Abdominal Pain
Bart Besinger, MD
Abdominal Pain:
YOU WILL SEE IT ON EVERY SHIFT.
Case #1
• 46 year-old woman
• Sudden onset severe abdominal pain x 30
minutes
• Epigastric burning on/off x 2 wks
• PMHx: rotator cuff tendonitis
• Meds: Ibuprofen
• Soc: smoker, occasional EtOH
Case #1
• Exam
– 112 132/78 22 374C
– Sweaty, obvious discomfort
– Abdomen rigid, diffusely tender
– Remainder of exam unremarkable
Case #1
What test will confirm your
suspected diagnosis?
Case #1
History and Physical
• Thorough, but focused
• Sometimes diagnostic
• Guides work-up, management, disposition
History and Physical
Location
History and Physical
• Time Course – Sudden Onset
– Ruptured viscus
– Vascular catastrophes
– Renal colic
– Ruptured ectopic pregnancy
– Ruptured ovarian cyst
– Ovarian torsion
History and Physical
• Radiation
– Pancreatitis to back
– Renal colic to groin/testicles
• Migration
– Appendicitis: periumbilical to RLQ
History and Physical
• Associated symptoms
• Anorexia: be careful
– anorexia is absent in 10-30% of patients
with appendicitis
History and Physical
• Abdominal examination
– Localize area of tenderness
– Degree of tenderness
– Peritoneal signs
History and Physical
• Abdominal examination
– Inspect:
History and Physical
• Abdominal examination
– Inspect:
History and Physical
• Bowel sounds
– Occasionally helpful
• Palpation
– Distract the patient!
– Tenderness, masses, hernias
• Peritoneal signs
• Specific examination techniques
Case #1
What are some
indications for
abdominal plain films?
Case #2
• 15 year-old female
• Holding abdomen, moaning in pain
• Seen in ED yesterday
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


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Lower abd pain x 2 days, mild dysuria
LMP 1 week ago
Mild suprapubic tenderness
+ Leukocyte esterase
Discharged with TMP/SMX
Case #2
• Today, reports increased pain and vaginal
spotting
• Vitals: 134 78/46 24 366C
• Abdomen distended, markedly tender
Case #2
What should have been done
on the first visit?
Pregnancy Test
UPT
• The best test in all of medicine
√Cheap
√Non-invasive
√Incredibly accurate
√Yes-No answer
UPT
• Required for every reproductive age
female with abdominal pain
– Sexual hx unreliable
– Undiagnosed ectopic can be fatal
Diagnostic Tests
• WBC count
– Debatable utility
– Lacks specificity
– Lacks sensitivity
• 80-85% for appendicitis
Diagnostic Tests
• CT has revolutionized the evaluation of
acute abdominal pain
– AAA
– Appendicitis
– Ureterolithiasis
– Diverticulitis
– SBO
– Many others
Diagnostic Tests
• CT: the downside
Good, but not perfect
Cost
Contrast
Radiation
Diagnostic Tests
• Ultrasound
– Bedside vs. formal
– RUQ
– OB/gyn
Case #3
• 43 yo male
• LUQ and epigastric pain “all day”
• N/Vx2, no diarrhea
• Improved slightly with antacids
• PMHx: none
• Meds: none
• Soc: 1 ppd smoker, drinks 6 pk. per day
Case #3
• VS: 98.9F 92 116/84 18
• Awake, alert, uncomfortable
• HEENT, Chest, CV normal
• Abd: minimal LUQ tenderness, no
peritoneal signs
• Rectal: trace heme +
• Diagnostic tests?
Case #3
Always consider
extra-abdominal causes
of abdominal pain.
Extra-abdominal causes
• CV: MI
• Pulm: PE, pneumonia
• ENT: Streptococcal pharyngitis
• Abdominal wall: muscular, herpes zoster
• GU: testicular torsion
• Tox: lead, iron, Black Widow spider
• Metabolic: DKA, porphyria, uremia, Ca++
• Psych
Case #4
• 77 yo F
• 1 day of N/V/D, several hours of severe,
intermittent, diffuse abdominal pain.
• PMHx: CAD, DM, HTN
• VS: 108 128/92 22 99.5F
• Abdomen: diffuse mild tenderness
Case #4
• CBC, BMP, UA, lipase, CT unremarkable
• Improved with morphine, ondansetron,
fluids
• Diagnosis: “acute gastroenteritis”
• Discharged to follow up with PMD
Case #4
• Returns 6 hours later
• Increased pain, less responsive
• VS: 120 90/60 28 99.8F
• Abdomen: diffuse tenderness with
guarding and rebound
• Differential?
• Next step?
Case #4
• Surgery Consulted
• To OR
• Necrotic bowel resected
Be very wary of:
• Acute Gastroenteritis
• Abdominal pain in the elderly
Acute Gastroenteritis
• Common initial diagnosis for patients who
return with more significant abdominal
pathology
• Vomiting (gastritis) AND Diarrhea
(enteritis) should be present
• V/D seen in many other processes
• Abdominal pain should not be prominent
Abdominal pain in the elderly
• Significant pathology more likely
– Diverticulitis, ischemic bowel, AAA, biliary tract disease,
etc.
• Co-morbidities common
• More difficult to assess
–
–
–
–
poor historians
exam less reliable
increased pain threshold
atypical presentations common
Abdominal pain in the elderly
• Consider a more aggressive
work-up
• Low threshold for admission
What is the classic presentation of mesenteric ischemia?
PAIN OUT OF PROPORTION TO
THE PHYSICAL EXAMINATION
Case #5
• 21 yo M presents with classic appendicitis
• Surgeon is in OR – will be delayed 2 hours
• How do you want to manage the patient
in the meantime?
ED management
• NPO
• IV fluids
– GI losses, third spacing, poor po intake
– Isotonic crystalloid (NS or LR)
• Antiemetics
– Side effects of older agents
– Use 5-HT antagonists (ondansetron)
ED management
• Analgesia
– Historically controversial
– Historic concern: masking of peritoneal
signs
– Multiple studies demonstrate no alteration
of diagnostic accuracy
– May improve exam
ED management
• Analgesia
– Ketorolac
• Excellent for biliary or renal colic
• Not studied in setting of undifferentiated
abdominal pain
ED management
• Antibiotics
– indications: peritonitis, suspected
perforation
– many acceptable regimens
– cover gram - and anaerobes
Take Home Points
• Take a careful, focused H&P
• UPT for every reproductive age woman
• Avoid labeling abdominal pain
“gastroenteritis”
• Abdominal pain in the elderly: take it very
seriously
• Provide analgesia when needed