1. Dr. Kevin J. Pacheco
Abdominal Pain

2. Introduction Moving Targets vs. Bull’s Eye; Ex. Gallbladder
Visceral – Epigastric
Somatic – RUQ (Murphy’s)
Referred – Shoulder pain
Humbling Presentations
Not mentioned in textbook but you can have appendicitis or other conditions present with epigastric pain because of not eating etc… (usually still have RLQ tenderness)

3. History Sudden Often Equals Surgical Pain precedes vomiting
Examples: mesenteric ischemia, torsions, intestinal perforation
Infections = Gradual
Slow and gradual more likely to represent appendicitis and diverticulitis

4. Often Overlooked
Lower abdominal pain = asking about sexual activity, abnormal discharge, testicular pain
Generalized pain = asking about previous surgeries

5. Physical Exam Thinking muscular wall…
Carnett’s test – have the patient sit partially up (crunch) and palpate again
If it worsens – muscular
If it improves – internal (protected)

6. Often Overlooked
Hernias in older patients, particularly for generalized abdominal pain and possible SBO (including described “constipation”)

7. Can’t Miss Differential
Emergent
Ruptured AAA
Ruptured ectopic pregnancy
Urgent
Perforated viscous
Obstruction
Mesenteric ischemia
Pancreatitis
Torsions (testicle/ovary)
Incarcerated hernia
Ascending cholangitis
Appendicitis
Cholecystitis
Diverticulitis
Choledocholithiasis

8. Work Up
Labs
CBC – Lack of leukocytosis is often false reassurance (particularly in the elderly)
CMP – Only a few dollars more than BMP
Lipase
Upreg
UA – Leukocytes will be seen in appendicitis, AAA, tumor, TOA
Lactate – Severe generalized pain in older patient (helps pick up mesenteric ischemia)
Imaging
US – RUQ, pelvis/testicle
CT Abdomen and Pelvis - When you are concerned about an emergent or urgent diagnosis. Have a lower threshold for elderly patients.

9. Contrast When is Oral Contrast needed? When is IV Contrast needed?
Thin (low BMI), pediatric, bowel altering surgery, and inflammatory bowel disease history (Crohn’s, ulcerative colitis)
When is IV Contrast needed?
If you are not convinced it is a ureteral stone and they have good renal function

10. Humbling Surprises
72 year old female presents with generalized abdominal pain and vomiting. Exam shows tenderness. No fever, slight tachycardic or hypoxic
CT abdomen/pelvis reveals bilateral basal PE
CTA chest reveals large bilateral clot burden
Similar presentations for lower lobe pneumonia

11. Often Overlooked
Be careful blaming it on an ovarian cyst, often other pathology exists and cyst is incidental (appendicitis, cholecystitis, diverticulitis, etc)
Remember appendix is not necessarily in RLQ during pregnancy and be careful blaming biliary disease

12. Negative Work-up – Now What?
Up to 30% of patients will be discharged without a specific diagnosis
First, consider things you may have missed (pelvic exam, lower lobe pneumonia)
Second, have a discussion about how your CT and labs are not 100% in case it is early appendicitis etc…
Third, specify acute vs. chronic and location in ICD-10

13. Negative Work-up – Now What?
Lastly, if it is chronic have a conversation about other causes and refer to GI
You do not need to discuss this differential but let the patient know about there are other reasons for their chronic recurring pain:
Acute intermittent porphyria
Angioedema
Abdominal vasculitis
Abdominal migraine
Gastroparesis
Cyclic vomiting syndrome
Opioid withdrawal

14. Abd Pain in the Elderly Older than 60 60% admitted 50% surgical cases
5% die within 2 weeks of presentation
Often no fever
Often no peritoneal signs (thin abdominal wall musculature)
CT is the rule (only deviate when US is better or another reason is prominent, such as Shingles)