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Approach to abdominal pain
August 4, 2015
Douglas Koo, MD, MPH, FACP
Department of Medicine, Hospital Medicine Service
Visceral pain
http://batesvisualguide.com/multimediaplayer.aspx?multimediaid=6091322
Liver Spleen
Stomach
Gallbladder Pancreas
Aorta
Col...
New admit: PAIN, T.
21291723. severe abdominal
pain. Pls call back to
confirm. –chiefs 6733
Quick initial assessment
• Serious or Surgical?
– Tense or rigid abdomen
– Involuntary guarding
– Signs of shock
Get help ...
High risk features of abdominal pain
Hx PE DDx Labs Imaging
Acute or chronic
Location
Onset
Provocation/palliation
Quality
Radiation
Severity
ROS
PMH/PSH
Meds
...
Pearls & Pitfalls
• Failure of careful and timely evaluation in elderly patients when overt signs
of disease are absent
• ...
Cases
Case #1
• 58M L ocular melanoma 3 years prior s/p brachytherapy then enucleation
• 2days of 9/10 acute constant “achy” RUQ...
Case #2
• 71M new pancreatic mass, ERCP today
• On drive home after procedure, acute 8/10 epigastric abdominal pain
radiat...
Case #3
• 82F met CRC to peritoneum with ascites s/pTenckhoff, chronic
hyponatremia, sent in from Nephrologist’s office fo...
RLQ
LLQ
Corrected neutrophil/PMN count >250
Rimola A, Garcia-Tsao G, Navasa M, Piddock LJ, Planas R, Bernard B, Inadomi JM. Diagnosis, treatment and prophylaxis of
sp...
Case #4
• 66F met CRC (liver), COPD, DVT/PE on Lovenox
• RFA of liver mets 8 days prior and 2 days after discharge had int...
Case #5
• 67M cholangiocarcinoma s/p partial hepatectomy 4 years prior, recurrence
one year ago, biliary stent placed 2 we...
Case #6
• 51F met CRC (liver, peritoneum, pelvis, lung) just started chemo week before
• Yesterday with 8/10 intermittent,...
Case #7
• 88F new pancreatic mass s/p biliary stent at OSH
• Yesterday with dull, 9/10 epigastric and RUQ pain
• PMH: macu...
Hx PE DDx Labs Imaging
Acute or chronic
Location
Onset
Provocation/pall
iation
Quality
Radiation
Severity
ROS
PMH/PSH
Meds...
Pearls & Pitfalls
• Failure of careful and timely evaluation in elderly patients when overt signs
of disease are absent
• ...
Thank you!....Questions? Comments? Stories?
Approach to abdominal pain
Approach to abdominal pain
Approach to abdominal pain
Approach to abdominal pain
Approach to abdominal pain
Approach to abdominal pain
Approach to abdominal pain
Approach to abdominal pain
Approach to abdominal pain
Approach to abdominal pain
Approach to abdominal pain
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Approach to abdominal pain

Approach to abdominal pain

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Approach to abdominal pain

  1. 1. Approach to abdominal pain August 4, 2015 Douglas Koo, MD, MPH, FACP Department of Medicine, Hospital Medicine Service
  2. 2. Visceral pain
  3. 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. 4. New admit: PAIN, T. 21291723. severe abdominal pain. Pls call back to confirm. –chiefs 6733
  5. 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. 6. High risk features of abdominal pain
  7. 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. 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. 9. Cases
  10. 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
  11. 11. 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
  12. 12. 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
  13. 13. RLQ
  14. 14. LLQ
  15. 15. Corrected neutrophil/PMN count >250
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. Thank you!....Questions? Comments? Stories?

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