1. Systematic Approach to Abdominal Pain
Dr Devinder Singh Bansi BM DM FRCP
Consultant Gastroenterologist
Imperial College Healthcare NHS Trust

2. What Do They Have?
As you go through this presentation, think about each of these cases:
An 18 mo old that suddenly became inconsoleable from AP while playing
A 20 yo man with 12 hours of diffuse crampy AP that migrated to RLQ that became sharp
78 yo woman with h/o chronic steroid use with sudden sharp AP and a rigid exam

3. Scale of the Problem GI symptoms in primary care
% of all primary consultations are with regard to GI complaints
Gastric pain: per 1000/yr
Regurgitation: 2.0
Abdominal pain: 6.1
Nausea: 2.9
Diarrhoea: 6.7
Constipation: 8.1
Thompson WG, Gut 2000: 46: 78-82

4. Scale of the Problem: Abdominal pain in the general population
Community prevalence 15-20%
75% of these abdominal complaints non-consulting
25% consulting
23.5% stay in primary care
1-2% referred to secondary care

5. Scale of the Problem: Abdominal pain in general practice
578 cases of non-acute abdominal pain presenting to 11 general practices
Follow up 15 months
Females predominated in the younger age groups
80% visited GP <3 times during F/U
83% managed entirely in the practices
64% received a prescription
Only 20% were additionally investigated in anyway by the GP
Hardly any differences in dx between patients who had complaints less than 1 week or more than 1 week before presenting to their GP
Family Practice Vol 10:

6. Scale of the Problem: Prevalence of GI disease
Peptic ulcer: 1.9 per 1000/yr
Oesophagitis: 2.9
IBD: 1.5
GI cancer: 1.6
Functional dyspepsia: 12
GORD: 5.8
IBS:
80% of chronic GI disease has a functional background
Thompson WG . Gut 2000: 46: 78-82

7. Scale of the problem; Acute abdominal pain
Acute abdominal pain is not uncommon.
Approximately 5 admissions to the MRI/day with acute abdominal pain from a population base of 500,000.
1 case per GP per month for an average list size of 2,000.

8. Acute Abdominal Pain Approximately 6% of ED visits
Admission rates vary by population, up to about 65% in high risk elderly populations
Most common diagnosis is NONSPECIFIC (ie, “I dunno”)
Use H+P, risk factors, and directed studies to arrive at diagnosis
MUST rule out emergency conditions

9. Acute Abdominal Pain Causes in 10320 patients
Appendicitis 28%
Cholecystitis 10%
Small bowel obstruction 4%
Gynaecological 4%
Pancreatitis 3%
Renal colic 3%
Peptic ulcer 2%
Cancer 2%
No clinical diagnosis 34%
De Dombal, Scand J Gastroenterol 1988

10. Abdominal Pain Across the Ages
Colic, GE, viral illness, constipation
Ages 2-12
Functional, appendicitis, GE, toxins
Teens to adults
Addition of genitourinary problems
Elderly
Beware of what seems like everything!

11. Special Populations Elderly/ nursing home patients Immunocompromised
Post operative patients
Infants

12. Abdominal Pain in the Elderly
Diminished sensation of pain in the elderly
Comorbid diseases
Polypharmacy
Combinations of above result in many more vague, nonspecific presentations
Twice as likely to require surgery with presentation over age 65
Social factors

13. Understanding the Types of Abdominal Pain
Visceral
Stretch fibers in capsules or walls of hollow viscus that enter both sides of spinal cord
Somatic
Fibers dermatomally distributed and enter unilaterally in the spinal cord
Referred
Overlap of fibers from other locations

14. Understanding the Types of Abdominal Pain
Visceral
Crampy, achy, diffuse,
Poorly localized
Somatic
Sharp, lancinating
Well localized
Referred
Distant from site of generation
Symptoms, but no signs

15. Understanding the Types of Abdominal Pain
Location, location, location
Organs and their corresponding fiber entry to the spinal cord
C3-5 – liver, spleen, diaphragm
T5-9 – gallbladder, stomach, pancreas, small intestine
T10-11– colon, appendix, pelvic viscerat11-l1 – sigmoid, renal capsules, ureters, gonads
S2-4 - bladder

16. History Taking in Abdominal Pain Presentations
“OLD CARS”
O- onset
L- location
D- duration
C- character
A-alleviating/aggravating factors
associated symptoms
R- radiation
S- severity

17. History Taking for Abdominal Pain Presentations
PMH
Similar episodes in past
Other medical problems that increase disease likelihood of problems (ex: DM and gastroparesis)
PSH
Adhesions, hernias, tumors
MEDS
Abx, NSAIDS, acid blockers, etc
GYN/URO
LMP, bleeding, discharge
Social
Tob/EtoH/drugs/home situation/agenda

18. Physical Exam in Abdominal Pain Presentations
General appearance
“Sick versus not sick”
Mobile versus still
Obvious pain or discomfort
“Doorway” impression
Vital signs
“That’s why they’re called vital”

19. Physical Exam in Abdominal Pain Presentations
Inspection
Distention, scars, bruises
Auscultation
Present, hyper, or absent
Actually not that helpful!
Palpation
Often the most helpful part of exam
Tenderness versus pain
Start away from painful area first
Guarding, rebound, masses

20. Physical Exam in Abdominal Pain Presentations
Signs
Iliopsoas
Murphy’s
Extra-abdominal exam
Pelvic or scrotal exams
Lungs, heart
Remember it’s a patient, not a part
Rectal
Adds very little (despite the angst) beyond gross blood or melena

21. Laboratory Testing Everybody likes a CBC, but…
Lacks sensitivity, no specificity
Little to no change in diagnostic probabilities
Should not dramatically alter approach (tender is still tender)

22. Laboratory Testing Directed approach to lab studies
There are no “standard belly labs”
Pregnancy test in women of child bearing age
Urine dipsticks

23. Imaging Plain films Ultrasound Computed Tomography
Free air, obstruction, air-fluid, FBs
Ultrasound
Rapid “yes or no” ED evaluations
Formal studies
May add doppler
Computed Tomography
Revolutionized acute care
Often better than we are!

24. Common Diagnoses by Quadrant

26. Management of Abdominal Pain
Always right to start with ABC’s
IV access
Fluid administration
Antiemetics
Analgesics
Directed testing and imaging
Re-evaluations
Antibiotics
Consultants
Surgeons, OB/GYN, urologists, cardiologists, etc

27. Now How About Those Cases
18 mo old had classic presentation of intussusception, and symptoms may wax and wane; rectal would be to look for current jelly stool. Air enema for diagnosis and reduction. Involve consultants early in the course.

28. Now How About Those Cases
20 year old with classic presentation of appendicitis, which likely does not need CT scan. Most do not present so simply, quite a wide array of presentations. General surgery consultation, pain meds, IVF, and an operation would all be good, but don’t be shocked if CT requested.

29. Now How About Those Cases
78 yo has perforated abdomen, with age, multiple problems, and chronic steroids risks for perforation. Rapid resuscitation, plain films to confirm free air, antibiotics, pain medicine, and a surgeon as fast as you can would be good practice.

30. Pearls, Pitfalls and Myths
Do not restrict the diagnosis solely by the location of the pain.
Consider appendicitis in all patients with abdominal pain and an appendix, especially in patients with the presumed diagnosis of gastroenteritis, PID or UTI.
Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain.
The WBC count is of little clinical value in the patient with possible appendicitis.
Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative.
Pain medications reduce pain and suffering without compromising diagnostic accuracy.
An elderly patient with abdominal pain has a high likelihood of surgical disease.
Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain.
A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis; they need an operation.
The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA.

31. Simplified rules for the diagnosis of acute abdominal pain.
Think in terms of the area of the pain.
Common conditions are common.
Disease prevalence changes with age.
Different patterns of disease between men and women.