- Perforated peptic ulcer
- Acute pancreatitis
- Hepatitis
- Cholecystitis
- Choledocholithiasis
- Mesenteric ischemia
Workup
- Rectal
- CBC, electrolytes, amylase, lipase, lactate, LFTs
- KUB
- CT-abdomen
- Upright CXR
- Endoscopy (including H. pylori testing)
18 M boxer, severe LUQ pain radiates to L scapula, had mono 3 wks ago
DDx
- Splenic rupture
- Kidney stone
- Rib fracture
- Pneumonia
- Perforated peptic ulcer
- Splenic infarct
Workup
- Rectal
- CBC, electrolytes
- CXR
- CT-abdomen
- US-abdomen
40 M crampy abdominal pain, v, abdominal distention, inability to pass flatus/stool, Hx of multiple abdominal surgeries
DDx
- SBO
- Small bowel or colon CA
- Volvulus
- Gastroenteritis
- Food poisoning
- Ileus
- Hernia
Workup
- Rectal
- CBC, electrolytes
- AXR
- CT-abd/pelvis
- CXR
70 F acute onset severe crampy abd pain, recently vomited and had massive dark bowel movement, Hx CHF and A-Fib, on digitalis, pain is out of proportion to exam
DDx
- Mesenteric ischemia/infarction
- Diverticulitis
- PUD
- Gastroenteritis
- Acute pancreatitis
- Cholecystitis/choledocholithiasis
- MI
Workup
- Rectal
- CBC, amylase, lipase, lactate
- ECG, CPK-MB, troponin
- AXR
- CT-abdomen
- Mesenteric angiography
- Barium enema
21 F, acute onset severe RLQ pain, n/v; no fever, urinary symptoms, or vaginal bleeding and never taken OCPs; LMP was regular and no Hx of STIs
DDx
- Ovarian torsion
- Appendicitis
- Nephrolithiasis
- Ectopic pregnancy
- Ruptured ovarian cyst
- PID
- Bowel infarction or perforation
Workup
- Pelvic exam
- Rectal
- Urine hCG
- UA
- CBC
- Doppler US pelvis
- CT abdomen
- Laparoscopy
68 M LLQ abd pain, f/c for 3 days, alternating diarrhea/constipation, consumes low-fiber, high-fat diet
DDx
- Diverticulitis
- Crohn disease
- Ulcerative colitis
- Gastroenteritis
- Abscess
Workup
- Rectal
- CBC, electrolytes
- CXR
- AXR
- CT-abd
20 M RLQ pain, n/v, started yesterday with vague periumbilical, became worse, sharp and migrated to RLQ, McBurney and psoas signs positive
DDx
- Acute appendicitis
- Gastroenteritis
- Diverticulitis
- Crohn disease
- Nephrolithiasis
- Volvulus or other intestinal obstruction/perforation
Workup
- Rectal
- CBC, electrolytes
- AXR
- CT-abdomen
- US-abdomen
30 F with periumbilical pain for 6 months, never awakens her from sleep, relieved by defecation and worsens when she is upset, alternating constipation and diarrhea, but no n/v, weight loss, or anorexia
DDx
- IBS
- Crohn’s
- Celiac
- Chronic pancreatitis
- GI parasitic infection (amebiasis, giardiasis)
- Endometriosis
Workup
- Rectal, stool for blood
- Pelvic
- Urine hCG
- CBC/electrolytes
- Colonoscopy
- CT-abd/pelvis
- Stool for ova, parasites, entamoeba histolytica antigen
24 F bilateral lower abdomnial pain started first day of menstrual period, associated with fever and thick, green-yellow vaginal discharge, has unprotected sex with multiple sexual partners
DDX
- PID
- Endometriosis
- Dysmenorrhea
- Vaginitis
- Cystitis
- Spontaneous abortion
- Pyelonephritis
Workup
- Pelvic
- Rectal
- Urine hCG
- Cervical Cx
- CBC/ESR
- UA, UCx
- US pelvis
