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The Problem of Pain Approach to Abdominal Pain Jason Phillips, MD.

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1 The Problem of Pain Approach to Abdominal Pain Jason Phillips, MD

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5 ER approach to abdominal pain Chief complaint: abd pain  Labs: CBC, chem, LFTs, lipase  CT abdomen  History  Possible PE

6 How do you approach a workup for abdominal pain? What are the most likely possibilities? How do you organize your thoughts?

7 The Problem of Pain  Neurologic basis of pain Why is it difficult to localize? Why does the intensity of the pain vary?  General overview of approaching a patient with abdominal pain  Pain syndromes

8 Neurologic basis of abdominal pain  Pain receptors respond to Mechanical stimuli Chemical stimuli  Nociception mechanical receptors are located on serosa, within the mesentery, in the GI tract wall in the myenteric plexus (Auerbach plexus) submucosal plexus (Meissner plexus)

9 Neurologic basis of abdominal pain  Mucosal receptors respond to chemical stimuli  Substance P, serotonin, histamine, and prostaglandins  Chemical stimuli are released in response to inflammation or ischemia

10 Two basic problems with abdominal pain  Localization of visceral pain  Intensity of pain response

11 Localization of visceral pain  Visceral pain localizes to midline Bilateral, symmetric innervation Afferent fibers  celiac, superior mesenteric, or inferior mesenteric ganglion Localizes: epigastrium, periumbilical, and lower abdomen

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13 Localization of visceral pain  Exceptions to the bilateral rule  Gallbladder  Ascending and descending colon  Although bilaterally innervated, they have predominant ipsilateral innervation

14 Localization of visceral pain  Referred pain Somatic fiber “cross-talk” Activate same spinothalamic pathways  referred pain as the cutaneous dermatome sharing the same spinal cord level (Gallbladder – scapula) Results in aching pain with skin hyperalgesia and rigidity

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16 Intensity of pain response  Threshold for perceiving pain from visceral stimuli has marked individual variability  Balloon distension experiment in IBS

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18 History  MOST IMPORTANT CLUE to the source of abdominal pain  Type of pain Visceral = dull, aching, poorly localized Parietal = sharp, well localized Referred pain

19 History  General location Generalized, RUQ, epigastric, LUQ, periumbilical, RLQ, LLQ, and ‘migratory’ General region localizes organs/structures to include in the DDX Radiation of pain (e.g., acute pancreatitis)

20 History  Onset of pain Most gradual, steady crescendo (e.g., cholecystitis) Abrupt, “10/10” – suggestive of perforation  Quality of pain Colicky (comes and goes) – e.g., gastroenteritis Steady – (e.g., acute pancreatitis; biliary colic is a misnomer) Burning

21 History  Severity of pain Generally corresponds to severity of illness However, marked patient variability (“12/10 pain” is often functional or has functional overlay)  Aggravating or Relieving factors Eating (mesenteric ischemia vs PUD) Position changes (acute pancreatitis, peritonitis)

22 History  Associated symptoms Nausea/vomiting Weight loss Changes in bowel habits

23 Physical exam: Acute abdomen or not?  General appearance and Vital signs  Abdominal exam Auscultation  Bowel sounds present?  High pitched sounds of obstruction  Stethoscope palpation Percussion  Tympany = distended bowel  Most humane test for rebound tenderness

24 Physical exam: Acute abdomen or not?  Palpation: Acute abdomen or not? Peritoneal signs Rebound tenderness Mass? Hernia  Abdominal wall maneuvers Leg lift maneuvers (Carnett’s sign) Abdominal crunch

25 Further evaluation  Directed at pain syndromes  Labs  Imaging

26 Is the pain functional or not?

27 Functional abdominal pain  Can be difficult to distinguish from organic pain  Can only be labeled as functional when organic causes are excluded  Can superimpose on organic pain  Should not cause Weight loss, Anemia, GI bleeding, Fever, Night sweats

28 Is it functional or not?  Clues that are suggestive of functional Atypical history  RUQ that lasts 20 sec is not biliary colic  Dyspesia that worsens with a PPI Overly dramatic descriptions of pain  “It feels like a knife stabbing me over and over and then something is pushing inside out” Hyperbolic intensity  “11/10 epigastric pain” with a benign abd exam

29 Is it functional or not?  Clues that are suggestive of functional Absence of nocturnal symptoms Exacerbated by stress Distractible exam “Gut feeling”

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31 Pain syndromes

32 Irritable Bowel Syndrome  Prevalence: 10-15% of overall population  Only ~15% of patients seek medical care  25-50% of gastroenterology visits  Annual healthcare cost: $1.7 billion

33 Irritable Bowel Syndrome ROME criteria:  12 weeks or more of abdominal pain/discomfort in the last 12 months (does not have to be consecutive)  Two or more features: 1. Relieved with defecation 2. Change in frequency of stool 3. Change in appearance of stool

34 Irritable Bowel Syndrome 3 types of IBS patients  Constipation-predominant  Diarrhea-predominant  Alternating

35 Irritable Bowel Syndrome What is the normal range for frequency of bowel movements? Rule of 3s: - Normal = Anywhere from 3x per week to up to 3x per day

36 Irritable Bowel Syndrome Pathophysiology Alterations in motility Visceral hyperalgesia Postinfectious IBS – lymphocytic infiltration of myenteric plexus?

37 Irritable Bowel Syndrome How do you prove its only IBS? Rome criteria positive for IBS   No alarm features and mild symptoms, reassurance and treatment of symptoms  Alarm features or severe symptoms, consider referral to GI

38 Upper abdominal pain  Biliary disease  Dyspepsia  Pancreatitis  Gastroparesis  Other

39 Upper abdominal pain: Biliary disease 1. Most common location – epigastric NOT RUQ 2. Steady onset; last hours (not minutes or seconds) 3. Can radiate to right scapula Biliary colic Cholecystitis Acute cholangitis

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41 Upper abdominal pain: Biliary disease  Workup: Labs: When are liver tests abnormal? Imaging: What is the most sensitive imaging study for biliary tract disease? What are its limitations?

42 Upper abdominal pain: Biliary disease  Labs: LFTs increase with choledocholithiasis (first transaminases, then AP/T Bili)  Ultrasound: SensitivitySpecificity Cholecystitis88%89%  HIDA97%90% Gallstones84%99% Biliary dilation55-91% Choledocholithiasis50 vs 75% (nondilated vs dilated CBD)

43 Upper abdominal pain: Dyspepsia  Dyspepsia = “persistent or recurrent abdominal pain or discomfort in the upper abdomen.”  Vague diagnosis that includes a long DDX

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45 Upper abdominal pain: Dyspepsia  % of ‘dyspepsia’ is a acid-related phenomenon or functional  Usually an outpatient problem  Peptic ulcer pain = epigastric, burning or hunger-like, worse between meals, relieved with food, nocturnal pain, associated nausea

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47 Upper abdominal pain: Dyspepsia  GERD = heartburn (retrosternal burning), water brash (acid taste in mouth), regurgitation, and sensation of dysphagia

48 Upper abdominal pain: Dyspepsia  Functional dyspepsia = same symptoms but no organic etiology can be found 12 weeks over last 12 months Not relieved with BM or associated with alterations in BMs (i.e., NOT IBS)

49 Upper abdominal pain: Dyspepsia  Best test?  3 strategies Empiric PPI H pylori – test and treat EGD

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51 Gastroparesis  Often overlooked as a cause for epigastric pain  Gastroparesis symptoms Nausea 93% Abdominal pain 90%  Epigastric burning, vague, cramping Early satiety 86% Vomiting 68%

52 Gastroparesis  60% report pain is worse after eating  80% reports pain interrupted sleep  Vomiting food hours later  Look for important historical clues Diabetes Meds (narcotics, anticholinergics) Recent viral gastroenteritis CNS disease Amyloid, scleroderma

53 Gastroparesis  Workup EGD or UGI – rule out GOO Gastric emptying scan

54 Upper abdominal pain: Pancreatitis  Acute Pancreatitis = acute epigastric pain that radiates to back, constant, severe, rapid onset within 1 hour, lasts days, associated nausea/vomiting, relieved with sitting forward; assoc restlessness  Rarely diffuse pain, RUQ, or LUQ

55 Upper abdominal pain: Pancreatitis Diagnosis is made when you have at least 2 of the 3 criteria: - Typical pancreatitic pain - Elevation in amylase and lipase - Abnormal imaging

56 Upper abdominal pain: Pancreatitis  Chronic pancreatitis = similar pain, less severe and onset minutes after a meal, can be episodic (early in disease course) or constant (late finding)  Associated malabsorption (pancreatic exocrine insufficiency) and diabetes (endocrine insufficiency) Steatorrhea does not occur until 90% or more of pancreatic function is lost

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58 Upper abdominal pain: Other causes  Acute MI  Pneumonia  Splenic abscess or infarct

59 Lower abdominal pain  Appendicitis  Diverticular disease  IBS  Crohn’s disease  Hernia  Other

60 Lower abdominal pain  Appendicitis = begins as periumbilical pain that localizes to RLQ (McBurney’s point) Initially visceral pain (superior mesenteric ganglion) RLQ when inflammation extends to peritoneal surface (parietal pain)  Pain evolves over hours  Exam: peritoneal irritation (rebound) + fever  Labs: Elevated WBC

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62 Lower abdominal pain  Diverticulitis = usually LLQ abdominal pain Constant w insidious onset Worsening over days Associated symptoms of fever and worsening constipation

63 Lower abdominal pain  Exam: spectrum of severity Mild  LLQ tenderness Severe  LLQ rebound  Labs: Elevated WBC  Imaging

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65 Lower abdominal pain  70% of diverticulitis in Western countries in left sided. What group of patients usually have right sided diverticultitis (~75%)?  Do seeds cause diverticulitis and should they be avoided?

66 Lower abdominal pain  IBD can give lower abdominal pain with diarrhea, weight loss, hematochezia, fever These clues are more obvious  However, 10% of patients with Crohn’s disease will NOT have diarrhea and can present with abdominal pain RLQ  ileocecal CT, colonoscopy, SBFT

67 Lower abdominal pain  Hernia = weakness or disruption of the abdominal wall Indirect: at the internal ring Direct: Hesselbach’s triangle Umbilical Epigastric Incisional

68 Lower abdominal pain  Groin hernias  pain or dull pressure with lifting, straining, or increasing intrabdominal pressure; worse with prolonged standing and at end of day Physical exam is crucial  Outright pain at rest is concerning for strangulation

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70 Lower abdominal pain  If in doubt, consult surgery for an opinion  If a hernia is bright red and impossible to reduce, call a surgeon immediately

71 Lower abdominal pain: Non-GI causes  Nephrolithiasis Colicky pain (spasms lasting mins) Site depends on location of stone (flank  groin) UA: hematuria (neg in 20-30% of cases) CT renal stone protocol

72 Lower abdominal pain: Non-GI causes  Pelvic inflammatory disease Pelvic pain during menses or coitus Onset during of shortly after menses Bilateral Usually less than 2 weeks Exam critical: speculum and bimanual exam

73 Diffuse abdominal pain  Gastroenteritis  IBS  Obstruction  Mesenteric ischemia

74 Diffuse abdominal pain  Viral gastroenteritis = colicky abdominal cramps, watery diarrhea, and nausea/vomiting Incubation hours Symptoms begin with abdominal cramps and/or nausea  most have vomiting and watery diarrhea Mild fever, myalgias Lasts hrs

75 Diffuse abdominal pain  Obstruction Periumbilical pain with paroxysms of cramps occurring every 4-5 minutes Abdominal distension Nausea Obstipation may be delayed up to 24 hours History of abdominal surgery or malignancy

76 Diffuse abdominal pain  Obstruction Exam: distended appearance, tympanic, high pitched tinkle or large bowel sounds NGT decompression Abdominal x-rays – supine and upright

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78 Ischemia  Acute mesenteric ischemia Embolism Thrombosis Vasospasm  Chronic mesenteric ischemia Intestinal angina  Can be difficult to diagnose

79 Acute mesenteric ischemia  Embolic  sudden onset of severe, diffuse pain Writhing in pain Abdominal exam feels benign - :pain out of proportion to exam” Be suspicious in the right patient: atrial fibrillation, mechanical heart valves, age

80 Acute mesenteric ischemia  Thrombotic and non-occlusive  insidious onset of pain  Labs: nonspecific until late in the course  Imaging: mesenteric angiogram

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82 Questions?


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