Abdominal Pain: Signs, Examination & Diagnosis – Emergency Medicine | Lecturio



hi we're going to be talking about the approach to abdominal pain for patients who present to the emergency department so abdominal pain in the emergency department it's actually the most common chief complaint in the United States so this is the most common thing that you're going to be seeing coming through the doors of the IDI it represents approximately 25% of IDI visits and it's the percentage of non injury abdominal pain visits so it's actually on the rise so this is something that potentially can increase in numbers over the next few years rather than decrease so we're gonna be seeing lots of patients coming in with discomfort in their abdomen now again we always want to make sure when we're thinking about presenting complaints and patients presenting to the emergency department that we always go back to the basics and that is airway breathing and circulation now you might be thinking that airway and breathing might not necessarily play a role here but due to the fact that there's such a wide range of things that can cause abdominal pain we actually always want to make sure that we're thinking in this stepwise fashion because if we start to not think in that stepwise fashion that's when we get ourselves into trouble circulation can definitely play a role here especially in settings where you were concerned that someone could have a life-threatening cause of their abdominal pain such as a triple-a so you always want to make sure that we're thinking about this one of the biggest challenges when patients come to the emergency department for abdominal pain is that there's such a wide range of things that can be causing the abdominal pain and they want very from things that are benign things like GERD or gastro esophageal reflux a viral illness that for the most part most patients can really tolerate on their own they may be uncomfortable they might have some belly pain and some vomiting and diarrhea but for the most part patients will be okay then they range to more serious things such as appendicitis bowel obstruction diverticulitis pancreatitis and kidney stones and these potentially have very serious implications some of these require surgical intervention Shen's some of these require admission to the hospital for IV antibiotics IV fluid replacement pancreatitis can become very severe and can really cause serious problems for patients down the line kidney stones can lead to obstruction and urinary tract infections which can then lead to sepsis so we definitely need to make sure that we're thinking about these more serious causes and then if that's not enough we move on to the fact that abdominal pain can actually be related to life-threatening conditions so an abdominal aortic aneurysm can cause abdominal pain and that is obviously something that can be very very serious and life-threatening for a patient patients can bleed out very rapidly from abdominal aortic aneurysms that rupture a ruptured ectopic pregnancy also poses significant challenges perforation of the GI tract that's something that requires emergent surgical intervention the patient needs to go to the operating room emergently so when we're thinking about patients who come into the emergency department with belly pain we have to be thinking about this whole spectrum of things we can't just be thinking about the benign things or the life threats we have to be thinking about all the things that are benign more serious and then those life-threatening conditions because if we're not thinking broadly in this situation that's how we run into problems and we get come up with a misdiagnosis we come up with an incorrect diagnosis so always maintaining that high level of suspicion you know there are also extra abdominal things that can cause abdominal pain so things outside the belly so as if things weren't complicated enough already we're gonna go ahead and complicate them even further myocardial infarction is a classic example of extra abdominal things presenting with belly pain classically inferior wall mi so an inferior wall myocardial infarction is the classic thing that we think about presenting with epigastric abdominal pain and nausea and vomiting and I would say you could probably ask every emergency medicine physician if they've ever seen an inferior mi present with primarily abdominal pain symptoms and I would say that we would all say yes I can think of a handful of times that patients were present with epigastric belly pain got an EKG and it turned out to be an ST elevation mi in the inferior distribution you always just have to keep it in the back of your mind that epigastric pain can potentially be an MI especially in the appropriate patient population and especially if your patient appears ill if their diaphoretic if they're sweaty if they're pale those are the patients so you want to get that EKG a little bit more rapidly ketoacidosis is another very serious and life-threatening condition that could potentially cause abdominal pain so classically diabetic ketoacidosis so a diabetic patient that is having ketoacidosis that is producing ketone bodies and their blood is acidotic by similar pathway alcoholic ketoacidosis can cause abdominal pain as well diabetic patients patients who drink alcohol regularly you want to be thinking about this and you want to be potentially working your patient up for it pneumonia especially in Pediatrics so especially for those younger kids can present just with abdominal pain so be thinking about pneumonia herpes zoster or shingles can actually present with pain in lots of different areas so sometimes it's like a red herring and chest pain presentations sometimes it's a red herring in abdominal pain presentations as well this is a time where you want to make sure you ask a patient have you seen a rash on your body and also where you want to sometimes inspect the abdomen again this is something where every so often you go ahead and you take a look at the belly and you see in that dermatome mole distribution shingles in that area where that patient is complaining of pain so just make sure you keep it in the back of your mind and that you're thinking about that when someone comes in complaining of pain now the classic pain with herpes zoster is kind of like people describe it as an itchy burning sort of a discomfort so even more so when they describe their pain in that way other things glaucoma I know that seems like a total outlier but someone having elevated intraocular pressure can cause abdominal pain this is why we you know it's really important to talk with our patients find out if they're having their eye malignancies potentially henoch-schonlein purpura more common in Pediatrics but can be seen in adult patients the classic association with that is that patients will have a proper crash most commonly on the lower extremities and then testicular and ovarian torsion we'll be talking about those concepts in another lecture but it's important to always ask about any pain in the testicles especially for those adolescent male patients so abdominal pain is not all created equal there's different kinds of ways that patients are going to explain pain and it all has to go back to embryology so it all has to go back with how the organ is developed so there's visceral pain and visceral pain originates in the hollow organs and the capsules of the solid organs this corresponds to embryonic development pain generally related to visceral pain is a dull or achy pain parietal pain is due to stretching or irritation of the parietal peritoneum so that's the lining of the of the parietal purge of the peritoneal cavity this pain is generally sharper so it's more like a sharp or stabbing kind of a pain then the referred pain is the last kind of pain referred pain is felt at a site far from the diseased organ the classic thing that we think about when we think about referred pain is gall bladder pain felt in the right shoulder so when someone has cholecystitis or potentially biliary colic that pain may radiate to the right shoulder so you want to make sure you're thinking about that now for abdominal pain this is one of those classic times where you want to go back to your original history taken class whatever that might be and you want to go back to really thinking about the different factors that are affecting the pain does the pain radiate anywhere so this Opie qrst phenomenon so o stands for onset was the onset sudden or gradual because that can point you in one direction or the other P stands for provocative factors or palliating factors are there certain things that make the pain worse does eating make the pain worse especially like in gallbladder disease we think about eating fatty foods making the pain worse though certain things make it better does it get better when you lay on your side does it get better when you eat potentially there are certain things that actually get better when you eat so thinking about and asking patients about what makes it better what makes it worse q is the quality of the pain so is it that dull achy pain is it a crampy pain is it a sharpen stabbing pain so kind of figuring out and having the patient describe their pain to you can be a useful piece of information for you to have that can help you form your differential diagnosis radiation does it radiates to the back the classic thing that radiates to the back is pancreatitis so it goes from the epigastric abdominal area into the back does it go to the chest we discuss the fact that myocardial infarction can potentially be on your differential here S stands for site where is the pain our belly if you've done Anatomy is divided into different quadrants and there's different stuff that lives in each of these different quadrants now granted some patients don't always follow the rules but every so often but for the most part knowing the site and knowing where they're describing their pain is helpful do they have any other symptoms with the pain vomiting anorexia diarrhea fever vomiting and appendicitis can be very helpful to know did the pain come first or did the vomiting come first is there any blood in the stool all of this stuff can help you figure out what to do the timing when did it start is it constant or intermittent colicky pain like biliary colic or renal colic by definition is intermittent pain it's pain that becomes more or less severe constant pain is pain that just stays there constantly again helpful to know the way the patient is describing and reporting their symptoms so in the exam we want to go through a few steps so step one in the physical exam is the vital signs vitals are vital you probably have heard me say that if you've listened to some of these other lectures you want to make sure you have a full set of vital signs on your patient sometimes it can be easy that one of them may be overlooked a little bit but definitely having an accurate temperature reading a blood pressure reading pulse oximeter a heart rate and a respiratory rate all will benefit you in this situation and you want to make sure you're paying attention to all of those vital signs step 2 is to inspect so is the patient lay still or are they restless are there any prior surgical scars on their abdomen similar to when a patient comes in with respiratory distress there's a lot of information you can get just by looking at your patient if they're laying still that could potentially indicate that they have peritoneal signs that moving around might make their pain a little bit worse if the patient is restless that might support renal colic or a kidney stone diagnosis classically those patients are very restless some patients also aren't very good at remembering what procedures they've had on their abdomen and some patients might you might ask them I've had this situation for sure have you ever had any surgeries on your abdomen and they say no and then you look at their belly and there's lots of scars there so in those situations you want to go ahead and maybe ask them a little bit more probing details if you see surgical scars or look in the medical record to try and figure out what happened surgical scars are becoming harder and harder to necessarily notice especially with more and more people getting laparoscopic surgery because those laparoscopic surgical scars are very very small and are often try to do them in less noticeable areas so one classic place is just around the umbilicus and those can be a little bit harder to pick up on step 3 is to listen historically everyone's taught to listen before you palpate so we'll go ahead and go with that for now you want to listen for two minutes and you're listening for bowel sounds if you don't hear any bowel sounds after a full two minutes the patient does not have bowel sounds likely so you want to make sure you're listening for that appropriate time period and your hearing if the bowel sounds are overactive underactive not present at all or potentially in the normal range step four is palpation you want to start in the area away from the pain so if the patient's pain is on the right side in the lower abdomen go ahead and start on the left upper abdomen and then work your way around to that area you're going to want to palpate lightly and then go ahead and push a little bit more deeply depending on the exam that you're getting for the patient when you're palpating you also want to go ahead and assess for rebound tenderness so rebound tenderness is basically pain that occurs when you let go so basically you push down on the abdomen and when you release your hand I tell people to try and focus does it hurt more when I push down or does it hurt more when I let go rebound tenderness is potentially supportive of the patient more likely having a surgical process the other things you can do to assess for rebound tenderness is that you can sometimes shake the bed this was a tip that I learned actually when I was a medical student from one of my surgery residents and he would go in the rooms for patients that were being worked up and he would basically take his knee and he would nudge the bed a little bit and see if the patient reacted shaking of the bed reproducing abdominal pain is again something that indicates that the patient may have peritoneal irritation and possibly a surgical process the other thing that you can do and this is more commonly done in the pediatric population is you can get your patient up out of bed and you can have them jump on one foot again that's something that indicates that if they have pain that's reproduced in that situation then the patient may have more likely to have appendicitis or surgical process this is a classic thing in Pediatrics that they get their patient up and have them jump on one foot and if the kids willing to or able to do without pain a lot of pediatric Eadie people will say that the likelihood of appendicitis is far less likely the other thing that I do sometimes ask patients is I have them estimates when they came to the emergency department in their car if going over bumps bother them again it's an element of just that little shaking movement or vibrations causing or making that pain worse now there are some additional examiners that you want to think about doing so one of them is Murphy's sign and that is taking a closer look at the gallbladder or kind of indicating if there's disease in the gallbladder for cholecystitis and what you do in that situation is you feel in the right upper quadrant and when your palpating deeply in the right upper quadrant the patient stops inspiring and that's indicating that that pain is so severe or intense or localized to that area that the patient will stop inspiring this is something that can be done on a physical exam and also can be done during an ultrasound exam so when you're doing the ultrasound for the patient you can see if they have a positive Murphy's the other thing you can do and this is generally done in the center of the abdomen is you can palpate the aorta you want to think about a triple-a in older patients so as patients are older is when this disease process generally does start to develop so for those patients you want to go ahead and feel in the center of the belly and see if you feel any kind of larger palpable mess any ones skinny younger people you actually may be able to feel their aorta because they're generally skinny and younger and you're able to feel it in the center of their abdomen other maneuvers are the psoas obturator and raphson sign those are indicative of appendicitis and we'll talk more about those when we discuss appendicitis further the other things to focus on our agenda urinary exams the testicular exam and the pelvic exam the testicular exam is especially important for the patient he or concern may not necessarily be able to accurately report to you whether or not they're having testicular pain the pelvic exam I always tell women when they come to the IDI with abdominal pain that they're really quite tricky because in addition to having your intestines and the normal stuff in your belly you also have your reproductive organs so you have the uterus and the ovaries and those are sometimes a source of the pain so doing the public exam for all women who have uterus and ovaries is a key thing to do when they present with abdominal pain because you don't want to miss a pelvic infection or some kind of ovarian mass that's presenting in that way you also want to look for any kind of extra abdominal findings so that means that the herpes zoster rash that was discussed it means listening to the patient's lungs and seeing if there's any concern for pneumonia looking at the respiratory rate and seeing if the respiratory rate is elevated that might make you support diabetic ketoacidosis if you're worried about glaucoma examining the face and the eyes so next we want to move on to lab testing and we want to think about what tests to get for these patients a majority of patients who come to the emergency department for abdominal pain will get blood tests sent a key and very important test that you want to make sure you send is an HCG test for all women of childbearing age HCG is the hormone that's secreted in pregnancy and this test can be done very rapidly and easily using a urine pregnancy test you can also send a serum pregnancy test which will give you a more accurate reading as to what the number is but generally urine pregnancy tests are very sensitive for pregnancy a CBC or a complete blood count is the next test that's generally said it's important to note that this is not a specific test when we send this test we're looking at the white blood cell count a white blood cell count is a nonspecific marker of stress on the body it goes up in times of infection but it also goes up in lots of other things it can increase in and of itself in pregnancy it can increase just with stress life stress certain medications can increase the white blood cell count also on that CBC you'll get an idea as to whether or not the patient is anemic which can also potentially help you a metabolic panel with liver and pancreatic testing can be helpful as well so that will give you an idea as to what the kidney function is what the glucose level is it'll tell you if the patient is having any liver issues any indication if the patient is having increase of their pancreatic enzymes an important thing to note here is that lipase is generally the test that should be sent for pancreatitis amylase and lipase are both pancreatic enzymes but amylase is also secreted in other things so amylase can come from the bowel wall in general and also salivary glands so for the most part to practice the most cost effective emergency medicine just go ahead and send the lipase the lactic acid level is something else that can help lactate is elevated due to periods of ischemia so commutative volume depletion can be due to there not being enough blood flow to the tissues it can also be due to infection and possibly sepsis so sending a lactate can indicate to you whether or not the patient is having elements of decreased blood flow to their tissues other testing to get would be an EKG the EKG can evaluate for myocardial ischemia so again I want to stress that that's classically associated with inferior wall mi s so patients who are having epigastric abdominal pain always think about that inferior wall mi but your analysis can also look for blood which would be indicative of possibly a kidney stone it can also look for white blood cells and nitrites and leukocyte esterase and see if there's any concern for infection the other thing you can do on your urine test is you can send a urine test especially in the male patient for gonorrhea and chlamydia testing we'll talk more about that in another lecture as well after we've sent off our blood tests we definitely want to start thinking about whether or not our patient needs abdominal imaging we have a few choices when were thinking about abdominal imaging the first thing that we can do is possibly a plain film a plain film is basically used to evaluate for bowel obstruction or possibly perforation of the viscus now the advantages here are this give me perform very quickly so you can have someone come to a portable abdominal x-ray very quickly right at the bedside so it's good for a sicker patient potentially or for a patient who you don't feel safe leaving the department or someone in whom you want to get testing very rapidly the disadvantages are that this is a low yield test this test is not going to give you a ton of information and the truth is is that if it's negative you potentially may need to still move on and get additional testing so be sure to get it so if you're worried that someone has perforation of their intestines you actually want to go ahead and you want to get an upright chest film and the reason for that is that the free air that's an abdomen will go up and you'll be able to see it more accurately under the diaphragms now again I want to stress that this is not the most sensitive or specific test for either bowel obstruction or perforation so if you are very worried about those conditions you're going to want to move on and get as cat scan ultrasound is another option when looking for pathology and patients who are coming in with abdominal pain so what is ultrasound good for ultrasound is good for looking for an abdominal aortic aneurysm which is what's pictured over here in this picture on the side of the screen and it can go ahead and take a look and see how big the aorta is gall bladder stuff as well as genitourinary conditions like testicular torsion or ovarian torsion it may also help in renal colic so you can get an ultrasound of the patient's kidneys and see if there's any obstruction you can look at the appendix that's very operator dependent so some people when they're performing ultrasound are very good at looking at the appendix and that's actually ultrasound is the most common and imaging modality that's used when working on pediatric patients for appendicitis it can also be used for bowel obstruction there's a lot more evidence for using it for this in the European literature than the American literature but that may be something that becomes a lot more common moving forward that ultrasound is used for bowel obstruction the advantage is here that there's no radiation exposures so you're not exposing your patient to any radiation and that's one of the big disadvantages of CT scan and it can also be performed at the bedside in the emergency department we're generally pretty proud of our point of care ultrasound skills which basically means that we have ultrasound machines in the emergency department that we're bringing to the bedside where we can actually look for a lot of this stuff on our own so if you're at a facility that doesn't have ultrasound capabilities available to you one of the edie staff can most likely go ahead and take a look for a lot of these conditions and we can also do it very quickly and on our time we don't need to wait for anyone to come or be there we can go ahead and get that test taken care of on our own now of course depending on your comfort ability with it you may need to go ahead and get additional testing so the disadvantage here is that it's operator dependent so it's dependent on how comfortable people feel obtaining those images because it does take a little bit of skill and a little bit of practice or rather a lot of skill and a lot of practice to get good at it to really be able to know what you're looking at and know what you see I always joke around that I tell students nowadays that when I was a student I thought everything on the ultrasound looked like a snowstorm it's all at black and white and gray and I had no idea what I was looking at so for students now generally there's a lot more teaching about this in medical school and it's really a great resource for you to get your hands on and get comfortable with the last imaging modality is CT scan CT scan is the thing that's used very commonly when looking for abdominal pain issues what it's good for is mostly internal diagnosis so this is good for looking for appendicitis it's good at looking for any kind of bowel obstruction it's good at looking for any kind of infection or abscess in the abdomen the advantages here are that it's generally readily available and the image quality is oftentimes great you're able to see lots of different stuff and you're able to evaluate for lots of different conditions the disadvantage here is that it's ionizing radiation exposure so you're exposing someone to radiation and that matters because over the course of a lifetime we know that radiation exposure can add up and potentially put patients at increased risk for malignancy so we want to make sure that we're being thoughtful about when we're using this and we want to make sure that we're using it in the appropriate patient setting now if you're worried about any kind of vascular concerns you want to go ahead and give intravenous contrast and that's going to help light up the blood vessels and make them easier to see now like lots of things that we've talked about during the emergency medicine lectures it's important to always maintain a high level of suspicion of some kind of badness going on in elderly patients immuno compromised patients or diabetic patients you want to have a high level of suspicion that they have something bad going on in their abdomen they may not necessarily have clear signs or clear exam symptoms or lab values but have a low threshold in these patients for potential imaging or possible surgical consultation definitely the one thing you don't want to do in these patient populations is you don't want to necessarily always jump to a more benign diagnosis like reflux you want to have a high suspicion that something could be going on in there after men you

19 comments

  1. Very informative. Mabey add some clouds to explain certain medical terms for us simple folk that are not fully fluent in Doctor linguistics lol

  2. https://youtu.be/rm8TnbVh9pI?t=1344
    Is it me or she refers to the US image as aortic aneurysm? I think is a gallblader with some stone in it? min 22:24
    lol

Leave a Reply

(*) Required, Your email will not be published