1. Abdominal Pain William Beaumont Hospital Department of Emergency Medicine

2. Abdominal Pain • One of the most common CC • Confounders making dx difficult • Age • Corticosteroids • Diabetics • Recent antibiotics

3. Abdominal Pain: Pitfalls • Consider non-GI causes • Acute MI (inferior), ectopic pregnancy, DKA, sickle cell anemia, porphyria, HSP, acute adrenal insufficiency • History • Location, quality, severity, onset, duration, aggravating and alleviating factors, prior symptoms

4. Abdominal Pain: History • Sudden onset – perforated viscus • Crushing – esophageal or cardiac dz • Burning – peptic ulcer dz • Colicky – biliary or renal dz • Cramping – intestinal • Ripping – aneurysmal rupture

5. Abdominal Pain: Physical Exam • Abdomen • Inspection • Bowel sounds • Tenderness (rebound, guarding) • Extra-abdomen exam • Lung, cardiac, pelvic, GU and rectal

6. Work up: Labs • Beta-hCG • WBC – poor sensitivity and specificity • LFTs – hepatobiliary • Lipase – pancreatic • Electrolytes – CO2 • Lactic acid • Urinalysis – BEWARE

7. Work up: Imaging • Acute Abdominal Series • Free air and bowel gas • KUB • Poor screening test • Ultrasound – • Biliary dz, AAA, free fluid or air, pelvic pathology • CT – appendicitis, diverticulitis

8. Case: Upper Abdominal Pain • 79 yo female presents with aching sharp pain in the epigastrium and right upper quadrant ½ hour after eating. Pain radiates to the back. +N, –V • Differential diagnosis? • Testing?

9. RUQ/midepigastric pain • Biliary disease • PUD/gastritis • Pancreatitis • AAA • Pneumonia (RLL) • Pyelonephritis • Acute MI • Hepatitis • Appendicitis • Fitz-Hugh Curtis syndrome

10. Gallstones: Risk Factors • Female 4:1 • Fertile • Forty • Fat • Family history • Crohns, UC, SCA, thalassemia • Rapid weight loss, starvation, TPN • Elevated TGs, cholesterol

11. Cholelithiasis • History: • RUQ/epigastric pain • Nausea/vomiting with fatty meals • Similar episodes in past • PE: RUQ tenderness • Labs: may be normal • ECG: consider in older patients • Imaging: test of choice = US

12. Cholelithiasis: Treatment • Symptomatic gallstones • Pain control • Anti-emetics • Consult general surgery • 90% with recurrent symptoms • 50% develop acute cholecystitis

13. Cholelithiasis: Treatment • Asymptomatic gallstones • Incidental finding • 15-20% become symptomatic • Outpatient elective surgery if • Frequent, severe attacks • Diabetic • Large calculi

14. Acute Cholecystitis • Sudden GB inflammation • Bacterial infection in 50-80% • E. coli, Klebsiella, Enterococci • History/PE: • Fever, tachycardia, RUQ tenderness • Murphy’s sign – low sensitivity • Labs: • Elevated WBC with left shift • LFTs – large elevation  CBD stone

15. Acute Cholecystitis: Imaging • KUB – stones only seen @ 10% • Air in biliary tree  gangrenous • Ultrasound – sensitivity 90-95% • Gallstones (absent in biliary stasis) • Thickened GB wall • Pericholecystic fluid • CT scan – sensitivity 50% • HIDA scan – negative scan rules out dx • Positive = no visualization of the GB

16. Acute Cholecystitis

17. Acute Cholecystits: Treatment • Admit • NPO, IVF • Pain control • Anti-emetics • Antibiotics • Surgical consult

18. Pancreatitis • Autodigestion of pancreatic tissue • B – Biliary • A – Alcohol • D – Drugs • S – Scorpion bite • H – HyperTG, HyperCa • I – Idiopathic, Infection • T – Trauma

19. Pancreatitis: History and Physical • History: • Boring pain in LUQ or epigastrium • Constant • Radiates to midback • Nausea, vomiting • PE: • Epigastric or LUQ tenderness • Grey-Turner or Cullen sign

20. Gray-Turner sign • Flank ecchymosis • Intraperitoneal bleeding • Hemorrhagic pancreatitis, ruptured abdominal aorta, or ruptured ectopic pregnancy

21. Cullen's Sign • Periumbilical hemorrhage

22. Pancreatitis: Diagnosis • Lipase – most specific • Ranson’s criteria – predicts outcome • Acutely: >55 yo, glucose > 200, WBC >16k, SGOT (ALT) > 250, LDH > 350 • 48 hrs: HCT decreases > 10%, BUN rises > 5, Ca < 8, pO2 < 60, base deficit >4, fluid sequestration > 6L • 3-4 criteria – 15% mortality • 5-6 criteria – 40% mortality • 7-8 criteria – 100% mortality

23. Pancreatitis: Imaging • Plain films – sentinel loop (local ileus) • Ultrasound – poor (biliary tree) • *CT scan with contrast*

24. Pancreatitis: Treatment • NPO, IVF, pain control, antiemetics • Antibiotics if gallstones or septic • Surgical consult • If gallstones, abscess, hemorrhage or pseudocyst • ERCP if CBD stone

25. Gastritis/PUD • Duodenal 80%; gastric 20% • Etiology: H pylori, NSAIDS, zollinger-ellison syndrome, smoking, ETOH, FHx, male, stress • H pylori – 95% duodenal; 85% gastric • History: • Epigastric constant, gnawing pain • Food lessens – duodenal • Food worsens - gastric

26. PUD: Workup/Treatment • Workup: • Hemoglobin • PT/PTT – if bleeding • Lipase – rule out pancreatitis • Hemoccult stool – rule out GI bleed • Treatment: • Antacids (GI cocktail), PPI, outpatient endoscopy and H. pylori testing

27. Perforated Viscus • Rare in small bowel and mid-gut • History: abrupt onset pain • Diagnosis: upright CXR • Tx: IVF, IV abx, NGT, OR

28. Questions on Upper Abdominal Pain? Let’s Move On Down

29. Case: Lower Abdominal Pain • History: 35 y/o female c/o 1 day of periumbilical aching pain. +N,+V, +D, +F, +C, +anorexia. Today, she has crampy lower abdominal pain. No urinary sx. • Exam: afebrile, bilateral lower quadrant tenderness (R > L), no rebound or guarding. • Other questions? • Differential diagnosis? Testing?

30. Appendicitis • Incidence – 6% • Mortality – 0.1% • Perforation 2-6% (9% elderly) • All ages – peak 10 – 30 yo • Difficult dx: young, old, pregnant (RUQ), immunocompromised

31. Appendicitis • Abdominal pain (98%) • Periumbilical migrating to RLQ < 48 hrs • Anorexia 70% • Nausea, vomiting 67% • Common misdiagnosis – gastroenteritis, UTI

32. Appendicitis • PE: RLQ tenderness 95% • Rovsing: RLQ pain palpating LLQ • Psoas: R hip elevation,extension • Obturator: flexion, internal rotation

33. Appendicitis: Diagnosis • Labs: • WBC > 10k – 75% • UA – sterile pyuria • Imaging: • Ultrasound • CT scan

34. Appendicitis: Treatment • IV fluids, NPO, analgesia • Antibiotics • Surgery consult

35. Diverticulitis • Inflammation of a diverticulum (herniation of mucosa through defects in bowel wall); sigmoid colon is the most common site • History: • L > R • 3% under 40 • LLQ pain with BMs • N/V/constipation • PE: LLQ tenderness • Diagnosis: clinical, CT

36. Diverticulitis: Treatment • Admit if fever, abscess • NPO, IV fluids, IV antibiotics • Surgical consultation

37. Case: Generalized Abdomen Pain • History: 80 y/o male c/o nausea and crampy abdominal pain x 1 day. Emesis which was bilious and is now malodorous and brown. • PE: Diffusely tender, distended, with hyperactive bowel sounds. • Differential Diagnosis? • Workup?

38. SBO • Etiology • Adhesions (>50%) • Incarcerated hernia • Neoplasms • Adynamic ileus – non mechanical • Abd trauma (post op), infection, hypokalemia, opiates, MI, scleroderma, hypothyroidism • Rare: intusseception, bezoar, Crohn’s ds, abscess, radiation enteritis

39. LBO • Etiology • Tumor  left = obstruct; right = bleeding • Diverticulitis • Volvulus • Fecal impaction • Foreign body

40. Bowel Obstruction • Pathophysiology: 3rd spacing  bowel wall ischemia  perforates, peritonitis  sepsis  shock • History: crampy, colicky diffuse abd pain, vomiting (feculent), no flatus or BMs • PE: abdominal distension, high pitched BS, diffuse tenderness • Diagnosis: AAS shows A/F levels with dilated bowel (SB > 3cm; LB > 10cm)

41. SBO: Imaging

42. SBO: Treatment • IV fluids! • Correct electrolyte abnormalities • NPO/NGT • Broad spectrum abx if peritonitis • Surgery consult

43. Sigmoid Volvulus • History: • Elderly, bedridden, psychiatric pts • Crampy lower abd pain, vomiting, dehydration, obstipation • Prior h/o constipation • PE: • Diffuse abd tenderness • Distension

44. Sigmoid Volvulus

45. Sigmoid Volvulus: Imaging and Treatment • AAS: dilated loop of colon on left • Barium enema: “bird’s beak” • WBC > 20k: suggests strangulation • CT scan • Treatment: IVF, surgical consult, abx if suspect perforation

46. Cecal volvulus • Most common in 25-35 year olds • No underlying chronic constipation • History: Severe, colicky abd pain, vomiting • PE: Diffusely tender abdomen, distension

47. Cecal Volvulus • KUB: coffee bean – large dilated loop colon in midabdomen, empty distal bowel • Tx: surgery • Mortality: 10-15% if bowel viable; 30-40% if gangrene

48. Hernias • Inguinal (most common) 75% • Indirect 50% vs direct 25% men > women, high risk incarceration in kids • Femoral 5% - women > men • Incisional 10% • Umbilical – newborns, women > men • Incarcerated – unable to reduce • Strangulated – incarcerated with vascular compromise

49. Hernias • Clinical presentation: • Most are asymptomatic • Leads to SBO sxs • Peritonitis and shock – if strangulation • Treatment: • Reduce if non-tender – trendelenberg, sedation, warm compresses • Do not reduce if possible dead bowel • Admit via OR if strangulation

50. Mesenteric Ischemia • Etiology • 50% arterial emboli • 20% non-occlusive dz (CHF, sepsis, shock) • 15% arterial thrombi • 5% venous occlusion • Mortality rates 70-90% - delayed dx