1. An approach to abdominal pain
Dr. Shamim Ahmad Bhat
Consultant Emergency Medicine
King Saud Medical City
Riyadh. KSA

2. INTRODUCTION Types of pain Special Populations Assessment
History
Examination
Investigations
Differential Diagnosis
Management - overview
Cases ( if time permits)
Sticking to basics!

3. Types Of Pain Visceral Parietal Pain
Useful to have a basic understanding of the mechanism of abdominal pain’

4. Visceral Pain
Stretching of nerve fibres of walls or capsules of organs
Crampy
Dull
Achy
Often unable to lie still
Bilateral innervation
Caused by stretching of Unmyelinated fibres innervating the capsules or walls of organs
Can also be caused by early ischaemia or inflammation
Intermittent or constant
Bilateral innervation – stimuli sent to both sides of spinal cord therefore felt midline regardless of the R or L sided origin of the stimulus
Localization is to the approximate embryologic origin of the organ involved. E.g. T10 for appx

5. Parietal Pain Parietal peritoneum irritated
Usually anterior abdominal wall
Localised to the dermatome superficial to the site of painful stimulus
Irritation of Myelinated fibres in the parietal peritoneum
Parietal afferents are sent from a specific area of the peritoneum and can be localized to the dermatome superficial to the painful stimulus

6. Course
Visceral
Non specific
Parietal
Localised tenderness
Guarding
Rigidity
Rebound
As the disease progresses visceral pain gives way to signs of parietal pain
As localized peritonitis ( inflammation of the peritoneum) develops  rigidity and rebound
Patient with peritonitis lie still

7. Referred Pain Examples of referred pain? Shoulder tip pain
Free fluid in abdomen eg perforated ectopic
Testicular pain
Renal Colic
Referred pain follows the path of the embryological origin of the organ
Felt distant to the site of the origin of the pain
Normally felt on the SAME side as the involved organ as it is not mediated by fibres that provide bilateral innervation to the organ

8. 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 %
Perforated ulcer %
Cancer 2%
Diverticular dz 2%
Other 6%

9. Special Populations WOMEN OF CHILD BEARING AGE
OLD AGE (ELDERLY PATIENTS)

10. Elderly May lack physical findings despite having serious pathology
As patients age increases diagnostic accuracy declines
Risk of Vascular Catastrophes
Assume surgical cause until proven otherwise
30-40% of geris with abdo pain need surgery
Biliary tract Disease is the commonest cause
Age > 65 need to think of reasons not to CT!
Mortality is 7% in the over 80’s - equivalent to AMI!

11. Elderly Patient think Nasties!
AAA
Ischaemic Gut
Bowel Obstruction
Diverticulitis
Perforated Peptic Ulcer
Cholecystitis
Appendicitis
Constipation is a diagnosis of exclusion – never make until all serious pathology has been excluded!

12. Women of Childbearing Age
Must Ascertain whether PREGNANT
ALL WOMEN OF CHILDBEARING AGE WITH ABDO PAIN NEED BHCG
Gravid uterus displaces intra-abdominal organs making presentations atypical
Pregnant women still get common surgical abdominal conditions
Needs to prove that they are not pregnant
Can affect nature of presentation – ie atypical presentation. Pregnancy related condition- ectopic/ abruption etc
The pregnant patient presenting with nontraumatic abdominal pain adds dozens of potential diagnoses to the equation.
It is also common for typical illness- es (like appendicitis) to present in atypical fashion due to the anatomic changes brought about by an enlarging uterus

13. History What are the key points of the abdominal pain history?
For Symptoms associated with the pain think from the top down
Nausea
Vomiting
Dyspepsia
Change in bowels
Urinary Symptoms
PV loss or bleeding

14. History HPC Pain Associated Symptoms – Consultations/ Presentations
Provocative
Palliative
Quality
Radiation
Symptoms associated with
Timing
Taken for the pain
Consultations/ Presentations
Associated Symptoms –
Gastro – intestinal
Genito-urinary
Gynaecologic
For Symptoms associated with the pain think from the top down
Nausea
Dyspepsia
Vomiting
Change in bowels
Urinary Symptoms
PV loss or bleeding

15. History PMH PSH DM HT Liver Disease Renal Disease
Sexually Transmitted Infections
PSH
Abdominal Surgery
Pregnancies
Deliveries/ Abortions/ Ectopics
Trauma

16. History Meds ALLS NSAIDs Steroids OCP/ Fertility Drugs Narcotics
Immunosuppressant
Chemotherapy agent
ALLS
Contrast
Analgesic

17. High Yield Questions Which came first – pain or vomiting?
How long have you had the pain?
Constant or intermittent?
History of cancer, diverticulosis, gall stones, Inflammatory BD?
Vascular history, HT, heart disease or AF?
Advanced age = increased risk of nasty
Pain first is worst –more likely to be caused by surgical disease
Pain for less than 48 hours more likely to have a surgical cause
Constant pain more likely to be serious than intermittent
First episode more likely to be something bad
Abs and steroids mask infection
Vascular history etc – consider mesenteric ischaemia or AAA

18. Examination Lots of information from the end of the bed Vital Signs
Distressed vs. non distressed
Lying still - peritonitis
Writhing – Renal Colic
Vital Signs
NEVER ignore abnormal vital signs!
Always document as part of your assessment
Absent or diminished BS add little clinically significant info
Hyperacive or obstructed BS are slightly more useful
Can have normal BS in SBO
Palpaption
How do you diminish voluntary guarding PR
PV All women with lower abdo pain looking for cervical excitation, adnexal tenderness, discharge – dont forget to take genital swabs when you perform the PV – blue and pinswabs for general and STD culture

19. ABDOMINAL EXAMINATION
This video shows an a thorough GI examination. Once you have perfected the full examination in the emergency department setting you need to perform a slick focused examination.

20. Whiteboard
Think Medical Surgical Female ( Don’t forget non-intra abdominals)
Stress AAA
Male Female
Differentials according to quadrant of pain

22. Investigations Bedside Bloods UE
Leucocyte Esterase and nitrites
Urine HCG
ECG – anyone with upper abdominal pain or elderly
Bloods
ALL WOMEN OF CHILDBEARING AGE NEED BHCG
What are your differentials?
Avoid machine gun approach!
CXR looking for perforation, referred pathology eg pneumonia, associated problems eg effusion with pancreatitis

23. Radiology CXR –?perforation ?Extra abdominal pathology
?Complications of intra-abdominal disease
Abdominal XR is overutilised.

24. Tracking Renal Calculi Foreign Body
Which of the following is NOT an indication for plain abdominal imaging?
Bowel Obstruction
Constipation
Tracking Renal Calculi
Foreign Body
As other diagnostic modalities have become more readily available over the past decade, the role of plain film abdominal radiography has come under question

25. SOME INTRESTING AXRs

26. What would you do with this?
If passed through the oesophagus into stomach will be OK
If vomiting
Abdo pain
Toxic – e.g. Pb or will need endoscopy.
Iron
Safety pins
Heavy metals

27. Patient brought in from the airport after getting off flight from South America

28. Large L renal Calculus
& stones radio opaque
CT is the primary investigation of choice
AXR will identify sufficiently large radiopaque stones such as calcium, struvite, and cystine stones
Miss small stones or stones overlying bony structures, and will not detect obstruction.
Used to tract progress of radiopaque stones to avoid multiple CTs

29. Other imaging ULTRASOUND Biliary Disease Good for gynae complaints
Rule out Ectopic pregnancy
Appendicitis in children
No radiation
If negative for appx does not exclude

30. CT ABDOMEN CT is accurate for diagnosis of Avoid repeated CT scans
Renal colic
Appendicitis
Diverticulitis
AAA
Intra abdominal Abscesses
Mesenteric Ischaemia
Bowel Obstruction
Avoid repeated CT scans
Limit use in younger patients
Avoid where possible in pregnant females
CT use has double in the last decade
Excellent diagnostic modality but radiation dose associated with it

31. Imaging Dose (mSV) CXR equivalents Pelvic XR 0.6 6 Abdominal XR 0.7 7
CT abdo-pelvis 14
140
CT aortogram 24
240
Mettler, FA, Huda, W, Yoshizumi, TT, Mahesh, M. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology 2008; 248:254.
Sievert (symbol: Sv) is the International System of Units (SI) SI derived unit of dose equivalent radiation.

32. Management Resuscitate with ABC APPROACH
Large bore access
N Saline bolus 20ml/kg x 2 if shocked
If bleeding think hypotensive resuscitation
All should be NBM until provisional diagnosis
Ensure normothermia
Maintenance fluids and fluid balance
Analgesia doesn’t mask signs
Use a the pain scale
Morphine titrated to pain. Normally 0.1mg/Kg
Paracetamol adjunct
NSAIDs for renal colic
Correct Electrolytes
Thromboprophylaxis

33. Cases

34. Case 1
21 year old female
24 hour history of vague peri-umbilical abdominal pain.
Moved down to the RIF.
Now constant and sharp.
Associated with 2x vomits and feels flushed
No appetite
Normal Bowels

35. What clinical signs may lead you to a diagnosis of appendicitis?
Lie still RIF tenderness Rebound Rovsig’s sign Psoas Sign
Lie still
RIF tender
Rebound
Weak cough or grabs abdomen whilst coughing
Rovsigs sign – highly sensitive for acute appx – gentle pressure on L then release - pain on the R
PR May get referred tenderness but seldom changes management
Psoas sign – lie patient L lateral and extend the hip – if increased pain of appx sitting on psoas – 95% specific

36. Imaging? AXR rarely useful USS Not as good as CT
Good for female to exclude gynae pathology
If appendix is visualised is useful CT
Only if there is doubt about diagnosis
Sensitivity up to 98%
High radiation dose
Diagnose other pathology if no appendicitis
Elderly
AXR rarely useful – may show appx faecolith, appendicieal gas, localised ileus, blurred R psoas muscle, free air if perforated
CT greater sensitivity, accuracy and negative predictive value than US.
High radiation dose – women and children
Provides alternative diagnoses
CT does not change management in men but can prevent unnecessary appendectomies in women

37. CT examination of the right lower quadrant after the administration of intravenous and enteric contrast material shows a dilated, fluid-filled appendix with a thickened wall (arrows). There are inflammatory changes in the adjacent fat tissue (arrowheads). Laparotomy confirmed the diagnosis of acute appendicitis, and an appendectomy was performed. The patient had an uneventful recovery.

38. Management NPO Analgesia Anti-emetic if necessary Maintenance fluids
IVABs – e.g. Ceftriaxone, Gentamicin and Metronidazole
Surgical Referral
Delay may lead to perforation and peritonitis
IV abs reduce the incidence of wound infection and abdominal wall abscess
OT either laparoscopy – reduced inpatient stay and analgesia requirements but takes longer
WCC sensitive but not specific

39. Case 2 40 yr old obese female RUQ pain Pain is constant
nausea, vomiting
fevers and chills
PMH Asthma
MEDS OCP SH
Drinks 2 std / week
Smokes 20/day
Nil drugs

40. On Examination Looks distressed. Not jaundiced T 38 C P 120 BP 100/60
RR 20
Sats 98% RA
Tender in the RUQ and Murphy’s positive.
What is Murphy’s sign?

41. What blood Tests will you order on this patient?

42. HB 13.8
WCC 16.0
Neuts 12.4
Lymph 1.6
EUC Normal
Bil 9 (<18)
ALP 450 (30-130)
GGT 320 (<60)
ALT 41 (5-55)
AST 30 (5-55)
Amylase 28 (<120)
Lipase 40 (<60)

43. Gall bladder here is 74mm ie greater than 5cm = enlarged

44. GB wall 7mm= > 5mm = thickened

45. Management NPO IVF IV abs –Ampicillin + Gentamicin
Analgesia +- anti emetic
Refer to surgeons
CT if diagnosis unclear or USS unavailable
USS is the investigation of choice

46. Case 3
52 yr old alcoholic
Constant epigastric pain radiating to the back. Worsening over the past 2 days
Improved with sitting up and forwards
Nausea and vomiting
Bowels OK
PMH Chronic Airways Limitation
Alcoholic Gastritis
MEDS Thiamine 100 mg daily
SH Boarding house resident
Drinks 4 litres wine/day
Smokes 20/day
52 yr old alcoholic from Bigge Park

47. Looks unwell and dehydrated T38.4C P105 BP 130/70 RR 18 Sats 93% RA
Cullen’s Sign Blue discolouration around periumbilicus due to haemoperitoneum – necrotic pancreatitis or intraabdominal bleeding
Grey Turner’s sign Grey discolouration to the flanks due to haemaglobin catbolism
his sign takes 24–48 hours. It can predict a severe attack of acute pancreatitis,[1] with mortality rising from 8-10% to 40%

48. Tender Epigastrium and RUQ
Reduced AE L base
Tender Epigastrium and RUQ
No guarding/ rebound
Turners sign – bluish discoloration of flank due to pancreatitis
Neither sign is specific to pancreatitis – can occur in other causes of retroperitoneal haemorrhage

49. What blood tests will you order?

50. Blood Results Glucose 15 Alb 23 Ca (Corr) 2.0 Haem HB 114 WCC 17
Biochem
Na 129
K 4.0
Cr 62
Ur 8.0
Amylase 1080 (<120)
Lipase 950 (<60)
Bil 11 ( 18)
GGT 900 (<60)
ALP 200 ( < 140)
AST 300 (5-55)
ALT 250 (5-55)
LDH 800( )
Glucose 15
Alb 23
Ca (Corr) 2.0
Haem
HB 114
WCC 17
Coags Normal
NB Lipase is more sensitive than amylase for pancreatitis.
If lipase is 3x upper limit of normal this is almost 100 % sensitive for pancreatitis
Rises within 4-8 hours in acute pancreatitis.
Peaks at 24 hours. Normal after 2 weeks
Amylase - > 3x upper limit of normal 80% sensitive, 95 % specific. Once > % sensitiveEUC Normal
Bil 9 (<18)
ALP 450 (30-130)
GGT 320 (<60)
ALT 41 (5-55)
AST 30 (5-55)
Amylase 28 (<120)
Lipase 40 (<60)

51. What imaging will you perform ( if any)?

52. CXR

53. Imaging CT USS CXR Look for complications
Confirms diagnosis
Identifies complications
Help’s grade severity
Not always necessary in ED
USS
Poor visualisation of pancreas
Good for looking at gall stones/ biliary tree dilatation
CXR
Look for complications
Pleural Effusion, Atelectasis, ARDS
AXR – not specific for pancreatitis – may see sentinal loop . Good for looking for other diagnoses such as obstruction

54. Management O2 NBM IVF Analgesia +-Antibiotics (controversial)
Correct Electrolytes
Thromboprophylaxis
ICD/Art-line/CVC depending on severity
Surgical Admit +_ ICU review
Several trials show that antibiotic prophylaxis reduce the development of sepsis
Large volumes of fluid may be needed due to ileus, effusions and oedema
Correct electrolytes such as hypocalcaemia
Antibiotics indicated if proven pancreatic necrosis on CT
Prophylactic abs may decrease septic complications in severe necrotising pancreatitis

55. Causes G all stones E toh T rauma S teroids M umps A utoimmune
S corpion Bites
H yperlidaemia/ hypercalcaemia/hypothermia
E RCP
D rugs
Gall stones commonest cause in women
Alcohol – normally after 10 years of heavy drinking. Commonest cause in men
Alcohol and gall stomes account for 90% cases
Drugs Azathiprine, Sulphonamides, thiazides, frusemide, oestrogens,tetracylcines,valproate

56. Case 4 27 yr old female 6/40 LIF constant severe sharp pain
Radiating to the back
Light bright red PV spotting
Feels light headed
PMH
IVF
Previous D+C x 2
Ovarian Cysts
MEDS Nil
SH Lives with partner
Non-smoker
Non-Drinker

57. On Examination Looks unwell. Pale, diaphoretic, restless P 150
BP 70/40
RR 26 Sats
98% RA
Tender and guarding in the LIF PV
Bright red blood spotting
L adnexal tenderness ++

58. How do you manage this patient?
Panic! ( don’t!)
Call for senior help
Large bore IV access x 2 (16 G or larger)
Urgent Cross Match
Fluid resuscitation
Call O+G urgently
Needs OR immediately
Cautious volume resus

59. Case 5
88 yr old female.
Peri-umbilical, colicky abdominal pain for 2 days
Abdominal distension
Vomits x 10
Reduced flatus for 2 days.
PMH
Cholecystectomy
appendectomy
TAH BSO
Hypertension

60. On examination Looks distressed Lying Still T 37.5 P 110 sinus
BP 150/80
RR 18
Sats 98% RA
Abdomen
Distended
Generally tender
No guarding rebound or rigidity
High pitched bowel sounds

61. Investigations
CT good at differentiating mechanical obstruction from an ileus or for the differentiation of simple SBO from stangulation

62. Investigations
Labs
AXR
CXR CT

63. Dilated loops of small Bowel
Multiple Air fluid levels 6
Adhesions
Neoplasm
Sms
Hernias-external, internal
Crohns \

64. Fee air under the diaphrag – small bowel obstruction and perforation

65. Management NPO Fluid resuscitation
Monitor volume status – may have large volume shifts
Correct Electrolytes
Analgesia
NG if vomiting
IV Abs – Ceftriaxone, metronidazole
Urgent Surgical consult for OR
IV abs for all people with mechanical obstruction as risk of infection and septicaemia is high
Discontinue medications that limit gut motility

66. Small Bowel Adhesions Hernias Polyps Lymphoma Adenocarcinoma
Gall Stones
Inflammatory BD
Bezoar – vegetable matter or pulp form persimmons – concretion in the small intestine
UPPER LIMIT OF NORMAL DIAM FOR SMALL BOWEL IS 2.5CM
Small intesitne has linear densities EXTENDING ACROSS the bowel lumen ( plicae circulares)

67. Large Bowel Almost never adhesions or hernia CARCINOMA Diverticulitis
Sigmoid Volvulus
Faecal Impaction
UPPER LIMIT OF NORMAL FOR LARGE BOWEL IS 5.5 CM
Colon - larger diameter. Thick densities HAUSTRA EXTEND PARTIALLY into the lumen

68. Case 6
73 yr old male presents with sudden onset of central abdominal pain radiating to the back. He also reports weakness to both legs
PMH HT
Hypercholesterolemia
Current smoker 30/day
MEDS
Aspirin 100mg Daily
Perindopril 5 mg Daily
Atorvastatin 10 mg Daily SH
Lives Alone
Fully independent with ALS
Occasional alcohol

69. Examination Distressed P 130 BP 80/60 RR 26 Sats 99% RA Abdomen
Non-distended
Generally tender.

70. Bedside Ultrasound 9cm Abdominal Aortic Aneurysm (AAA):
The diagnosis of AAA (defined as a maximal aortic diameter of greater than 3 cm) and ruptured AAA has increased over the last several years.
majority of patients with rup- tured AAA do not present with the classic triad of abdominal pain, shock, and pulsatile abdominal mass.
Nearly 30% of patients who present to the ED with ruptured AAA are initially misdiagnosed.
Early detection of a ruptured AAA with prompt surgical intervention can decrease mortality from 75 to 35%

71. Management of ruptured AAA
Senior help
ABC
Large Bore IV Access x 2
Hypotensive resuscitation
Analgesia
Ensure O neg available
Ensure normothermia
Urgent Vascular Consult
To OR
Cautious fluids – if give rapid volume expansion may cause loss of retroperitoneal tamponade and accelerated bleeding
If patient is perfusing vital organs this can be delayed
Target SBP of
Obviously if pre arrest need volume resuscitation

72. Last Case! 85 yr old male. Nursing home resident
Central Abdominal Pain
Sudden onset. Severe
PMH
Dementia MI
MEDS
Clopidogrel 75 mg Daily
Metoprolol 25 mg BD
Perindopril 5 mg daily SH
Mild dementia
Forgetful
Requires some assistance with bathing and toileting
Feeds Self
Walks with frame
Non-smoker
Non-drinker

73. Examination Looks dry and emaciated P 120- 140 BP 110/70 RR 30
Sats 96% RA
T 37.4 C
Abdomen
Generally tender
No guarding rigidity or rebound

74. ECG

75. Differential?

76. ABG
pH 7.10
pCO2 15
P02 80
Bic 8
BE -15
Lactate 10.2

77. Management ABC NPO IV access IVF Analgesia IV abs
Urgent Surgical Consult
Urgent CT mesenteric angiogram OR
Surgical Emergency
Small bowel has warm ischaemic time of 2-3 hours
Rapidly progresses to gangrene, septic shock and death
Need high index of suspicion to diagnose it
Severe pain but little tenderness on examination

78. Mesenteric Ischaemia Surgical Emergency
Small bowel has warm ischaemic time of 2-3 hours
Rapidly progresses to gangrene, septic shock and death
Need high index of suspicion to diagnose it
Severe pain but little tenderness on examination

79. Case 7
40 yr old male presents with sudden onset of severe R loin to groin pain. Excruciating pain. Coming in waves. Feels nauseated and has vomited x 2.
Patient is agitated, pacing around the room, unable to sit still.
Screaming in pain.
P 120 sinus BP 160/80 T 37.0 C RR 18 Sats 99% RA
R renal angle tender

80. Differential Diagnosis?
Renal Colic
Pancreatitis
Cholecystitis
Appendicitis
Ruptured/leaking AAA

81. UA
Erythrocytes ++++
No leucocytes
No nitrites

82. KUB XR Ray
Where do the ureters run on this XR?
Medial to the tips of the transverse processes of the lumbar vertebrae
Crosses the pelvic brim at the sacro-iliac joint
Shadow then passes to the ischial spine and to the pubic tubercle

83. Investigations UA EUC FBC (other bloods if diagnosis unclear) CT KUB
Beware phleboliths and calcified mesenteric lLM
Trace the path of the ureters carefully on the fil

84. Management Analgesia NSAID Morphine IV titrated to pain
IV fluids – maintenance only
Observe

85. Who should we CT CT On going pain Impaired renal function Fever
Diagnosis not clear

86. Indications for admission
Infection
Impaired Renal Function
Pain ongoing– needing IV opiates
Stone > 5mm
Obstruction/hydronephrosis on CT
Stag horn Calculus on CT

87. Take Home Message Exclude life threatening pathology
BHCG in female of child bearing age
Be mindful of radiation exposure
Beware of Abdominal pain in the Elderly
Never ignore abnormal vital signs
Ask for help if not sure about diagnosis/Rx

88. Thanks for your patience!