Case #1

1. Case #1 • 24 yo healthy M with one day hx of abdominal pain. Pain was generalized at first, now worse in right lower abd & radiates to his right groin. He has vomited twice today. Denies any diarrhea, fevers, dysuria or other complaints. No appetite today. ROS otherwise negative. • PMHx: negative • PSurgHx: negative • Meds: none • NKDA • Social hx: no alcohol, tobacco or drug use • Family hx: non-contributory

2. Abdominal pain • What else do you want to know? • What is on your differential diagnosis so far? • (healthy male with RLQ abd pain….) • How do you approach the complaint of abdominal pain in general? • Let’s review in this lecture: • Types of pain • History and physical examination • Labs and imaging • Abdominal pain in special populations (Elderly, HIV) • Clinical pearls to help you in the ED

3. “Tell me more about your pain….” • Location • Quality • Severity • Onset • Duration • Modifying factors • Change over time

4. What kind of pain is it? • Visceral • Involves hollow or solid organs; midline pain due to bilateral innvervation • Steady ache or vague discomfort to excruciating or colicky pain • Poorly localized • Epigastric region: stomach, duodenum, biliary tract • Periumbilical: small bowel, appendix, cecum • Suprapubic: colon, sigmoid, GU tract • Parietal • Involves parietal peritoneum • Localized pain • Causes tenderness and guarding which progress to rigidity and rebound as peritonitis develops • Referred • Produces symptoms not signs • Based on developmental embryology • Ureteral obstruction → testicular pain • Subdiaphragmatic irritation → ipsilateral shoulder or supraclavicular pain • Gynecologic pathology → back or proximal lower extremity • Biliary disease → right infrascapular pain • MI → epigastric, neck, jaw or upper extremity pain

5. GI symptoms • Nausea, vomiting, hematemesis, anorexia, diarrhea, constipation, bloody stools, melena stools • GU symptoms • Dysuria, frequency, urgency, hematuria, incontinence • Gyn symptoms • Vaginal discharge, vaginal bleeding • General • Fever, lightheadedness

6. And don’t forget the history • GI • Past abdominal surgeries, h/o GB disease, ulcers; FamHx IBD • GU • Past surgeries, h/o kidney stones, pyelonephritis, UTI • Gyn • Last menses, sexual activity, contraception, h/o PID or STDs, h/o ovarian cysts, past gynecological surgeries, pregnancies • Vascular • h/o MI, heart disease, a-fib, anticoagulation, CHF, PVD, Fam Hx of AAA • Other medical history • DM, organ transplant, HIV/AIDS, cancer • Social • Tobacco, drugs – Especially cocaine, alcohol • Medications • NSAIDs, H2 blockers, PPIs, immunosuppression, coumadin

7. Physical Examination • General • Pallor, diaphoresis, general appearance, level of distress or discomfort, is the patient lying still or moving around in the bed • Vital Signs • Orthostatic VS when volume depletion is suspected • Cardiac • Arrhythmias • Lungs • Pneumonia • Abdomen • Look for distention, scars, masses • Auscultate – hyperactive or obstructive BS increase likelihood of SBO fivefold – otherwise not very helpful • Palpate for tenderness, masses, aortic aneurysm, organomegaly, rebound, guarding, rigidity • Percuss for tympany • Look for hernias! • rectal exam • Back • CVA tenderness • Pelvic exam • CMT • Vaginal discharge – Culture • Adenexal mass or fullness

8. Abdominal Findings • Guarding • Voluntary • Contraction of abdominal musculature in anticipation of palpation • Diminish by having patient flex knees • Involuntary • Reflex spasm of abdominal muscles • aka: rigidity • Suggests peritoneal irritation • Rebound • Present in 1 of 4 patients without peritonitis • Pain referred to the point of maximum tenderness when palpating an adjacent quadrant is suggestive of peritonitis • Rovsing’s sign in appendicitis • Rectal exam • Little evidence that tenderness adds any useful information beyond abdominal examination • Gross blood or melena indicates a GIB

9. Appendicitis: Psoas Sign

10. Diagnosis WBC Clinical appendicitis – call your surgeon Maybe appendicitis - CT scan Not likely appendicitis – observe for 6-12 hours or re-examination in 12 hours Treatment NPO IVFs Preoperative antibiotics – decrease the incidence of postoperative wound infections Appendicitis

11. Case #2 • 68 yo F with 2 days of LLQ abd pain, diarrhea, fevers/chills, nausea; vomited once at home. • PMHx: HTN, diverticulosis • PSurgHx: negative • Meds: HCTZ • NKDA • Social hx: no alcohol, tobacco or drug use • Family hx: non-contributory11

12. Case #2 Exam • T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99% room air • Gen: uncomfortable appearing, slightly pale • Pulmonary: normal heart and lung exam, no LE edema, normal pulses • Abd: soft, moderately tender in LLQ • What is your differential diagnosis & what next?

13. Risk factors Diverticula Increasing age Clinical features Steady, deep discomfort in LLQ Change in bowel habits Urinary symptoms Tenesmus Paralytic ileus SBO Physical Exam Low-grade fever Localized tenderness Rebound and guarding Left-sided pain on rectal exam Occult blood Peritoneal signs Suggest perforation or abscess rupture Diverticulitis

14. Diagnosis CT scan (IV and oral contrast) Pericolic fat stranding Diverticula Thickened bowel wall Peridiverticular abscess Leukocytosis present in only 36% of patients Treatment Fluids Correct electrolyte abnormalities NPO Abx: gentamicin AND metronidazole OR clindamycin OR levaquin/flagyl For outpatients (non-toxic) liquid diet x 48 hours cipro and flagyl Diverticulitis

15. Case #3 • 46 yo M with hx of alcohol abuse with 3 days of severe upper abd pain, vomiting, subjective fevers. • Med Hx: negative • Surg Hx: negative • Meds: none; Allergies: NKDA • Social hx: homeless, heavy alcohol use, smokes 2ppd, no drug use

16. Case #3 Exam Vital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat: 95% room air • General: ill-appearing, appears in pain • CV: tachycardic, normal heart sounds, pulses normal • Lungs: clear • Abdomen: mildly distended, moderately TTP epigastric, +voluntary guarding • Rectal: heme neg stool • What is your differential diagnosis & what next?