Differential Diagnosis of Acute Abdominal Pain with narration 2003 com

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Differential Diagnosis of Acute Abdominal Pain:

Differential Diagnosis of Acute Abdominal Pain Micki Raber, MSN, FNP-C, PNP-C Cindy Herf, MSN, FNP-C

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Abdominal pain is one of the most frequent complaints in primary care Most patients with abdominal pain have minor, non-surgical causes. Nonspecific abdominal pain (NSAP) is common in all ages and the most frequent cause in pediatric patients You must be able to quickly recognize life-threatening causes of acute abdominal pain

Abdominal anatomy review:

Abdominal anatomy review

Abdominal regions:

Abdominal regions

History: HPI:

History: HPI Evaluation of abdominal pain starts with a careful, detailed history Onset : when did it start? Did it come on suddenly or gradually? Location : where is the pain? Has the pain moved? Use the abdominal regions to document location Duration : How long have you had pain? Is this acute or chronic (> 2 weeks) Character : Is the pain sharp, well localized? Is it dull, diffuse? Burning, gnawing, crampy , colicky?

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Aggravating factors : What makes the pain worse? Food? Movement? Position? Relieving factors : What makes the pain better? Position? Antacids? Food? Defecation or urination? Timing : Is the pain constant or intermittent? Is it worse at certain times of the day? Is the timing related to meals or other activities such as school attendance? Associated symptoms : fever, vomiting, diarrhea, anorexia, hematemesis or melena, constipation, amenorrhea, dysuria, jaundice

Past Medical History:

Past Medical History History of chronic GI problems: IBD, IBS, GERD History of constipation, change in bowel habits Abdominal surgeries Gyn history for all women of childbearing age: LMP, method of contraception, STD risks Medications: many cause constipation, diarrhea or nausea, NSAIDS and ASA increase risk of PUD

Social History:

Social History Smoking: worsens symptoms in GERD, PUD, Crohn’s, may lessen symptoms in Ulcerative colitis Alcohol use: very important to quantify. Binge drinking associated with pancreatitis. Recent travel, camping, unusual food exposures: increase risk of infectious agents

Abdominal Exam:

Abdominal Exam Look: distension, previous surgical scars, visible peristalsis, pulsations, engorged veins, skin turgor , hernias Listen: assess bowels sounds in all quadrants, assess for bruits Feel: palpate painful area last, distract patient by talking to lessen voluntary guarding, assess size of spleen/ liver, rigidity, masses, pulsations, rebound tenderness Percuss : ascites , CVA tenderness, Hepatospleenomegaly

Special exams:

Special exams Rectal exam on most patients with abdominal pain: check for stool in vault, guiac stool for occult blood GYN exam on females of reproductive age: pregnancy, ovarian cysts, dysmenorrhea, endometriosis, and PID all present with abdominal pain Testicular exam on males: hernia, testicular torsion can have pain in lower abdomen radiating to the groin

Common Causes by Location:

Common Causes by Location Diffuse: Inflammatory bowel disease (IBD), Irritable bowel syndrome (IBS), gastroenteritis, AAA, bowel obstruction, ischemic bowel Epigastric : MI, peptic ulcer disease (PUD), biliary disease, pancreatitis Right upper quadrant: hepatitis, gallbladder ( biliary ) disease, renal disease ( pyleo or renal stone) Left upper quadrant: spleen, renal disease Periumbilical : early appendicitis, small bowel disease Left lower quadrant: diverticulitis (can be diffuse), PID, ovarian cyst, ectopic pregnancy Right lower quadrant: appendicitis, PID, ovarian cyst, ectopic pregnancy

Terminology: Signs:

Terminology: Signs Murphy’s: RUQ pain on deep inspiration: seen with inflamed gallbladder. May also be elicited by palpating the RUQ as they take a deep breath.

Rovsing sign:

Rovsing sign Palpation of the left lower quadrant causes pain in the right lower quadrant. Seen with appendicitis

Cope Obturator Test:

Cope Obturator Test Pain felt in the right lower quadrant on internal rotation of the right hip. Often just called the obturator sign. Seen with appendicitis.

Iliopsoas sign:

Iliopsoas sign Extension of the right hip causes pain in the right lower quadrant. Seen with appendicitis.

Signs of peritoneal irritation:

Signs of peritoneal irritation Guarding: voluntary: usually symmetric, muscles more tense on inspiration, usually does hurt to rise from supine to sitting position (using abdominal muscles), lessens with distraction. involuntary: aysmmetrical , rigidity present on inspiration and expiration, rising to sitting position greatly increases pain, doesn’t change with distraction Rebound tenderness: slowly compress abdomen, then quickly release pressure, pain increases.

Lab Tests:

Lab Tests CBC with diff to look for infection and blood loss CMP: check hydration with BUN, Creatinine , electrolytes, check LFTs for hepatitis or biliary disease Amylase/ lipase: elevated in pancreatitis UA: nitrates, leukocytes, RBCs may indicate UTI Stool for occult blood: cancer, IBD, diverticulitis, PUD Pregnancy test on ALL childbearing age females (remember this even in young teens)


Imaging KUB: may detect renal stones, look for stool in colon, free air in perforation, dilated loops of bowel in obstruction Abdominal Ultrasound: look for gallstones, ovarian cysts or ectopic pregnancy, hydronephrosis due to renal stone, high specificity for appendicitis but not as sensitive as CT. CT: most sensitive test for diagnosing acute abdominal pain. Useful for appendicitis, abscesses, AAA, diverticulitis, bowel obstruction, tumors

Disorders caused by inflammation of the GI tract:

Disorders caused by inflammation of the GI tract Appendicitis Cholecystitis Pancreatitis Gastroenteritis Diverticulitis


Appendicitis Symptoms: Anorexia, periumbilical pain that later migrates to RLQ, nausea &vomiting usually after onset of pain, prefers to remain still Signs: pain at McBurney’s point (RLQ), rebound tenderness, + Obturator , Rovsing and Iliopsoas signs, involuntary abdominal guarding (rigidity) WBC may be normal or slightly elevated Diagnostic imaging: Ultrasound very specific but not as sensitive as CT, useful in females to rule out gyn causes. CT more sensitive If high suspicion of appendicitis, some surgeons forego imaging prior to surgery


Cholecystitis Acute or Chronic inflammation of the gallbladder Symptoms develop from mechanical obstruction, local inflammation, or a combination of these factors. Pain is colicky, located in the RUQ with radiation to the flanks & occasionally the R shoulder. Classic pain occurs within 1 hour after eating a large meal, lasts for several hours, & is followed by a residual aching that can last for days. May have anorexia, nausea, & fever & less often with vomiting. RUQ ultrasound has a sensitivity >95% in detecting stones in the gallbladder. Treatment: bowel rest, pain management, antibiotics. Surgery after infection is controlled.


Pancreatitis Risks: hx of gallstones, heavy alcohol use, hypertrigylceridemia , abdominal trauma. May be a hx of recent heavy drinking or a large meal prior to attack. Symptoms: abrupt onset of severe epigastric pain that may radiate to the back. Nausea, vomiting, sweating & anxiety. Pain is movement or lying supine and patient prefers to sit up and lean forward. Signs: abdominal tenderness without guarding, rigidity or rebound. Distension, fever, tachycardia, absent bowel sounds, pallor and hypotension may be present Labs: amylase & lipase elevated 3x normal CT if unsure Imaging: KUB, CT if unsure REFER!!


Gastroenteritis Acute infectious diarrhea: 70-80% due to viruses such as Rotavirus, Adenovirus or Norwalk virus after ingestion of contaminated food or water or by person-to-person spread. 10-20% due to bacterial infections: S. aureus, Salmonella, Shigella, C. difficile, Vibrio, E. coli after ingested of contaminated foods or antibiotic exposure (C. difficile) <10% due to parasites: Giardia, Cryptospridium, Entamoeba histolytica: Look for daycare attendance or camping (untreated water)


Gastroenteritis Usually self-limiting. Very young or elderly at more risk for complications Symptoms: Viral: large volume, watery stool, no blood, Lasts 1-2 days, associated N/V, crampy abd pain, fever, malaise, dehydration in young children. Bacterial: variable from mild symptoms to severe, may have bloody diarrhea. C. difficile may occur up to 8 weeks after exposure to antibiotics, esp. Clindamycin , with watery diarrhea and cramps Parasitic: watery diarrhea which may be prolonged, cramps


Gastroenteritis Treatment is supportive for most Assess for dehydration Testing with stool culture not needed if less than3 days duration unless <3mo or >70 years or at risk of transmitting to others Treatment: oral rehydration for all ages with mild to moderate diarrhea. Infants and children may continue diet for age, adults should avoid dairy, caffeine and alcohol and eat rice, potatoes, wheat, bananas, yogurt and soup and crackers Antimotility agents such as Lomotil or Immodium for adults. Antibiotics if bacterial cause is suspected


Diverticulitis Essentials of Diagnosis: 1. Acute abdominal pain and fever 2. Left lower abd tenderness and mass 3. Leukocytosis Perforation of a diverticulum results in intra-abd infection that varies from micro to macro-perforation. Symptoms: mild to moderate aching abd pain, usually in LLQ, constipation or loose stools, N&V may occur, usually symptoms are mild and pts do not seek medical attention until several days after onset.


Diverticulitis Physical exam : low-grade fever, LLQ tenderness, and a palpable mass, stool occult blood is common, but hematochezia is rare, leukocytosis is mild to moderate; if a free perforation is present pt will appear will present a more dramatic picture with generalized abd pain and peritoneal signs. Differential Diagnosis : 1. Perforated colonic carcinoma, Crohn’s disease, appendicitis, ischemic colitis, and gyn disorders.


Diverticulitis Imaging : 1. Plain abd films to look for evidence of free abd air, ileus, and small or large bowel obstruction. 2. Barium enema gives the best visualization, but if a stricture or mass is seen colonoscopy is needed. 3. Barium enema and flex sigmoidoscopy are contraindicated during the initial stages of an acute attack because of risk of perforation. 4. CT scan of the abd is sometimes needed to rule out abscess formation.

Peptic Ulcer Disease:

Peptic Ulcer Disease Risks: male gender, smoker, NSAID use, past hx of PUD and H.pylori infection Dyspepsia: Diffuse, gnawing, hunger-like, burning pain in epigastric area. Pain may awaken patient. Symptoms wax and wane. May have relief with food intake or antacids and return of pain 2-4 hr later. Up to 60% NSAID-induced PUD have no symptoms. Physical exam: may be normal or slight epigastric tenderness. May have + guiac stools Labs: usually normal. Anemia if bleeding has occurred

Disorders caused by disruption of the GI Mucosal lining:

Disorders caused by disruption of the GI Mucosal lining GERD Peptic Ulcer Disease


GERD Heartburn is the typical symptom. Usually occurs 30-60min after meals and with reclining. Burning chest pain and regurgitation are common. Pain may be relieved by antacids. Most have no structural defects Non-GI symptoms include asthma, chronic cough, laryngitis, sore throat or non-cardiac chest pain. “Alarm” symptoms: age > 55, anemia, melena , or hematemesis , dysphagia, significant weight loss or difficult/painful swallowing

GERD Work-up:

GERD Work-up Patients under 55 without alarm symptoms may be treated empirically without further testing. Patients with alarm symptoms or poor response to empiric therapy should be referred for upper GI endoscopy

GERD Treatment:

GERD Treatment Empiric therapy: Proton Pump Inhibitor once daily for 4-8 weeks. PPI are preferred over H2 receptor antagonists PPI should be taken 30 min. before breakfast Many PPIs now have OTC formulations 10-20% will need twice daily PPI to get relief Patients will good symptom control on empiric therapy should be continued on PPI for 8-12 weeks.


PUD Diagnostic testing: Upper endoscopy with biopsy if gastric ulcers are present. Barium upper GI not as sensitive. H. pylori testing: urea breath test or fecal antigen if prior hx of PUD or if ulcer diagnosed on barium upper GI. Biopsy and rapid urea test & histology if endoscopy is performed Treatment: Medications Acid antisecretory agents: PPIs have replaced most H2 receptor antagonist Antacids, bismuth, misoprostol to enhance mucosal healing Antibiotics to eradicate H. pylori (see texts)

Abdominal Complaints in Children Less than 2 Yrs of Age::

Abdominal Complaints in Children Less than 2 Yrs of Age: Colic Intussusception Incarcerated Hernias Intestinal Malrotation Hirschsprung Disease Pyloric Stenosis GERD UTIs


Colic A colicky infant is defined as one who is healthy and well fed but cries for more than 3 hrs. a day, for more than 3 days a week, and for more than 3 weeks. Characterized by severe & paroxysmal crying that occurs mainly in the late afternoon. Infant’s knees are drawn up & its fists are clenched. A behavioral sign that begins in the first few weeks and peaks at age 2-3 months. In 30-40% of cases, it continues into the 4 th and 5 th months. Management consists of parent ed , medications have not been proven to ameliorate colic.


Intussusception Most common cause of intestinal obstruction in the first 2 yrs of life. Presents as a thriving infant aged 3-12 months with paroxysmal, colicky pain. Vomiting & diarrhea occur soon afterward in 90% of cases and bloody BMs with mucus appear within the next 12 hrs. (currant jelly stools) Prostration and fever supervene. Abd is tender and becomes distended. A sausage-shaped mass may be palpated in the upper mid abdomen. Barium or air enema is diagnostic and therapeutic. Prognosis relates to the duration before reduction.


Hernias Umbilical Hernias – affects African American and preterm children more often; most close spontaneously within 1 st yr of life and majority close by the 5 th year; Large defects and those persisting after age 4 are repaired surgically; in adults umbilical hernias need repair because of the high risk of incarceration and strangulation. Inguinal hernias – account for 75% of abdominal hernias. In children these hernias are congenital, but can be acquired from obesity, chronic cough, ascites , chronic constipation with straining, and lifting heavy objects.

Management of Hernias:

Management of Hernias Do not try to reduce strangulated hernias because reduction can cause gangrenous bowel to enter the peritoneal cavity. Refer immediately. If hernia is reducible, you can refer for elective repair. Alarm markers for referral are acute onset of colicky abd pain, N&V, and edema and discoloration at the site. Strapping an umbilical hernia (belly band or coin) will not speed the spontaneous closure


Malrotation Consider this diagnosis when a healthy infant suddenly refuses to eat, vomits bile, and becomes inconsolable, and develops abdominal distention. This usually occurs during the first 3 weeks of life. Diagnosis: UGI shows the malrotation and it can be further confirmed with a BE. Treatment: Surgery

Pyloric Stenosis:

Pyloric Stenosis Cause is unknown; males predominate S/S: vomiting begins 2-4 wks of age and rapidly becomes projectile after every feeding; it starts at birth in 10% of infants and onset may be delayed in premature infants. Vomitus may be blood streaked. Infant eats frequently, & eventually has constipation, dehydration, wt loss, & is fretful. After feeding upper abd may be distended, prominent gastric peristaltic waves may be seen and in some infants an olive-sized mass can be felt on deep palpation in the right upper abdomen.

Pyloric Stenosis:

Pyloric Stenosis Diagnosing : UGI series may be performed but an abd US will demonstrate the hypoechoic ring with a thickness >4mm. Differentials: The vomitus with pyloric stenosis is not bilious as in other conditions such as malrotation, volvulus and other lesions causing small bowel obstruction. Treatment : Hydration and correction electrolyte of abnormalites prior to surgical repair (pyloromyotomy). The post-op barium x-ray will remain abnormal for many months. Vomiting is common due to gastritis and GE reflux.

Common causes of Abdominal pain in children > 2 yr:

Common causes of Abdominal pain in children > 2 yr Functional or nonspecific abdominal pain Lactose intolerance

Nonspecific or functional Abdominal Pain :

Nonspecific or functional Abdominal Pain Most common cause of chronic abdominal pain accounting for >90% of abd pain in children. Recurrent attacks of abd pain at least 2x week for > 2 mo. Pain is usally periumbilical and varies in intensity and duration. May be colicky or persistant and have associated N&V and pallor. School attendance suffers. No associated weight loss, fever or bleeding. Normal growth & development.

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Labs: CBC, sed rate and stool for occult blood sufficient and usually normal. Diagnosis of exclusion Treatment: reassurance, education, resumption of normal activities, esp. school Education :concept of viseral hyperalgesia: increased pain signaling form normal stimuli such as gas, acid secretion or stool. Psychotherapy for stressors may help Antispasmodics rarely helpful unless the have IBS.

Lactose Intolerance:

Lactose Intolerance Symptoms usually begin around 4-6 yrs of age. Symptoms include intestinal dilatation, bloating, increased flatulence, pain and eventually diarrhea. Symptoms appear 2 hrs. after ingestion of milk or products, sometimes as long as 12 hrs. after. Often confused with cow’s milk intolerance, which occurs in infancy and has symptoms of blood in the stools and often manifestations of allergies such as eczema, hives and asthma. Treatment: Lactase supplement to diary products (Lact-aid) or restriction of diary products

GYNECOLOGIC causes of abdominal pain:

GYNECOLOGIC causes of abdominal pain PID Ectopic pregnancy Twisted ovarian cyst Mittelschmerz Will be discussed more in GYN unit

Ruptured Ectopic Pregnancy:

Ruptured Ectopic Pregnancy Acute onset of unilateral lower quadrant pain which usually is continuous and crampy with some degree of vaginal bleeding and a low-grade fever. Positive pregnancy test Ultrasound fails to reveal intrauterine pregnancy Emergent referral to OB


Mittelschmerz Mid-cycle pain caused by irritation of the peritoneum due to spillage of fluid from the ruptured follicular cyst at time of ovulation. Sudden onset of localized unilateral lower quadrant pain, which persists for a few minutes to as long as 8 hrs. Rarely mimics the abd findings of appendicitis, torsion or rupture of ovarian cyst, or ectopic pregnancy.

MISCELLANEOUS Causes of Abdominal Pain:

MISCELLANEOUS Causes of Abdominal Pain Dissecting aortic aneurysm Acute pyelonephritis Splenic infarction or rupture Acute mesenteric vascular occlusion and related conditions


NONSURGICAL CONDITIONS SIMULATING ACUTE ABD PAIN Metabolic conditions: Diabetes mellitus ( ketoacidosis ) Hyperthyroidism Hypercalcemia / Hyperkalemia Familial mediterranean fever Pneumonias Sickle Cell Crisis Papillary necrosis of the kidney Herpes zoster Hemolytic uremic syndrome Henoch-Schonlein purpura

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