Management of Patients with Abdominal Pain in the Emergency Department Jim Holliman, M.D., F.A.C.E.P.Professor of Military and Emergency MedicineUniformed Services University of the Health SciencesClinical Professor of Emergency MedicineGeorge Washington UniversityBethesda, Maryland, U.S.A.

Abdominal PainLecture 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

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

General Approach to the Patient Presenting with Abdominal PainEvaluate & treat the ABC's (Airway, Breathing, Circulation) first in same sequence as for any other emergency patientDetermine if an immediate life-threatening cause of abd. pain may be present & if there is any history of possible abd. traumaStart 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

Immediate Life-Threatening Causes of Abdominal PainThese must be recognized from the primary survey :Ruptured abdominal aortic aneurism (AAA)Rupture of the spleen or liverRuptured ectopic pregnancyBowel infarctionPerforated viscusAcute myocardial infarction (MI)

Ruptured Abdominal Aortic Aneurism (AAA)More common in males > 65 years of ageMay present initially as back or groin painTypically would have epigastric or periumbilical pain radiating to backMay 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 patientAbd. CT scan is best Dx test for stable patient (surgeon may also want angiography preop if patient is stable)

Ultrasound showing 7.5 cm AAA with intraluminal clot

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

Emergency Management of Ruptured AAAOxygen & 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 bloodInsert foley catheterObtain an electrocardiogramEmergently consult a surgeonNotify the operating room

Ruptured Spleen or LiverUsually due to trauma, but can be spontaneous from malaria, mononucleosis, or hematologic diseasesPatient 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.)

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

Bowel InfarctionDue to clot embolus or thrombosis in mesenteric arteryMost 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

Bowel Infarction (cont.)Usual lab findings :High WBCSevere 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 DxRx : Oxygen, IV fluid resuscitation, IV broad spectrum antibiotics, consult surgeon

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

Perforated ViscusCauses :Blunt or penetrating trauma, tumors, inflammaory bowel disease, typhoid fever, amebiasis, other parasitesTypically 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

Free air under the diaphragm from a perforated peptic ulcer

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

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

Acute Myocardial Infarction (MI) as a Cause of Abdominal PainSuspect in adult patient with upper abd. pain but no or minimal abd. tendernessInferior 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 alsoRx : Oxygen, IV line, nitrates, aspirin, consider thrombolytics, etc., & admit to monitor bed unit

Now That Immediate Life-Threatening Causes of Abd. Pain Have Been Reviewed, Next the Lecture Will Review History and Exam for the Stable PatientHistory items to ask the patient with abd. pain :Time and rapidity of onsetCharacter of pain (burning, cramping, etc.)Associated symptomsSigns of bleeding (dark vomitus or stool)Prior surgeries & illnessesLast menstrual periodMedications (especially steroids, aspirin, warfarin)Alcohol intakeUnusual ingestion or foreign travel

Physical Exam for the Patient with Abdominal PainNeed complete set of vital signsLook 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 coagulapathyCareful chest & lung exam (basilar pneumonias can present as abd. pain)Palpate and observe the backGenital and rectal exam (& stool guiac) should usually be routine

Exam of the Abdomen in the Patient with Abdominal PainInspection : Look for :Scars from prior surgeriesDistensionLocalized swelling or massEccymoses or erythemaVisible peristalsisAuscultation with stethescopeListen for bowel sounds & bruitsPalpation & percussion

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

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

Palpation of the AbdomenShould be done following inspection & auscultationAssess for tenderness, guarding, mass, crepitus, referred tendernessDifferentiate lower rib tenderness from true upper abd. tendernessDon'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)

Lab Studies for Patients with Abdominal PainUse selectively ; not all are needed for all patientsFor 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

List of Lab Studies to Consider for Patients with Abdominal PainType 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 sensitivityLiver function tests (bilirubin, SGOT, SGPT, alk. phos.)Electrolytes, glucose, creatinine, blood urea nitrogen (BUN)Serum alcohol, serum or urine drug screenSerum 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)

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

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

Plain Radiographs for Abdominal PainIf 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 airUpright 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)

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

Disadvantages of Diagnostic UltrasoundVisualization may be limited by bowel gas or obesityGood interpretation requires experienceNot good at showing retroperitoneal conditionsMay not directly visualize solid organ lacerations

Use of Computed Tomography (CT) for Abdominal PainNoncontrast 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

Other Diagnostic Studies to Consider for Abdominal PainIf contrast CT not available :Gastrografin Upper GI study for suspected :Stomach or bowel perforationDiaphragm ruptureDuodenal hematomaNever do barium GI study if any chance of barium leak (causes severe peritonitis)Intravenous pyelogram (IVP) for suspected :Ureteral stone or injuryRenal mass

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

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

Usefulness Of NG Tube Suction for the Patient with Abdominal PainAllows decompression of stomachLessens risk of aspirationCan remove some of residual toxins in stomachMay demonstrate upper GI bleedingRequired before peritoneal lavageContraindicated if nasal or midface fractures or severe coagulapathy (insert via mouth instead)

General Mechanisms Causing Abdominal PainPain originating in the abdomenPeritonitisDistension of hollow visceraIschemiaPain referred to the abdomen from another part of the bodyMetabolic disordersNeurogenic disorders

Causes of Referred Abdominal Pain from Chest ConditionsAcute coronary syndromes (and "angina equivalents")Pneumonia (especially basilar)Spontaneous pneumothoraxPulmonary embolus (rare cause)Pericarditis

Metabolic Causes of Abdominal PainDiabetic ketoacidosisHyperlipidemia (often with pancreatitis)Acute prophyriasBlack Widow spider bitesScorpion bitesSickle cell crisis (sequestration in spleen or liver, or vaso-occlusive)

Neurogenic Causes of Abdominal PainHerpes zoster (Shingles)Pain often present several days before characteristic dermatomal vesicles appearThoracic or lumbar spinal disc disease or compressionSyphilis ("tabetic crisis")

Patient with Herpes Zoster (Shingles) of the abdomen

Trauma-Related Causes of Abdominal PainMay present delayed, or from seemingly minor trauma in the elderly :Ruptured spleen or liverBowel or stomach perforationPancreatic contusion or transectionRuptured bladderMesenteric hematomaAbdominal wall hematoma (U/S is good at diagnosing this)

Pregnancy-Related Causes of Abdominal PainEctopic (usually tubal) pregnancyFalse labor (Braxton-Hicks contractions)Active laborAbruptio placentae (note that placenta previa which can cause severe bleeding is usually painless)Septic abortion

Genitourinary Tract Causes of Abdominal PainCystitisPyelonephritisUreterolithiasisPerinephric abscess (may see gas around kidney on KUB film)Renal infarction (as from sickle cell disease)Psoas abscessTesticular torsionUrinary retention (as from prostatic hypertrophy)

Peritonitis Causing Abdominal PainDefinition : inflammation of the peritoneumCauses : 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 ileusSymptoms and signs : abdominal pain, rebound tenderness, abdominal muscle guarding or rigidity, fever, emesis, decreased bowel sounds, abdominal distentionKey Rx : IV fluid resuscitation, IV antibiotics (usually), EARLY PAIN RELIEF WITH NARCOTICS, try to determine the most likely cause, emergently consult a surgeon

List of Most Common Causes of Acute Abdominal Pain in AdultsAcute gastroenteritisAcute cholecystitisAcute cholangitisAcute appendicitisAcute diverticulitisAcute gastritis or peptic ulcerAcute esophagitisAcute panceatitisBowel obstructionInflammatory Bowel DiseaseAcute salpingitis (pelvic inflammatory disease)Acute pyelonephritisAcute cystitisUreterolithiasisUrinary retentionAcute viral hepatitisMesenteric ischemiaOvarian cystsComplications of pregnancy

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 diagnosisFor 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

Acute GastroenteritisPresent with nausea / emesis / diarrheaUsually viral or reaction to foodIf bacterial, usually have abd. tenderness +/- lower GI bleedingIf abd. nontender and diarrhea is nonbloody, usually do not need lab studiesRx with IV LR 1 to 5 liters, oral, rectal, or parenteral antiemetics, +/- antidiarrheals

Choices for AntiEmetics in the E.D.My favorite : hydroxyzine (Atarax, Vistaril)Antihistamine, also an antianxiety agentVery low incidence of side effects25 to 50 mg IM or PO q 6 hoursPromethazine (Phenergan)Some risk of dystonic reactions & sedation25 to 50 mg q 6 hours IV, IM, PO, or PRProchlorperazine (Compazine)40 to 50 % incidence of dystonic reactions10 to 25 mg q 6 hours IV, IM, PO, or PRMetclopromide (Reglan) : 5 to 20 mg q 4 hrs. IV, IM, or PO

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

Acute CholecystitsUsual clinical profile is obese female > age 40May cause more complications in diabeticsUsually RUQ +/- epigastric tenderness and emesisU/S is best Dx testLFT'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 emergentlyRx : IV fluids, NPO at first, pain meds, surgery consult unless quickly resolves

Emphysematous cholecystitis (arrows show gas around the gallbladder)

Acute AppendicitisAccuracy of Dx on clinical grounds alone is not goodUsually periumbilical pain, then migrates to RLQUsually anorexia, nausea, +/- low grade feverKUB film rarely shows diagnostic appendicolith in RLQU/S and CT can make definitive DxConsult surgeon if suspected

Acute DiverticulitisMore common after age 45Typically pain & tenderness in LLQ, but can be diffuseCan result in inflammatory mass in LLQ or perforationCT with contrast is best Dx testMilder cases can be discharged on oral antibiotics

Acute Gastritis ; Peptic UlcerTypically epigastric pain & tendernessIf perforation or severe bleeding, may require laparotomyDefinitive Dx by endoscopy preferred over Upper GI contrast study, but not needed for many patientsRx with H2 blockers such as ranitidine (in addition to IV fluids, etc. for severe cases)

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

Bowel ObstructionCan be either large or small bowelMost common causes : Adhesions from prior surgery, incarcerated hernia, cancer, volvulus, mass of parasites, inflammatory bowel diseasePlain X-ray films are key Dx testIf possible associated bowel necrosis (infarction), consult surgeon emergently

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

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

Upright film of sigmoid volvulus in a 67 year old male

Supine film showing sigmoid volvulus in a 67 year old male

Upright film showing cecal volvulus in a 62 year old male

Inflammatory Bowel DiseaseTwo types :Ulcerative colitisCrohn's DiseaseUlcerative 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

Acute Salpingitis (Pelvic Inflammatory Disease)Typically present as severe lower abd. pain & vaginal dischargeGet cervical cultures as part of workupUsually caused by gonococcus or chlamydia, but can involve other bacteriaRx : IV antibiotics, pain medsAdmit to hospital if :Toxic, pregnant, immunosuppressed, suspected tubo-ovarian abscess

Acute PyelonephritisUsually have dysuria & back pain & CVA tenderness, but can show projected anterior abd. tendernessAdmit 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

UreterolithiasisCommonly have sudden back or flank and/or abd. pain +/- groin radiation, but not much tendernessNeed early Rx with pain meds (parenteral NSAID such as ketorolac 30 mg IV is most effective) ; IV morphine if more analgesia neededNoncontrast spiral CT is Dx method of choiceIVP or U/S are alternativesShould "cover" with antibiotic (such as Bactrim or Cipro) if any bacteria noted on urinalysisOver 90 % of patients can be discharged from E.D.

Urinary RetentionMost common in elderly men with benign prostatic hypertrophyCan occur also from acute prostatitisRx with foley catheterIf bladder residual > 100 cc, should leave foley catheter in at least 24 hours to allow bladder to recover its muscle toneRoutine use of coverage antibiotics while foley is in is debated

Acute Viral HepatitisIncidence greatly decreased by use of Hep B and A vaccinesTypically present with nausea, emesis, +/- RUQ pain, +/- jaundiceNeed to check serologies on close contacts of index caseAdmit to hospital if encephalopathic, GI bleed, increased protime, hypoglycemic

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

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

"Secondary" Aspects to Remember for Abdominal PainOxygen if any possible major systemic compromiseQuestion patient about prior anesthetic complications if surgery anticipatedAdditional doses of pain meds as neededTetanus immunization if associated skin injuryAntibiotics (+/- cultures if indicated)Tell the patient & family what is going on

Abdominal PainSummaryAssess the ABC's & provide emergent Rx if life-threatening cause suspectedComplete exam prior to deciding on other Dx testsFocus on the most likely Dx's initiallyDecide early if surgical consult or hospital admission neededDon't forget "secondary" treatments