Abdominal Pain
Case 1
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A 19 year old male presents with a two day
history of abdominal pain. He states that at
onset, his pain was in the middle of his
abdomen, and has since moved to the right
lower side. He notes nausea, emesis,
anorexia, and a low grade fever. On exam,
he has rebound tenderness to the RLQ, pain
with leg movement, hip rotation, and pain in
the RLQ on LLQ palpation. How often do
perfect clinical cases like this present to the
ED?
Introduction
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6.7% of ED visits are for abdominal pain
History, physical, labs often not as helpful as
Cope would have you believe.
Goal is to detect life-threatening causes of
abdominal pain, if not to make a solid
diagnosis.
The Elderly, the Young, and those who
cannot get follow-up are high risk groups
that may require further study and admission
even in the absence of abnormal findings.
Pain
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Visceral
◦ Stretching of unmyelinated fibers that
innervate walls or capsules of organs.
◦ Crampy, dull, achey pain.
◦ Localized to a sensory level, but often midline
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Parietal
◦ Irritaion of myelinated fibers in the parietal
peritoneum
◦ Localizable, causing guarding, rebound
◦ Patients like to stay still
Pain
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Referred pain
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Pain that is remote from the source
Caused by developmental embryology
Normally ipsilateral
Boaz Sign?
Kehr’s Sign?
Where might renal pain get referred to?
Priorites
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Finding critical illness and stabilizing
◦ Normal vitals signs are not excluding for
critical illness
◦ Resuscitate and diagnose at the same time
 2 LB IV’s, O2, monitor
 CBC, BMP, Coag, T&S
◦ Don’t neglect to do a thorough exam.
◦ Intensity of pain bears no relation to severity
of illness.
Priorities
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Finding critical illness
◦ Red Flags
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Extremes of age
Rapid onset of severe pain
Abnormal vitals
Dehydration
Pallor, vomiting, diaphoresis
◦ Shock most likely hemorrhagic if of rapid
onset
◦ Temperature least helpful of vitals
History
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OPQRST
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Onset
Provocations/palliations
Quality
Radiation
Severity
Timing
What has been done
 Last oral intake
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History
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Pertinent illnesses
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DM
HTN, CAD, PVD
Liver or Renal disease
Surgical history
Sexual history
Meds/IUDs
Any trauma
Any similar episodes?
Physical Exam
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Uncover as much as necessary
◦ Check for that perirectal abscess and
Fournier’s
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First, inspect
◦ Distended, stigmata of liver disease, surgical
scars? Masses?
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Then, auscultate
◦ Low sensitivity!
Physical exam
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Finally palpate
◦ Have the patient point to where it hurts
◦ Hit that area last
◦ May have patient bend knees if they cannot
otherwise relax abdominal wall muscles
◦ Interrater reliability 60-92% for abdominal
tenderness (Yen, K, et al, Arch Ped Adol Med,
2005, Apr, 159(4):373-6)
◦ Consider early use of Ultrasound at the time
of palpation.
Labs
Should be diagnosis specific
 Consider pattern of pain
 How likely is it that an LFT will help
someone with LLQ pain?
 Preg test – always necessary for women
of childbearing age and capability
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Labs
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CBC
◦ WBC least useful in the panel
◦ Hemoglobin – anemia from what?
 Can be useful for trending
◦ Platelet counts – liver disease, ITP, HEELP
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BMP
◦ Renal function most important
◦ Calcium
◦ CO2 level as a flag for metabolic acidosis
Imaging
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Ultrasound
◦ Many choose to use ultrasound like a
stethoscope
◦ Modality of choice for RUQ pain
◦ Recommended as first line for flank pain, RLQ
pain in kids – operator dependent
◦ Modality of choice for pelvic pain
Imaging
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Plain films
◦ Useful only for
 Free air
 Obstruction/volvulus
 Pneumonia
◦ Overall, low value
Imaging
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CT
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High sensitivity
High specificity
High radiation risk
High cost
Elderly, immune compromised, those who
you are uncertain, but look ill.
PO contrast – bowel obstruction, bowel
mass
No contrast – renal stone, renal insufficiency
Name that Story!
Dull RUQ pain in a 16 year old male,
worse with eating, associated with nausea
and diarrhea?
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Name that Story!
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Low grade fever, LLQ tenderness, and
rectal bleeding in a 55 year old male.
Name that Story!
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Epigastric pain which is boring and
cramping, which radiates to back, and is
associated with eating cheese and
alchohol. Amylase and lipase are normal.
This is the 6th visit for this in a year.
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What level of bilirubin is needed to
produce scleral icterus?
Name that Story
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55 year old diabetic with epigastric pain,
weakness, nausea and vomiting. Some
SOA, no diarrhea. Hx of HTN. Pain is off
and on for the past week.
Name that Story
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Post parandial pain in a 65 year old female
who has nausea, emesis, appears to be in
pain, but a benign abdominal exam, trace
blood on rectal exam.
Name that Story
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65 year old male who presents with left
flank pain that is gnawing, kept him up at
night, and is not associated with syncope
or hypotension. His last US showed a
3.5cm AAA.
Name that Story
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20 year old male sharp flank pain after
backing into something. Has a 1 inch
laceration to left flank. Vitals signs are
stable. 30 minutes later, he is dead.
Name that Story!
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16 year old virgin presents with vaginal
bleeding, RLQ abdominal pain and
weakness. She is tachycardic, and her
rosary-holding mother (who has been in
the room) is concerned about fibroids.
High Risk Groups
Treatment
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TRUE OR FALSE?
Pain should not be treated until a surgeon
has laid hands on the patient?
Treatment
Fluids
 Symptom management
 NPO status until you know a surgeon
won’t be needed anytime soon
 Antibiotics
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Gram negative for gut (flagyl, AG)
E.coli for gut and urine (Cipro)
Gram positives for SBP
STD guidelines for PID
Disposition
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Discharge
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Pain better
Nasuea better
Tolerates PO
Negative eval, or no critical findings
Adequate follow-up
Otherwise admit
 Surgical consults as needed.
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Gastric Bypass
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High risk for leak
◦ Septic, abdominal pain, fever
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Dumping Syndrome
◦ Dietary changes
◦ Octreotide SQ drips for severe cases
Internal hernia
 Immediate bowel obstruction may cause
gastric rupture.
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