Acute Abdominal Pain

Acute Abdominal Pain – Alex Mamunes

General Approach:

  • Rule out life threatening causes:
    • Obstruction, Perforation, Dissection, AAA rupture, Inferior MI, Ectopic Pregnancy
  • History: pain quality/timing/location/severity, aggravating and alleviating factors (eating, bowel movements, position), Nausea/Emesis, bowel changes, flatus & prior episodes
  • Initial labs: CBC, BMP, LFTs, INR, lactate, lipase, U/A, urine hCG ( ♀ childbearing age

 

System

Causes

Common features

Workup

Esophagus

Esophagitis – GERD, EOE, candida, HSV, CMV, pill, functional

Epigastric, nocturnal reflux, odynophagia, dysphagia, thrush, immunocompromised

Trial PPI, nystatin swish and swallow, consider EGD

 

Stomach

Dyspepsia

 

Epigastric, indigestion, bloating

H. pylori testing, Trial PPI, ± EGD

Peptic ulcer disease

NSAID use, better or worse w/ food, ± melena

CBC, H. pylori testing, EGD

Gastritis

 

NSAID use, ETOH abuse, burning epigastric pain

 

Liver

Hepatitis: Ischemic, Viral, ETOH, trauma, toxins, autoimmune, congestive

RUQ pain ± jaundice

EtOH, Tylenol or IVDU

LFTs, INR, ETOH, tylenol lvl, viral panel, RUQ U/S + dopplers;  CT

 

Spleen

Splenomegaly: increased size, infarct, abscess

 

LUQ pain

Physical exam, CT

Biliary

 

 

 

 

 

Biliary colic

 

Overweight, ♀, 40’s, lasts hrs, worse with food,

RUQ pain scapula  

LFTs, RUQ U/S

Cholecystitis

RUQ (Murphy’s sign), nausea, emesis with fever

 

Choledocholithiasis

RUQ, n/v with jaundice

CBC, LFTs, RUQ U/S, blood cx

Ascending cholangitis

RUQ, N/V, jaundice, fever; hypotension, AMS

 

Pancreas

Acute or Chronic Pancreatitis; Complications (fluid, collection, necrosis, pseudocyst)

ETOH use, gallstones, epigastric pain back, nausea, emesis

Chronic pancreatitis: calcifications on CT

 

 

Lipase, CT A/P (rarely necessary within 24-48 hrs), RUQ U/S for gallstones

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intestines

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gastroenteritis

Nausea, emesis, sick contact, undercooked food, travel

Supportive care

Diverticulitis

Older, h/o diverticulosis, LLQ pain with fever

CBC (leukocytosis)

CT A/P w contrast

Constipation

h/o IBS, narcotic use, unable to pass stool

KUB

Bowel Obstruction/Ileus

Prior hernia, abd surgery or malignancy, pain, nausea, emesis, distention inability to pass stool or flatus

KUB (air fluid levels)

CT is more sensitive

If concerned, page EGS and consider NGT to suction

 

Acute Small Bowel Mesenteric Ischemia

Vascular disease, A-Fib,  dissection, thrombosis, rapid onset, severe, periumbilical with n/v, recent hypotensive episode, post-prandial

CBC (leukocytosis)

BMP (metabolic acidosis), Lactate

CT A/P w contrast (CTA if suspicion)

 

Colonic Mesenteric Ischemia: ischemic colitis

Cramping pain, laterally (most often left), urge to defecate + hematochezia

CBC, BMP, Lactate

CT A/P w contrast

No colonoscopy

 

Appendicitis

Periumbilical to RLQ with n/v, later fever

CBC, Lactate, CT A/P w/contrast

 

IBD Flare

H/o Crohn’s or UC, Abd pain, fever, diarrhea, hematochezia

CBC, Lactate, CTE, ESR, CRP, C-diff GIPP

 

C. diff colitis

Antibiotic exposure, diarrhea, abdominal cramping

C-diff PCR, CBC (leukocytosis)

KUB (megacolon)

Ogilvie’s syndrome

Pseudo-obstruction in elderly pt, signs of  obstruction w/o  mechanical cause

CBC, lactate, CT A/P w contrast

Volvulus

Progressive abdominal pain, nausea, distention, constipation, vomiting

CBC, lactate

CT A/P w contrast

Typhlitis

Neutropenia, abdominal pain (often RLQ), fever

CBC with diff, CTE, blood cx, C-diff;

empiric abx

 

OBGYN

Ectopic pregnancy

 

Sexually active, 6-7 wks after LMP, RLQ or LLQ pain + vaginal bleeding

Urine hCG, pelvic US, CBC, T&S

Pelvic inflammatory disease, endometritis

Tubo-ovarian abscess

Sexually active, h/o STI,  purulent discharge, cervical motion tenderness, ± fever

Pelvic exam w/ culture, GC probe, pelvic US

 

Ovarian torsion

Young, sudden onset & severe, often with n/v

Pelvic US w/ doppler

 

Kidney

 

 

 

 

 

Kidney

(Continued)

Nephrolithiasis

 

h/o kidney stones, Crohn’s disease, sharp flank pain, paroxysms,

± hematuria

U/A, CT A/P without contrast

UTI

Suprapubic pain, dysuria, cloudy urine, new odor

U/A with culture

Pyelonephritis

Flank pain, fever/chills, CVA tenderness, usually UTI symptoms

U/A with culture, BMP

CT A/P w/contrast

Urinary Retention

Older pt, male with BPH, anticholinergics

Post-void residual

Renal infarct

h/o vascular disease or A-fib, acute flank pain with n/v, +/- fever, HTN

CBC, BMP, UA, ECG (r/o a-fib)

CT A/P w contrast

Vascular

Myocardial infarction

CAD risk factors, DoE, epigastric, diaphoresis

ECG, troponin

Aortic Dissection

Vascular Risk factors, sudden onset, tearing pain back

CT dissection rule out

AAA rupture

Vascular risk factors, sudden onset back, hypotensive, pulsatile abdominal mass

CT A/P w contrast, consult vascular surgery

MSK/skin

Herpes zoster

Immunocompromised, dermatomal dist. rash, burning pain

Physical exam

Vesicle PCR for zoster

Muscle strain

h/o trauma, overuse, heavy exercise, worse with twisting or bending

Physical exam; rest, NSAIDs

Hernia

Bulge, worse w/valsalva

CT A/P non con

Pulmonary

Pneumonia

Productive cough, fever

CXR, CBC, sputum cx

Pulmonary embolus

Tachycardia, tachypnea, hypoxemia

ECG, trop, BNP

CTA chest

Functional

IBS, depression, dyspepsia, anxiety Abdominal migraine,  Functional

Image negative

Negative w/u

Above w/u

Other

Adrenal crisis

Hypotension, fatigue, lethargy, n/v, weight loss, hyperpigmentation

BMP (Na, K, Glu) Cort. stim

Intra-abdominal abscess

Prior intra-abdominal disease or surgery, fever

CBC, blood cx

CT A/P contrast

DKA

Nausea, emesis, general abdominal pain

CBC, BMP, U/A

β – hydroxy butyrate

Hypercalcemia

N/V, constipation,

thirst, urination, bone pain, muscle weakness, confusion, fatigue

BMP, ionized calcium, PTH, Vit D, PTHrp

Acute intermittent porphyria

Severe, poorly localized with motor/sensory neuropathy, red urine, tachycardia

Urinary PBG