Approach to abdominal pain

1. Approach to abdominal pain
August 4, 2015
Douglas Koo, MD, MPH, FACP
Department of Medicine, Hospital Medicine Service

2. Visceral pain

3. http://batesvisualguide.com/multimediaplayer.aspx?multimediaid=6091322
Liver Spleen
Stomach
Gallbladder Pancreas
Aorta
Colon
Small intestine
Bladder
Ovaries
Ureters
Lymph nodes
Testicles
Kidneys
Appendix

4. New admit: PAIN, T.
21291723. severe abdominal
pain. Pls call back to
confirm. –chiefs 6733

5. Quick initial assessment
• Serious or Surgical?
– Tense or rigid abdomen
– Involuntary guarding
– Signs of shock
Get help & escalate care
• Pain severity
• Pain control with IV opiates
– May alter exam but no increase in incorrect
management decisions

6. High risk features of abdominal pain

7. Hx PE DDx Labs Imaging
Acute or chronic
Location
Onset
Provocation/palliation
Quality
Radiation
Severity
ROS
PMH/PSH
Meds
FH
SH
*If recent procedure,
speak to whoever did
procedure
General
VS
Inspection
Auscultation
Palpation
Percussion
Eliciting signs
Rectal
GU
CBC
Chem (anion gap)
LFTs
Amylase/lipase
Lactate
UA
Urine pregnancy test
Ascites sampling
CT
US
AXR
Bladder scan
EKG
Likelihood of dz
a.k.a. Pretest
probability

8. Pearls & Pitfalls
• Failure of careful and timely evaluation in elderly patients when overt signs
of disease are absent
• Failure to appreciate high-risk features of abdominal pain
• Failure to perform pelvic and testicular examinations in low abdominal pain
• Failure to reassess pain of unclear etiology
• Reassess
• Thresholds
• Imaging

9. Cases

10. Case #1
• 58M L ocular melanoma 3 years prior s/p brachytherapy then enucleation
• 2days of 9/10 acute constant “achy” RUQ pain without radiation, worse with
inspiration
• PMH: HTN, GERD, depression,TIA, appy, colonic polypectomy
• FH: brother stomach cancer
• SH: social EtOH, 18pk-yrs
• ROS: +fatigue, +anorexia, -CP, SOB, n/v, fever, chills, wt loss, melena
• Exam:VSS, RUQ tenderness to deep palpation, no guarding

12. Case #2
• 71M new pancreatic mass, ERCP today
• On drive home after procedure, acute 8/10 epigastric abdominal pain
radiating to back with nausea and vomiting,Tylenol without relief
• PMH: HTN, pancreatic mass

14. Case #3
• 82F met CRC to peritoneum with ascites s/pTenckhoff, chronic
hyponatremia, sent in from Nephrologist’s office for worsening ascites, SOB,
anasarca
• Prior MSSA peritonitis at NYP treated with oxacillin;Tenckhoff removed
• Several days of 6/10 dull, intermittent, diffuse abdominal pain
• PMH: essential tremor, s/p appy, s/p hernia repair
• FH: +CRC
• SH: lives in nursing home
• ROS: +fatigue, +40lbs wt gain, -fever, chills
• Exam: distended, no BS, priorTenckhoff scar, +fluid wave, +shifting dullness,
10cm palpable RLQ mass

16. RLQ

17. LLQ

18. Corrected neutrophil/PMN count >250

21. Rimola A, Garcia-Tsao G, Navasa M, Piddock LJ, Planas R, Bernard B, Inadomi JM. Diagnosis, treatment and prophylaxis of
spontaneous bacterial peritonitis: a consensus document. International Ascites Club. J Hepatol. 2000;32:142–153
Correction factor: 1 PMN per 250 RBCs

22. Case #4
• 66F met CRC (liver), COPD, DVT/PE on Lovenox
• RFA of liver mets 8 days prior and 2 days after discharge had intermittent
cramping abdominal pain
• PMH: essential tremor, s/p appy, s/p hernia repair
• FH: +CRC
• SH: lives in nursing home
• ROS: +nausea, -fever, bleeding
• Exam: mild RUQ tenderness

24. Case #5
• 67M cholangiocarcinoma s/p partial hepatectomy 4 years prior, recurrence
one year ago, biliary stent placed 2 weeks prior
• Fever and jaundice at home; spending all day in bed, weak, no other
complaints,Tbili in clinic 4.6
• PMH: Roux enY
• FH: none
• SH: lives at home with sons
• ROS: no pain
• Exam: tachycardic, abd exam unremarkable

26. Case #6
• 51F met CRC (liver, peritoneum, pelvis, lung) just started chemo week before
• Yesterday with 8/10 intermittent,sharp abdominal pain across midabdomen
• PMH: sigmoidectomy 2 years prior, adjuvant FOLFOX at OSH
• FH: breast cancer
• SH: nonsmoker, no etoh
• ROS: +nausea, vomiting, abd distention
• Exam: distended, quiet BS, tympanic, dull flanks, diffusely tender

29. Case #7
• 88F new pancreatic mass s/p biliary stent at OSH
• Yesterday with dull, 9/10 epigastric and RUQ pain
• PMH: macular degeneration, blind, diverticulosis/itis
• FH: CRC
• SH: nonsmoker, no etoh
• ROS: +nausea, vomiting
• Exam: distractable RUQ tenderness without rebounding or guarding

32. Hx PE DDx Labs Imaging
Acute or chronic
Location
Onset
Provocation/pall
iation
Quality
Radiation
Severity
ROS
PMH/PSH
Meds
FH
SH
*If recent
procedure,
speak to
whoever did
procedure
General
VS
Inspection
Auscultation
Palpation
Eliciting signs
Rectal
GU
CBC
Chem (anion
gap)
LFTs
Amylase/lipase
Lactate
UA
Preg test
Ascites
sampling
CT
US
AXR
Bladder scan
EKG
Likelihood of dz
Pretest
probability

33. Pearls & Pitfalls
• Failure of careful and timely evaluation in elderly patients when overt signs
of disease are absent
• Failure to appreciate high-risk features of abdominal pain
• Failure to perform pelvic and testicular examinations in low abdominal pain
• Failure to reassess pain of unclear etiology
• Reassess
• Thresholds
• Imaging

34. Thank you!....Questions? Comments? Stories?