Chapter 27 - Abdominal Pain

Question 1

Which patients require special considerations?

Answer 1

1) Elderly
Ruptured AAA
diverticulitis
mesenteric ischemia

2) immunocompromised (uncontrolled DM, HIV, liver disease, chemo)
- presentation can be misleading due to lack of an inflammatory response

3) Women of reproductive age
- ectopic pregnancy
- pelvic organs

Question 2

What is the pathophysiology of pain in abdominal pain?

Answer 2

pain is derived from three pathways:

1) visceral
- stimulation from autonomic nerves in the visceral
- if the affected organ undergoes peristalsis, then the pain is usually intermittent, crampy and/or colicky in nature
- Localization of pain only occurs when the parietal peritoneum becomes affected by the inflammatory process

2) somatic
- occurs with irritation of parietal peritoneum, thereby allowing the patient to localize exactly the location of the pain

3) referred
- pain felt at a distance from its originating source

Question 3

List 8 different causes of life-threatening abdominal pain

Answer 3

1) ruptured ectopic pregnancy
Inv: FAST, U/S, B-HcG
2) ruptured or leaking abdominal aneurysm
SSx: acute onset epigastric, back pain WITH syncope and shock \
Bedside U/S, CT abdomen
3) Mesenteric ischemia
SSx: periumbilical then diffuse pain, with N and V, at times post-prandial
- need CT to diagnose
-peak: elders, CV disease, CHF, arrhythmias, sepsis, dehydration

4) Intestinal obstruction
- peak in infants and the elderly or post-op
- etiology: adhesions, cancer, hernias, volvulus, infarctions

5) perforated viscus
symptoms: acute onset epigastric pain, vomiting then developing into a fever
- diffuse board-like abdomen with guarding, tachycardia and fever
- imaging: upright radiograph shows air under diaphragm in 70-80% if cases

6) Acute pancreatitis
- due to alcohol, stones or manipulation
- hyperlipidemia, hypercalcemia, ERCP, cancer, ischemia, trauma, ARDS, spontaneous rupture
- signs: grey turner’s or cullen’s sign if it’s hemorrhagic
- w/u: lipase (NOT amylase), U/S, +/- CT scan to show necrosis or abscess

7) ascending cholangitis
- Charcoat triad: fever, RUQ, Jaundice
- Tx: antibiotics asap

8) complicated diverticulitis or appendicitis
- Tx: IV fluids, antibiotics, surgery

Question 4

List 15 causes of extra-abdominopelvic abdominal pain

Answer 4

1) thoracic
MI/angina\
Pneumonia/ PE
Perimyocarditis

2) GU
torsion of the testicles
penile pathology
intra vaginal FB/mass/pathology

3) Superficial
Muscle hematoma or HSV

4) Systemic:
a) Infectious
pharyngitis in kids
Mono
b) metabolic
DKA
sickle cell disease
SLE/vasculitis

5) Toxic
methanol/heavy metal poisoning
scorpion
black widow spider bite

Question 5

Why does the WBC have so little utility in abdominal pain?

Answer 5

WBC count is neither sensitive not specific

WBC count is never helpful except when they indicate immunosuppresion

Question 6

When is an abdominal X-ray useful in managing abdominal pain?

Answer 6

Gasses, masses, bones, stones

• query foreign body i.e. body packers
• query drug overdose i.e. iron, mercury, calcium carbonate
• query perforated viscus

Question 7

what are the exceptions in pediatric patients with regards to the utility of an abdominal x-ray ?

Answer 7

in peds where suspected:

volvulus/malrotation
NEC