Upper Abdominal Pain Flashcards
What are the classifications of abdominal pain based on location?
Right upper quadrant, epigastric, left upper quadrant, periumbilical, right lower quadrant, and left lower quadrant.
What is the first step in evaluating a patient with abdominal pain?
Assess ABCDE to determine if the patient is stable or unstable.
What immediate management should be done for an unstable patient with abdominal pain?
Stabilize the airway, provide supplemental oxygen, establish IV access, and continuously monitor hemodynamics.
What is the first step in evaluating a stable patient with abdominal pain?
Obtain a focused history and physical exam (H&P).
What are the key aspects of history-taking in a patient with abdominal pain?
Location, severity, chronicity, aggravating and alleviating factors, associated symptoms, and recent abdominal or GI procedures (EDG, colonoscopy, recent surgeries, or aortic abdominal aneurysm).
What are the physical exam findings of an acute abdomen?
Diffuse tenderness, rebound pain, rigidity, and guarding.
What imaging should be obtained to rule out a perforated viscus?
Upright chest x-ray or abdominal x-ray series to check for free air under the diaphragm.
Patients with evidence of peritonitis should first have an upright chest X-ray obtained to evaluate for free air. If this is negative, the next best step is … ?
Imaging with CT of the abdomen and pelvis to better differentiate between primary, secondary, and tertiary causes of peritonitis. Primary peritonitis requires paracentesis for definitive diagnosis. Clinical evidence of peritonitis, which is caused by inflammation of the peritoneum is marked by diffuse tenderness, rebound pain, rigidity, guarding, abdominal distention, or diffuse abdominal tenderness. Patients with evidence of peritonitis should first have an upright chest radiograph to evaluate for free air and pneumoperitoneum. If negative, the next best step involves obtaining a CT of the abdomen and pelvis to better differentiate between primary, secondary, and tertiary etiologies of peritonitis.
Depending on the etiology, peritonitis can be divided into primary (caused by intra abdominopelvic fluid), secondary (caused by a process in the gastrointestinal tract), or tertiary (caused by postoperative inflammatory process). Clinical clues that may point to an underlying etiology include early history of the pain (e.g. right sided pain in a young patient may suggest ruptured appendicitis, or left sided pain in an elderly patient may suggest a perforated diverticulitis). Primary peritonitis may be suggested by history of liver disease or endometriosis and should be diagnosed with paracentesis.
What are the common causes of acute abdomen requiring emergency surgery?
Perforated viscus, abdominal sepsis, ruptured abdominal aortic aneurysm.
What is the role of exploratory laparotomy in acute abdomen?
It is both diagnostic and therapeutic.
Right upper quadrant pain is associated with what major conditions?
RIGHT UPPER QUADRANT PAIN:
* Biliary colic
* Cholelithiasis
* Acute cholecystitis
* Acute cholangitis
* Acute hepatitis
* Liver abscess
* Budd-Chiari syndrome
* Portal vein thrombosis
* Pancreatitis
* Duodenal ulcer
* Nephrolithiasis
Which labs become critical for diagnosing RUQ pain?
CBC, CMP (LFTs), LIPASE, AMYLASE
What is the classic presentation of biliary disease?
Acute onset of pain after eating a fatty meal, nausea, vomiting, and sometimes fever.
What are key risk factors for biliary disease?
Female sex, obesity, age over 40.
What physical exam finding is associated with acute cholecystitis?
RUQ tenderness with a positive Murphy sign.
What are common lab findings in biliary disease?
Leukocytosis with a left shift, elevated LFTs, and normal lipase/amylase.
What imaging modality is first-line for suspected biliary disease?
Right upper quadrant ultrasound.
What imaging findings suggest biliary disease?
Gallbladder sludge, stones, pericholecystic fluid, thickened gallbladder wall.
Gallbladder sludge or stones with no other findings is diagnostic for …?
Biliary colic.
Fever, positive Murphy’s sign with pericholecystic fluid or a thickened gallbladder wall, without jaundice is diagnostic for … ?
Cholecystitis.
A dilated common bile duct is diagnostic for … ?
Choledocholithiasis.
Fever with pericholecystic fluid or a thickened gallbladder wall, with jaundice or hyperbilirubinemia is diagnostic for … ?
Cholangitis.
What symptoms are associated with liver disease?
Nausea, vomiting, fever, RUQ tenderness, hepatomegaly, jaundice, altered mental status in extreme cases. Patients may also have substantial risk factors.
RISK FACTORS:
~ SUBSTANCE USE DISORDER
~ IMMUNOSUPPRESSION
~ CANCER
~ HYPERCOAGULABLE STATE
What lab findings suggest liver disease?
Leukocytosis with left shift (for an abscess), elevated LFTs, elevated PT/PTT, hyperglycemia, normal lipase and amylase.
What imaging should be ordered if liver disease is suspected and biliary disease is ruled out with U/S?
Abdominal CT scan.
What CT finding is diagnostic of a liver abscess?
Peripheral rim-enhancing liver lesion in a patient with fever.
What CT finding is diagnostic of Budd-Chiari syndrome?
Hepatomegaly and thrombosed hepatic veins.
What CT finding is diagnostic of portal vein thrombosis?
Thrombus in the portal vein.
What are key risk factors for acute hepatitis?
Recent travel, substance use disorder, immunosuppression, cancer, hypercoagulable states.
What are the major causes of liver disease?
acute viral hepatitis, toxin-related hepatitis (eg. acetaminophen), alcoholic hepatitis, or nonalcoholic steatohepatitis.
What is the major cause of acute liver failure in the United States?
Toxin-related hepatitis secondary to acetaminophen overdose. This usually requires liver transplant but is treated acutely with oral acetylcysteine.
What lab findings suggest acute hepatitis?
Elevated LFTs with fractionated bilirubin changes.
Liver disease causes which two labs to be elevated?
LFTs (ALT and AST):
- ALT is elevated with drugs, virus infections and toxins.
- AST is elevated in alcoholism.
Indirect Bilirubin is elevated in liver disease (Direct Bilirubin is elevated in gallbladder disease)
How is viral hepatitis diagnosed?
Viral hepatitis serology (IgM anti-HAV, HBs antigen, anti-HBc antibodies).
What are the main causes of epigastric pain?
EPIGASTRIC REGION PAIN:
* Acute myocardial infarction
* Functional dyspepsia
* Acute pancreatitis
* Chronic pancreatitis
* Peptic ulcer disease
* GERD
* Gastritis
* Gastropareisis
A 72-year-old man presents to the emergency department for evaluation of three days of worsening upper abdominal pain and associated vomiting. The patient drinks alcohol daily and has a past medical history of diabetes, hypertension, and gastric ulcers. Temperature is 36°C (96.8°F), blood pressure is 96/66 mmg, pulse is 112/min, respiratory rate is 22/min, and oxygen saturation is 94% on room air. The patient is lying on his left side in the stretcher and appears uncomfortable. Physical examination reveals diffuse tenderness to palpation that is more prominent in the epigastrium and is associated with rebound and guarding. The patient is started on intravenous fluids and his blood pressure improves. He is started on IV pantoprazole, morphine, and empiric antibiotics. A surgery consultation is called. Which of the following is the best next step in management?
This patient presents for evaluation of worsening upper abdominal pain with signs, symptoms, and a physical exam that is suggestive of peritonitis and a possible perforated viscus. Given this patient’s history of gastric ulcers and daily alcohol use, he likely has a perforated gastric ulcer. The patient has been stabilized with IV fluids and analgesia, therefore the next best step in management is to obtain an upright chest radiograph to screen for evidence of free air under the diaphragm, and to call for a surgery consult for evaluation and management of an acute abdomen. Upper abdominal pain is a symptom that is associated with many conditions, which can range from benign to serious to life-threatening and requiring surgical intervention. One approach to creating a differential diagnosis for upper abdominal pain is to classify the pain by location-right upper quadrant, epigastric, or left upper quadrant. Right upper quadrant pain may be caused by biliary or hepatic processes, while epigastric pain may be caused by pancreatic or gastric pathology. Left upper quadrant pain typically suggests a splenic process. The first step in management of a patient with upper abdominal pain involves an ABCDE assessment to determine if they are stable or unstable. If the patient is unstable, they require acute management before pursuing a diagnostic workup. Management should involve stabilizing the airway, providing supplemental oxygen, establishing IV access, and continuously monitoring hemodynamics. Unstable patients often have evidence of peritonitis, including diffuse tenderness, rebound tenderness, rigidity, and guarding. These patients should have an upright chest radiograph to screen for free air and a surgical consultation should be called.
What are classic symptoms of pancreatitis?
Sudden severe epigastric pain radiating to the back, nausea, vomiting, chills, malaise.
What lab findings are indicative of pancreatitis?
Leukocytosis, elevated LFTs, lipase, and amylase.
What imaging is done for suspected pancreatitis?
RUQ ultrasound or CT scan.
What CT finding suggests pancreatitis?
Enlarged edematous pancreas with peripancreatic inflammation and fluid.
What are classic symptoms of gastric conditions (e.g., GERD, gastritis, PUD)?
Burning sensation after eating, bloating, nausea, vomiting, hematemesis.
What are key risk factors for gastric conditions?
Alcohol use, chronic NSAID use, steroid use.
What is the Carnett sign and how is this used to help diagnose abdominal pathology?
While supine, ask the patient to tense their abdomen while lifting their head or legs. If the pain increases the source of pain is likely in their abdominal wall. A negative sign would indicate that pain is in their abdominal cavity.
What imaging should be done before an upper GI endoscopy?
Upright chest x-ray or abdominal x-ray series to rule out perforation.
Upper EGD will help to diagnose … ?
PUD, Gastritis, Duodenitis, GERD.
What are the main causes of Left Upper Quadrant pain?
LEFT UPPER QUADRANT PAIN:
* Splenomegaly
* Splenic infarct
* Peptic ulcer
* Gastritis
* Nephrolithiasis
What hematologic conditions cause left upper quadrant pain?
Splenic conditions (splenic abscess, infarction, splenic artery aneurysm) and hematologic disorders (sickle cell anemia, lymphoma).
What is the diagnostic workup for suspected hematologic conditions?
Blood smear!
What are classic symptoms of splenic pathology?
Abdominal fullness, early satiety, fatigue, referred shoulder pain.
What is Kehr’s sign?
Referred shoulder pain due to splenic pathology (usually infarction).
Why is endocarditis a risk factor for splenic infarctions?
Septic emboli.
What lab findings suggest splenic disease?
Leukocytosis, thrombocytopenia due to sequestration.
What imaging should be ordered for suspected splenic pathology?
Abdominal ultrasound followed by CT if needed.
What CT finding suggests splenic infarction?
Wedge-shaped hypodense lesion.
What is characteristic of a splenic abscess?
Riim enhancements and septations.
What CT finding suggests a splenic artery aneurysm?
Well-defined, round, hyperdense lesion (surgical emergency).
What is the importance of the hepatic and splenic flexures in abdominal pain?
Colon diseases can ALSO present with upper quadrant pain.
