Abdominal Pain : Abdominal Pain Acute abdominal pain is the chief complaint in about 5% of ED visits
Most patients are discharged after ED evaluation
Only about 10% require urgent surgery Causes of Acute Abdominal Pain Stratified by Age : Causes of Acute Abdominal Pain Stratified by Age 8500 patients, 200 EDs in 17 countries over a 10-year period. [Gallagher EJ, in Emergency Medicine, Tintinalli JE, p 490] Causes of Acute Abdominal Pain Stratified by Age : Causes of Acute Abdominal Pain Stratified by Age In all large series of acute abdominal pain in adults, the largest groups are (in order):
Nonspecific abdominal pain (NSAP)
Biliary disease (usually cholecystitis)
This accounts for 75% of cases
In older patients, biliary disease is most common:
Nonspecific abdominal pain (NSAP)
Appendicitis Immediately Life-Threatening 1 HOUR : Immediately Life-Threatening 1 HOUR Abdominal aortic aneurysm (AAA)
Myocardial infarction (MI)
Ruptured ectopic pregnancy Rapidly Life-ThreateningBETWEEN 1 H AND 1 DAY : Mesenteric ischemia
Volvulus / Intussusception
Diabetic ketoacidosis (DKA) Rapidly Life-ThreateningBETWEEN 1 H AND 1 DAY Serious Threat to Health or Life BETWEEN 1 DAY & 1 WEEK : Serious Threat to Health or Life BETWEEN 1 DAY & 1 WEEK Appendicitis
Rupture or torsion of ovarian cyst Small bowel obstruction (SBO)
Pelvic inflammatory disease (PID)
Intra-abdominal abscess Mild-Moderate Morbidity> 1 WEEK : Mild-Moderate Morbidity> 1 WEEK Diverticulitis
Prostatitis Biliary or Renal colic
Inflammatory bowel disease (IBD)
Undifferentiated abdominal pain (UDAP) No Morbidity : No Morbidity Gastroenteritis
Herpes Zoster Dysmenorrhea
Normal intrauterine pregnancy (IUP)
Urinary tract infection (UTI) Rapid Assessment/Stabilization : Rapid Assessment/Stabilization Up to 7% of patients with abdominal pain may have a life-threatening process
Physiologically compromised patients should be identified in triage and brought immediately to the treatment area for resuscitation Your worst nightmare : Your worst nightmare A 60 year old woman with Type II diabetes mellitus, hypertension, coronary artery disease, chronic renal insufficiency, two prior myocardial infarctions, Marfan’s syndrome, who is a smoker and drinker for >40 years, presents to the ED on Monday night with abdominal pain, fever, nausea, vomiting, vaginal bleeding, bloody diarrhea, and syncope. On exam, she is lethargic, tachypneic, hypotensive, with a barely palpable pulse. Her abdomen is distended and rigid. She’s deaf and mute.
What do you do? Rapid Assessment/Stabilization : Rapid Assessment/Stabilization All critically ill patients require resuscitation before beginning a diagnostic assessment
What is important is not to make a specific diagnosis, but to identify and treat life threatening conditions
Profound shock or protracted emesis may compromise airway and require intubation
Provide supplemental O2
O2 saturation monitoring Rapid Assessment/Stabilization : Rapid Assessment/Stabilization Circulation:
IV access (2 large bore IV catheters)
Cardiac rhythm monitoring
Volume repletion with an isotonic crystalloid solution
May require several liters of fluid
Titrate volume to hemodynamic status and urine output
Extreme conditions e.g. ruptured AAA, massive GI hemorrhage, ruptured spleen, and hemorrhagic pancreatitis may require blood replacement
Nasogastric tube (for bowel obstruction)
Urinary catheter for critically ill patients (to monitor urine output) Pivotal Findings: History : Pivotal Findings: History How old are you?
Advanced age means increased risk.
Which came first--pain or vomiting?
Pain first is more likely caused by surgical disease.
How long have you had the pain?
Pain < 48 hours is worse.
Have you ever had abdominal surgery?
Is the pain constant or intermittent?
Constant pain is worse.
Have you ever had this before?
No prior episodes is worse.
Colucciello SA, et al. Emerg Med Pract 1:2, 1999. Pivotal Findings: History : Pivotal Findings: History Do you have a history of cancer, diverticulosis, pancreatitis, kidney failure, gallstones, or inflammatory bowel disease?
All are suggestive of more serious disease.
Do you have human immunodeficiency virus (HIV)?
Consider occult infection or drug-related pancreatitis.
Are you pregnant?
Obtain urine pregnancy test in all women of child-bearing age-consider ectopic pregnancy.
Colucciello SA, et al. Emerg Med Pract 1:2, 1999. Pivotal Findings: History : Pivotal Findings: History Are you taking antibiotics or steroids?
These may mask infection.
Did the pain start centrally and migrate to the right lower quadrant?
High specificity for appendicitis.
Do you have a history of vascular or heart disease, hypertension, or atrial fibrillation?
Consider mesenteric ischemia and abdominal aneurysm.
Colucciello SA, et al. Emerg Med Pract 1:2, 1999. Pivotal Findings: History : Pivotal Findings: History A few classic descriptions:
diffuse, severe, colicky pain:
“pain out of proportion to examination”:
radiation of pain from epigastrium straight through to the midback:
pancreatitis, either primary or from a penetrating ulcer
Always obtain a thorough gynecologic history including
menses, mode of contraception (if any), vaginal discharge
pregnancies, deliveries, abortions, ectopics, cysts, fibroids, pelvic inflammatory disease, sexually transmitted diseases, laparoscopy Physical Exam : Physical Exam Vital signs:
Tachypnea may be an indication of
metabolic acidosis from gangrenous viscera or sepsis or DKA
hypoxemia from pneumonia
Tachycardia or hypotension
may indicate hypovolemia or shock
does not accurately predict abdominal pathology
often no fever in elderly patients with intraperitoneal infections
Female patients should have a pelvic exam
All patients with possible obstruction and with mid or lower abdominal pain should be examined for hernias
Serial exams may reveal a diagnosis Ancillary Testing : Ancillary Testing Urinalysis and urine pregnancy test are perhaps the most cost-effective tests
UPT should be sent on all women of reproductive age
The urinalysis must be interpreted with respect to the clinical picture
Pyuria often present without UTI
Up to 30% of patients with appendicitis have abnormal urinalysis
Elevated WBC is neither sensitive nor specific for anything
Electrolytes are abnormal in <1% of patients Ancillary Testing : Ancillary Testing Plain radiography
limited to suspected bowel obstruction, foreign body, and perforated viscus
imaging modality of choice for nonobstetric abdominal pain.
establishes a diagnosis in over 95% of cases
unstable patients should not be moved to the radiology suite until stabilized
In life-threatening processes: detection of
lowers the chances of ectopic pregnancy to < 1 in 20,000 but don’t forget about heterotopic pregnancies
free intraperitoneal hemorrhage or pus
In non-life-threatening processes: detection of
gallstones, dilated common bile duct
ovarian torsion Appendicitis : Appendicitis The problem:
Up to 20% of appendicitis is missed
Normal appendix found in 15-40% of all operations for suspected appendicitis
The acceptable number of negative appendectomies depends upon the age and sex of the patient:
In young men: <10%
In young women: approaches 20% (other pelvic processes make diagnosis more difficult)
Two methods to achieve a low negative appendectomy rate:
close in-hospital observation
use of CT and ultrasound Appendicitis : Appendicitis “The use of abdominal CT and ultrasound has had a dramatic impact on the rate of negative appendectomies.”
True or False? Appendicitis : Appendicitis False. A large study suggests that the rate of negative appendectomies (15 to 20 percent) has not declined during the last 15 years despite the increasing use of CT and ultrasound
63,707 appendectomies from 1987-1998
despite the use of CT, US, and laparoscopy:
84.5% had appendicitis (25.8% with perforation)
15.5% had no evidence of appendicitis
Flum DR, et al. JAMA 2001 Oct 10;286(14):1748-53 Appendicitis : Appendicitis “Among the history, physical exam, and laboratory tests, the clinical feature most predictive of appendicitis is right lower quadrant pain.”
True or False? Appendicitis:History and Exam : Appendicitis:History and Exam True. Five clinical features have high predictive value for appendicitis
the presence of any one should indicate an imaging procedure Gallagher EJ, in Emergency Medicine, Tintinalli JE, McGraw Hill, 2004; p 491 Appendicitis: Ancillary Testing : Appendicitis: Ancillary Testing Laboratory tests are not particularly useful
30% of patients have normal WBC count
However, more than 95% of these have a left shift
microscopic hematuria and pyuria found in up to 30% of pts
(presumably because the inflamed appendix is in close proximity to the bladder and ureter) Appendicitis: Ancillary Testing : Appendicitis: Ancillary Testing Ultrasound
Technically challenging and operator dependent
High enough LR (+) to diagnose appendicitis
But LR (-) too high to rule out appendicitis
The LR (+) for all varieties of CT (with/without oral, IV, rectal contrast) is so high that they invariably drive surgical intervention
LR (-) is not as strong as LR (+)
Hence, absence of appendicitis on CT does not exclude the diagnosis with as much certainty as a positive CT confirms it Appendicitis: Ancillary Testing : Appendicitis: Ancillary Testing Gallagher EJ, in Emergency Medicine, Tintinalli JE, McGraw Hill, 2004; p 492 Appendicitis:Special Populations : Appendicitis:Special Populations Children <5 y.o.
Rate of misdiagnosis is high
Many childhood illnesses associated with anorexia, nausea, and vomiting
Appendiceal wall thin perforation
Omentum immature unable to wall off infection peritonitis
Maintain high index of suspicion and get surgical consultation early
Misdiagnosis can exceed 50%
3x more likely to perforate than the general population
(? Age-related weak appendiceal wall)
Mortality for patients >70 y.o. with appendicitis ~ 30% Case : Case A 34 year old woman in her 34th week of gestation presents with vague constant right-sided abdominal pain for about 12 hours. The pain seems to be located more in the RUQ than anywhere else. She feels some mild nausea, but otherwise has no complaint. On exam, her vital signs are normal, and her abdomen is gravid with some tenderness in the right lateral mid-abdomen, and right upper quadrant.
What is your differential diagnosis? Appendicitis:Special Populations : Appendicitis:Special Populations Pregnant women
Appendicitis the most common extra-uterine surgical emergency in pregnancy
Early symptoms (nausea/vomiting) are frequent in normal pregnancy
Enlarging uterus changes the location of the appendix can cause RUQ pain
diagnosis often delayed rate of perforation 2-3x higher than the general population
Fetal mortality in 20% of cases of perforation
Ultrasound the test of choice Appendicitis:Disposition : Appendicitis:Disposition Stratify patients into 4 groups:
Prompt surgical consultation appendectomy
Presentation suspicious but not diagnostic
Imaging studies (CT or US)
Observation for 4-6 hrs with serial exams
Surgical consultation for patients with evolving exam
Observation in ED with serial exams
If clinical course benign discharge with diagnosis “nonspecific abdominal pain” (not “gastroenteritis”)
Explain worrisome symptoms and instruct to return if any
Arrange for reevaluation by primary care MD or ED in 12-24 hrs
Pediatric, elderly, pregnant
Maintain low threshold for imaging and surgical consultation Biliary Disease : Biliary Disease The most common diagnosis in patients >50 y.o
Cholecystitis, biliary colic, and common duct obstruction often difficult to distinguish on clinical grounds alone
The majority of patients with pathologically proven cholecystitis have no fever
40% of patients with cholecystitis have no leukocytosis
Individual signs and symptoms are weak clinical indicators
Only 1/3 of patients have RUQ pain
The rest complain of diffuse upper abdominal pain
A small group with RLQ pain
Only 2/3 of patients have RUQ tenderness
Murphy’s sign (inspiratory pause during RUQ palpation) is non-specific Biliary Disease:Diagnostic Testing : Biliary Disease:Diagnostic Testing Ultrasound
The most useful test
Can be performed at the bedside by EP’s with a high degree of accuracy
Visualization of the gallbladder without stones has a high negative predictive value for cholecystitis
Visualization of stones, a thickened gallbladder wall, and pericholecystic fluid has a positive predictive value in excess of 90% [LR(+) = 29; LR(-) = 0.1]
Nuclear scintigraphy with technetium-99m-labeled iminodiacetic acid (IDA) is the most sensitive and specific imaging test for cholecystitis Small Bowel Obstruction : Small Bowel Obstruction The main issues:
Diagnosis of the primary disorder
Early detection of strangulation or ischemia
Only 2 historical features have predictive value:
Previous abdominal surgery
Only 2 physical findings have predictive value:
Abnormal bowel sounds
2/3 of patients complain of generalized or central abdominal pain
½ of patients have generalized abdominal tenderness Small Bowel Obstruction : Small Bowel Obstruction Flat and upright plain abdominal films
demonstrate small bowel obstruction in 50% to 60% of cases
suggest obstruction in another 20% to 30%
are hampered by the large number of indeterminate readings Gallagher EJ, in Emergency Medicine, Tintinalli JE, McGraw Hill, 2004; p 490 Small Bowel Obstruction : Small Bowel Obstruction Small Bowel Obstruction : Small Bowel Obstruction Small Bowel Obstruction : Small Bowel Obstruction CT
far superior to plain films in the detection of high-grade SBO
more limited in the detection of low-grade obstruction Small Bowel Obstruction : Small Bowel Obstruction CT, cont.
not required in most cases for the diagnosis of bowel obstruction.
main use is in better defining the site and cause of obstruction
demonstrates intussusception, volvulus, and extraluminal lesions like abscesses and tumors
useful in the setting of abdominal malignancy or inflammatory bowel disease
demonstrates closed-loop obstruction and findings suggestive of strangulation Large Bowel Obstruction : Large Bowel Obstruction Causes: Cancer, Diverticulitis, and Volvulus
Volvulus usually in elderly, bedridden, or psychiatric patients taking anticholinergic meds
Sigmoid much more common than cecal
Abdominal pain, crampy and intermittent, distention, may hear “rushes” – high pitched bowel sounds Perforation : Perforation Rebound tenderness
Severe abdominal pain]
Tympanitic to percussion
Bilious vomitus in proximal obstruction
Feculent vomitus in distal obstruction
Flat plate and upright xray to look for free air
Labs, elevated WBC Perforated Bowel : Perforated Bowel Volvulus : Volvulus NG tube to decompress the bowel
Barium enema can be diagnostic and therapeutic
Sigmoidoscopy and rectal tube often successful
Surgical with closed loop obstruction, cecal volvulus, or necrotic bowel
Antibiotics Volvulus : Volvulus Adynamic Ileus : Adynamic Ileus Abdominal distention
No Flatus, obstipation
Conservative Therapy: IVF, NG decompression, observation
Discontinue meds that inhibit bowel motility Case : Case A 22 year old woman presents to the ED complaining of severe lower abdominal pain. The pain began the day before presentation, and was crampy and intermittent, but she was awakened today at 4 am with severe pain which is constant, and lightheadedness. On exam, her vital signs are: pulse 130 and thready, BP 80/60, RR 28, T 37, O2 sat 94%. She has lower abdominal tenderness.
What is your diagnosis? Ectopic Pregnancy:Epidemiology : Ectopic Pregnancy:Epidemiology 2% of all pregnancies in the USA
The leading cause of pregnancy-related death during the first trimester
The second leading cause (10%) of all maternal mortality
Case-fatality rate per 100,000 ectopic pregnancies has dropped considerably because of improved diagnostics (pregnancy tests and US) and heightened awareness:
1989 3.8 Risk Factors for Ectopic Pregnancy : Risk Factors for Ectopic Pregnancy Ankum WM, et al. Fertil Steril 1996;65:1093 Ectopic Pregnancy : Ectopic Pregnancy Risk factors, history and physical exam have poor sensitivity and specificity
<50% of women with ectopic pregnancy give a history of risk factors
Therefore, all women of reproductive age presenting with abdominal pain or abnormal vaginal bleeding should receive a qualitative pregnancy test
If the pregnancy test is positive
further testing to exclude ectopic (ultrasound and quantitative HCG) Ectopic Pregnancy : Ectopic Pregnancy Bedside transvaginal sonography (TVS):
One question: “Is this pregnancy in the uterus?”
Clear visualization of IUP excludes ectopic pregnancy except for the rare heterotopic pregnancy : historically 0.3/10000 but now overall incidence 1.25/10000 (.3/10000 up to 2.5-6.25/10000 in PID, and 33/10000 in reproductive technology and 100/10000 in IVF patients
If an IUP is not seen, it is correlated with the discriminatory zone (DZ) of the quantitative HCG
DZ = the threshold level above which a normal IUP should be seen on US
A typical DZ is 1500-2000 mIU/ml for TVS
(corresponds to 5-6 weeks from LMP) Slide 51: IUP OB consultation IUP No IUP If low risk for ruptured ectopic:
Repeat hCG in 48 hrs
Repeat TVS in 48 hrs
or when hCG >1500 to determine ectopic or miscarriage Resuscitation:
IV crystalloid + blood
bedside TVS No IUP “formal” TVS IUP Ectopic or no IUP “formal” TVS bedside bedside (-) Abdominal Aortic Aneurysm:Physical Exam : Abdominal Aortic Aneurysm:Physical Exam <1/2 of ruptured AAA’s present with the triad of abdominal or back pain, hypotension, and pulsatile mass
>3/4 are normotensive
Absence of abdominal pain or tenderness does not rule out contained leak into the retroperitoneum
Neither the presence nor absence of femoral pulses or abdominal bruits are helpful clinically
LR’s ≈ 1
Palpation of AAA is the only feature of the exam with clinical utility
LR(+) = 12 (for >3 cm) — 16 (for >4 cm)
LR(-) = 0.5-0.7 (i.e. poor)
Therefore, inability to palpate an AAA should not deter workup Abdominal Aortic Aneurysm:Diagnostic Testing : Abdominal Aortic Aneurysm:Diagnostic Testing Ultrasound
can exclude AAA from the differential diagnosis
Disadvantage: can’t identify leakage
CT: the standard test for leaking/ruptured AAA
For unstable patients
If bedside US demonstrates AAA in suggestive clinical circumstances this is taken as evidence of rupture AAA : AAA Case : Case An 85 year old man with HTN, Type II diabetes mellitus, CAD, history of MI x 2, CHF with an ejection fraction of 20%, paroxysmal atrial fibrillation (not on warfarin), stroke x 2, presents with severe constant diffuse abdominal pain which began 1 hour ago after dinner. He had a normal bowel movement today and had a good appetite at dinner. On exam, the patient is crying out in distress and writhing around on the stretcher. His vital signs are: pulse 110, BP 150/100, RR 24, T 37, O2 sat 92%. His abdomen is not distended, there are no bowel sounds, and the abdomen is non-tender throughout.
What is your diagnosis? Mesenteric Ischemia : Mesenteric Ischemia Several types
Mesenteric venous thrombosis (MVT)
Mesenteric artery disease (>60% of cases; mortality >60%)
Occlusive disease (usually SMA)
Thrombotic – usually long months of ischemia
Embolic – 40-50% - usually mural thrombus from MI or a fib
Nonocclusive disease (NOMI or low-flow state)
Young patients tend to have either
Arrhythmia (usually Afib) embolization
Hypercoagulable state MVT
Most patients are old with lots of comorbidities Mesenteric Ischemia : Mesenteric Ischemia Diagnosis is difficult
Pain is typically poorly localized and visceral, without tenderness (“pain out of proportion to exam”)
May be abrupt in onset (embolism) or indolent (MVT)
Patients often become transiently better after a few hours of ischemia because of mucosal infarction then develop peritoneal findings hours later after full thickness necrosis
Nausea, vomiting, may also have bloody stools
Distention, late finding
Elderly patients often do not appear as ill as they are
Timely diagnosis requires early angiography
Must maintain a high clinical suspicion Mesenteric Ischemia : Mesenteric Ischemia Elevated WBC counts
Metabolic Acidosis, elevated lactate
Arteriography for early diagnosis if stable
Key to make diagnosis before infarction occurs
IVF, Antibiotics, bowel decompression
Surgery if infarction or dead bowel (70% mortality)
Anticoagulation, infusion of vasodilating drugs Mesenteric Ischemia : Mesenteric Ischemia