Presentation on theme: "UNC Emergency Medicine Medical Student Lecture Series"— Presentation transcript:
1 UNC Emergency Medicine Medical Student Lecture Series Acute Abdominal PainUNC Emergency MedicineMedical Student Lecture Series
2 Case #124 yo healthy M with one day hx of abdominal pain. Pain was generalized at first, now worse in right lower abd & radiates to his right groin. He has vomited twice today. Denies any diarrhea, fevers, dysuria or other complaints. No appetite today. ROS otherwise negative.PMHx: negativePSurgHx: negativeMeds: noneNKDASocial hx: no alcohol, tobacco or drug useFamily hx: non-contributoryBasic cases to go through the most common abd pain complaints we see in the ED
3 Abdominal pain What else do you want to know? What is on your differential diagnosis so far?(healthy male with RLQ abd pain….)How do you approach the complaint of abdominal pain in general?Let’s review in this lecture:Types of painHistory and physical examinationLabs and imagingAbdominal pain in special populations (Elderly, HIV)Clinical pearls to help you in the ED
4 “Tell me more about your pain….” LocationQualitySeverityOnsetDurationModifying factorsChange over time
5 What kind of pain is it? Visceral Parietal Referred Involves hollow or solid organs; midline pain due to bilateral innvervationSteady ache or vague discomfort to excruciating or colicky painPoorly localizedEpigastric region: stomach, duodenum, biliary tractPeriumbilical: small bowel, appendix, cecumSuprapubic: colon, sigmoid, GU tractParietalInvolves parietal peritoneumLocalized painCauses tenderness and guarding which progress to rigidity and rebound as peritonitis developsReferredProduces symptoms not signsBased on developmental embryologyUreteral obstruction → testicular painSubdiaphragmatic irritation → ipsilateral shoulder or supraclavicular painGynecologic pathology → back or proximal lower extremityBiliary disease → right infrascapular painMI → epigastric, neck, jaw or upper extremity pain
7 And don’t forget the history GIPast abdominal surgeries, h/o GB disease, ulcers; FamHx IBDGUPast surgeries, h/o kidney stones, pyelonephritis, UTIGynLast menses, sexual activity, contraception, h/o PID or STDs, h/o ovarian cysts, past gynecological surgeries, pregnanciesVascularh/o MI, heart disease, a-fib, anticoagulation, CHF, PVD, Fam Hx of AAAOther medical historyDM, organ transplant, HIV/AIDS, cancerSocialTobacco, drugs – Especially cocaine, alcoholMedicationsNSAIDs, H2 blockers, PPIs, immunosuppression, coumadin
8 Moving on to the Physical Exam GeneralPallor, diaphoresis, general appearance, level of distress or discomfort, is the patient lying still or moving around in the bedVital SignsOrthostatic VS when volume depletion is suspectedCardiacArrhythmiasLungsPneumoniaAbdomenLook for distention, scars, massesAuscultate – hyperactive or obstructive BS increase likelihood of SBO fivefold – otherwise not very helpfulPalpate for tenderness, masses, aortic aneurysm, organomegaly, rebound, guarding, rigidityPercuss for tympanyLook for hernias!rectal examBackCVA tendernessPelvic examCMTVaginal discharge – CultureAdenexal mass or fullnessOrthostatic VS are less reliable in the diabetic, elderly, those on beta-blocker. Pulse increase of 30 or presyncope on standing are highly sensitive for loss of 1 L of blood or 3L of fluid. BP changes are less reliable. Patient must be standing at least one minute before measurements are taken.
9 Abdominal Findings Guarding Rebound VoluntaryContraction of abdominal musculature in anticipation of palpationDiminish by having patient flex kneesInvoluntaryReflex spasm of abdominal musclesaka: rigiditySuggests peritoneal irritationReboundPresent in 1 of 4 patients without peritonitisPain referred to the point of maximum tenderness when palpating an adjacent quadrant is suggestive of peritonitisRovsing’s sign in appendicitisRectal examLittle evidence that tenderness adds any useful information beyond abdominal examinationGross blood or melena indicates a GIBHeme positive stool – 10% of people over the age of 50 sent home with diagnosis of NSAP and heme positive stools were found to have cancer within a year.Heme positive stool in the setting of suspected PUD should elicit more urgent referral for further evaluation
10 Differential Diagnosis It’s Huge!Use history and physical exam to narrow it downRule out life-threatening pathologyHalf the time you will send the patient home with a diagnosis of nonspecific abdominal pain (NSAP or Abdominal Pain – NOS)90% will be better or asymptomatic at 2-3 weeks
12 Most Common Causes in the ED Non-specific abd pain 34%Appendicitis 28%Biliary tract dz 10%SBO 4%Gyn disease 4%Pancreatitis 3%Renal colic 3%Perforated ulcer %Cancer 2%Diverticular dz 2%Other 6%
13 What kind of tests should you order? Depends what you are looking for!Abdominal series3 views: upright chest, flat view of abdomen, upright view of abdomenLimited utility: restrict use to patients with suspected obstruction or free airUltrasoundGood for diagnosing AAA but not ruptured AAAGood for pelvic pathologyCT abdomen/pelvisNoncontrast for free air, renal colic, ruptured AAA, (bowel obstruction)Contrast study for abscess, infection, inflammation, unknown causeMRIMost often used when unable to obtain CT due to contrast issueLabsCBC: “What’s the white count?”ChemistriesLiver function tests, LipaseCoagulation studiesUrinalysis, urine cultureGC/Chlamydia swabsLactate
14 Disposition Depends on the source Non-specific abdominal pain No source is identifiedVital signs are normalNon specific abdominal exam, no evidence of peritonitis or severe painPatient improves during ED visitPatient able to take fluidsHave patient return to ED in hours for re-examination if not better or if they develop new symptoms
15 Back to Case #1….24 yo with RLQ pain Physical exam:T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat: 100% room airUncomfortable appearing, slightly paleAbdomen: soft, non-distended, tender to palpation in RLQ with mild guarding; hypoactive bowel soundsGenital exam: normalWhat is your differential diagnosis and what do you do next?
16 Appendicitis Classic presentation Periumbilical painAnorexia, nausea, vomitingPain localizes to RLQOccurs only in ½ to 2/3 of patients26% of appendices are retrocecal and cause pain in the flank; 4% are in the RUQA pelvic appendix can cause suprapubic pain, dysuriaMales may have pain in the testiclesFindingsDepends on duration of symptomsRebound, voluntary guarding, rigidity, tenderness on rectal examPsoas signObturator signFever (a late finding)Urinalysis abnormal in 19-40%CBC is not sensitive or specificAbdominal xraysAppendiceal fecalith or gas, localized ileus, blurred right psoas muscle, free airCT scanPericecal inflammation, abscess, periappendiceal phlegmon, fluid collection, localized fat stranding
21 Appendicitis Diagnosis Treatment WBC Clinical appendicitis – call your surgeonMaybe appendicitis - CT scanNot likely appendicitis – observe for 6-12 hours or re-examination in 12 hoursTreatmentNPOIVFsPreoperative antibiotics – decrease the incidence of postoperative wound infectionsCover anaerobes, gram-negative and enterococciZosyn grams IV or Unasyn 3 grams IVAnalgesia
22 Case #268 yo F with 2 days of LLQ abd pain, diarrhea, fevers/chills, nausea; vomited once at home.PMHx: HTN, diverticulosisPSurgHx: negativeMeds: HCTZNKDASocial hx: no alcohol, tobacco or drug useFamily hx: non-contributory22
23 Case #2 Exam T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99% room air Gen: uncomfortable appearing, slightly paleCV/Pulmonary: normal heart and lung exam, no LE edema, normal pulsesAbd: soft, moderately TTP LLQRectal: normal tone, guiac neg brown stoolWhat is your differential diagnosis & what next?
24 Diverticulitis Risk factors Clinical features Physical Exam DiverticulaIncreasing ageClinical featuresSteady, deep discomfort in LLQChange in bowel habitsUrinary symptomsTenesmusParalytic ileusSBOPhysical ExamLow-grade feverLocalized tendernessRebound and guardingLeft-sided pain on rectal examOccult bloodPeritoneal signsSuggest perforation or abscess rupture
25 Diverticulitis Diagnosis Treatment CT scan (IV and oral contrast) Pericolic fat strandingDiverticulaThickened bowel wallPeridiverticular abscessLeukocytosis present in only 36% of patientsTreatmentFluidsCorrect electrolyte abnormalitiesNPOAbx: gentamicin AND metronidazole OR clindamycin OR levaquin/flagylFor outpatients (non-toxic)liquid diet x 48 hourscipro and flagyl
26 Case #346 yo M with hx of alcohol abuse with 3 days of severe upper abd pain, vomiting, subjective fevers.Med Hx: negativeSurg Hx: negativeMeds: none; Allergies: NKDASocial hx: homeless, heavy alcohol use, smokes 2ppd, no drug use
27 Case #3 ExamVital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat: 95% room airGeneral: ill-appearing, appears in painCV: tachycardic, normal heart sounds, pulses normalLungs: clearAbdomen: mildly distended, moderately TTP epigastric, +voluntary guardingRectal: heme neg stoolWhat is your differential diagnosis & what next?
28 Pancreatitis Risk Factors Clinical Features Physical Findings Alcohol GallstonesDrugsAmiodarone, antivirals, diuretics, NSAIDs, antibiotics, more…..Severe hyperlipidemiaIdiopathicClinical FeaturesEpigastric painConstant, boring painRadiates to backSevereN/VbloatingPhysical FindingsLow-grade feversTachycardia, hypotensionRespiratory symptomsAtelectasisPleural effusionPeritonitis – a late findingIleusCullen sign*Bluish discoloration around the umbilicusGrey Turner sign*Bluish discoloration of the flanks*Signs of hemorrhagic pancreatitis
29 Pancreatitis Treatment Diagnosis NPO IV fluid resuscitation Maintain urine output of 100 mL/hrNGT if severe, persistent nauseaNo antibiotics unless severe diseaseE coli, Klebsiella, enterococci, staphylococci, pseudomonasImipenem or cipro with metronidazoleMild disease, tolerating oral fluidsDischarge on liquid dietFollow up in hoursAll others, admitDiagnosisLipaseElevated more than 2 times normalSensitivity and specificity >90%AmylaseNonspecificDon’t bother…RUQ US if etiology unknownCT scanInsensitive in early or mild diseaseNOT necessary to diagnose pancreatitisUseful to evaluate for complications
30 Case #472 yo M with hx of CAD on aspirin and Plavix with several days of dull upper abd pain and now with worsening pain “in entire abdomen” today. Some relief with food until today, now worse after eating lunch.Med Hx: CAD, HTN, CHFSurg Hx: appendectomyMeds: Aspirin, Plavix, Metoprolol, LasixSocial hx: smokes 1ppd, denies alcohol or drug use, lives alone
31 Case #4 Exam T: 99.1, HR: 70, BP: 90/45, R: 22, O2sat: 96% room air General: elderly, thin male, ill-appearingCV: normalLungs: clearAbd: mildly distended and diffusely tender to palpation, +rebound and guardingRectal: blood-streaked heme + brown stoolWhat is your differential diagnosis & what next?
32 Peptic Ulcer Disease Physical Findings Epigastric tenderness Risk FactorsH. pyloriNSAIDsSmokingHereditaryClinical FeaturesBurning epigastric painSharp, dull, achy, or “empty” or “hungry” feelingRelieved by milk, food, or antacidsAwakens the patient at nightNausea, retrosternal pain and belching are NOT related to PUDAtypical presentations in the elderlyPhysical FindingsEpigastric tendernessSevere, generalized pain may indicate perforation with peritonitisOccult or gross blood per rectum or NGT if bleeding
33 Peptic Ulcer Disease Diagnosis Treatment Empiric treatment Rectal exam for occult bloodCBCAnemia from chronic blood lossLFTsEvaluate for GB, liver and pancreatic diseaseDefinitive diagnosis is by EGD or upper GI barium studyTreatmentEmpiric treatmentAvoid tobacco, NSAIDs, aspirinPPI or H2 blockerImmediate referral to GI if:>45 yearsWeight lossLong h/o symptomsAnemiaPersistent anorexia or vomitingEarly satietyGIB
35 Perforated Peptic Ulcer Abrupt onset of severe epigastric pain followed by peritonitisIV, oxygen, monitorCBC, T&C, LipaseAcute abdominal x-ray seriesLack of free air does NOT rule out perforationBroad-spectrum antibioticsSurgical consultation
36 Case #535 yo healthy F to ED c/o nausea and vomiting since yesterday along with generalized abdominal pain. No fevers/chills, +anorexia. Last stool 2 days ago.Med Hx: negativeSurg Hx: s/p hysterectomy (for fibroids)Meds: none, Allergies: NKDASocial Hx: denies alcohol, tobacco or drug useFamily Hx: non-contributory
37 Case #5 Exam T: 36.9, HR: 100, BP: 130/85, R: 22, O2 sat: 97% room air General: mildly obese female, vomitingCV: normalLungs: clearAbd: moderately distended, mild TTP diffusely, hypoactive bowel sounds, no rebound or guardingWhat is your differential and what next?
39 Bowel Obstruction Physical Findings Mechanical or nonmechanical causes #1 - Adhesions from previous surgery#2 - Groin hernia incarcerationClinical FeaturesCrampy, intermittent painPeriumbilical or diffuseInability to have BM or flatusN/VAbdominal bloatingSensation of fullness, anorexiaPhysical FindingsDistentionTympanyAbsent, high pitched or tinkling bowel sound or “rushes”Abdominal tenderness: diffuse, localized, or minimal
40 Bowel Obstruction Diagnosis CBC and electrolytes electrolyte abnormalitiesWBC >20,000 suggests bowel necrosis, abscess or peritonitisAbdominal x-ray seriesFlat, upright, and chest x-rayAir-fluid levels, dilated loops of bowelLack of gas in distal bowel and rectumCT scanIdentify cause of obstructionDelineate partial from complete obstructionTreatmentFluid resuscitationNGTAnalgesiaSurgical consultHospital observation for ileusOR for complete obstructionPeri-operative antibioticsZosyn or unasyn
41 Case #648 yo obese F with one day hx of upper abd pain after eating, does not radiate, is intermittent cramping pain, +N/V, no diarrhea, subjective fevers. No prior similar symptoms.Med hx: deniesSurg hx: deniesNo meds or allergiesSocial hx: no alcohol, tobacco or drug use
42 Case #6 ExamT: 100.4, HR: 96, BP: 135/76, R: 18, O2 sat: 100% room airGeneral: moderately obese, no acute distressCV: normalLungs: clearAbd: moderately TTP RUQ, +Murphy’s sign, non-distended, normal bowel soundsWhat is your differential and what next?
43 Cholecystitis Clinical Features Physical Findings RUQ or epigastric painRadiation to the back or shouldersDull and achy → sharp and localizedPain lasting longer than 6 hoursN/V/anorexiaFever, chillsPhysical FindingsEpigastric or RUQ painMurphy’s signPatient appears illPeritoneal signs suggest perforation
44 Cholecystitis Diagnosis Treatment CBC, LFTs, Lipase RUQ US HIDA scan Elevated alkaline phosphataseElevated lipase suggests gallstone pancreatitisRUQ USThicken gallbladder wallPericholecystic fluidGallstones or sludgeSonographic murphy signHIDA scanmore sensitive & specific than USH&P and laboratory findings have a poor predictive value – if you suspect it, get the USTreatmentSurgical consultIV fluidsCorrect electrolyte abnormalitiesAnalgesiaAntibioticsCeftriaxone 1 gram IVIf septic, broaden coverage to zosyn, unasyn, imipenem or add anaerobic coverage to ceftriaxoneNGT if intractable vomiting
45 Case #734 yo healthy M with 4 hour hx of sudden onset left flank pain, +nausea/vomiting; no prior hx of similar symptoms; no fevers/chills. +difficulty urinating, no hematuria. Feels like has to urinate but cannot.PMHx: negSurg Hx: negMeds: none, Allergies: NKDASocial hx: occasional alcohol, denies tobacco or drug useFamily hx: non-contributory
46 Case #7 Exam T: 98.9, HR: 110, BP: 150/90, R: 20, O2 sat: 99% room air General: writhing around on stretcher in pain, +diaphoreticCV: tachycardic, heart sounds normalLungs: clearAbd: soft; non-tenderBack: mild left CVA tendernessGenital exam: normalNeuro exam: normalWhat is your differential diagnosis and what next?
47 Renal Colic Clinical Features Physical Findings Acute onset of severe, dull, achy visceral painFlank painRadiates to abdomen or groin including testiclesN/V and sometimes diaphoresisFever is unusualWaxing and waning symptomsPhysical Findingsnon tender or mild tenderness to palpationAnxious, pacing, writhing in bed – unable to sit still
48 Renal Colic Diagnosis Treatment Urinalysis CBC BUN/Creatinine CT scan RBCsWBCs suggest infection or other etiology for pain (ie appendicitis)CBCIf infection suspectedBUN/CreatinineIn older patientsIf patient has single kidneyIf severe obstruction is suspectedCT scanIn older patients or patients with comorbidities (DM, SCD)Not necessary in young patients or patients with h/o stones that pass spontaneouslyTreatmentIV fluid bolusesAnalgesiaNarcoticsNSAIDSIf no renal insufficiencyStrain all urineFollow up with urology in 1-2 weeksIf stone > 5mm, consider admission and urology consultIf toxic appearing or infection foundIV antibioticsUrologic consult
49 Just a few more to go….hang in there Ovarian torsionTesticular torsionGI bleedingAbd pain in the Elderly
50 Ovarian Torsion Obtain ultrasound Labs IV fluids NPO Pain medications Acute onset severe pelvic painMay wax and wanePossible hx of ovarian cystsMenstrual cycle: midcycle also possibly in pregnancyCan have variable exam:acute, rigid abdomen, peritonitisFeverTachycardiaDecreased bowel soundsMay look just like AppendicitisObtain ultrasoundLabsCBC, beta-hCG, electrolytes, T&SIV fluidsNPOPain medicationsGYN consult
51 Testicular Torsion Detorsion Emergent urology consult Sudden onset of severe testicular painIf torsion is repaired within 6 hours of the initial insult, salvage rates of % are typical. These rates decline to nearly 0% at 24 hours.Approximately 5-10% of torsed testes spontaneously detorse, but the risk of retorsion at a later date remains high.Most occur in males less than 20yrs old but 10% of affected patients are older than 30 years.DetorsionEmergent urology consultUltrasound with doppler
52 Abdominal Pain in the Elderly Mortality rate for abdominal pain in the elderly is 11-14%Perception of pain is alteredAltered reporting of pain: stoicism, fear, communication problemsMost common causes:CholecystitisAppendicitisBowel obstructionDiverticulitisPerforated peptic ulcerDon’t miss these:AAA, ruptured AAAMesenteric ischemiaMyocardial ischemiaAortic dissection
53 Abdominal Pain in the Elderly Appendicitis – do not exclude it because of prolonged symptoms. Only 20% will have fever, N/V, RLQ pain and ↑WBCAcute cholecystitis – most common surgical emergency in the elderly.Perforated peptic ulcer – only 50% report a sudden onset of pain. In one series, missed diagnosis of PPU was leading cause of death.Mesenteric ischemia – we make the diagnosis only 25% of the time. Early diagnosis improves chances of survival. Overall survival is 30%.Increased frequency of abdominal aortic aneurysmsAAA may look like renal colic in elderly patients
54 Mesenteric IschemiaConsider this diagnosis in all elderly patients with risk factorsAtrial fibrillation, recent MIAtherosclerosis, CHF, digoxin therapyHypercoagulability, prior DVT, liver diseaseSevere pain, often refractory to analgesicsRelatively normal abdominal examEmbolic source: sudden onset (more gradual if thrombosis)Nausea, vomiting and anorexia are common50% will have diarrheaEventually stools will be guiaic-positiveMetabolic acidosis and extreme leukocytosis when advanced disease is present (bowel necrosis)Diagnosis requires mesenteric angiography or CT angiography
55 Abdominal Aortic Aneurysm Risk increases with age, women >70, men >55Abdominal pain in 70-80% (not back pain!)Back pain in 50%Sudden onset of significant painAtypical locations of pain: hips, inguinal area, external genitaliaSyncope can occurHypotension may be presentPalpation of a tender, enlarged aorta on exam is an important findingMay present with hematuriaSuspect it in any older patient with back, flank or abdominal pain especially with a renal colic presentationUltrasound can reveal the presence of a AAA but is not helpful for rupture. CT abd/pelvis without contrast for stable patients. High suspicion in an unstable patient requires surgical consult and emergent surgery.
56 GI Bleeding Upper Lower Proximal to Ligament of Treitz Peptic ulcer disease most commonErosive gastritisEsophagitisEsophageal and gastric varicesMallory-Weiss tearLowerHemorrhoids most commonDiverticulosisAngiodysplasiaFirst: r/o upper GI bleedLower GI bleed: most common hemorrhoidsDiverticulosis has potential for massive bleeding
57 Medical History Common Presentation: High level of suspicion with Hematemesis (source proximal to right colon)Coffee-ground emesisMelenaHematochezia (distal colorectal source)High level of suspicion withHypotensionTachycardiaAnginaSyncopeWeaknessConfusionCardiac arrest
58 Labs and Imaging Type and crossmatch: Most important! Other studies: CBC, BUN, creatinine, electrolyte, coagulation studies, LFTsInitial Hct often will not reflect the actual amount of blood lossAbdominal and chest x-rays of limited value for source of bleedNasogastric (NG) tubeGastric lavageAngiographyBleeding scanEndoscopy/colonoscopyNG tube for all significant bleeds: in 14% of bright red blood or maroon per rectum from upper GI sourceNegative NG aspirate does not r/o upper sourceUse room temp water for lavage and lavage until clear
59 Management in the ED ABCs of Resuscitation AIRWAY: BREATHING Consider definitive airway to prevent aspiration of bloodBREATHINGSupplemental OxygenContinuous pulse oximetry
60 Management in ED Circulation Cardiac monitoring Volume replacement Crystalloids2 large-bore intravenous lines (18g or larger)Blood ProductsGeneral guidelines for transfusionActive bleedingFailure to improve perfusion and vital signs after the infusion of 2 L of crystalloidLower threshold in the elderlyNOT BASED ON INITIAL HEMATOCRIT ALONECoagulation factors replaced as neededUrinary catheter with hypotension to monitor output
61 Management Early GI consult for severe bleeds Therapeutic Endoscopy: band ligation or injection sclerotherapyAlso….electrocoagulation, heater probes, and lasersDrug Therapy: somatostatin, octreotide, vasopressin, PPIsBalloon tamponade: adjunct ortemporizing measureSurgery: if all else failsOctreotide is 50 µg IV bolus, followed by 50 µg 8–24hSomatostatin is 250–500 µg IV bolus followed by 250–500 µg per hProtonix 80mg IV bolus x 1; then 8mg/hr for 72 hours
62 DispositionADMITCertain patients with lower GI bleeding may be discharged for Outpatient work-upPatients are risk stratified by clinical and endoscopic criteriaIndependent predictors of adverse outcomes in upper GI bleeding (Corley and colleagues):Initial hematocrit < 30 %Initial SBP < 100 mm HgRed blood in the NG lavageHistory of cirrhosis or ascites on examinationHistory of vomiting red blood
63 Abdominal Pain Clinical Pearls Significant abdominal tenderness should never be attributed to gastroenteritisIncidence of gastroenteritis in the elderly is very lowAlways perform genital examinations when lower abdominal pain is present – in males and females, in young and oldIn older patients with renal colic symptoms, exclude AAASevere pain should be taken as an indicator of serious diseasePain awakening the patient from sleep should always be considered signficantSudden, severe pain suggests serious diseasePain almost always precedes vomiting in surgical causes; converse is true for most gastroenteritis and NSAPAcute cholecystitis is the most common surgical emergency in the elderlyA lack of free air on a chest xray does NOT rule out perforationSigns and symptoms of PUD, gastritis, reflux and nonspecific dyspepsia have significant overlapIf the pain of biliary colic lasts more than 6 hours, suspect early cholecystitisFor free air – instill 500cc of air into stomach via NGT and repeat xray or do noncontrast CT scan