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William Beaumont Hospital Department of Emergency Medicine

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1 William Beaumont Hospital Department of Emergency Medicine
Abdominal Pain William Beaumont Hospital Department of Emergency Medicine

2 Abdominal Pain One of the most common chief complaints
Confounders making diagnosis difficult Age Corticosteroids Diabetics Recent antibiotics

3 Pitfalls Consider non-GI causes History
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 History Sudden onset – perforated viscus
Crushing – esophageal or cardiac disease Burning – peptic ulcer disease Colicky – biliary or renal disease Cramping – intestinal pathology Ripping – aneurismal rupture

5 Physical Exam Abdomen Extra-abdominal exam Inspection Bowel sounds
Tenderness (rebound, guarding) Extra-abdominal exam Lung Cardiac Pelvic GU Rectal

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

7 Imaging Acute Abdominal Series KUB Ultrasound CT Biliary disease
Free air Bowel gas KUB Poor screening test Ultrasound Biliary disease AAA Free fluid or air Pelvic pathology CT Appendicitis Diverticulitis

8 Case #1 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 Upper Abdominal Pain Biliary disease Hepatitis Pancreatitis
PUD/gastritis/esoph agitis AAA Pneumonia (RLL) Pyelonephritis Acute MI Appendicitis Fitz-Hugh Curtis

10 Gallstone Risk Factors
Female 4:1 Fertile Forty Fat Family history Others: Crohns, UC, SCA, thalassemia, rapid weight loss, starvation, TPN, elevated TGs, cholesterol

11 Cholelithiasis History: PE: RUQ tenderness Labs: may be normal
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 Asymptomatic Pain control Anti-emetics Consult general surgery 90% with recurrent symptoms 50% develop acute cholecystitis Incidental finding 15-20% become symptomatic Outpatient elective surgery if Frequent, severe attacks Diabetic Large calculi

13 Acute Cholecystitis Sudden gallbladder 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

14 Acute Cholecystitis: Imaging
KUB – stones only seen ~ 10% Air in biliary tree  gangrenous CT scan – sensitivity 50% Ultrasound – sensitivity 90-95% Gallstones (absent in biliary stasis) Thickened gallbladder wall Pericholecystic fluid HIDA scan – negative scan rules out diagnosis Positive = no visualization of the GB HIDA – including cystic duct stones

15 Acute Cholecystitis

16 Acute Cholecystits: Treatment
Admit NPO IVF Pain control Anti-emetics Antibiotics Surgical consult

17 Hepatitis Viral Bacterial Alcoholic Immune Medications Hepatitis A
RNA, fecal-oral Hepatitis B DNA, STD/parenteral Chronic hepatitis (10%) Hepatitis C RNA, blood borne Chronic hepatitis (50%), cirrhosis (20%) Hepatitis D RNA, co-infects Hep B Bacterial Alcoholic Immune Medications

18 Hepatitis: Diagnosis History: Labs: Malaise, low-grade fever, anorexia
Nausea/vomiting, abd pain, diarrhea Jaundice (altered MS, liver failure) Labs: ALT and AST (10-100x normal) AST > ALT – alcoholic hepatitis Elevated bilirubin Abnormal PT Hepatitis panel Tylenol level

19 Hepatitis: Treatment Symptomatic – IVF, electrolytes
Remove toxins – ETOH, acetaminophen Admit if altered MS or coagulopathy

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

21 Pancreatitis: History and Physical
Boring pain in LUQ or epigastrium Constant Radiates to mid-back Nausea, vomiting PE: Epigastric or LUQ tenderness Grey-Turner or Cullen sign

22 Gray-Turner sign Flank ecchymosis Intraperitoneal bleeding
Hemorrhagic pancreatitis Ruptured abdominal aorta Ruptured ectopic pregnancy

23 Cullen's Sign

24 Pancreatitis: Diagnosis
Lipase – most specific Ranson’s criteria – predicts outcome Acutely: >55 yo, glucose > 200, WBC >16k, 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

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

26 Pancreatitis: Treatment
NPO IVF Pain control Antiemetics Antibiotics if gallstones or septic Surgical consult If gallstones, abscess, hemorrhage or pseudocyst ERCP if CBD stone

27 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

28 Peptic Ulcer Disease Workup: Treatment: Hemoglobin
PT/PTT – if bleeding Lipase – rule out pancreatitis Hemoccult stool – rule out GI bleed Treatment: Antacids (GI cocktail) PPI Outpatient endoscopy H. pylori testing

29 Perforated Viscus Rare in small bowel and mid-gut
History: abrupt onset pain Diagnosis: upright CXR Treatment: IVF IV antibiotics NG tube OR

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

31 Case #2 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?

32 Lower Abdominal Pain Appendicitis Diverticulitis UTI/Pyleonephritis
Renal colic Torsion/TOA/PID Ectopic pregnancy

33 Appendicitis Incidence – 6% Mortality – 0.1%
Perforation 2-6% (9% elderly) All ages – peak 10 – 30 yo Difficult diagnosis: Young and old Pregnant (RUQ) Immunocompromised

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

35 Appendicitis PE: RLQ tenderness 95% Rovsing: RLQ pain palpating LLQ
Psoas: R hip elevation, extension Obturator: flexion, internal rotation Psoas – have pt lie on left side; hyperextend right thigh at the hip

36 Appendicitis: Diagnosis
Labs: WBC > 10k – 75% UA – sterile pyuria Imaging: Ultrasound CT scan MRI

37 Appendicitis: Treatment
IV fluids NPO Analgesia Antibiotics Surgery consult

38 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

39 Diverticulitis: Treatment
Admit if fever, abscess, elderly NPO IV fluids IV antibiotics Ciprofloxacin AND metronidazole Surgical consultation

40 Case #3 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?

41 Differential Diagnosis
Small bowel obstruction Large bowel obstruction Sigmoid volvulus Cecal volvulus Hernia Mesenteric ischemia GI Bleed

42 Small Bowel Obstruction
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 disease, abscess, radiation enteritis

43 Large Bowel Obstruction
Etiology Tumor Left  obstruct Right  bleeding Diverticulitis Volvulus Fecal impaction Foreign body

44 Bowel obstruction Pathophysiology: 3rd spacing  bowel wall ischemia  perforates, peritonitis  sepsis  shock History: crampy, colicky diffuse abdominal pain, vomiting (feculent), no flatus or BM PE: abdominal distension, high pitched BS, diffuse tenderness Diagnosis: AAS shows air fluid levels with dilated bowel SB > 3cm; LB > 10cm Loss of colonic air with SBO

45 SBO: Imaging

46 SBO: Treatment IV fluids! Correct electrolyte abnormalities NPO
NG tube Broad spectrum antibiotics if peritonitis Surgery consult

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

48 Sigmoid Volvulus

49 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 Antibiotics if suspect perforation

50 Cecal volvulus Most common in 25-35 year olds
No underlying chronic constipation History: Severe, colicky abd pain Vomiting PE: Diffusely tender abdomen Distension

51 Cecal Volvulus KUB: Treatment:
Coffee bean – large dilated loop colon in midabdomen Empty distal bowel Treatment: Surgery Mortality –10-15% if bowel viable; 30-40% if gangrene

52 Hernias Inguinal (most common) 75% Femoral 5% - women > men
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

53 Hernias Clinical presentations: Treatment 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

54 Mesenteric Ischemia Etiology
50% arterial emboli 20% non-occlusive disease (CHF, sepsis, shock) 15% arterial thrombi 5% venous occlusion Mortality rates 70-90% - delayed diagnosis

55 Mesenteric Ischemia History:
Pathophysiology: impaired blood supply from SMA, IMA, celiac trunk  adynamic ileus  mucosal infarction & 3rd spacing  bacterial invasion  sepsis  shock History: Acute, severe, colicky, poorly localized pain Postprandial pain Nausea, vomiting and diarrhea

56 Mesenteric Ischemia: Diagnosis
Pain out of proportion to exam! Heme positive stools (>50%) May present as LGIB Peritonitis and shock Late findings WBC > 15k Metabolic acidosis Lactic acid – high sensitivity, not specific

57 Mesenteric Ischemia: Diagnosis
CT scan Bowel wall edema/gas, +/- mesenteric thrombus Normal CT does NOT rule out Plain films – late findings Portal venous gas Pneumatosis intestinalis Treatment: IVF NG tube IV antibiotics IR consult for angiography Surgical consult

58 GI hemorrhage: Upper GIB vs. Lower GIB
History: Hematemesis seen in 50% UGIB Melena 70% UGIB 30% LGIB Hematochezia – LGIB vs. rapid UGIB Ask about: NSAID, ASA, ETOH, Plavix, warfarin Night sweats, weight loss, bowel changes  malignancy Iron, bismuth – guaiac negative, black stools

59 GI hemorrhage Consider with chief complaints:
Weakness SOB Dizzy Abdominal pain PE: orthostatics, abdomen, rectal Conjunctival pallor Cool, clammy skin Spider angiomata, palmer erythema, jaundice, bruises  liver disease

60 GIB: Diagnosis Hemoccult – iodide, methylene blue and red meat cause false pos Labs: CBC (Hg < 8) PT T & S Increased BUN (blood, hypovolemia) ECG – rule out silent MI (anemia) NG tube – rule out UGI bleed

61 Upper GI Hemorrhage: Etiology
PUD 60% Gastritis/esophagitis 15% Varices – portal HTN, liver disease Mallory-Weiss Aortoenteric fistula – H/o AAA repair Other: Stress ulcers, malignancy, AVM, ENT bleeds, hemoptysis

62 Lower GI Hemorrhage: Etiology
Hemorrhoids – most common overall Diverticulosis – most common severe cause LGIB Angiodysplasia Polyps/cancer Rectal disease IBD

63 GIB: Treatment Unstable: Upper GI bleed  GI for endoscopy
IV x 2, O2, monitor Blood products – FFP, pRBCs, platelets NG tube with lavage if upper GIB suspected Upper GI bleed  GI for endoscopy Lower GI bleed  GI and/or surgery consults Tagged red blood cell study – need 0.1 – 0.2 ml/min of hemorrhage

64 GIB: Treatment Colonscopy – ligate or sclerose diverticulosis, AVM bleeds EGD – band ligation or sclerose varices Octreotide – varices, PUD Vasopressin – varices Sengstaken-Blakemore tube – varices

65 GIB: Surgical Indications
Hemodynamically unstable Unresponsive to endoscopy, IV fluids, and correction of coagulopathy Transfused > 5units in 4-6 hrs Mortality 23% if emergent surgery

66 GIB: Disposition Admit Observation Discharge home Any UGIB
Any hemodynamic instability Significant LGIB Observation LGIB with stable vital signs and HgB Discharge home Hemorrhoid bleed, rectal negative with normal HgB

67 Case #4 70 y/o male with HTN, DM c/o acute onset right flank pain. Pain is sharp and crampy, radiates to the groin. He is pale, diaphoretic. Abdomen is soft, diffusely tender, no rebound or guarding. What are you thinking and what are you going to do?

68 Differential Diagnosis
Renal colic Mesenteric ischemia PUD with perforation GI bleed Diverticulitis Cholecystitis Pancreatitis Low back pain

69 AAA 4 male: 1 female Peak incidence 70 yo
98% infrarenal (50% involve iliacs) 33% of cases initially misdiagnosed Renal colic, low back pain Risk factors: HTN*, smoking, COPD, diabetes, hyperlipidemia, connective tissue disease (Marfan’s, Ehlers-danlos)

70 AAA: Pathophysiology Atherosclerosis causes loss of elastin and collagen in aortic wall Normal aorta diameter = 2 cm Uncommon to rupture if < 5 cm Elective repair 30% of aneurysms >5 cm rupture within 5 years

71 AAA History: PE: Sudden onset severe constant mid-abdomen or back pain
Pain may radiate to the thigh or testes Back/flank pain – retroperitoneal ureteral irritation PE: Pulsatile mass 50-90% Abdominal distension due to RP or IP blood Abdominal bruit 3-8% Blue toe syndrome 5% due to emboli

72 AAA: Diagnosis ECG Plain films US CT Angiography
R/o free air or SBO Calcified aorta US Helpful to diagnosis Does not delineate rupture or leaking aneurysm CT Evaluates size, leakage and extent Angiography May miss AAA if mural thrombus

73 AAA

74 AAA: Treatment Asymptomatic patient Symptomatic patient
Incidental finding <4 cm – repeat US Q6 months >4 cm – elective repair Symptomatic patient CT to confirm diagnosis (if stable) 2 large bore IVs T&C pRBC - ~8 units Admit via OR (vascular surgery consult)

75 AAA: Mortality Elective repair – 4% Post rupture – 45% Normal BP – 20%
Hypotensive, responds to volume – 40% Hypotensive, incomplete response 60% Hypotensive, no urinary output – 80%

76 The End Any Questions?


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