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The Problem of Pain. Approach to Abdominal Pain Jason Phillips, MD. ER approach to abdominal pain. Chief complaint: abd pain Labs: CBC, chem, LFTs, lipase CT abdomen History Possible PE. How do you approach a workup for abdominal pain?. What are the most likely possibilities?

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the problem of pain

The Problem of Pain

Approach to Abdominal Pain

Jason Phillips, MD

er approach to abdominal pain
ER approach to abdominal pain

Chief complaint: abd pain

  • Labs: CBC, chem, LFTs, lipase
  • CT abdomen
  • History
  • Possible PE
how do you approach a workup for abdominal pain

How do you approach a workup for abdominal pain?

What are the most likely possibilities?

How do you organize your thoughts?

the problem of pain7
The Problem of Pain
  • Neurologic basis of pain
    • Why is it difficult to localize?
    • Why does the intensity of the pain vary?
  • General overview of approaching a patient with abdominal pain
  • Pain syndromes
neurologic basis of abdominal pain
Neurologic basis of abdominal pain
  • Pain receptors respond to
    • Mechanical stimuli
    • Chemical stimuli
  • Nociception mechanical receptors are located on serosa, within the mesentery, in the GI tract wall in the
    • myenteric plexus (Auerbach plexus)
    • submucosal plexus (Meissner plexus)
neurologic basis of abdominal pain9
Neurologic basis of abdominal pain
  • Mucosal receptors respond to chemical stimuli
  • Substance P, serotonin, histamine, and prostaglandins
  • Chemical stimuli are released in response to inflammation or ischemia
two basic problems with abdominal pain
Two basic problems with abdominal pain
  • Localization of visceral pain
  • Intensity of pain response
localization of visceral pain
Localization of visceral pain
  • Visceral pain localizes to midline
    • Bilateral, symmetric innervation
    • Afferent fibers  celiac, superior mesenteric, or inferior mesenteric ganglion
    • Localizes: epigastrium, periumbilical, and lower abdomen
localization of visceral pain13
Localization of visceral pain
  • Exceptions to the bilateral rule
  • Gallbladder
  • Ascending and descending colon
  • Although bilaterally innervated, they have predominant ipsilateral innervation
localization of visceral pain14
Localization of visceral pain
  • Referred pain
    • Somatic fiber “cross-talk”
    • Activate same spinothalamic pathways  referred pain as the cutaneous dermatome sharing the same spinal cord level (Gallbladder – scapula)
    • Results in aching pain with skin hyperalgesia and rigidity
intensity of pain response
Intensity of pain response
  • Threshold for perceiving pain from visceral stimuli has marked individual variability
  • Balloon distension experiment in IBS
history
History
  • MOST IMPORTANT CLUE to the source of abdominal pain
  • Type of pain
    • Visceral = dull, aching, poorly localized
    • Parietal = sharp, well localized
    • Referred pain
history19
History
  • General location
    • Generalized, RUQ, epigastric, LUQ, periumbilical, RLQ, LLQ, and ‘migratory’
    • General region localizes organs/structures to include in the DDX
    • Radiation of pain (e.g., acute pancreatitis)
history20
History
  • Onset of pain
    • Most gradual, steady crescendo (e.g., cholecystitis)
    • Abrupt, “10/10” – suggestive of perforation
  • Quality of pain
    • Colicky (comes and goes) – e.g., gastroenteritis
    • Steady – (e.g., acute pancreatitis; biliary colic is a misnomer)
    • Burning
history21
History
  • Severity of pain
    • Generally corresponds to severity of illness
    • However, marked patient variability (“12/10 pain” is often functional or has functional overlay)
  • Aggravating or Relieving factors
    • Eating (mesenteric ischemia vs PUD)
    • Position changes (acute pancreatitis, peritonitis)
history22
History
  • Associated symptoms
    • Nausea/vomiting
    • Weight loss
    • Changes in bowel habits
physical exam acute abdomen or not
Physical exam:Acute abdomen or not?
  • General appearance and Vital signs
  • Abdominal exam
    • Auscultation
      • Bowel sounds present?
      • High pitched sounds of obstruction
      • Stethoscope palpation
    • Percussion
      • Tympany = distended bowel
      • Most humane test for rebound tenderness
physical exam acute abdomen or not24
Physical exam:Acute abdomen or not?
  • Palpation:
    • Acute abdomen or not? Peritoneal signs
    • Rebound tenderness
    • Mass? Hernia
  • Abdominal wall maneuvers
    • Leg lift maneuvers (Carnett’s sign)
    • Abdominal crunch
further evaluation
Further evaluation
  • Directed at pain syndromes
  • Labs
  • Imaging
functional abdominal pain
Functional abdominal pain
  • Can be difficult to distinguish from organic pain
  • Can only be labeled as functional when organic causes are excluded
  • Can superimpose on organic pain
  • Should not cause
    • Weight loss, Anemia, GI bleeding, Fever, Night sweats
is it functional or not
Is it functional or not?
  • Clues that are suggestive of functional
    • Atypical history
      • RUQ that lasts 20 sec is not biliary colic
      • Dyspesia that worsens with a PPI
    • Overly dramatic descriptions of pain
      • “It feels like a knife stabbing me over and over and then something is pushing inside out”
    • Hyperbolic intensity
      • “11/10 epigastric pain” with a benign abd exam
is it functional or not29
Is it functional or not?
  • Clues that are suggestive of functional
    • Absence of nocturnal symptoms
    • Exacerbated by stress
    • Distractible exam
    • “Gut feeling”
irritable bowel syndrome
Irritable Bowel Syndrome
  • Prevalence: 10-15% of overall population
  • Only ~15% of patients seek medical care
  • 25-50% of gastroenterology visits
  • Annual healthcare cost: $1.7 billion
irritable bowel syndrome33
Irritable Bowel Syndrome

ROME criteria:

  • 12 weeks or more of abdominal pain/discomfort in the last 12 months (does not have to be consecutive)
  • Two or more features:
    • Relieved with defecation
    • Change in frequency of stool
    • Change in appearance of stool
irritable bowel syndrome34
Irritable Bowel Syndrome

3 types of IBS patients

  • Constipation-predominant
  • Diarrhea-predominant
  • Alternating
irritable bowel syndrome35
Irritable Bowel Syndrome

What is the normal range for frequency of bowel movements?

Rule of 3s:

- Normal = Anywhere from 3x per week to up to 3x per day

irritable bowel syndrome36
Irritable Bowel Syndrome

Pathophysiology

Alterations in motility

Visceral hyperalgesia

Postinfectious IBS – lymphocytic infiltration of myenteric plexus?

irritable bowel syndrome37
Irritable Bowel Syndrome

How do you prove its only IBS?

Rome criteria positive for IBS 

  • No alarm features and mild symptoms,

reassurance and treatment of symptoms

  • Alarm features or severe symptoms, consider referral to GI
upper abdominal pain
Upper abdominal pain
  • Biliary disease
  • Dyspepsia
  • Pancreatitis
  • Gastroparesis
  • Other
upper abdominal pain biliary disease
Upper abdominal pain:Biliary disease
  • Most common location – epigastric NOT RUQ
  • Steady onset; last hours (not minutes or seconds)
  • Can radiate to right scapula
  • Biliary colic
  • Cholecystitis
  • Acute cholangitis
upper abdominal pain biliary disease41
Upper abdominal pain:Biliary disease
  • Workup:
    • Labs: When are liver tests abnormal?
    • Imaging: What is the most sensitive imaging study for biliary tract disease?
    • What are its limitations?
upper abdominal pain biliary disease42
Upper abdominal pain:Biliary disease
  • Labs: LFTs increase with choledocholithiasis (first transaminases, then AP/T Bili)
  • Ultrasound: Sensitivity Specificity
    • Cholecystitis 88% 89%
      • HIDA 97% 90%
    • Gallstones 84% 99%
    • Biliary dilation 55-91%
    • Choledocholithiasis 50 vs 75% (nondilated vs dilated CBD)
upper abdominal pain dyspepsia
Upper abdominal pain:Dyspepsia
  • Dyspepsia = “persistent or recurrent abdominal pain or discomfort in the upper abdomen.”
  • Vague diagnosis that includes a long DDX
upper abdominal pain dyspepsia45
Upper abdominal pain:Dyspepsia
  • 80-100% of ‘dyspepsia’ is a acid-related phenomenon or functional
  • Usually an outpatient problem
  • Peptic ulcer pain = epigastric, burning or hunger-like, worse between meals, relieved with food, nocturnal pain, associated nausea
upper abdominal pain dyspepsia47
Upper abdominal pain:Dyspepsia
  • GERD = heartburn (retrosternal burning), water brash (acid taste in mouth), regurgitation, and sensation of dysphagia
upper abdominal pain dyspepsia48
Upper abdominal pain:Dyspepsia
  • Functional dyspepsia = same symptoms but no organic etiology can be found
    • 12 weeks over last 12 months
    • Not relieved with BM or associated with alterations in BMs (i.e., NOT IBS)
upper abdominal pain dyspepsia49
Upper abdominal pain:Dyspepsia
  • Best test?
  • 3 strategies
    • Empiric PPI
    • H pylori – test and treat
    • EGD
gastroparesis
Gastroparesis
  • Often overlooked as a cause for epigastric pain
  • Gastroparesis symptoms
    • Nausea 93%
    • Abdominal pain 90%
      • Epigastric burning, vague, cramping
    • Early satiety 86%
    • Vomiting 68%
gastroparesis52
Gastroparesis
  • 60% report pain is worse after eating
  • 80% reports pain interrupted sleep
  • Vomiting food hours later
  • Look for important historical clues
    • Diabetes
    • Meds (narcotics, anticholinergics)
    • Recent viral gastroenteritis
    • CNS disease
    • Amyloid, scleroderma
gastroparesis53
Gastroparesis
  • Workup
    • EGD or UGI – rule out GOO
    • Gastric emptying scan
upper abdominal pain pancreatitis
Upper abdominal pain:Pancreatitis
  • Acute Pancreatitis = acute epigastric pain that radiates to back, constant, severe, rapid onset within 1 hour, lasts days, associated nausea/vomiting, relieved with sitting forward; assoc restlessness
  • Rarely diffuse pain, RUQ, or LUQ
upper abdominal pain pancreatitis55
Upper abdominal pain:Pancreatitis

Diagnosis is made when you have at least 2 of the 3 criteria:

- Typical pancreatitic pain

- Elevation in amylase and lipase

- Abnormal imaging

upper abdominal pain pancreatitis56
Upper abdominal pain:Pancreatitis
  • Chronic pancreatitis = similar pain, less severe and onset 20-30 minutes after a meal, can be episodic (early in disease course) or constant (late finding)
  • Associated malabsorption (pancreatic exocrine insufficiency) and diabetes (endocrine insufficiency)
    • Steatorrhea does not occur until 90% or more of pancreatic function is lost
upper abdominal pain other causes
Upper abdominal pain:Other causes
  • Acute MI
  • Pneumonia
  • Splenic abscess or infarct
lower abdominal pain
Lower abdominal pain
  • Appendicitis
  • Diverticular disease
  • IBS
  • Crohn’s disease
  • Hernia
  • Other
lower abdominal pain60
Lower abdominal pain
  • Appendicitis = begins as periumbilical pain that localizes to RLQ (McBurney’s point)
    • Initially visceral pain (superior mesenteric ganglion)
    • RLQ when inflammation extends to peritoneal surface (parietal pain)
  • Pain evolves over hours
  • Exam: peritoneal irritation (rebound) + fever
  • Labs: Elevated WBC
lower abdominal pain62
Lower abdominal pain
  • Diverticulitis = usually LLQ abdominal pain
    • Constant w insidious onset
    • Worsening over days
    • Associated symptoms of fever and worsening constipation
lower abdominal pain63
Lower abdominal pain
  • Exam: spectrum of severity
    • Mild  LLQ tenderness
    • Severe  LLQ rebound
  • Labs: Elevated WBC
  • Imaging
lower abdominal pain65
Lower abdominal pain
  • 70% of diverticulitis in Western countries in left sided. What group of patients usually have right sided diverticultitis (~75%)?
  • Do seeds cause diverticulitis and should they be avoided?
lower abdominal pain66
Lower abdominal pain
  • IBD can give lower abdominal pain with diarrhea, weight loss, hematochezia, fever
    • These clues are more obvious
  • However, 10% of patients with Crohn’s disease will NOT have diarrhea and can present with abdominal pain
    • RLQ  ileocecal
    • CT, colonoscopy, SBFT
lower abdominal pain67
Lower abdominal pain
  • Hernia = weakness or disruption of the abdominal wall
    • Indirect: at the internal ring
    • Direct: Hesselbach’s triangle
    • Umbilical
    • Epigastric
    • Incisional
lower abdominal pain68
Lower abdominal pain
  • Groin hernias  pain or dull pressure with lifting, straining, or increasing intrabdominal pressure; worse with prolonged standing and at end of day
    • Physical exam is crucial
  • Outright pain at rest is concerning for strangulation
lower abdominal pain70
Lower abdominal pain
  • If in doubt, consult surgery for an opinion
  • If a hernia is bright red and impossible to reduce, call a surgeon immediately
lower abdominal pain non gi causes
Lower abdominal pain: Non-GI causes
  • Nephrolithiasis
    • Colicky pain (spasms lasting 20-60 mins)
    • Site depends on location of stone (flankgroin)
    • UA: hematuria (neg in 20-30% of cases)
    • CT renal stone protocol
lower abdominal pain non gi causes72
Lower abdominal pain: Non-GI causes
  • Pelvic inflammatory disease
    • Pelvic pain during menses or coitus
    • Onset during of shortly after menses
    • Bilateral
    • Usually less than 2 weeks
    • Exam critical: speculum and bimanual exam
diffuse abdominal pain
Diffuse abdominal pain
  • Gastroenteritis
  • IBS
  • Obstruction
  • Mesenteric ischemia
diffuse abdominal pain74
Diffuse abdominal pain
  • Viral gastroenteritis = colicky abdominal cramps, watery diarrhea, and nausea/vomiting
    • Incubation 24-48 hours
    • Symptoms begin with abdominal cramps and/or nauseamost have vomiting and watery diarrhea
    • Mild fever, myalgias
    • Lasts 48-72 hrs
diffuse abdominal pain75
Diffuse abdominal pain
  • Obstruction
    • Periumbilical pain with paroxysms of cramps occurring every 4-5 minutes
    • Abdominal distension
    • Nausea
    • Obstipation may be delayed up to 24 hours
    • History of abdominal surgery or malignancy
diffuse abdominal pain76
Diffuse abdominal pain
  • Obstruction
    • Exam: distended appearance, tympanic, high pitched tinkle or large bowel sounds
    • NGT decompression
    • Abdominal x-rays – supine and upright
ischemia
Ischemia
  • Acute mesenteric ischemia
    • Embolism
    • Thrombosis
    • Vasospasm
  • Chronic mesenteric ischemia
    • Intestinal angina
  • Can be difficult to diagnose
acute mesenteric ischemia
Acute mesenteric ischemia
  • Embolic  sudden onset of severe, diffuse pain
    • Writhing in pain
    • Abdominal exam feels benign - :pain out of proportion to exam”
    • Be suspicious in the right patient: atrial fibrillation, mechanical heart valves, age
acute mesenteric ischemia80
Acute mesenteric ischemia
  • Thrombotic and non-occlusive  insidious onset of pain
  • Labs: nonspecific until late in the course
  • Imaging: mesenteric angiogram