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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

- Distention of a viscous or organ capsule or spasm of intestinal muscularis fibers - Pain is constant and colicky

- 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

- Abdominal: - Distended abdomen - Abnormal bowel sounds: - High-pitched rushes with bowel obstruction - Absence of sound with ileus or peritonitis

- 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

- 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])

- MRI: - If concerns for radiation exposure or nephrotoxicity - Contraindicated in patients with metallic implants

  • Parietal pain:Irritating material causing peritoneal inflammationPain transmitted by somatic nervesExacerbated by changes in tension of the peritoneumPain 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 areaPain from midgut structures to the periumbilical areaPain from hindgut structures to the suprapubic regionDistention of a viscous or organ capsule or spasm of intestinal muscularis fibersPain is constant and colickyInflammation:Focal tenderness develops once the inflammation extends to the peritoneumIschemia from vascular emergencies:Pain is severe and diffuse
  • Referred pain:Felt at distant location from diseased organDue to an overlapping supply by the affected neurosegment
  • Abdominal wall pain:Constant, aching with muscle spasmInvolvement 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

  • PainNature of onset of painTime of onset and duration of painLocation of pain initially and at presentationExtra-abdominal radiationsQuality of pain (sharp, dull, crampy)Aggravating or alleviating factorsRelation 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:AnorexiaTachycardiaTachypneaHypotensionFeverYellow sclera (icterus)Distal pulses and pulse amplitudes between lower and upper extremities
  • Abdominal:Distended abdomenAbnormal bowel sounds:High-pitched rushes with bowel obstructionAbsence of sound with ileus or peritonitisPulsatile abdominal massRebound 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 thighObturator sign suggests pelvic appendicitis (on the right only)Pain on rotation of the flexed thigh, especially internal rotationMcBurney 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 liverCarnett sign indicates abdominal wall painPain when a supine patient tenses the abdominal wall by lifting the head and shoulders.Tender or discolored hernia siteRectal and pelvic examination:Tenderness with pelvic peritoneal irritationCervical motion tendernessAdnexal massesRectal mass or tendernessGuaiac positive stool
  • Genitourinary:Flank painDysuriaCostovertebral angle tendernessSuprapubic tendernessTender adnexal mass on pelvisTesticular 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:JaundiceLiver disease (caput medusa)HemorrhageGrey Turner sign of flank ecchymosisCullen sign is ecchymotic area round the umbilicusHerpes zosterCellulitisRash (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 uprightCT is superior for suspected visceral perforation and bowel obstruction.
  • Upright CXR:PneumoperitoneumIntrathoracic disease causing referred abdominal pain
  • US:Biliary abnormalitiesHydronephrosisIntraperitoneal fluidAortic aneurysmIntussusception
  • US (Doppler ultrasonography)Volvulus and malrotationTesticular and ovarian torsionHepatitis, cirrhosis, and portal vein thrombosis
  • Abdominal CT:Spiral CT without contrast:Renal ColicRetroperitoneal hemorrhageAppendicitisCT with intravenous contrast only:Vascular rupture suspected in a stable patient (e.g., acute abdominal aortic aneurtsn [AAA], aortic dissection)Ischemic bowelPancreatitisCT with IV and oral contrast:Indicated when there is a suspicion of a surgical etiology involving bowelHistory of inflammatory bowel diseaseThin patients (low BMI)DiverticulitisCT angiography:
  • IVP:CT has replaced the use of intravenous urography in detection of ureteral stones
  • Barium enema:IntussusceptionTreatment and confirmation of intussusception is with air contrast enema.
  • MRI:If concerns for radiation exposure or nephrotoxicityContraindicated 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 infarctionPneumonia
  • Abdominal wall pain:Abdominal wall hematoma or infectionBlack widow spider biteHerpes zoster
  • Under 2 yr:Hirschsprung diseaseIncarcerated herniaIntussusceptionVolvulusForeign body ingestion
  • 2-5 yr:AppendicitisIncarcerated herniaMeckel diverticulitisSickle cell crisisHSPConstipation

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 μg/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)