Patient Presentation: Chronic Abdominal Pain

Question 1

Pick a section and write it down

Answer 1

Question 2

When a patient presesnts with abdominal pain, is the problem always contained within the abdomen?

Answer 2

no, paitent culd have pelvic disorders

could be a myocardial infarction if pain in epigastric of LUQ

if associated with cough/fever, could be pneumonia

Question 3

What is the definition of chronic abdominal pain?

Where could pain be originating from?

What are they two suptypes of chronic abdominal pain?

Answer 3

• continuous or intermittent abdominal discomfort lasting for at least 6 months
  
  • genitourinary tract, gastrointestinal tract, gynecologic tract
• subtpes
  
  • organic etiology
  • functional etiology
    
    • may not find the issue, but there is still abdominal pain

Question 4

What are important questions to ask in the following categories when taking a history?

Description

Onset

Intensity

Duration/Progression

Associated symptoms

Aggregating/Alleviateing

Others?

Answer 4

• Description
  
  • sharp vs. aching or gnawing
  • location
• Onset
  
  • acute vs. chronic
  • radiation
• Intensity
  
  • severity (older patients may have mild pain with severe conditions)
  • pain scale 0-10; look for paitient cue (grimmace, gripping abdomen)
• Duration/Progression
  
  • persistent, worsening pain is obviously bad, chronic
• Associated symptoms
  
  • nausea
  • vomiting
  • heartburn
  • melena (dark sticky feces containing partly digested blood)
  • hematochezia (passage of fresh blood per anus, usually in or with stools.)
  • hematemesis (vomiting blood)
  • diaphoresis (sweating)
  • cough
  • cold symptoms
  • fever
  • vaginal discharge
  • Last menstrual period
• Aggregating/Alleviateing
  
  • pain with bowel movement- peritoneal?
  • Pain with any food- mesenteric ischemis?
• Others?
  
  • last colonoscopy/EGD
  • Surgeries?
  • Medications?
  • Allergies?

Question 5

What are the steps to the physical exam?

Answer 5

• Vital signs
  
  • septic
  • in distress/ tachycardic/ high blood pressure
• Chest and abdominal examsn
  
  • others if pertinent
• OMT
  
  • areas with referred visceral pain
• Rectal exam

Question 6

What are the 4 types of pain used to describe abdominal pain?

Answer 6

1. Visceral: originates from abdominal organs covered by peritoneum. “deep” pain
2. Colic: crampy, intermittent pain, comes and goes
3. Parietal: Irritation or parietal peritoneum, more easily localized
4. Referred: pain in one area goes toa nother

Question 7

What are 5 signs that the abdominal pain is urgent/emergent?

Answer 7

1. rebound
2. guarding
3. distension
4. abdominal vital signs
5. blood in stool– cancer, PUB, IBD

Question 8

Identify the definitions and differential diagnosis associated with each sign

Answer 8

Question 9

Idetify the lcation you would expect to see pain for the affected organ for visceral pain, parietal pain, and referred pain

Answer 9

Question 10

What are is the lab workup for someone who presents with abdominal pain?

Answer 10

• complete blood count (CBC)
  
  • elevated white count?
  • hemoglobin/hematocrit– bleeding? anemia?
• complete metabolic panel (CMP)
  
  • includes liver function tests, glucose, kidney function, potasium, sodium,chloride, etc.
• urinalysis- UA
  
  • sugar? protein in the liver?
• Amylase/lipase
  
  • pancreas
• Thyroid studies
• People who can get pregnant - pregnancy

Question 11

What diagnositc imaging would you order for someone with abdominal pain?

Answer 11

• US- transabdominal/vaginal
• CT- with/without contrast (IV, oral, rectal)
• X-ray (Flat and upright)

Question 12

What emergent causes do you need to rule out when a patient presents to you with abdominal pain?

Answer 12

• Ruptured AAA
  
  • abdominla aortic aneurysm
  • v. low BP, anemic
• Aortic dissection
• Perforated bowel
  
  • distended bowel, guarding, rebound
• Volvulus
• Mesenteric ischemia
• Torsion
  
  • could be intestinal, ovarian, testicular
• Incarcerated hernia
  
  • palpate abdomen
• pregnancy

Question 13

What is irritable bowel syndrome?

Symptoms?

Diagnosis?

Answer 13

Functional GI disorder characterized by abdominal pain adn altered bowel habit in teh abscence of a specific pathology

• Symptoms
  
  • constipation/diarrhea or both
• Diagnosis: Rome Criteria (need at least 2)
  
  • lab testing/ diagnositic imaging not recommended in patients w/ IBS <50 w/o
    
    • weight loss
    • iron deficiency from anemia
    • family history or organic GI illness (IBD, celiac sprue, colorectal cancer)

Question 14

What symptoms would lead you to suspect chronic pancreatitis?

What is the workup steps you woudl follow from here?

Answer 14

Question 15

What is the difference between diverticular disease and diverticulitis?

Answer 15

both examples of diverticulosos: when small pockets form in the digestive tract– usually colon & last part SI

• diverticular disease
  
  • pain starts and stops in lower left abdomen
  • coudl be worse with eating & relieved by bowel movement
  • bloating feeling
  • constipation
  • diarrhea
  • small pellet-like stools
• Diverticulitis (inflamation of one of the diverticuli)
  
  • constant pain in lower left abdomen
  • fever
  • malaise
  • nausea
  • vomiting

Question 16

What is Celiac disease?

Symptoms?

Diagnosis?

Answer 16

• Gluten-sensitive enteropathy
  
  • chronic disorder of digestive tract - inability to tolerate gliadin (alcohol soluble fraction of gluten)
• Symptoms:
  
  • abdominla pain,
  • diarrhea,
  • weight loss fatigue
  • gas pains
• Diagnosis
  
  • blood antibody testing - IgA anti-tissue transglutaminase antibody (IgA TTG) and endomysial antibody
  • endoscopy (upper endoscopy with at least 6 duodenal biopsies)

Question 17

What is eosinophil esophagitis? (EoE)

Symptoms?

Answer 17

• When the esophagus has an increased number of eosinophils & that inflammtion is limited to the esophagus
• Symptoms
  
  • related to esophageal dysfunctoin
  • dysphagia
  • food impaction
  • chest pain

Question 18

Differential?

Key information?

Next steps?

–> you do an ultrasound and it is normal; next steps?

Answer 18

• Differential
  
  • Cholecystitis (inflamation gallbladder)
  • Cholelithiasis (gallstone formation)
  • pancreatitis
• Key information:
  
  • they have trouble with fried – very possible it is the gallbladder
• Next steps
  
  • How long has it been going on?
    
    • w/ gallbladder, past month pain right after eating
  • Fever?
  • Pregnancy test
  • Rate pain? Describe it.
    
    • right now its 2, when get the attackes its 10
  • Have you had a cholecystectomy? (gall bladder removal)
  • bowel sounds, palpation
• Ultrasound normal
  
  • CMT
    
    • elevated bilirubin? elevated liver enzymes?
  • Amylase & lipase – make sure not pancreatic issue

Question 19

Differential?

Next Steps?

Answer 19

• Differential
  
  • Diverticular disease
  • constipation
  • IBS
  • Inguinal/incarcerated hernia
• Next steps
  
  • history of surgery
  • last bowel movement – how often? what do they look like?
    
    • rectal bleeding & what that looks like
    • mucous in stool?
  • diet?
  • weight loss?
  • colonoscopy?
  • Lab work
    
    • white count elevated
    • electrolytes stable?
    • CT scan? –
      
      • could be a perforated diverticulum
      • do they need to be in the hospital

Question 20

Differential?

Key information?

Next steps?

Answer 20

• Key information
  
  • DO NOT forget to rule out heart problems
  • get an EKG on this patient
  • diarrhea could be distractors
• Differential
  
  • GERD
  • heart attack
• Next steps
  
  • EKG
    
    • act as if they could be having a heart attack
  • heart enzymes lab test
  • send to ER

Question 21

Differential?

Key information?

Next steps?

Answer 21

• Differential
  
  • IBS
• Key info
  
  • bowel movement
• Next step
  
  • not 50, so physical but prob won’t do lab work