1. EM Clerkship: Abdominal Pain

2. Objectives Standard approach to abdominal pain as CC Broad differential diagnosis development Properly use labs and studies Properly treat pain and other symptoms Choose appropriate patient disposition

3. Introduction Abdominal pain is a very common CC Can represent a broad range of pathology Benign appearing presentations can mask life-threatening disease Abdominal pain seems simple but similar mistakes occur over and over again

4. History History is crucial to work-up and diagnosis of abdominal pain Location, timing, quality, radiation, migration, modifying factors, associated symptoms “Have you ever had this pain before?”

5. History Past Medical History Past Surgical History Medications Family History Social history

6. Physical Examination Can be very helpful in diagnosis Vital Signs General Appearance Lungs/CV Extremities

7. Physical Examination Abdomen: –Inspection –Auscultation “.. of all the modalities of physical diagnosis of the abdomen auscultation is one of the least valuable and most misleading.” --- Cope’s Early Diagnosis of the Acute Abdomen

8. Physical Examination Abdomen: –Palpation Assess for focal area of tenderness, masses, guarding, hernias, ascites Rebound tenderness – “We do not recommend the performance of this test for it elicits no more than can be ascertained by careful pressure and may cause unexpected and unnecessary pain.” -- Cope’s Early Diagnosis of the Acute Abdomen

9. Physical Examination Rectal: –Not necessary for every abdominal pain patient GU: –Necessary for most patients with pain in lower quadrants

10. Differential Diagnoses Quite broad range of pathology can cause abdominal pain – START BROADLY Use abdomen geography Use modifying factors and associated symptoms Use physical exam Then use studies

11. Differential Diagnoses Up to 40% of ED abdominal pain may remain a diagnostic mystery –Don’t call it something it’s not Undifferentiated abdominal pain is not gastroenteritis “abdominal pain, unclear etiology,” or “abdominal pain, not otherwise specified”

12. Studies Labs EKG Plain radiography Ultrasound CT

13. Abdominal Pain Special Situations The Elderly –Presentations are less likely to be “typical” –Often less reliable historians –Confounding medical problems, medications –Twice as likely to be admitted or go to surgery –~10 times as likely to die during hospital stay Serious disease often mistakenly diagnosed as constipation

14. Abdominal Pain Special Situations The immunocompromised or anyone with altered sensorium –Presentations often atypical –Significant disease can present without a lot of pain or tenderness –High index of suspicion –Low threshold to use CT

15. Abdominal Pain Special Situations The very young –Often must rely on parents for history –May not be cooperative on exam –Must try to limit radiographic studies –This makes diagnosis much more difficult: ~90% of children <2 with appendicitis have perforation by time of diagnosis –Different anatomy / physiology

16. Abdominal Pain Sick or not sick? Significant disease can present as benign –Broad DDx, high index of suspicion PE often more helpful than Hx for acuity –Vitals, general appearance, abdominal exam Most abdominal pathology evolves –Frequent re-examinations key – when in doubt, observe and recheck

17. Abdominal Pain Treatment Narcotics will not hide the disease process –E.g., 2003 study showed no difference in diagnostic accuracy for appendicitis Avoid platelet inhibitors (ketoralac) or oral medications in patients with possible surgical disease

18. Abdominal Pain Treatment Treat associated symptoms –Fluids (often amazingly therapeutic) –Anti-emetics, antacids –+/- Bowel regimen (diarrhea, constipation) Special cases –Kidney stones - ketorolac –Biliary colic - ketorolac –Antibiotics if appropriate

19. Disposition Admission Discharge –Strict return precautions –Close follow up (24 hour recheck) Observation in the ED Always consider social situation, reliability for follow up, and resources