Abdominal Pain, Emergency Medicine

Basics

Description

Parietal pain:
- Irritating material causing peritoneal inflammation
- Pain transmitted by somatic nerves
- Exacerbated by changes in tension of the peritoneum
- Pain is sharp, well localized with abdominal, rebound tenderness and involuntary guarding
Visceral pain:
- Afferent impulses result in poorly localized pain based on the embryologic origin rather than true location of an organ.
  - Pain of foregut structures to the epigastric area
  - Pain from midgut structures to the periumbilical area
  - Pain from hindgut structures to the suprapubic region
- Distention of a viscous or organ capsule or spasm of intestinal muscularis fibers
  - Pain is constant and colicky
- Inflammation:
  - Focal tenderness develops once the inflammation extends to the peritoneum
- Ischemia from vascular emergencies:
  - Pain is severe and diffuse
Referred pain:
- Felt at distant location from diseased organ
- Due to an overlapping supply by the affected neurosegment
Abdominal wall pain:
- Constant, aching with muscle spasm
- Involvement of other muscle groups

Etiology

Peritoneal irritants:
- Gastric juice, fecal material, pus, blood, bile, pancreatic enzymes
Visceral obstruction:
- Small and large intestines, gallbladder, ureters and kidneys, visceral ischemia, intestinal, renal, splenic
Visceral inflammation:
- Appendicitis, inflammatory bowel disorders, cholecystitis, hepatitis, peptic ulcer disease, pancreatitis, pelvic inflammatory disease, pyelonephritis
Abdominal wall pain
Referred pain: (e.g., intrathoracic disease)

Diagnosis

Signs and Symptoms

History

Pain
- Nature of onset of pain
- Time of onset and duration of pain
- Location of pain initially and at presentation
- Extra-abdominal radiations
- Quality of pain (sharp, dull, crampy)
- Aggravating or alleviating factors
- Relation of associated finding to pain onset
Anorexia
Nausea
Vomiting (bilious, coffee-ground emesis)
Malaise
Fainting or syncope
Cough, dyspnea, or respiratory symptoms
Change in stool characteristics (e.g., melena)
Hematuria
Changes in bowel or urinary habits
History of trauma or visceral obstruction
Gynecologic and obstetric history
Postoperative (e.g., cause ileus)
Family history (e.g., familial aortic aneurysm)
Alcohol use and quantity
Medications: (e.g., aspirin and NSAIDs)

Physical Exam

General:
- Anorexia
- Tachycardia
- Tachypnea
- Hypotension
- Fever
- Yellow sclera (icterus)
- Distal pulses and pulse amplitudes between lower and upper extremities
Abdominal:
- Distended abdomen
- Abnormal bowel sounds:
  - High-pitched rushes with bowel obstruction
  - Absence of sound with ileus or peritonitis
- Pulsatile abdominal mass
- Rebound tenderness, guarding, and cough test for peritoneal irritation (e.g., appendicitis, peritonitis)
- Rovsing sign, suggestive of appendicitis:
  - Palpation of left lower quadrant causes pain in right lower quadrant (RLQ).
- Psoas sign suggests appendicitis (on right)
  - Pain on extension of thigh
- Obturator sign suggests pelvic appendicitis (on the right only)
  - Pain on rotation of the flexed thigh, especially internal rotation
- McBurney point tenderness associated with appendicitis:
  - Palpation in RLQ 2/3 distance between umbilicus and right anterior superior iliac crest causes pain.
- Murphy sign, suggestive of cholecystitis:
  - Pause in inspiration while examiner is palpating under liver
- Carnett sign indicates abdominal wall pain
  - Pain when a supine patient tenses the abdominal wall by lifting the head and shoulders.
- Tender or discolored hernia site
- Rectal and pelvic examination:
  - Tenderness with pelvic peritoneal irritation
  - Cervical motion tenderness
  - Adnexal masses
  - Rectal mass or tenderness
  - Guaiac positive stool
Genitourinary:
- Flank pain
- Dysuria
- Costovertebral angle tenderness
- Suprapubic tenderness
- Tender adnexal mass on pelvis
- Testicular pain:
  - May be referred from renal or appendiceal pathology
Referred pain:
- Kehr sign (diaphragmatic irritation due to blood or other irritants) causes shoulder pain.
Extremities:
- Pulse deficit or unequal femoral pulses
Skin:
- Jaundice
- Liver disease (caput medusa)
- Hemorrhage
  - Grey Turner sign of flank ecchymosis
  - Cullen sign is ecchymotic area round the umbilicus
- Herpes zoster
- Cellulitis
- Rash (Henoch-Sch ¶nlein purpura [HSP])

Essential Workup

For a woman in reproductive age group a pregnancy test is essential
Where applicable for majority of cases, ultrasonography should be done with CT used in cases of negative or inconclusive ultrasonography.

Diagnosis Tests & Interpretation

Lab

CBC
Serum electrolytes, creatinine, and glucose
ESR
LFTs
Lactic acid
Serum lipase:
- More sensitive and specific than amylase
Urinalysis
Stool analysis and culture
Pregnancy testing (age reproductive women)

Imaging

EKG:
- Consider if risk factors for coronary artery disease are present
Abdominal radiograph: Supine and upright
- CT is superior for suspected visceral perforation and bowel obstruction.
Upright CXR:
- Pneumoperitoneum
- Intrathoracic disease causing referred abdominal pain
US:
- Biliary abnormalities
- Hydronephrosis
- Intraperitoneal fluid
- Aortic aneurysm
- Intussusception
US (Doppler ultrasonography)
- Volvulus and malrotation
- Testicular and ovarian torsion
- Hepatitis, cirrhosis, and portal vein thrombosis
Abdominal CT:
- Spiral CT without contrast:
  - Renal Colic
  - Retroperitoneal hemorrhage
  - Appendicitis
- CT with intravenous contrast only:
  - Vascular rupture suspected in a stable patient (e.g., acute abdominal aortic aneurtsn [AAA], aortic dissection)
  - Ischemic bowel
  - Pancreatitis
- CT with IV and oral contrast:
  - Indicated when there is a suspicion of a surgical etiology involving bowel
  - History of inflammatory bowel disease
  - Thin patients (low BMI)
  - Diverticulitis
- CT angiography:
  - Mesenteric ischemia
  - AAA
IVP:
- CT has replaced the use of intravenous urography in detection of ureteral stones
Barium enema:
- Intussusception
- Treatment and confirmation of intussusception is with air contrast enema.
MRI:
- If concerns for radiation exposure or nephrotoxicity
- Contraindicated in patients with metallic implants

Ultrasonography and MRI should be preferred to prevent exposure of ionizing radiation to the fetus.

Differential Diagnosis

AAA
Abdominal epilepsy or abdominal migraine
Boerhaave syndrome
Adrenal crisis
Early appendicitis
Bowel obstruction
Cholecystitis
Constipation +/- fecal impaction
Diabetic ketoacidosis
Diverticulitis
Dysmenorrhea
Ectopic pregnancy
Esophagitis
Endometriosis
Fitz-Hugh-Curtis syndrome
Gastroenteritis
Hepatitis
Incarcerated hernia
Infectious gastroenteritis
Inflammatory bowel disease
Irritable bowel syndrome
Ischemic bowel
Meckel diverticulitis
Neoplasm
Ovarian torsion
Ovarian cysts (hemorrhagic)
Pancreatitis
Pelvic inflammatory disease
Peptic ulcer disease
Renal/ureteral calculi
Renal Infarction
Sickle cell crisis
Spider bite (Black widow)
Splenic infarction
Spontaneous abortion
Testicular torsion
Tubo-ovarian abscess
UTI
Volvulus
Referred pain:
- Myocardial infarction
- Pneumonia
Abdominal wall pain:
- Abdominal wall hematoma or infection
- Black widow spider bite
- Herpes zoster

Under 2 yr:
- Hirschsprung disease
- Incarcerated hernia
- Intussusception
- Volvulus
- Foreign body ingestion
2-5 yr:
- Appendicitis
- Incarcerated hernia
- Meckel diverticulitis
- Sickle cell crisis
- HSP
- Constipation

Treatment

Ed Treatment/Procedures

Nasogastric tube decompression and bowel rest
IV fluids and electrolyte repletion
Antiemetics are important for comfort.
Narcotics or analgesics should not be withheld.
Send for blood type and cross-match for unstable patient
Surgical consultation based on suspected etiology

Medication

Fentanyl: 1-2 Î¼g/kg IV qh
Morphine sulfate: 0.1 mg/kg IV q4h PRN
Ondansetron: 4 mg IV
Prochlorperazine: 0.13 mg/kg IV/PO/IM q6h PRN nausea; 25 mg PR q6h in adults
Promethazine: 25-50 mg/kg IM/PO/PR

Follow-Up

Disposition

Admission Criteria

Surgical intervention
Peritoneal signs
Patient unable to keep down fluids
Lack of pain control
Medical cause necessitating in-house treatment (MI, DKA)
IV antibiotics needed

Discharge Criteria
No surgical or severe medical etiology found in patient who is able to keep fluid down, has good pain control, and is able to follow detailed discharge instructions

Followup Recommendations

The patient should return with any warning signs:

Vomiting
Blood or dark/black material in vomit or stools
Yellow skin or in the whites of the eyes
No improvement or worsening of pain within 8-12 hr
Shaking chills, or a fever >100.4 °F (38 °C)

Pearls and Pitfalls

Elderly patients are more likely to present with atypical presentations and life threatening etiologies requiring admission.
Do not consider constipation if stool is absent in the rectal vault.
Etiology requiring surgical intervention is less likely when vomiting precedes the onset of pain.

Additional Reading

Flasar MH, Cross R, Goldberg E. Acute abdominal pain. Prim Care. 2006;33(3):659-684.
McNamara R, Dean AJ. Approach to acute abdominal pain. Emerg Med Clin North Am. 2011;29(2):159-173.
Ross A, LeLeiko NS. Acute abdominal pain. Pediatr Rev. 2010;31(4):135-144.
Yeh EL, McNamara RM. Abdominal pain. Clin Geriatr Med. 2007;23(2):255-270.

Codes

ICD9

789.00 Abdominal pain, unspecified site
789.06 Abdominal pain, epigastric
789.07 Abdominal pain, generalized
789.09 Abdominal pain, other specified site
789.01 Abdominal pain, right upper quadrant
789.02 Abdominal pain, left upper quadrant
789.03 Abdominal pain, right lower quadrant
789.04 Abdominal pain, left lower quadrant
789.05 Abdominal pain, periumbilic
789.0 Abdominal pain

ICD10

R10.9 Unspecified abdominal pain
R10.13 Epigastric pain
R10.84 Generalized abdominal pain
R10.0 Acute abdomen
R10.10 Upper abdominal pain, unspecified
R10.11 Right upper quadrant pain
R10.12 Left upper quadrant pain
R10.1 Pain localized to upper abdomen
R10.30 Lower abdominal pain, unspecified
R10.31 Right lower quadrant pain
R10.32 Left lower quadrant pain
R10.33 Periumbilical pain
R10.3 Pain localized to other parts of lower abdomen
R10.83 Colic

SNOMED

21522001 abdominal pain (finding)
79922009 epigastric pain (finding)
102614006 Generalized abdominal pain
102613000 Localized abdominal pain (finding)
116290004 Acute abdominal pain (finding)
438506002 Visceral abdominal pain (finding)
54586004 lower abdominal pain (finding)
83132003 upper abdominal pain (finding)
9991008 Abdominal colic (finding)

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