Abdominal Pain – UpToDate

1 Given a patient with abdominal pain, paying particular attention to its location and chronicity:

a) Distinguish between acute and chronic pain:

Arbitrary distinction, 6-12 wk for chronic pain


b) Generate a complete differential diagnosis (ddx).

  1. Periumbilical – gastro, obstipation, small bowel/large bowel obstruction, mesenteric ischemia, peritonitis, abd aortic dissection, pancreatitis, MI, sickle cell crisis, early appendicitis
  2. RUQ – hepatitis, biliary colic, acute cholecystitis, PUD, pyelonephritis, ascending cholangitis, pneumonia
  3. RLQ – appendicits, IBD, uretral stones, salpingitis, ruptured corpus luteum cyst, ovarian torsion, ectopic pregnancy
  4. LUQ – MI, pancreatitis, splenic infarction, pyelonephritis, pneumonia
  5. LLQ – IBD, diverticulitis, sigmoid volvulus, ureteral stone, salpingitis, ruptured corpus luteum cyst, ectopic pregnancy
  6. Epigastric – MI, PUD, Pancreatitis

CHRONIC ABD PAIN:

PUD, cancer (many), cholecystitis, chronic pancreatitis, IBD, IBS, recurrent bowel obstruction, mesenteric ischemia, endometriosis, mittleschmerz, radiculopathy, GERD


c) Investigate in an appropriate and timely fashion.

Initial diagnostic testing —

  • CBC, Lytes, BUN, Creatinine, glucose, ALT, AST, ALK, bilirubin, lipase, U/A, U preg
  • Ferritin, Anti-tissue transglutaminase, IgA
  • 3 views of Abd – only for perforation or obstruction
  • CT – AAA, appendicitis
  • Ultrasound – gallbladder disease, gynecological problems, appendicitis in young women

3 In a woman with abdominal pain:

  1. Always rule out pregnancy if she is of reproductive age.
  2. Suspect gynecologic etiology for abdominal pain.
  3. Do a pelvic examination, if appropriate.

4 In a patient with acute abdominal pain, differentiate between a surgical and a non-surgical abdomen.

SURGICAL ABD

  1. diffuse peritonitis, severe or increasing localized tenderness, progressive distention, tender mass with fever or hypotension (abscess), suspect bowel ischemia (acidosis, fever, tachycardia)
  2. x-ray-free air, massive bowel distention (colon > 12cm), space occupying lesion with fever
  3. paracentesis – blood, pus, bile, feces, urine

5 In specific patient groups (e.g., children, pregnant women, the elderly), include group-specific surgical causes of acute abdominal pain in the ddx.

CHILDREN

  1. acute abd pain : gastro, incarcerated hernia/volvulus/intussusception, appendicitis, malrotation, mesenteric adenitis, cholecystitis, meckel‘s diverticulitis, UTI, HSP, sickle cell crisis, pneumonia, DKA, nephrolithaisis
  2. Chronic abd pain : constipation, IBD, pancreatic, recurrent UTI/stones, functional/recurrent abd pain (RAP)

WOMEN

  • ectopic, PID, endometriosis, dysmenorrhea, mittleschmertz, ovarian torsion, pregnancy

ELDERLY

  • bowel obstruction, cancer, AAA dissection, mesenteric ischemia, biliary, pancreatic, diverticulosis, constipation

6 Given a patient with a life-threatening cause of acute abdominal pain recognize the life-threatening situation.

A ruptured AAA -triad-

  1. sudden onset CP/abd or back pain,
  2. shock hypotension, syncope, cool mottled extremities
  3. pulsatile mass

A ruptured ectopic pregnancy

  • increasing abd pain, abd distention, shock, febrile, rebound

Stabilize the patient.- airway/breathing/circulation-iv access, fluids, cross and match,

Promptly refer the patient for definitive treatment. -emergency laparotomy/laparoscopy


7 In a patient with chronic or recurrent abdominal pain:

a) Ensure adequate follow-up to monitor new or changing symptoms or signs.
b) Manage symptomatic with medication and lifestyle modification (e.g., for irritable bowel syndrome).

  1. Educate and reassure- altered intestinal motility and visceral hypersensitivity, chronic relapsing but benign disorder, validate symptoms, diet and emotional stress may exacerbate symptoms.
  2. healthy diet, avoid food fads, excessive caffeine, alcohol, sorbito (gum, candies), fructose (preservative)
  3. if constipated increase dietary fiber
  4. Chronic abd pain –> low dose amitriptyline
  5. No single drug shown to benefit IBS
  6. lifestyle- stress management, relaxation advice
  7. treat comorbid depression, anxiety, panic
  8. avoid inappropriate referral and surgery
  9. if non pharmacologic approach fails target most troublesome symptom:
    1. Diarrhea- loperamide prn
    2. Constipation- increase bran, psyllium

c) Always consider cancer in a patient at risk. (eg elderly)


8 Given a patient with a diagnosis of inflammatory bowel disease (IBD) recognize an extra intestinal manifestation.

  1. Crohns-
    1. oral aphthous lesions,clubbing & erythema nodosum
    2. cholelithiasis
    3. nephrolithiasis (secondary to oxalate malabsorption),
    4. arthritis & iritis
    5. fissure, perianal abscess
  2. UC-
    1. arthritis, ankylosing spondylitis
    2. sclerosing cholangitis, cholelithaisis
    3. colon cancer
    4. pyoderma gangrenosum
    5. episcleritis, anterior uveitis

Complete Differential:

GI tract

  • Inflammatory: gastroenteritis, appendicitis, gastritis, esophagitis, diverticulitis, Crohn’s disease, ulcerative colitis, microscopic colitis
  • Obstruction: hernia, intussusception, volvulus, post-surgical adhesions, tumours, superior mesenteric artery syndrome, severe constipation, hemorrhoids
  • Digestive: peptic ulcer, lactose intolerance, coeliac disease, food allergies

Vascular:

  • embolism, thrombosis, hemorrhage, sickle cell disease, abdominal angina, blood vessel compression (such as celiac artery compression syndrome)
  • left renal vein entrapment
  • aortic dissection, abdominal aortic aneurysm
  • vasculitis

Hepatobiliary system

  • Inflammatory: cholecystitis, cholangitis, hepatitis, liver abscess, pancreatitis
  • Obstruction: cholelithiasis, tumours

Renal and urological

  • Inflammation: pyelonephritis, bladder infection
  • Obstruction: kidney stones, urolithiasis, Urinary retention, tumours

Gynaecological or obstetric

  • Inflammatory: pelvic inflammatory disease
  • Mechanical: ovarian torsion
  • Endocrinological: menstruation, Mittelschmerz
  • Tumors: endometriosis, fibroids, ovarian cyst, ovarian cancer
  • Pregnancy: ruptured ectopic pregnancy, threatened abortion

Abdominal wall

  • muscle strain or trauma
  • neurogenic pain: herpes zoster, radiculitis in Lyme disease, abdominal cutaneous nerve entrapment syndrome (ACNES)
  • Referred pain from the thorax: pneumonia, pulmonary embolism, ischemic heart disease, pericarditis
  • from the spine:
  • from the genitals: testicular torsion

Metabolic disturbance

  • uremia, diabetic ketoacidosis, porphyria, adrenal insufficiency, narcotic withdrawal

Immune system

  • sarcoidosis

Idiopathic

  • irritable bowel syndrome (affecting up to 20% of the population, IBS is the most common cause of recurrent, intermittent abdominal pain)
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Posted in 1 Abdominal Pain, 99 Priority Topics, FM 99 priority topics, GI
One comment on “Abdominal Pain – UpToDate
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