Approach to Abdominal Pain Flashcards
Common causes of abdominal pain
acute appendicitis
cholelithiasis/cholecystitis
perforated ulcer
acute pancreatitis
bowel obstruction
hernia
diverticulitis
ischemic bowel
ruptured AAA
GYN causes
Peritonitis
Localized or generalized inflammation of the peritoneum
Many potential causes: infection, trauma, visceral inflammation, leakage of blood/bile/urine/gastric juices
Symptoms: abdominal pain, fever, N/V
Exam: fever, abd. tenderness rigidity, rebound and guarding–-an acute abdomen
Often represents a surgical emergency
Acute Appendicitis
MC ages: 10-30
Symptoms: anorexia, N/V, low grade fever, abdominal pain with gradual onset that migrates from the periumbilical region to RLQ
Exam: RLQ tenderness over McBurney’s point with rebound tenderness and guarding; + Rovsing’s sign
Labs:
- elevated WBC
- CT with oral/IV contrast
- Consider US in kids/pregnant women
**Complications of rupture: **
- intra-abdominal abscess
- adhesions/future SBO
- infertility in women (if tubes get scarred down)
- death
Tx: appendectomy, start ppx abx in ED
Be aware of atypical presentations, esp. in very young, very old and immunocompromised
Do not delay tx for lab or imaging if dx. is clinically evident
Cholelithiasis/Cholecystitis
(RF’s, pathophys, sxs, PE, labs, imaging, complications, tx)
Cholelithiasis: presence of gallstones
Cholecystitis: gallstones + inflammation of gallbladder (due to GB outlet obstruction)–often have recurrent attacks
Risk Factors: Fat, Forty, Fertile, Female
Patholophysiology:
- GB contracts in response to fats in small intenstine; sxs occur when gallstones migrate to GB neck, cystic duct, or CBD
- If obstruction persists, cholecystitis may occur
Symptoms:
- occur 30-60min after meal
- RUQ pain
- N/V
- fever, toxic appearance suggests cholecystitis
PE: RUQ tenderness, +Murphy’s sign
Labs:
- WBC, alk. phos, AST/ALT–WNL in cholelithiasis, elevated in cholecystitis
- Lipase/amylase suggests gallstone pancreatitis
Imaging:
- RUQ US is the study of choice
- HIDA scan–isotope not taken up in cholecystitis
**Complications: **
- gangrene of GB
- pancreatitis
- ascending cholangitis
- LIFE THREATENING
- complete obstruction in presence of bacteria–>reflux into systemic circulation
- Charcot’s triad: high fever, jaundice, RUQ pain
Treatment:
- uncomplicated cholelithiasis–diet modifications, analgesics, elective cholecystectomy
- Acute cholecystitis–surgery 24-72hrs after GB cooled down + abx ppx
Perforated Ulcer
(RF, sxs, PE, lab, imaging, tx)
LIFE THREATENING
RFs:
- tobacco, EtOH
- NSAID use
- steroids
- usually have hx of PUD, antacid use
Sxs:
- sudden, severe epigastric pain, often radiating straight to back + vomiting
PE:
- severe distress
- marked abd. tenderness, often rigid
- bowel sounds possibly absent
- tachycardic, hypotensive
Lab:
- CBC, electrolytes
Imaging:
- abd. flat/upright x-ray: shows free air
- CT if plain films aren’t diagnostic
Tx:
- vigorous IV fluid resuscitation
- NG tube
- broad-spectrum abx
- emergency laparotomy
Acute Pancreatitis
RF, sxs, PE, lab, imaging, tx
**RFs/Common causes: **
- ETOH
- gallstones
- familial hyperlipidemia
Sxs:
- upper abd. pain–R or L UQ
- N/V
PE:
- epigastric, R/LUQ tenderness
- if hemorrhagic may see abd. distention
- if severe: hypotension, shock
Lab:
- elevated amylase/lipase
- CBC: usually leukocytosis, may see anemia if hemorrhagic
- hypocalcemia (potentially)
Imaging:
- US/CT–shows pancreatic edema, possibly pseudocyst or abscess
Tx:
- NPO, IV fluids/analgesia
- if obstructing stone present–ERCP
- drain pseudocyst or abscess if present
Bowel Obstruction
RFs, sxs, PE, lab, imaging, tx
**RFs/Common etiologies: **
- SBO
- adhesions from prior surgery–MC
- incarcerated hernia
- CA or polyps LC
- LBO
- colon CA MC
- diverticulitis
- volvulus
Sxs: VODKA
- vomiting
- obstipation
- distention
- krampy abdominal pain
PE:
- diffuse abdominal tenderness
- tympany to percussion
- high pitched bowel sounds, later in presentation may be absent
- visibly distended
Lab:
- CBC, lytes, BUN/Cr
Imaging:
- Flat/upright AXR–air fluid levels, distended bowel loops
Tx:
- NG tube to suction for decompression
- IV fluid resuscitation, NPO
- Admit
- If does not resolve, surgery
Hernia
pathophys, types, sxs, tx
**Pathophysiology: **
- protrustion of preperitoneal fat, peritoneum, and bowel through abdominal wall
**Types: **
- inguinal
- femoral–just below inguinal ligament
- umbilical–at or near umbilicus
**May be: **
- reducible–can pop it back in w/ slow gentle pressure
- incarcerated–irreducible
- strangulated–incarcerated hernia with vascular compromise–can lead to gangrene (EMERGENCY)
**Sxs: **
- pain, bulging mass
- incarcerated–may have SBO
- strangulated–fever, leukocytosis, toxicity (sick appearing), diffuse peritonitis
Tx:
- attempt reduction
- if strangulation–do not try reduction, immediate surgery + ppx abx
Diverticulitis
pathogenesis, sxs, PE, lab, imaging, tx
Pathogenesis:
- fecal material trapped in diverticuli–> bacterial proliferation–>inflammation and walled off
- MC occurs in sigmoid, prevalence increases with age
Sxs:
- pain
- diarrhea/constipation
- straining with BM’s
- possibly fevers, N/V
PE:
- low grade fever
- localized abd. tenderness
- tender rectal exam
- if perforated, toxic with diffuse abd. tenderness
Lab:
- elevated WBC
Imaging:
- Dx confirmed by CT–thickened bowel wall, inflammation
**Tx: **
- can tx as inpt or outpt depending on pts status
- NPO, fluids, broad antibx
Ischemic Bowel
RFs, sxs, PE, lab, imaging, tx
LIFE THREATENING
RFs:
- usually seen in teh elderly and those with severe peripheral vascular disease
Sxs:
- severe diffuse abd. pain out of proportion to tenderness on exam
- fever
- N/V
PE:
- fever, toxicity
- diffuse abd. tenderness
Lab:
- elevated WBC
- acidosis, elevated lactate (metabolic acidosis)
Imaging:
- plain AXR may show bowel wall thickening (thumb printing)
- CT–study of choice–shows bowel wall edema
Tx:
- aggressive IV fluids, abx
- immediate surgery to resect infarcted bowel
Ruptured AAA
RFs:
- elderly
- HTN
- DM
- peripheral vascular disease
- aneurysms >5cm at significant risk for rupture
Sxs:
- acute onset of severe abd./back pain
- possibly syncope
Exam:
- hypotensive, tachycardic, frank shock
- pulsatile tender abd. mass
- abd. distension
Lab:
- CBC, lytes, BUN/Cr, PT/PTT
- immediately type and cross 6 units
Imaging:
- US/CT will make dx, but do not delay tx for unstable pt
Tx:
- immediate surgical repair
- 2 large bore IVs, rapid fluids, blood transfusion
GYN Causes
Ectopic Pregnancy
- lower abd. pain +/- vaginal bleeding
- pelvic US
- immediate OB/GYN surgical consult
**Ovarian torsion **
- severe low abd. pain
- in great distress
- pelvic US
- surgical consult
Pelvic Inflammatory Disease (PID)
- infx of fallopian tubes from STI
- low abd. pain/tenderness + vaginal discharge
- cervical motion tenderness
- cultures + CBC
- Tx w/ abx (in or outpt)
Pain Management in an Acute Abdomen
Current literature supports judicious use of analgesics–does NOT obscure diagnosis and may actually improve PE
abdominal pain with unclear origin
pts may leave ED with no definitive dx.
can admit for observation if H&P are concerning–perform serial exams
if pt discharged–have them get rechecked within 12-24hrs
