Abdominal Pain. LSU Medical Student Clerkship, New Orleans, LA. Historical Elements. O- onset P-provocation /palliation Q- quality/quantity R- region/radiation S- severity/scale T- timing/time of onset. Physical Exam. General Appearance and Vitals (sick vs Not sick)
LSU Medical Student Clerkship, New Orleans, LA
T- timing/time of onset
General Appearance and Vitals (sick vs
Abdominal exam-Inspection (scars, masses, ecchymosis, distention)-Auscultation (bowel sounds, bruits),-Percussion (organomegaly, dullness)-Palpation (tenderness, guarding, rebound, referred pain, masses)-Don't forget GU, Rectal and Pelvic
Stretching of hollow viscus or capsule of solid viscus
Visceral fibers enter the spinal cord at several levels leading to poorly localized, poorly characterized pain. (dull, cramping, aching)
Visceral pain can be localized by the sensory cortex to an approximate spinal cord level determined by the embryologic origin of the organ involved.
Foregut organs (stomach, duodenum, biliary tract) produce pain in the epigastric region
Midgut organs (most small bowel, appendix, cecum) cause periumbilical pain
Hindgut organs (most of colon, including sigmoid) as well as the intraperitoneal portions of the genitourinary tract cause pain initially in the suprapubic or hypogastric area.
Parietal abdominal pain is caused by irritation of fibers that innervate the parietal peritoneum
Parietal pain, in contrast to visceral pain, can be localized to the dermatome superficial to the site of the painful stimulus.
As the underlying disease process evolves, the symptoms of visceral pain give way to the signs of parietal pain, causing tenderness and guarding. As localized peritonitis develops further, rigidity and rebound appear.
Pain or discomfort that is perceived at a site distant from the affected organ because of overlapping transmission pathways
Also reflects embryologic origin:
subdiaphragmatic irritation -> ipsilateral supraclavicular or shoulder pain gynecologic pathology -> back or proximal lower extremity painbiliary tract disease -> right infrascapular painmyocardial ischemia ->midepigastric, neck, jaw, or upper extremity painureteral obstruction -> ipsilateral testicular pain
Advantages: Quick, easy, non-invasive, lower radiation, lower cost, can be done at bedside and can help make decisions in certain disease states.
Only useful in certain conditions – otherwise low yield, difficult to position sick patients.
When are they useful?
Volvulus (cecal and sigmoid)
Radiopaque foreign bodies
Remember the radiopaque foreign bodies mneumonic:
BariumAntihistaminesTricyclic antidepressantsChloral hydrate, calcium, cocaineHeavy metalsIodinePhenothiazine, potassiumSlow-release (enteric coated)
Advantages: Can be done at bedside, easy to learn, repeatable, no radiation, cheap, can be used in pregnancy, patient does not need to leave the department
Disadvantages: Highly dependent on user’s skill level. Limited by body habitus and bowel gas
What conditions is it most useful for?
Ob/Gyn (Ectopic, IUP, Ovarian pathology)
Appendicitis (particularly in children)
Advantages: Highly diagnostic for most disease processes. High yield exam. Helpful with multiple, competing diagnoses.
Disadvantages: Time. Cost. Radiation. Contrast exposure (for IV contrast). Patient should be stable to go to CT.
The labs you order should be used confirm or exclude specific diagnoses suspected by your history and physical examination.
CBC, CMP, Amylase, Lipase and UA are routinely ordered as “belly labs” but should not be ordered blindly.
The studies you obtain (labs and imaging) should be ordered with the intention of changing your management of the patient. They should not be ordered “just because the patient is in the ED.”
The media weakens over time, the vessel dilates and expands over time. As the vessel weakens and expands, rupture becomes more likely.
The larger it becomes, the more likely is the rupture.
They are typically infrarenal
>3cm at this level is a AAA
Age, Family history, Atherosclerotic risk factors, infection, trauma, connective tissue disease are risk factors.
Rupture is associated with 80-90% mortality.
Vital signs can be normal. For now.
H&P: May not be symptomatic until the rupture
Syncope and Abdominal pain
Cullen’s sign and Grey Turner’s sign
Imaging: U/S 100% sensitive when the aorta is visualized.
CT requires a stable patient but is also highly sensitive and is better at detecting rupture and retroperitoneal fluid.
Treatment is surgical!! Despite what surgery tells you: There is no such thing as a stable rupture.
ED’s role is maintaining hemodynamic stability with blood products – SBP 90-100mg until surgery.
XR: pneumatosis intestinalis, air in the portal vein, pneumobilia, perforation.
US: Pneumatosis, decreased flow.
CT: The test of choice and the gold standard. Can determine etiology and extent of involvement, thus determining course of treatment. Requires a stable patient!
MR: No advantage over CT