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Abdominal Pain in the ER Flashcards

1
Q

What does visceral abdominal pain feel like?

A

Poorly localized

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2
Q

What causes visceral abdominal pain?

A

Stretching of the unmyelinated fibers of the walls/capsules of organs

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3
Q

What does parietal abdominal pain feel like?

A
  • Localized pain
  • Progresses from tenderness and guarding to rigidity and rebound tenderness
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4
Q

What causes parietal pain?

A

Irritation of the myelinated fibers of the parietal pleura

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5
Q

What is referred pain?

A
  • Pain at location distant from cause
  • Often percieved on ipsilateral side due to anatomically contiguous segmental innervations
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6
Q

What are intra-abdominal causes of abdominal pain?

A
  • Organ infection/inflammation
  • Peritonitis
  • Bowel obstruction
  • Vascular disorders
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7
Q

MC extra-abdominal causes of abdominal pain?

A
  • DKA
  • Alcoholic ketoacidosis
  • Pneumonia
  • PE
  • Herpes zoster
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8
Q

What should be considered with older patients who have abdominal pain?

A
  • Often less severe or atypical
  • 6-8 fold increase in mortality compared to younger patients
  • Consider ischemic heart disease, vasculopathies, coagulopathies
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9
Q

What do you need to consider regarding female patients with abdominal pain?

A
  • Pregnancy status
  • Etiologies related to respective sex organs
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10
Q

What are the 2 biggest historical factors to consider regarding abdominal pain?

A
  • Location
  • Onset
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11
Q

A patient has abdominal pain that is maximal intensity at onset. What is this a red flag for?

A
  • Ischemia
  • Dissection
  • Perforation
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12
Q

A patient has abdominal pain with a gradual onset. What etiologies should you consider?

A
  • Inflammatory
  • Infectious
  • Obstructive
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13
Q

If abdominal pain is constant or worsening over 6 hours, what sort of etiology is more likely?

A

Surgical etiology

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14
Q

If a patient has pain that improves after meals, what condition do you consider?

A
  • PUD
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15
Q

If a patient has pain that is worse after meals, what condition should be considered?

A

Biliary colic

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16
Q

If a patient has pain that improves when upright and is worse when supine, what condition should be considered?

A

Pancreatitis

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17
Q

If a patient has abdominal pain that is worse with sudden movements and improves with stillness, what should be considered?

A

Peritonitis

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18
Q

If vomiting occurs after the onset of abdominal pain, what is the abdominal pain more likely to be?

A

Surgical etiology

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19
Q

If a patient has bilious vomiting, what does that mean?

A

Obstruction distal to pylorus

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20
Q

If a patient has coffee-ground or hematemesis, what condition should be considered?

A
  • PUD
  • Varices
  • Aortoenteric fistula
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21
Q

If a patient has loose/watery diarrhea, what etiologies are considered?

A
  • Infectious
  • Diverticulitis
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22
Q

If a patient has mucoid diarrhea, what conditions are considered?

A
  • Infectious
  • Inflammatory
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23
Q

If a patient has bloody diarrhea, what conditions are considered?

A
  • Mesenteric ischemia
  • Infectious
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24
Q

If a patient has small scant amounts of diarrhea, what etiology should be considered?

A

Bowel obstruction

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25
If a patient has associated cardiorespiratory symptoms with abdominal pain such as cough, dyspnea, or chest pain, what differentials should be considered?
* Pneumonia * PE * MI
26
A patient has dysuria or hematuria. What conditions should be considered?
* UTI * Pyelonephritis * Nephrolithiasis
27
A patient has vaginal bleeding or discharge, recent changes in menstruation, or dyspareunia, which conditions should be considered?
* Vaginitis * PID * Tubo-ovarian abscess * Fitz-Hugh Curtis syndrome
28
If a male patient has penile discharge, scrotal pain/swelling, or recent trauma what conditions should be considered?
* Urethritis * Testicular torsion * Inguinal hernia
29
If a patient has CV/PAD disease, a.fib, or heart failure and abdominal pain, what conditions should be considered?
* AAA * Mesenteric ischemia * Atypical MI
30
If a patient is immunocompromised, what abdominal etiology should be considered?
Infection
31
If a patient has previous abdominal surgery, what abdominal pain etiology should be considered?
Bowel obstruction
32
If a patient is taking NSAIDs with abdominal pain, what etiology should be considered?
* Gastritis * Gastric ulcer/perforation
33
If a patient has recent antibiotic use in their history and abdominal pain, what should be considered?
* Masked infection * C. diff
34
If a patient is taking a new medication with abdominal pain, what etiology should be considered?
Medication SE/Complication
35
What social history can impact abdominal pain?
* Heavy ETOH use (thins blood, liver disease) * Opiate drug use (constipation, may have run out) * Smoking
36
If a patient has an elevated temperature with abdominal pain, what are you thinking? Low?
* Infection (high) * Infectious etiology in the elderly and neonates (low)
37
If respiratory rate is high with abdominal pain, what etiology should you consider?
Metabolic acidosis
38
Absence of bowel sounds in a patient with abdominal pain would indicate what?
* Peritonitis * Bowel obstruction
39
Periodic high-pitched bowel sounds in a patient with abdominal pain would indicate what?
Bowel obstruction
40
Hyperactive medium pitched bowel sounds in a patient with abdominal pain would indicate what?
Blood or inflammation within the GI tract
41
Abdominal bruit and abdominal pain would indicate what?
AAA
42
What can be used for peritoneal testing?
* Rebound * Heel tap * Jumping ## Footnote Not reliable in the elderly population or pregnancy
43
In patient >50 years of age with abdominal pain, what should be assessed?
Aorta ## Footnote obscured in obese
44
What does a positive Carnett's sign indicate?
Abdominal wall pathology
45
What does a positive Murphy's sign indicate?
Cholecystitis
46
What does a positive psoas sign indicate?
Retrocecal appendicitis
47
What does a positive obturators sign indicate?
Appendicitis
48
What does a positive Rovsing sign indicate?
Appendicitis
49
What does pain on CVA percussion indicate?
Pyelonephritis
50
If the pain is located in the lower 1/2 of the abdomen, what should be part of your physical exam?
Pelvic/testicular exams
51
If there is a concern for GI bleed or rectal mass leading to obstruction, which physical exam should be performed?
Rectal exam
52
What would you be looking for with heart and lungs PE in abdominal pain?
* Afib (risk of mesenteric ischemia) * Pneumonia
53
What would you be looking for with MSK exam in abdominal pain?
Hips- infectious and inflammatory process can radiate to lower abdomen
54
What skin signs are you looking for with abdominal pain and what do they indicate?
* Cullen's * Grey Turner's * Intra-abdominal or retroperitoneal hemorrhage * Ruptured/leaking AAA or hemorrhagic pancreatitis
55
Why assess a fingerstick glucose for abdominal pain?
DKA
56
Why might a CBC be helpful in abdominal pain?
* H&H for signs of anemia - GI bleed * WBC for infection ## Footnote note: physiological leukocytosis is seen in pregnancy Immunocompromised and elderly may have normal WBC in presence of infectious etiologies
57
Diagnostics for abdominal pain | `
* Fingerstick glucose * CBC * CMP * Amylase/lipase * Urinalysis * Pregnancy test
58
What would pyuria on urinalysis indicate?
* Urinary tract infection * Non-infectious pyuria in elderly * Inflammatory or infectious condition adjacent to the bladder
59
What would hematuria on urinalysis indicate?
* UTI * Nephrolithiasis * AAA
60
When would you consider adding EKG, troponin, CXR?
* EKG, trop: atypical MI populations * CXR if lung related
61
Indications for plain radiograph in abdominal pain
May include AP supine view, PA erect view, PA erect chest radiograph * Bowel obstruction * Perforation * Sigmoid volvulus * Radiopaque foreign body * Incarcerated inguinal hernia * Severe constipation
62
What can you visualize on ultrasound?
* Performed at bedside in emergency * Visualize GB * Pancreas * Kidneys * Ureters * Urinary bladder volume * Uterus/fallopian tubes * Aortic dimensions
63
Indications for ultrasound
* Unstable AAA * Cholecystitis * Ectopic pregnancy * Hemoperitoneum * Hydronephrosis (suspected in nephrolithiasis) * Pancreatitis * Appendicitis (only by experienced technicians/radiologists)
64
What is CT scan the preferred study for?
Undifferentiated abdominal pain
65
Non-contrasted CT indications
* Nephrolithiasis * Trauma * Hemoperitoneum * Bowel obstruction
66
Oral contast CT indications
* Oral: enhances GI tract * BMI <23 * GI abscess * Appendicitis * Diverticulitis * Perforation * Fistula
67
IV contrast CT function
* Visualize bowel mucosa * Visceral organ * Vascular structures
68
Indications for IV contrast
* Bowel obstruction/perforation * Stable AAA
69
Risks of IV contrast CT
Nephrotoxicity Allergic reactions
70
CI and caution to IV contrast CT
* Serum creatinine >1.5 or GFR <60 * Caution: metformin use
71
When is angiography indicated for abdominal pain?
* Mesenteric ischemia * Massive lower GI bleed (if going to surgery)
72
If concerned for extreme bleeding, what should be ordered in addition to CBC
type and crossmatch
73
If evidence of shock, what should be ordered?
ABG
74
If a patient has symptoms, signs, or risk factors suggestive of AAA, what should be done?
* Surgical consultation * Bedside ultrasound * Abdominal CT
75
If a patient has history, exam, or risk factors suggesting mesenteric ischemia (pain out of proportion to exam) what should be done?
* Surgical consult * Abdominal CT
76
If a patient has a bowel obstruction of perforation what are the next step?
* Abdominal radiograph series + free air: surgical consult + obstruction: abdominal CT + free air, obstruction: abdominal CT
77
If a patient has epigastric or right upper quadrant tenderness, what are next steps?
* RUQ US * Obtain lipase * LFTs, chest radiograph, or others based on history and exam
78
If a patient has RLQ and is female, what should be done?
* Perform pelvic examination * Obtain US or CT based on exam findings
79
If a patient has RLQ pain and is male, what should be done?
Palpate testicles * Tender testicle or tender scrotal mass: urology consult and obtain US
80
If RLQ in male and high suspicion for appendicits, what should be done?
Surgery consult
81
If RLQ in male without suspicion for appendicitis, what should be done?
Abdominal CT vs observation with serial exam
82
If LLQ, what additional study should be conducted (in addition to what is done for RLQ)
CT for diverticulitis
83
If LUQ tenderness, what should be done?
* Check for signs and symptoms of mono with splenic rupture: if present, US to assess hemoperitoneum and surgery consult if yes; if no hemo, consider abdominal CT * If no mono, obtain lipase, consider US biliary disease; CT, ECG, CXR
84
If pregnancy with abdominal pain, what should be done?
* US * Sterile pelvic exam * quantitative HCG and other laboratory tests * Obtain OB/GYN surgery consult * IUP: assess appendix with US; surgery and OB/GYN consult as indicated * Ectopic pregnancy: obtain OB/GYN consult
84
What should be done if abdominal pain if female of childbearing age but not pregnant
* Unilateral adnexal tenderness? * Yes: US to rule out ovarian torsion or ovarian cyst * No: clinical PID? * If clinical PID, check if toxic appearing or persistent vomiting * If toxic appearing: hospital admission, give IV abx, GYN consult * If not toxic, outpatient management and abx
84
If no clinical PID in female of childbearing age with unilateral adnexal tendernes,, what should be done?
* Check for predominant RLQ tenderness, if so evaluate appendix with US or CT * If no RLQ tenderness, consider UTI, nephrolithiasis, neoplasm, domestic violence, extraadominal causes
85
Management of abdominal pain (generally)
* Continuous cardiac monitoring if VS are abnormal * NPO (initially) and fluids: IV crystalloids * Antiemetics
86
Treatment of abdominal pain with fluids
* IV crystalloids (NS/LR) * Rapid infusion of 1 L bolus over 10-20 min if hypotensive or signs of dehydration are present (slower rate if hx of CHF) * Rate of 75-125 mL/h rate if normotensive
87
What antiemetics can be used for abdominal pain?
* Ondansetron 4-8 mg IV or ODT * Metoclopramide 10 mg slow push to avoid extrapyramidal SE, consider co-admin with diphenhydramine to avoid SE, avoid if prior hx of akathisia or dystonic reaction
88
Goals of abdominal pain management
* Improve pain to a tolerable level * Improve patient cooperation with exam
89
Agents for abdominal pain management
* Morphine * Fentanyl - shorter acting * Ketorolac (great for renal colic but avoid NSAIDs if concern for peritonitis)
90
What can be used for additional symptomatic relief of abdominal pain?
* NG tube * Foley catheter
91
What are indications for NG tube placement?
* Intractable emesis * Confirm upper GI bleed * Add light suction to decompress GI tract in a bowel obstruction * Consider in peritonitis and severe ileus
92
What are indications of foley catheter in abdominal pain?
* Relieve bladder obstruction * Monitor Is &Os * Assess renal perfusion
93
When would empiric antimicrobial therapy be used in abdominal pain?
* Suspected sepsis and peritonitis
94
Options for empiric antimicrobial therapy in abdominal pain
* Zosyn OR * gentamicin + metronidazole IV * Vary based on individual presentation and ddx
95
Disposition of abdominal pain
* Reassessment critical!! VS/symptom/exam change? * Surgical consult early if surgical or acute abdomen highly suspected * Admit if at high risk * Patients with normal CT and unclear dx: discharge with 12 hour f/u * If discharged, clear instructions, diet, medications, what to watch for and where and when to return/follow up
96
What patients are at high risk and should be admitted for abdominal pain?
* Geriatric * Immunocompromised * Unable to communicate or cognitively impaired * Ill appearing * Intractable pain or vomiting * Unable to comply with discharge or f/u instructions * Lack of social support
97
Symptoms that warrant return to ED for abdominal pain
* Increased/different pain * Fever * Vomiting * Syncope * Bleeding

Emergency Medicine (13 decks)

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