Eval Abd pain in Primary care-jaynstein-FINAL Flashcards
What % of all PCP visits are for a GI complaint?
-b/w 7-10%
Constipation: 8.1 per 1,000 pts Diarrhea: 6.7 Abdominal pain: 6.1 Gastric pain: 5.0 Nausea: 2.9 Regurgitation: 2.0
1 case per month of acute abd pain - sudden, severeabdominal pain of unclear etiology that is less than 24 hours in duration.
what % of GI complaints in primary care are referred to GI?
75% of these abdominal complaints are not referred to GI
25% are referred to GI
23.5% stay in primary care
1-2% referred to secondary care
**Almost 50% of GI referrals eventually get diagnosed with IBS
-Keep in mind that acute surgical complaints get sent out to ER/Surg
Acute Abdominal Pain in PC :
-top 5 diagnoses
- *- appendicitis-28%
- Cholecystitis- 10%
- Small bowel obstruction- 4%
- Gynecological-4%
- **No clinical dx-34%
The goal for treating abd pain:
Determine who needs a work-up for their abd pain (and how extensive that work up should be!)
Options:
1. Symptomatic care / watch and wait
- Lab and diagnostic work up –outpatient or emergent?
- Referral
PC Provider’s role in Abd Pain:
Upwards of ____% of abdominal complaints can be managed in primary care
–>Must work your way through the differentials and determine which patients are appropriate for “watch and wait” vs who you think has an underlying organic cause that needs to be treated
80%
Common PC abd pain diagnoses:
list top 4
Diarrhea
Constipation
Gastroenteritis
Food related (Celiac disease, Lactose intolerance)
- All of these can be dx with no to minimal work-up
acute abdominal pain ddx
Appendicitis Cholecystitis Pancreatitis Diverticulitis Perforation Obstruction Acute ischemia **AAA Ectopic PID Nephrolithiasis
chronic (>6 months) abdominal pain ddx
PUD Esophagitis IBD – CD and UC Chronic pancreatitis Diabetes – gastroparesis IBS Abdominal wall Functional
RUQ ddx
- acute cholecystitis and biliary colic
- acute hepatitis
- appendicitis
RLQ ddx
- apendicitis***
- incarc or strangulated hernia
- endometriosis
- diverticulitis
- PID
LUQ ddx
- acute pancreatitis
- gastric ulcer
- gastritis
- splenic enlargement/rupture/ifection
LLQ
- diverticulitis**
- endometriosis
- hernia
- PID
- Mittelschmerz
- PID
- regional enteritis
Pt’s who are unstable, toxic, in extreme pain, or present with a potentially surgical complaint need _______
to be sent to ER**
Pt’s who are stable and non-toxic should be worked up _______
in the office, A systematic approach by abdominal quadrant is the best step
RUQ pain: work-up
-hx should focus on differentiating b/w _____
-IF UTI suspected–> dx labs?
- pulmonary, urinary, and hepatobiliary pain
- If a pulmonary cause is suspected – imaging, labs?
- If UTI or nephrolithiasis is suspected- **urinalysis is starting point
- Patients with colic, fever, steatorrhea, or a positive Murphy’s sign–> should receive ultrasonography**
- Unsure? Ultrasonography test of choice for evaluation of RUQ
Cholecystitis:
epidemiology–> how many ppl are dx with gallstones/yr?
-20 million, more than 300,000 lab chole’s/yr
Cholecystitis: diagnostic keys
-NEED to differentiate b/w ______ and _______
RUQ Abdominal tenderness: test sensitivity? test specificity?
**cholelithiasis vs acute cholecystitis
RUQ Abdominal tenderness:
Test Sensitivity 77%
Test Specificity 54%
Cholecystitis:
Murphy’s sign is present in ___% (LR =5.0)
Test Sensitivity ? & Test Specificity?
-65%
Test Sensitivity 92%
Test Specificity 48%
Cholecystitis: diagnostic keys
-Pain persists beyond ____ hours and often reoccurs
-Feveris present in only ___% of cases of acute
5-6
35%
Cholecystitis work-up:
labs?
imaging?
- CBC, CMP (lipase)
- US all pts with suspicion of gallstones who have abnl labs
High suspicion with nl labs or before labs?
Watch and wait?
Get US?
