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Abdo Pain

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Abdominal Pain (acute and chronic)

Subjective

  • LOCATION of pain is starting point of abdo pain evaluation

      • Is it pulm, urinary, or hepatobiliary?

      • UTI/kidney stone → urinalysis

      • colic/fever/steatorrhea/Murphy’s → u/s

      • If suspected appendicitis, also get urgent surg consult

      • Not just hx of fever/ds, physical findings too (e.g. distention, tenderness, rectal blood, etc)

  • Onset, duration, severity, quality, exacerbating/remitting factors

  • Pain relief w/ bowel mvnt, More freq stools w/ onset of pain, Loose stools w/ onset of pain, Passage of mucus, Sensation of incomplete evacuation, abdo distention

    • Manning criteria (3 or more of) for IBS

  • Red flags

    • New onset of pain, Change in pain, Altered bowel habits in elderly

      • Check if all 3 are particular to elderly, or just the altered bowel habits

    • Wt loss (GI malignancy)

    • Pain radiating to back (pancreatitis, AAA)

    • Appendicitis (from highest to lowest PPV)

      • RLQ PAIN, pain migration from periumbilical to RLQ, fever, anorexia

    • Pain radiating to groin (testicular torsion, hernia, renal colic)

    • Bleeding per rectum, melena stool (GI bleed, Meckel’s, malignancy in elderly)

    • Anemia

    • Supraclavicular nodes

    • personal/family hx of serious bowel patho

    • Pain waking pt at night

    • Current abx/steroids (can mask peritoneal sx’s)

    • Cardiac hx incl. Afib, HTN (ischemic bowel, AAA, MI)

    • Bowel obstruction (highest to lowest PPV)

      • CONSTIPATION, abdo distention, ↓ pain after vomiting, colic, prev abdo surg

    • Antipsychotic use (ileus, obstruction, toxic megacolon)

    • EtOH (risk factor for pancreatitis, varices)

    • Sexually active (ectopic pregnancy, STIs)

    • Cholecystitis (highest to lowest PPV)

      • RUQ pain, fever, jaundice

  • IBS algorithm

Objective

  • General inspection

    • Change in mental status (infection - UTI)

    • Shock (perforated viscera, GI hemorrhage, severe pancreatitis, MI, sepsis)

  • Vitals

  • Upper abdo pain - pay attention to Cardiac (ischemia) & lung (pneumonia) exams

    • Tachypneic (pneumonia)

  • Abdo

    • peritoneal signs

    • Carnett’s sign (high ppv for abdo wall pain)

      • ↑ pain when supine pt raises head & shoulder, tensing abdo wall

    • Murphy’s sign (high ppv for choleycystitis)

    • Psoas sign (high ppv for appendicitis)

    • Sever pain out of proportion (ischemic bowel, pancreatitis)

    • restless/writhing (biliary/renal colic, testicular torsion)

    • LLQ tenderness (diverticulitis)

  • Rectal & pelvic exams if lower abdo & pelvic pain

    • DRE - fecal impaction, palpable mass, occult blood in stool

      • Tenderness & fullness on R of rectum suggests retrocecal appendix

    • Pelvic - vaginal discharge (vaginitis), cervical motion tenderness & peritoneal signs (ectopic pregnancy or other gyne complications e.g. tubo-ovarian abscess)

S&S of surgical abdo

  • Fever

  • Protracted (prolonged) vomiting

  • syncope/pre-syncope

  • Evidence of GI blood loss

Psychosocial factors assc w/ chr & recurrent abdo pain

Assessment

  • Common causes

    • IBS (discomfort/pain assc w/ altered bowel habits >3d/mo in prev 3 mo)

  • Less common but important causes

    • Appendicitis

    • Acute cholecystitis

    • Diverticulitis

    • Acute pancreatitis

    • Perforated ulcer

    • Bowel infarction

Plan (for acute abdo pain) - acute abdo = sudden, non-traumatic disorder needing urgent dx & tx

  • Labs

    • CBC (infection/blood loss)

    • Amylase + lipase (pancreatitis)

    • LFT (RUQ pain)

    • Urinalysis (hematuria, dysuria, flank pain - UTI/kidney stone)

    • Beta hcg (women in childbearing age)

    • Chlamydia + gonorrhea (women @ risk of STIs)

  • Imaging (based on location)

    • U/S (RUQ pain)

      • abdo/transvag ultrasound for pregnant women, even for LLQ/RLQ pain

      • Transvag u/s for ectopic pregnancy

    • CT w/ IV contrast media (adults w/ acute RLQ pain)

    • CT w/ oral + IV contrast media (LLQ pain) - for sigmoid diverticulitis

    • LUQ pain (many causes so depends)

      • Suggested esophageal/gastric patho = endoscopy or upper GI series

      • Others = CT (can image pancreas, spleen, kidneys, intestines, vasculature)

    • Xray

      • Free air under diaphragm (=perforation of GI tract)

      • Abn calcifications (10% gallstones, 90% kidney stones)

      • Mult dilated loops of bowel & air-fluid lvls (bowel obstruction)

        • May see with paralytic ileus

    • *occult UTI, perforated viscus, ischemic bowel ds* - potentially fatal, often missed or dx late in elderly pt

      • CONSIDER IN ALL OLDER PTS w/ abdo pain

Initial investigations & basic management for chr/recurrent abdo pain

  • IBS

    • Exercise: vigorous 3-5/week (all types of IBS)

    • Laxatives: OTC (polyethylene glycol (PEG - osmotic) - Miralax); only helps w/ constipation

    • Antidiarrheal: OTC loperamide (imodium); likely only helps diarrhea

    • Probiotics: in some OTC supplements & yogurts (lactobacillus, bifidobacterium, streptococcus)

      • To prevent worsening sx

    • Abx

      • Diarrheal/mixed: rifaximin (Xifaxan); prevent worsening global sx over 4wk

      • Constipation: neomycin; improve constipation & bloating

    • Antispasmodics: hyoscyamine (Levsin), dicyclomine (Bentyl)

    • Selective C-2 chloride channel activators: lubiprostone (Amitiza) - constipation

    • Antidepressants

      • SSRI - citalopram (celexa), fluoxetine (prozac), paroxetine (paxil)

      • TCA - amitriptyline, desipramine (norpramin), doxepin, imipramine (tofranil), trimipramine (surmontil)

    • Other: relaxation, herbals, peppermint oil

    • Not routinely recommended: CBC, lytes, thyroid, stool testing for ova & parasites, abdo img

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