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).
- Periumbilical – gastro, obstipation, small bowel/large bowel obstruction, mesenteric ischemia, peritonitis, abd aortic dissection, pancreatitis, MI, sickle cell crisis, early appendicitis
- RUQ – hepatitis, biliary colic, acute cholecystitis, PUD, pyelonephritis, ascending cholangitis, pneumonia
- RLQ – appendicits, IBD, uretral stones, salpingitis, ruptured corpus luteum cyst, ovarian torsion, ectopic pregnancy
- LUQ – MI, pancreatitis, splenic infarction, pyelonephritis, pneumonia
- LLQ – IBD, diverticulitis, sigmoid volvulus, ureteral stone, salpingitis, ruptured corpus luteum cyst, ectopic pregnancy
- 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:
- Always rule out pregnancy if she is of reproductive age.
- Suspect gynecologic etiology for abdominal pain.
- Do a pelvic examination, if appropriate.
4 In a patient with acute abdominal pain, differentiate between a surgical and a non-surgical abdomen.
- diffuse peritonitis, severe or increasing localized tenderness, progressive distention, tender mass with fever or hypotension (abscess), suspect bowel ischemia (acidosis, fever, tachycardia)
- x-ray-free air, massive bowel distention (colon > 12cm), space occupying lesion with fever
- 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.
- acute abd pain : gastro, incarcerated hernia/volvulus/intussusception, appendicitis, malrotation, mesenteric adenitis, cholecystitis, meckel‘s diverticulitis, UTI, HSP, sickle cell crisis, pneumonia, DKA, nephrolithaisis
- Chronic abd pain : constipation, IBD, pancreatic, recurrent UTI/stones, functional/recurrent abd pain (RAP)
- ectopic, PID, endometriosis, dysmenorrhea, mittleschmertz, ovarian torsion, pregnancy
- 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-
- sudden onset CP/abd or back pain,
- shock hypotension, syncope, cool mottled extremities
- 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).
- Educate and reassure- altered intestinal motility and visceral hypersensitivity, chronic relapsing but benign disorder, validate symptoms, diet and emotional stress may exacerbate symptoms.
- healthy diet, avoid food fads, excessive caffeine, alcohol, sorbito (gum, candies), fructose (preservative)
- if constipated increase dietary fiber
- Chronic abd pain –> low dose amitriptyline
- No single drug shown to benefit IBS
- lifestyle- stress management, relaxation advice
- treat comorbid depression, anxiety, panic
- avoid inappropriate referral and surgery
- if non pharmacologic approach fails target most troublesome symptom:
- Diarrhea- loperamide prn
- 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.
- oral aphthous lesions,clubbing & erythema nodosum
- nephrolithiasis (secondary to oxalate malabsorption),
- arthritis & iritis
- fissure, perianal abscess
- arthritis, ankylosing spondylitis
- sclerosing cholangitis, cholelithaisis
- colon cancer
- pyoderma gangrenosum
- episcleritis, anterior uveitis
- 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
- 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
- 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
- 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
- uremia, diabetic ketoacidosis, porphyria, adrenal insufficiency, narcotic withdrawal
- irritable bowel syndrome (affecting up to 20% of the population, IBS is the most common cause of recurrent, intermittent abdominal pain)