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AbdominalPain PDF
AbdominalPain PDF
ABDOMINAL PAIN
Objectives:
1.
Distinguish between somatic and referred pain
2.
3.
4.
Define the symptom review of patients with abdominal pain and know the
significance of different historical presentations
5.
6.
7.
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Ron Diekmann, MD
ABDOMINAL PAIN
Introduction
Abdominal pain accounts for 5% of all emergency department (ED) visits
and is an important and challenging component of emergency medicine practice
in all centers. There are myriad presentations. Patients may have acute
exacerbations of chronic problems (e.g., peptic disease, pancreatitis in
alcoholics, inflammatory bowel disease), acute surgical abdomens (e.g.,
appendicitis, ruptured viscus, acute volvulus) or nonsurgical abdominal
emergencies (e.g., gastritis, biliary colic, gastroenteritis). Sometimes abdominal
pain is related to acute trauma (e.g., splenic rupture, hepatic laceration, small
bowel rupture). The clinical evaluation, diagnostic workup and disposition of
patients with acute abdominal pain vary significantly, depending upon the initial
history and physical assessment. All patients with abdominal pain do not require
diagnostic tests. Sometimes, clinical evaluation alone is sufficient to provide
treatment and appropriate disposition. Identification of the patient with an acute
abdomen requiring immediate surgical intervention, is a critical skill for
emergency physicians.
Assessment
Appearance and general impression:
As you approach the patient, consider the degree of pain and note the
vital signs. If the patient is obviously uncomfortable, select an analgesic drug for
parenteral administration. Sometimes, oral medication is acceptable if the pain is
not too severe. But one way or another, treat the pain immediately.
If the vital signs are abnormal (HR>100, BP<100, RR >20, T>38),
approach the patient with a high degree of vigilance, and obtain vascular access
early for diagnostic testing and drug and fluid administration.
Pain management
If the patient is in pain, give analgesia right away. Ordinarily, use morphine
sulfate at 0.5-0.1 mg/kg or 2-4 mg IV or IM. Sometimes, especially if the patient
has probable renal colic, use ketolorac 30-60 mg IV or IM. In patients with low or
borderline BP, choose the short acting narcotic fentanyl, 0.5-1 ug/kg IV, which is
associated with less BP effects. These drugs will not interfere with the physical
examination, and in fact will usually enhance the sensitivity of the exam.
Tip: Give most patients with severe abdominal pain parenteral morphine
immediately.
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Ron Diekmann, MD
History History is the most important part of the assessment. Delineate the
character of the patient's pain carefully. There are several essential ingredients of
pain:
1.
Locationask the patient where the pain is. There are six anatomic
locations: RUQ, epigastrium, LUQ, RLQ, suprapubic, and LLQ. Pain
originating in any of these locations may suggest the source of the
pathology.
Tip: The more midline the pain is, the more likely it is bowel based. Pain
that localizes is of high concern and usually requires more diagnostic
evaluation.
Review of systems
Associated symptoms are important information to distinguish etiologies. Fever
and chills point to a possible acute inflammatory condition. Patients with
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Ron Diekmann, MD
respiratory complaints may have pneumonia with upper quadrant radiation. The
presence or absence of anorexia, nausea or vomiting helps diagnose or rule out
certain conditions. The absence of anorexia strongly rules against an acute
inflammatory condition. Diarrhea suggests gastroenteritis but may be present
with 20% of acute appendicitis. Ask women about pregnancy, vaginal bleeding,
STDs and LMP. Inquire about bowel movements, melena and hematochezia,
and symptoms of UTIsdysuria, frequency, and back pain.
Tip: Be careful calling abdominal pain gastroenteritis if diarrhea is not
present.
Past medical history
Ask about prior abdominal surgeries.
Tip: Abdominal pain with vomiting, no flatus or BM, and a midline
abdominal scar suggests an SBO.
Inquire about medical diagnoses such as DM, HTN, A fib and ESRD. In elderly
patients, these conditions are associated with ischemic bowelan elusive but
sometimes lethal condition.
List medications and consider iatrogenic causes of abdominal pain. Erythromycin
at 500 BID causes abdominal pain in 50% of recipients.
Habits
Bad habits and co-morbidities strongly influence assessment. Ask about alcohol
and quantity of consumption, IVDA, cocaine/amphetamine, HIV and prior bowel
problems.
Tip: Most alcoholics have some combination of pancreatitis, hepatitis and
gastritis.
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Ron Diekmann, MD
5.
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Ron Diekmann, MD
Ron Diekmann, MD
Differential diagnosis based upon pain type
Sudden onset of severe pain which does not diminish renal colic
perforated viscous myocardial infarction
torsion hemorrhage (e.g., AAA)
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Ron Diekmann, MD
Disposition Admit
Surgery
The surgical service is the best service for patients with acute
inflammatory conditions (appendicitis, cholecystitis, cholangitis), ruptured
viscus, severe third spacing (hemorrhagic pancreatitis), ischemic bowel,
incarcerated hernia, or SBO.
Medicine
The medical service is usually the preferred service for hepatitis, most
pancreatitis, peptic disease, IBD, gastroenteritis, pyelonephritis, and GI
bleeds.
Ob/Gyn
The Ob/Gyn service admits ovarian torsion, ectopic pregnancies, PID and
TOAs.
Urology
The urology service admits scrotal and testicular problems and
complicated renal colic.
Discharge Most patients can be discharged who have normal vital signs, pain
controllable with oral analgesia, and minimal exam findings. Sometimes, acidlowering agents or antibiotics are indicated for conditions such as peptic disease
or mild diverticulitis. Pepto-Bismol and anti-diarrheal agents, sometimes with antiemetics, are useful for gastroenteritis. Remember to caution patients to return
immediately if their pain becomes worse or their condition worsens.
Tip: Discharged patients must be able to tolerate fluids without emesis.
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