Approach to Abdominal Pain

Gasser El Azab, MD
Scale of the Problem

 Abdominal pain can be a challenging complaint for both

primary care and specialist physicians.
 Community prevalence 75%
 75% of these abdominal complaints non-consulting
Acute Abdominal Pain
Causes in 10320 patients

 Appendicitis 28%
 Cholecystitis 10%
 Small bowel obstruction 4%
 Gynaecological 4%
 Pancreatitis 3%
 Renal colic 3%
 Peptic ulcer 2%
 Cancer 2%
 No clinical diagnosis 34%

De Dombal, Scand J Gastroenterol 1988

 Abdominal Pain Across the Ages

 Ages 0-2
 Colic, GE, viral illness, constipation

 Ages 2-12
 Functional, appendicitis, GE, toxins

 Teens to adults
 Addition of genitourinary problems

 Elderly
 Beware of what seems like everything!
 Abdominal Pain in the Elderly
 Diminished sensation of pain in the elderly
 Comorbid diseases
 Polypharmacy
 Combinations of above result in many more vague,
nonspecific presentations
 Twice as likely to require surgery with presentation over
age 65
 Social factors
Special Populations

 Elderly/ nursing home patients

 Immunocompromised

 Post operative patients

 Infants
Understanding the Types of
Abdominal Pain
 Visceral
 Stretch fibers in capsules or walls of hollow viscus
that enter both sides of spinal cord

 Somatic
 Fibers dermatomally distributed and enter
unilaterally in the spinal cord

 Referred
 Overlap of fibers from other locations
Understanding the Types of
Abdominal Pain
 Visceral
 Crampy, achy, diffuse,
 Poorly localized

 Somatic
 Sharp, lancinating
 Well localized

 Referred
 Distant from site of generation
 Symptoms, but no signs
Referred Pain
Quadrant View of the Abdomen
Right Upper
Right Upper Quadrant Pain
 Hepatitis
 Cholecystitis
 Cholangitis
 Pancreatitis
 Budd-Chiari syndrome
 Pneumonia/empyema pleurisy
 Subdiaphragmatic abscess
 Ruptured aortic aneurysm
Left Upper
Left Upper Quadrant Pain

 Splenic abscess
 Splenic infarct
 Gastritis
 Gastric ulcer
 Pancreatitis
 Left lower lobe pneumonia
 Myocardial infarction
 Pericarditis
 Ruptured aortic aneurysm
Left Lower
Left Lower Quadrant Pain

 Diverticulitis
 Salpingitis
 Ectopic pregnancy
 Inguinal hernia
 Nephrolithiasis
 Irritable bowel syndrome
 Inflammatory bowel disease
Right Lower
Right lower Quadrant Pain
 Appendicitis
 Salpingitis
 Ectopic pregnancy
 Inguinal hernia
 Nephrolithiasis
 Inflammatory bowel disease
Diffuse Pain
 Generalized peritonitis
 Acute Pancreatitis
 Sickle Cell Crisis
 Mesenteric Thrombosis
 Gastroenteritis
 Metabolic disturbances
 Dissecting or Rupturing Aneurysm
 Intestinal Obstruction
 FMF
 Irritable bowel syndrom
 Psychogenic illness
Extra-abdominal causes
Cardiac Metabolic
 Myocardial ischemia and infarction  Uremia
 Myocarditis  Diabetes mellitus
 Endocarditis  Porphyria
 Heart failure  Acute adrenal insufficiency
 Hyperlipidemia
Thoracic  Hyperparathyroidism
 Pneumonitis
 Pulmonary embolism and infarction Hematologic
 Pneumothorax  Sickle cell anemia
 Empyema  Hemolytic anemia
 Esophagitis  Henoch-Schönlein purpura
 Esophageal spasm  Acute leukemia
 Esophageal rupture
Infections
Neurologic  Herpes zoster
 Radiculitis: spinal cord or peripheral nerve  Osteomyelitis
 tumors, degenerative arthritis of spine  Typhoid fever
 Abdominal epilepsy
 Tabes dorsalis
Miscellaneous
 Muscular contusion, hematoma,
Toxins  or tumor
 Hypersensitivity reactions  Narcotic withdrawal
 insect bites, reptile venoms  Familial Mediterranean fever
 Lead poisoning  Psychiatric disorders
 Heat stroke
History Taking in Abdominal Pain
Presentations
“OLD CARS”

 O- onset
 L- location
 D- duration
 C- character
 A-alleviating/aggravating factors
associated symptoms
 R- radiation
 S- severity
History Taking in Abdominal Pain
Presentations
Description of emesis and stool - color,
consistency, amount, presence of mucous and
blood.
History Taking for Abdominal Pain
Presentations
 PMH
 Similar episodes in past
 Other medical problems that increase disease likelihood
of problems (ex: DM and gastroparesis)
 PSH
 Adhesions, hernias, tumors
History Taking for Abdominal Pain
Presentations
 MEDS
 Abx, NSAIDS, acid blockers, etc
 GYN/URO
 LMP, bleeding, discharge
 Social
 Tob/EtoH/drugs/home situation
 Physical Exam in Abdominal Pain
Presentations
General appearance
 “Sick versus not sick”
 Mobile versus still
 Obvious pain or discomfort

Vital signs
 “That’s why they’re called vital”
Physical Exam in Abdominal Pain
Presentations
Inspection
 Distention, scars, bruises
Auscultation
 Present, hyper, or absent
Palpation
 Often the most helpful part of exam
 Tenderness versus pain
 Start away from painful area first
 Guarding, rebound, masses
Physical Exam in Abdominal Pain
Presentations
Signs
 Psoas sign.
 Murphy’s

Extra-abdominal exam
 Pelvic or scrotal exams
 Lungs, heart

Rectal
Laboratory Testing

Everybody likes a CBC, but…

 Lacks sensitivity, no specificity

 Little to no change in diagnostic probabilities
 Should not dramatically alter approach
(tender is still tender)
Laboratory Testing

CBC with Diff

Urine analysis.
Blood glucose
Electrolytes.
Liver function tests, amylase/lipase.
Pregnancy test in women of child
bearing age
Imaging
Plain films
 Free air, obstruction, air-fluid, FBs

Ultrasound
 Formal studies
 May add doppler

Computed Tomography
 Revolutionized acute care
 Often better than we are!
Initial Treatment
 Must decide whether to admit and observe, discharge
or operate.
 Keep NPO until diagnosis has been established.
 IV fluids for maintaining correct fluid balance
 Nasogastric tube for gastric decompression, vomiting
or bleeding.
 Foley catheter to ensure adequate hydration and urine
output.
 Pain medications as indicated.
Consultants
 Surgeons, OB/GYN, urologists, cardiologists, etc
 Summary

Think in terms of the area of the pain.

Common conditions are common.
Disease prevalence changes with age.
Different patterns of disease between
men and women.
Thank you