Management of Patients with Abdominal Pain in the Emergency PowerPoint Presentation

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Management of Patients with Abdominal Pain in the Emergency Department Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Clinical Professor of Emergency Medicine George Washington University Bethesda, Maryland, U.S.A.

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Abdominal Pain Lecture Outline Recognition & resuscitation for life-threatening causes of abd. pain Physical exam features Choosing diagnostic tests Initial treatment Differential diagnosis Key points about the most common specific causes

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Abdominal Pain : Diagnostic & Treatment Priorities First : recognize presence of shock or intraabdominal bleeding Second : start resuscitative measures for shock or bleeding (if these are present) Third : determine if the abdomen is the source of the shock or bleeding Fourth : determine if emergency laparotomy is needed Fifth : complete the secondary survey (head to toe exam) ; obtain needed lab or radiographic studies Sixth : Conduct frequent reassessments of the patient

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General Approach to the Patient Presenting with Abdominal Pain Evaluate & treat the ABC's (Airway, Breathing, Circulation) first in same sequence as for any other emergency patient Determine if an immediate life-threatening cause of abd. pain may be present & if there is any history of possible abd. trauma Start resuscitation and emergently consult a surgeon if an emergent laparotomy is needed Complete the secondary survey, treat pain, and decide what other diagnostic tests will be needed

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Immediate Life-Threatening Causes of Abdominal Pain These must be recognized from the primary survey : Ruptured abdominal aortic aneurism (AAA) Rupture of the spleen or liver Ruptured ectopic pregnancy Bowel infarction Perforated viscus Acute myocardial infarction (MI)

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Ruptured Abdominal Aortic Aneurism (AAA) More common in males > 65 years of age May present initially as back or groin pain Typically would have epigastric or periumbilical pain radiating to back May present in shock from intraperitoneal rupture (retroperitioneal rupture may initially be contained) Often can feel pulsating supraumbilical mass (if you can feel the aortic pulse width > 4 cm : suspect AAA) Can sometimes make this Dx from lateral X-ray of abd. Bedside ultrasound (U/S) is best Dx test for unstable patient Abd. CT scan is best Dx test for stable patient (surgeon may also want angiography preop if patient is stable)

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Ultrasound showing 7.5 cm AAA with intraluminal clot

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CT scan of AAA (L = lumen, T = thrombus)

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Emergency Management of Ruptured AAA Oxygen & IV fluid resuscitation (normal saline or lactated Ringer's) if systolic BP < 100 mm Hg (but do not "overresuscitate" ; do not increase the BP to over 120 systolic because higher BP may cause increased bleeding) Type and cross for at least 6 units of blood Insert foley catheter Obtain an electrocardiogram Emergently consult a surgeon Notify the operating room

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Ruptured Spleen or Liver Usually due to trauma, but can be spontaneous from malaria, mononucleosis, or hematologic diseases Patient may present with shock ; may also have referred pain to shoulder (Kehr's sign) Dx and Rx considerations & sequence same as for ruptured AAA (IV fluid, Type & cross, U/S or CT, call surgeon, etc.)

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Ruptured Ectopic Pregnancy Most common cause of pregnancy-related death in U.S.A. May NOT have missed menstrual period Typically have severe sudden onset lower abd. pain +/- shock Should obtain stat serum or urine HCG test in any female of reproductive age with abd. pain Pelvic U/S is Dx test of choice Rx : Oxygen, IV fluid (NS or LR), Type & cross at least 2 units, emergently consult surgeon or obstetrician

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Bowel Infarction Due to clot embolus or thrombosis in mesenteric artery Most patients have severe coronary artery disease (this can be a post-MI complication) May have "pain out of proportion to findings" (may not demonstrate much tenderness) Physical exam may show signs of peritonitis, hypoactive bowel sounds, blood in rectum or guiac positive stool

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Bowel Infarction (cont.) Usual lab findings : High WBC Severe lactic acidosis (anion gap > 18) Plain X-ray film findings : Free air, air in portal vein, air in bowel wall ("pneumatosis intestinalis") May need emergent angiography for Dx Rx : Oxygen, IV fluid resuscitation, IV broad spectrum antibiotics, consult surgeon

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Angiogram (arrow shows superior mesenteric artery clot) of a 65 year old male with bowel ischemia

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Perforated Viscus Causes : Blunt or penetrating trauma, tumors, inflammaory bowel disease, typhoid fever, amebiasis, other parasites Typically see free air under diaphragm on plain films (Chest X-ray is most sensitive to see small amounts of air) Rx : Oxygen, IV fluids, IV broad spectrum antibiotics (such as cefoxitin & metronidazole), emergently consult surgeon

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Free air under the diaphragm from a perforated peptic ulcer

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Chest X-ray showing colonic interposition (NOT free air)

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Abdominal film showing the “Rigler double wall sign” of free intraperitoneal air (can see both inside and outside wall of bowel)

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Acute Myocardial Infarction (MI) as a Cause of Abdominal Pain Suspect in adult patient with upper abd. pain but no or minimal abd. tenderness Inferior MI commonly presents as "indigestion" ; may also have emesis MI may also secondarily occur from shock due to an intraabdominal cause (such as intraluminal bleed, etc.) Dx by EKG +/- enzymes ; need Chest X-ray also Rx : Oxygen, IV line, nitrates, aspirin, consider thrombolytics, etc., & admit to monitor bed unit

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Now That Immediate Life-Threatening Causes of Abd. Pain Have Been Reviewed, Next the Lecture Will Review History and Exam for the Stable Patient History items to ask the patient with abd. pain : Time and rapidity of onset Character of pain (burning, cramping, etc.) Associated symptoms Signs of bleeding (dark vomitus or stool) Prior surgeries & illnesses Last menstrual period Medications (especially steroids, aspirin, warfarin) Alcohol intake Unusual ingestion or foreign travel

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Physical Exam for the Patient with Abdominal Pain Need complete set of vital signs Look in nose and mouth for sites of bleeding (swallowed blood may mimic an intraluminal bleed) Look at skin for stigmata of liver disease or signs of coagulapathy Careful chest & lung exam (basilar pneumonias can present as abd. pain) Palpate and observe the back Genital and rectal exam (& stool guiac) should usually be routine

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Exam of the Abdomen in the Patient with Abdominal Pain Inspection : Look for : Scars from prior surgeries Distension Localized swelling or mass Eccymoses or erythema Visible peristalsis Auscultation with stethescope Listen for bowel sounds & bruits Palpation & percussion

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Interpretation of Bowel Sounds (Associated, but not Definite, Diagnoses) High pitched or "tinkling" : bowel obstruction Continuous & hyperactive : acute gastroenteritis Absent : ileus or peritonitis (need to listen for at least one minute) Audible without stethescope : "borborygmi"

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Percussion of the Abdomen Should tap with 2 fingers on all 4 quadrants If tympanitic : implies bowel obstruction If dull, implies intraabdominal bleding or fluid (such as ascites) If tender, correlate with tender areas noted on palpation

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Palpation of the Abdomen Should be done following inspection & auscultation Assess for tenderness, guarding, mass, crepitus, referred tenderness Differentiate lower rib tenderness from true upper abd. tenderness Don't need to directly assess rebound ; just wiggle abdomen from the side & check for referred tenderness (direct rebound is cruel if peritonitis is present) Don't forget leg maneuvers (psoas, obturator, & heel tap signs)

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Lab Studies for Patients with Abdominal Pain Use selectively ; not all are needed for all patients For example, for young adults with simple acute viral gastroenteritis or food poisoning, usually no lab studies are needed (they may just need IV fluids & parenteral antiemetics) Draw with the initial venipuncture if an IV line is to be established

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List of Lab Studies to Consider for Patients with Abdominal Pain Type and Cross (the most important if patient has shock) Complete blood count (CBC) Urine or serum pregnancy test (HCG) Serum amylase, lipase Urinalysis, urine culture and sensitivity Liver function tests (bilirubin, SGOT, SGPT, alk. phos.) Electrolytes, glucose, creatinine, blood urea nitrogen (BUN) Serum alcohol, serum or urine drug screen Serum medication levels (such as digoxin) Clotting studies (platelet count, protime, PTT, fibrinogen) Cardiac enzymes (if coronary ischemia suspected) Blood culture (if sepsis or bacteremia suspected) Nonemergent tumor markers (CEA, AFP)

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Interpretation of Lab Studies for Abdominal Pain WBC typically elevated (+/- "left-shifted") in any cause of peritonitis & in bowel infarction & in spleen & liver bleeding However often NOT elevated appropriately in : the elderly immunocompromised patients patients on chronic corticosteroid Rx

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Interpretation of Lab Studies for Abdominal Pain (cont.) Hematocrit may be normal in early stages of even severe hemorrhage BUN to creatinine ratio of > 20 to 1 may indicate upper gastrointestinal (GI) bleed with digestion of blood in upper GI tract Degree of elevation of amylase or lipase does not always correlate with severity of panceatitis or of pancreatic injury Amylase may also be chronically elevated in patients with renal dysfunction

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Plain Radiographs for Abdominal Pain If needed, usually the 3 view "Acute Abdomen Series " is best (upright Chest X-ray, upright and flat plate of the abd.) Chest X-ray best shows small amounts of free air Upright abd. film best shows bowel air-fluid levels (indicating bowel obstruction or ileus if multiple) Look also for abnormal calcifications "KUB" film is oriented to include all the pelvis, whereas "abd. flat plate" is oriented to include the diaphragms (so these two are different for a tall patient)

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Diagnostic Ultrasound for Abdominal Pain Dx test of choice for : Unstable patient in shock & suspected intraabdominal bleed Gallstones (cholecystitis) Ectopic pregnancy Other complications of pregnancy (placenta previa, abruptio, etc.) Renal or ureteral stones in the pregnant patient

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Disadvantages of Diagnostic Ultrasound Visualization may be limited by bowel gas or obesity Good interpretation requires experience Not good at showing retroperitoneal conditions May not directly visualize solid organ lacerations

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Use of Computed Tomography (CT) for Abdominal Pain Noncontrast spiral scan is now method of choice for ureteral calculi (replaces intravenous pyelogram or IVP) Using both IV and oral (or via nasogastric tube) contrast can then show appendicitis, diverticulitis, etc. However even with greater use of CT for appendicitis, overall accuracy of this Dx in the E.D. has not improved

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Other Diagnostic Studies to Consider for Abdominal Pain If contrast CT not available : Gastrografin Upper GI study for suspected : Stomach or bowel perforation Diaphragm rupture Duodenal hematoma Never do barium GI study if any chance of barium leak (causes severe peritonitis) Intravenous pyelogram (IVP) for suspected : Ureteral stone or injury Renal mass

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Other Diagnostic Studies to Consider for Abdominal Pain (cont.) Retrograde urethrogram / cystogram for suspected urethral or bladder injury Fistulogram for any suspected abdominal wall fistula Technetium bleeding scan to localize intraluminal GI bleed Angiography for preop planning of surgery for stable patient with AAA, or for suspected arterial bleed or mesenteric ischemia

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Post-Exam "Procedures" to Consider for the Patient with Abdominal Pain Insertion of foley catheter Indicated for monitoring of any unstable patient or if urinary retention suspected Insertion of nasogastric (NG) tube (see next slide) Paracentesis (needle aspirate of abd. fluid) Indicated for : Suspected infected ascites (check cell count & culture) Relieving tense ascites Sometimes can make Dx of bowel perforation or intraabd. bleed

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Usefulness Of NG Tube Suction for the Patient with Abdominal Pain Allows decompression of stomach Lessens risk of aspiration Can remove some of residual toxins in stomach May demonstrate upper GI bleeding Required before peritoneal lavage Contraindicated if nasal or midface fractures or severe coagulapathy (insert via mouth instead)

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General Mechanisms Causing Abdominal Pain Pain originating in the abdomen Peritonitis Distension of hollow viscera Ischemia Pain referred to the abdomen from another part of the body Metabolic disorders Neurogenic disorders

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Causes of Referred Abdominal Pain from Chest Conditions Acute coronary syndromes (and "angina equivalents") Pneumonia (especially basilar) Spontaneous pneumothorax Pulmonary embolus (rare cause) Pericarditis

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Metabolic Causes of Abdominal Pain Diabetic ketoacidosis Hyperlipidemia (often with pancreatitis) Acute prophyrias Black Widow spider bites Scorpion bites Sickle cell crisis (sequestration in spleen or liver, or vaso-occlusive)

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Neurogenic Causes of Abdominal Pain Herpes zoster (Shingles) Pain often present several days before characteristic dermatomal vesicles appear Thoracic or lumbar spinal disc disease or compression Syphilis ("tabetic crisis")

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Patient with Herpes Zoster (“Shingles”) of the abdomen

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Trauma-Related Causes of Abdominal Pain May present delayed, or from seemingly minor trauma in the elderly : Ruptured spleen or liver Bowel or stomach perforation Pancreatic contusion or transection Ruptured bladder Mesenteric hematoma Abdominal wall hematoma (U/S is good at diagnosing this)

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Pregnancy-Related Causes of Abdominal Pain Ectopic (usually tubal) pregnancy False labor (Braxton-Hicks contractions) Active labor Abruptio placentae (note that placenta previa which can cause severe bleeding is usually painless) Septic abortion

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Genitourinary Tract Causes of Abdominal Pain Cystitis Pyelonephritis Ureterolithiasis Perinephric abscess (may see gas around kidney on KUB film) Renal infarction (as from sickle cell disease) Psoas abscess Testicular torsion Urinary retention (as from prostatic hypertrophy)

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Peritonitis Causing Abdominal Pain Definition : inflammation of the peritoneum Causes : exposure of peritoneum to gastric acid, bile, urine, blood, pancreatic enzymes, bacteria, stool, or exogenous toxins Complications : fluid & electrolyte disorders, "third spacing" of fluid causing hypovolemia & shock, paralytic ileus Symptoms and signs : abdominal pain, rebound tenderness, abdominal muscle guarding or rigidity, fever, emesis, decreased bowel sounds, abdominal distention Key Rx : IV fluid resuscitation, IV antibiotics (usually), EARLY PAIN RELIEF WITH NARCOTICS, try to determine the most likely cause, emergently consult a surgeon

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List of Most Common Causes of Acute Abdominal Pain in Adults Acute gastroenteritis Acute cholecystitis Acute cholangitis Acute appendicitis Acute diverticulitis Acute gastritis or peptic ulcer Acute esophagitis Acute panceatitis Bowel obstruction Inflammatory Bowel Disease Acute salpingitis (pelvic inflammatory disease) Acute pyelonephritis Acute cystitis Ureterolithiasis Urinary retention Acute viral hepatitis Mesenteric ischemia Ovarian cysts Complications of pregnancy

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Caveat About Workup of Abdominal Pain in the E.D. Several large studies show that even after complete workup, 60 % of E.D. patients with abdominal pain do not have a specific diagnosis For most of these patients, it is appropriate just to treat their symptoms (pain meds, antispasmodics, antiemetics, etc.) and perform further diagnostic tests only if their pain does not resolve in one to 2 days

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Acute Gastroenteritis Present with nausea / emesis / diarrhea Usually viral or reaction to food If bacterial, usually have abd. tenderness +/- lower GI bleeding If abd. nontender and diarrhea is nonbloody, usually do not need lab studies Rx with IV LR 1 to 5 liters, oral, rectal, or parenteral antiemetics, +/- antidiarrheals

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Choices for AntiEmetics in the E.D. My favorite : hydroxyzine (Atarax, Vistaril) Antihistamine, also an antianxiety agent Very low incidence of side effects 25 to 50 mg IM or PO q 6 hours Promethazine (Phenergan) Some risk of dystonic reactions & sedation 25 to 50 mg q 6 hours IV, IM, PO, or PR Prochlorperazine (Compazine) 40 to 50 % incidence of dystonic reactions 10 to 25 mg q 6 hours IV, IM, PO, or PR Metclopromide (Reglan) : 5 to 20 mg q 4 hrs. IV, IM, or PO

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Choices for AntiDiarrheals in the E.D. Do not use these in patients with tender abdomen or toxicity Lomotil (diphenoxylate and atropine) 2 tabs PO, then one after each diarrheal stool up to 8 per day Loperamide (Imodium) 2 mg tabs, same dosing as Lomotil Codeine 15 to 60 mg PO q 4 hours Donnatal elixir 2 tsp PO q 6 hours (good antispasmodic)

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Acute Cholecystits Usual clinical profile is obese female > age 40 May cause more complications in diabetics Usually RUQ +/- epigastric tenderness and emesis U/S is best Dx test LFT's usually normal ; lipase & amylase elevated if secondary panceatitis (common duct stone) If cholangitis (severe RUQ tenderness, fever, emesis, usually elevated LFT's, +/- air in biliary tree on X-ray) : consult surgery emergently Rx : IV fluids, NPO at first, pain meds, surgery consult unless quickly resolves

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Emphysematous cholecystitis (arrows show gas around the gallbladder)

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Acute Appendicitis Accuracy of Dx on clinical grounds alone is not good Usually periumbilical pain, then migrates to RLQ Usually anorexia, nausea, +/- low grade fever KUB film rarely shows diagnostic appendicolith in RLQ U/S and CT can make definitive Dx Consult surgeon if suspected

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Acute Diverticulitis More common after age 45 Typically pain & tenderness in LLQ, but can be diffuse Can result in inflammatory mass in LLQ or perforation CT with contrast is best Dx test Milder cases can be discharged on oral antibiotics

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Acute Gastritis ; Peptic Ulcer Typically epigastric pain & tenderness If perforation or severe bleeding, may require laparotomy Definitive Dx by endoscopy preferred over Upper GI contrast study, but not needed for many patients Rx with H2 blockers such as ranitidine (in addition to IV fluids, etc. for severe cases)

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Acute Pancreatitis Usually diffuse abd. pain + back pain, emesis, elevated amylase & lipase Often attributed to gallstones or alcohol, but many cases idiopathic Can have severe complications : Hypovolemia, ARDS, hypocalcemia, retroperitoneal bleeding or abscess CT is Dx method of choice

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Bowel Obstruction Can be either large or small bowel Most common causes : Adhesions from prior surgery, incarcerated hernia, cancer, volvulus, mass of parasites, inflammatory bowel disease Plain X-ray films are key Dx test If possible associated bowel necrosis (infarction), consult surgeon emergently

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Plain film showing small bowel obstruction from adhesions in a 72 year old male

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Upright film showing multiple air-fluid levels from small bowel obstruction

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Upright film of sigmoid volvulus in a 67 year old male

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Supine film showing sigmoid volvulus in a 67 year old male

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Upright film showing cecal volvulus in a 62 year old male

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Inflammatory Bowel Disease Two types : Ulcerative colitis Crohn's Disease Ulcerative colitis can sometimes have complication of "toxic megacolon" Complications of either type may need Rx with high dose IV steroids in addition to other usual Rx's

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Acute Salpingitis (Pelvic Inflammatory Disease) Typically present as severe lower abd. pain & vaginal discharge Get cervical cultures as part of workup Usually caused by gonococcus or chlamydia, but can involve other bacteria Rx : IV antibiotics, pain meds Admit to hospital if : Toxic, pregnant, immunosuppressed, suspected tubo-ovarian abscess

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Acute Pyelonephritis Usually have dysuria & back pain & CVA tenderness, but can show projected anterior abd. tenderness Admit to hospital for IV antibiotics if : Toxic, hypotensive, persistent emesis, pregnant, immunosuppressed, chronic or structural renal disease, failure of outpatient Rx, diabetic, age < 2 or > 60

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Ureterolithiasis Commonly have sudden back or flank and/or abd. pain +/- groin radiation, but not much tenderness Need early Rx with pain meds (parenteral NSAID such as ketorolac 30 mg IV is most effective) ; IV morphine if more analgesia needed Noncontrast spiral CT is Dx method of choice IVP or U/S are alternatives Should "cover" with antibiotic (such as Bactrim or Cipro) if any bacteria noted on urinalysis Over 90 % of patients can be discharged from E.D.

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Urinary Retention Most common in elderly men with benign prostatic hypertrophy Can occur also from acute prostatitis Rx with foley catheter If bladder residual > 100 cc, should leave foley catheter in at least 24 hours to allow bladder to recover its muscle tone Routine use of coverage antibiotics while foley is in is debated

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Acute Viral Hepatitis Incidence greatly decreased by use of Hep B and A vaccines Typically present with nausea, emesis, +/- RUQ pain, +/- jaundice Need to check serologies on close contacts of index case Admit to hospital if encephalopathic, GI bleed, increased protime, hypoglycemic

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Ovarian Cysts and Complications of Pregnancy U/S is Dx method of choice for these Ovarian cysts typically have lower abd. pain & lateralizing tenderness +/- adnexal mass on exam If large amount of blood in pelvis or suspected ovarian torsion on U/S, emergently consult surgeon or obstetrician

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Some Caveats About Abdominal Pain Don't hesitate to treat the patient's abd. pain early, even if consulting a surgeon It has been definitively shown that pain meds make the physical exam of the abd. pain patient MORE reliable Don't forget to consider child abuse or trauma as a cause for abd. pain Repeated physical exams over time may be needed to clarify the Dx

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"Secondary" Aspects to Remember for Abdominal Pain Oxygen if any possible major systemic compromise Question patient about prior anesthetic complications if surgery anticipated Additional doses of pain meds as needed Tetanus immunization if associated skin injury Antibiotics (+/- cultures if indicated) Tell the patient & family what is going on

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Abdominal Pain Summary Assess the ABC's & provide emergent Rx if life-threatening cause suspected Complete exam prior to deciding on other Dx tests Focus on the most likely Dx's initially Decide early if surgical consult or hospital admission needed Don't forget "secondary" treatments