Lecture 11: Abdominal Pain Flashcards
3 types of abdominal pain
- Visceral: Poorly localized d/t stretch of unmyelinated fibers of organ walls
- Parietal/somatic: Localized d/t irritation of myelinated fibers of parietal pleura, progression from tenderness + guarding to rigidity and REBOUND tenderness
- Referred: Usually ipsilateral side but distant
What kinds of conditions fall under intra-abdominal?
- Organ infection/inflammation
- Peritonitis
- Bowel obstruction
- Vascular disorders
What are the 5 MC Extra-abdominal etiologies?
- DKA
- Alcoholic ketoacidosis
- PNA
- PE
- Herpes Zoster
What two demographics are trickier for abdominal pain?
- Elderly: less severe or atypical, but way worse mortality. (consider ischemic heart disease, vasculopathies, and coagulopathies in your DDx)
- Females: pregnancy (gravid uterus can displace)
Maybe diabetics
What should you consider if abdominal pain is maximal at onset and sudden?
- Ischemia
- Dissection
- Perforation
What does a gradual onset (over days) for abdominal pain suggest?
- Inflammatory
- Infectious
- Obstructive
What does a constant/worsening abdominal pain over the last 6 hours suggest?
Surgical etiology
What abdominal condition improves after meals?
PUD
What abdominal condition worsens after meals?
Biliary colic
What abdominal condition improves in an upright position, and worse supine?
Pancreatitis
Leaning forward
What abdominal condition hurts with sudden mvmts but better when still?
Peritonitis
Does vomiting after pain onset suggest a surgical etiology?
Yes!
What does bilious vomiting suggest in terms of obstruction location?
DISTAL to PYLORUS
But proximal within the intestines
What might coffee-ground/hematemesis suggest?
- PUD
- Varices
- Aortoenteric fistula (If they have hx of AA repair)
What does bloody diarrhea suggest?
- Mesenteric ischemia
- Infectious
BANGS:
Bacteria: Such as Shigella, Salmonella, Campylobacter, E. coli (EHEC)
Ameba: Entamoeba histolytica
Norovirus
Giardia lamblia
Shigella dysenteriae
What does small, scant amounts of diarrhea suggest?
Bowel obstruction
What does loose/watery diarrhea suggest?
- Infectious
- Diverticulitis
What does mucoid diarrhea suggest?
- Infectious
- Inflammatory (IBD)
Why is smoking important to know for hx?
Nicotine replacement, otherwise pt will go AMA
What populations may have hypothermia with abdominal pain?
- Elderly
- Neonates
Infectious etiologies
What does the absence of bowel sounds suggest?
- Peritonitis
- Bowel obstruction (later?)
What do spider angiomatas on the abdomen suggest?
Cirrhosis (most likely alcoholic)
Also portal HTN
Who is peritoneal testing not reliable in?
- Elderly
- Pregnancy
How long do you listen to bowel sounds?
2 minutes
textbook medicine
What do hyperactive medium pitch bowel sounds suggest?
Blood/inflammation within GI tract
Where are bowel sounds best heard?
2 o clock from umbilicus
What does involuntary guarding almost always suggest?
Surgical etiology
What specialty signs are associated with appendicitis?
- Obturator’s
- Rovsing
- McBurney’s point
- Psoas = retrocecal appy (Pain on SOAS stretching)
The Obturator sign involves flexing the patient’s right hip and knee to 90 degrees, then internally rotating the hip by moving the foot outward. This maneuver causes tension on the obturator internus muscle. If the patient experiences pain in the right lower quadrant during this movement, it suggests irritation of the obturator muscle due to inflammation in the area, which can be indicative of appendicitis.
So, “HOPT” stands for “Hop on the bed, tenderness in the right lower quadrant,” helping to remember the procedure and purpose of the Obturator sign when assessing patients suspected of having appendicitis.
What sign is suggestive of cholecystitis?
Murphy’s
Inspiratory arrest
What physical exam finding should you test for pyelonephritis?
CVA tenderness
What is Carnett’s sign?
Abdominal wall pathology
Worsening = deeper, better = wall
The patient lies flat on the examination table.
The examiner identifies the area of maximum tenderness in the abdomen. This could be due to various reasons, such as muscle strain, inflammation of the abdominal wall, or other causes.
The patient is then asked to slightly lift their head and shoulders off the table, using their abdominal muscles (like doing a partial sit-up).
While the patient maintains this position, the examiner reevaluates the area of tenderness.
What are cullen’s and grey turner’s and what do they suggest?
- Cullen = Central bruising around umbilicus
- Grey Turner’s = Bilateral flank bruising
Suggestive of intra-abdominal/retroperitoneal bleeding
In what condition might leukocytosis not be concerning with abdominal pain?
Pregnancy (physiologic leukocytosis)
High-risk Pts with abdominal pain should get what lab ordered?
Elderly, female
Trops
Could be an atypical presenting MI
What are abdominal XRs primarily used to look for?
- Obstructions
- Perforations
- Volvulus
- FBs
- Incarcerated inguinal hernias
- Constipation
When is Abd US usually performed?
Emergency
Need a skilled provider
What is the preferred imaging modality for undifferentiated abd pain?
CT Scan
When is the purpose of Oral contrast for a CT abd?
GI tract enhancement
- BMI < 23 (she mistyped)
- GI abscess
- Appy
- Diverticulitis
- Perf
- Fistula
Quicker than IV, comes in neutral or positive (iodine-based)
Special note: If you are fat enough, your fat works as contrast
We don’t really need positive oral contrast nowadays with better CT scanners.
Why is CT abd w/ IV contrast not always ordered?
- Takes A LOT of prep time
- CIs: Cr > 1.5 or GFR < 60 (unless dying)
- Caution in metformin use
When is CT angiography indicated?
- Mesenteric ischemia
- Massive lower GI bleed
When must IV contrast be used for a CT abd?
Any vascular disease
per article
What is IV contrast for CT abd made of?
Iodine-based
Whereas MRI is gadolinium based
Allergy to MRI contrast != allergy to IV contrast for CT
If we suspect shock, what should we order besides the basic labs?
ABG
In what 3 conditions is IV contrast for CT Abd not needed?
- Bowel perf
- Nephrolithiasis
- Hematomas
When would you slow your rate of crystalloids for abdominal pain management showing signs of hypotension or dehydration?
Hx of CHF
75-125 mL/hr for normotensive
Which antiemetic should you push slow and why?
Metoclopramide/Reglan to avoid Extrapyramidal SE
Can give benadryl too
Must avoid in hx of akathisia or dystonia
What is the goal of pain management in abdominal pain?
Make it tolerable so they cooperate with your exam.
What condition is toradol good for? What condition should you avoid it in?
- Good in renal colic (kidney stones)
- Bad in peritonitis/bleeding (AVOID NSAIDS)
What’s faster-acting: morphine or fentanyl?
Fentanyl
Options for empiric abx for suspected sepsis and peritonitis?
- Zosyn (piptazo)
- Gentamicin + metronidazole/flagyl
How do we decompress the GI tract in a bowel obstruction?
Light suction via NG tube
How soon do we f/u a discharged patient with a normal CT and unclear dx for abd pain?
12 hr f/u
Many return precautions + diet, meds, what to watch for, where to go
- Increased/different pain
- Fever
- Vomiting
- Syncope
- Bleeding
Generally, who gets admitted for abd pain?
- Surgical Abd
- Elderly
- Very sick
- Immunocompromised
- No social support
