Abdominal Pain

LSU Medical Student

Clerkship, New Orleans, LA
 Historical Elements

O- onset
P-provocation /palliation
Q- quality/quantity
R- region/radiation
S- severity/scale
T- timing/time of onset
 Physical Exam
General Appearance and Vitals (sick
vs
Not sick)
Abdominal exam
-Inspection (scars, masses,
ecchymosis, distention)
-Auscultation (bowel sounds, bruits),
-Percussion (organomegaly,
dullness)
-Palpation (tenderness, guarding,
 Visceral Pain

Stretching of hollow viscus or capsule

of solid viscus

Visceral fibers enter the spinal cord at

several levels leading to poorly
localized, poorly characterized pain.
(dull, cramping, aching)
 Visceral Pain
Visceral pain can be localized by the sensory
cortex to an approximate spinal cord level
determined by the embryologic origin of the
organ involved.
Foregut organs (stomach, duodenum, biliary
tract) produce pain in the epigastric region

Midgut organs (most small bowel, appendix,

cecum) cause periumbilical pain

Hindgut organs (most of colon, including sigmoid)

as well as the intraperitoneal portions of the
 Parietal Pain
Parietal abdominal pain is caused by
irritation of fibers that innervate the
parietal peritoneum

Parietal pain, in contrast to visceral pain,

can be localized to the dermatome
superficial to the site of the painful
stimulus.

As the underlying disease process evolves,

the symptoms of visceral pain give way to
the signs of parietal pain, causing
 Referred Pain
Pain or discomfort that is perceived at a site
distant from the affected organ because of
overlapping transmission pathways

Also reflects embryologic origin:

subdiaphragmatic irritation -> ipsilateral
supraclavicular or shoulder pain
gynecologic pathology -> back or proximal lower
extremity pain
biliary tract disease -> right infrascapular pain
myocardial ischemia ->midepigastric, neck, jaw,
or upper extremity pain
ureteral obstruction -> ipsilateral testicular pain
 Radiology: Plain Films
Advantages:
Quick, easy, non-invasive, lower radiation,
lower cost, can be done at bedside and can
help make decisions in certain disease
states.

Disadvantages:
Only useful in certain conditions otherwise
low yield, difficult to position sick patients.
 Radiology: Plain Films
When are they useful?
Obstruction/Ileus
Volvulus (cecal and sigmoid)
Free air
Radiopaque foreign bodies
Constipation?
Plain Films: Small bowel
obstruction
Cecal Volvulus and Sigmoid
Volvulus
Pneumoperitoneum
Iron Overdose:
Remember the
radiopaque foreign
bodies mneumonic:

BAT CHIPS:

Barium
Antihistamines
Tricyclic antidepressants
Chloral hydrate,
calcium, cocaine
Heavy metals
Iodine
Phenothiazine,
potassium
Slow-release (enteric
coated)
 Radiology: Ultrasound
Advantages: Can be done at bedside,
easy to learn, repeatable, no radiation,
cheap, can be used in pregnancy,
patient does not need to leave the
department

Disadvantages: Highly dependent on

users skill level. Limited by body
habitus and bowel gas
 Radiology: Ultrasound
What conditions is it most useful for?

Gallbladder disease
AAA
Hydronephrosis
Volume status
Ob/Gyn (Ectopic, IUP, Ovarian
pathology)
Appendicitis (particularly in children)
Ultrasound: Cholecystitis
Ultrasound: AAA
Ultrasound: Appendicitis
 Radiology: CT
Advantages: Highly diagnostic for most
disease processes. High yield exam.
Helpful with multiple, competing
diagnoses.

Disadvantages: Time. Cost. Radiation.

Contrast exposure (for IV contrast).
Patient should be stable to go to CT.
 Laboratory:
The labs you order should be used confirm or
exclude specific diagnoses suspected by your
history and physical examination.

CBC, CMP, Amylase, Lipase and UA are routinely

ordered as belly labs but should not be ordered
blindly.

The studies you obtain (labs and imaging) should

be ordered with the intention of changing your
management of the patient. They should not be
ordered just because the patient is in the ED.
 Cases
A 60 y/o male presents after a syncopal
event with a complaint of abdominal
pain.
His pain is poorly localized but radiating
to his back.
His history is significant for HTN and
tobacco abuse.
His vitals are normal and his physical
exam reveals only the following:
 What is on the differential?
Pancreatitis Peritonitis
Mesenteric PE
Ischemia PUD
MI AAA
Gallbladder Valvular
Disease Insufficiency
GERD Perforated Viscus
Obstruction
Abdominal Aortic Aneurysm
What happens:
The media weakens over time, the
vessel dilates and expands over
time. As the vessel weakens and
expands, rupture becomes more
likely.
The larger it becomes, the more
likely is the rupture.
 AAA
Fun facts:
They are typically infrarenal
>3cm at this level is a AAA
Age, Family history, Atherosclerotic risk
factors, infection, trauma, connective
tissue disease are risk factors.
Rupture is associated with 80-90%
mortality.
Vital signs can be normal. For now.
 AAA: Diagnosis and
Management
H&P: May not be symptomatic until the rupture
Syncope and Abdominal pain
Cullens sign and Grey Turners sign
Imaging: U/S 100% sensitive when the aorta is
visualized.
CT requires a stable patient but is also highly
sensitive and is better at detecting rupture and
retroperitoneal fluid.
Treatment is surgical!! Despite what surgery tells you:
There is no such thing as a stable rupture.
EDs role is maintaining hemodynamic stability with
blood products SBP 90-100mg until surgery.
CT of Rupturing AAA:
 Cases
A 75 year old male presents with diffuse,
severe abdominal pain after having a
bloody bowel movement.
His history is significant for A. Fib and CHF.
His vitals show hypotension and
tachycardia.
You palpate a soft abdomen but even the
lightest touch causes him extreme pain.
You stabilize him and send him to the CT
film
 Differential?
Lower GI Bleed Small Bowel
Brisk Upper GI Obstruction
bleed Large Bowel
Mesenteric Obstruction
Ischemia
Peritonitis
Diverticulitis
Aorto-enteric
Fistula
Selections from Diffuse pain:
Mesenteric Ischemia
What happens: Most commonly from
emboli but can be from thrombus or
low-flow state to mesenteric vasculature
which leads to ischemia of the bowel.

Death of bowel leads to bacterial

translocation which leads to peritonitis,
sepsis, hemodynamic instability and
death.
 Imaging
XR: pneumatosis intestinalis, air in the portal
vein, pneumobilia, perforation.

US: Pneumatosis, decreased flow.

CT: The test of choice and the gold standard.

Can determine etiology and extent of
involvement, thus determining course of
treatment. Requires a stable patient!

MR: No advantage over CT

 Mesenteric Ischemia: Diagnosis
and Management
Begins with history/physical and a high
degree of clinical suspicion.

Initial treatment is resuscitative and

supportive. What does that actually mean?

Early surgical consult.

May require IR depending on etiology of

ischemia.
 Cases
A 23 year old female presents with severe,
intermittent right lower quadrant pain
associated with nausea and vomiting.
She has no medical history.
Her vital signs reveal tachycardia but are
otherwise normal.
Physical exam shows a soft abdomen, RLQ TTP
without peritoneal signs. Pelvic (which is part
of the physical exam), shows scant discharge.
If you could only order one test, what would it
be?
What is on your differential?
 Differential
Ectopic Pregnancy Nephrolithiasis
Ruptured Ovarian Pyelonephritis
Cyst Endometriosis
Appendicitis UTI
Right-sided Heterotopic
diverticulitis pregnancy
TOA Terminal ileitis
Ovarian Torsion
Ovarian Torsion
 Increased ovarian volume
(>15cc), multiple follicles and
decreased blood flow.
 Cases
A 24 y/o male presents with rapid onset,
non-radiating, diffuse abdominal pain.

He has no medical or surgical history.

He is tachycardic and tachypneic.

His exam reveals a distended abdomen

which is diffusely tender. He has decreased
bowel sounds.
 Differential?
Appendicitis Colitis
Bowel Obstruction PUD
Testicular torsion Peritonitis
Perforated Viscus Mesenteric
Ischemia
What happens and what
it looks like:
Compared to a Sigmoid
Volvulus
Obstructions: Small and Large
Bowel
Small Large
Adhesions Masses
Hernias Diverticulitis
Masses Sigmoid Volvulus
 Treatment
NPO
NasoGastric Tube suction.
Fluid and Electrolyte repletion
Antibiotics
Surgical consult
 Pitfalls:
Incomplete exams (rectals, pelvics and
genital exams)
Incomplete histories
Missing abnormal vitals
Relying on labs
Relying on imaging
Not performing serial exams
Elderly, the young, the pregnant, altered
or psychiatric patients
Constipation GERD Gastroenteritis
and UTI
 Other conditions
Systemic Thoracic
DKA Myocardial
Alcoholic ketoacidosis infarction/ Unstable
angina
Uremia Pneumonia
Sickle cell disease Pulmonary embolism
Porphyria Herniated thoracic disc
SLE (neuralgia)
Vasculitis Genitourinary
Glaucoma Testicular torison
Hyperthyroidism Renal colic
Toxic Infectious
Methanol poisoning Strep pharyngitis
(more often in
Heavy metal toxicity children)
Scorpion bite Rocky Mountain
Black widow spider Spotted Fever
bite Monocucleosis
Abdominal wall
Muscle spasm
Muscle hematoma
 References:
Me.
SBO PICTURE: http://www.healthhype.com/partial-and-complete-bowel-obstruction-symptoms-and-treat
ment.html
CECAL VOL. http://bestpractice.bmj.com/best-practice/monograph/877/resources/image/bp/2.html
Sigmoid:
http://www.learningradiology.com/archives2008/COW%20338-Sigmoid%20volvulus/sigmoidvolcorrect.ht
m
Pneumoperitnoeum: http://new.medicalfinals.co.uk/?p=425
Foreign bodies: http://lifeinthefastlane.com/2009/10/top-ten-foreign-bodies/
Gallbladder:
http://imaging.consult.com/imageSearch?query=impactions&qyType=AND&global_search=Search&mod
ality=&thes=true&normalVariantImage=false&groupByNode=none&anatomicRegion=&modalityFilter=U
ltrasound
AAA:
http://www.keepingyouwell.com/CareAndServices/VascularLabServices/AbdominalAorticAneurysms.aspx
Appendix 1: http://imagingsign.wordpress.com/category/ultrasound/
Appendix 2: http://www.madisonradiologists.com/SvcCTAbdominalPain.htm
CT AAA: http://radiographics.rsna.org/content/20/3/725/F44.expansion
Cullens: http://www.gastrointestinalatlas.com/English/Jejuno_and_Ileum/Etc__Etc_/etc__etc_.html
Portal air: http://www.nzma.org.nz/journal/119-1246/2343/
Ovarian torsion: http://medchrome.com/major/gynaeobstr/complications-of-ovarian-cyst/
Ovarian torsion U/S: http://www.med-ed.virginia.edu/courses/rad/edus/index13.html
Cecal volvulus diagram: http://imaging.consult.com/image/topic/dx/Gastrointestinal?title=Colonic
%20Obstruction&image=fig11&locator=gr11&pii=S1933-0332(06)70677-2
Cecal volvulus drawing: http://www.radiologyassistant.nl/en/4542eeacd78cf
Sigmoid volvulus illustration: http://alharthy.com/
Sigmoid X ray; http://rad.usuhs.edu/medpix/topic_display.html?recnum=1608&pt_id=10030&imageid=
Small bowel obstruction XR: http://allbleedingstops.blogspot.com/2009/01/solution-to-puzzle.html
other conditions slide: http://erweb.vghtpe.gov.tw/ skhou/ abdominal%20pain.ppt 91k