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Abdominal Pain - Abel Stephen 6M31

Pain Assessment Model
S
O
C
R
A
T
E
S
Site
Where exactly is the pain?
Onset
What were they doing when the pain
started?
Character
What does the pain feel like?
Radiates
Does the pain go anywhere else?
Associated symptoms
e.g. nausea/vomiting
Time/duration
How long have they had the pain?
Exacerbating/relieving factors
Does anything make the pain better or
worse?
Severity
Obtain an initial pain score.

6.

Abdominal Pain Causes
Inflammation of a viscus
Perforation of a viscus
Obstruction of a viscus
Infarction of a viscus
Intra-abdominal hemorrhage or retroperitoneal
hemorrhage
Extra-abdominal or medical causes for acute abdominal
pain like lower lobe pneumomia and inferior wall MI

7. RUQ

• Biliary Colic
• Acute cholecystitis
• Acute Cholangitis
• Emphysematous cholecystitis
• Acute Hepatitis
• Pyogenic Liver Abscess
• Duodenal ulcer
• Portal vein thrombosis
• Lower lobe pneumonia
• Lower lobe pulomonary infarction (pulmonary embolism
• Empyema
• Ureteric Colic
• Pyelonephritis

8.

RUQ
Diagnosis
Key History and Physical Findings
Symptomatic cholelithiasis
RUQ pain radiating around right back after fatty meals, resolves after a few hours, female multigravida,
obese
Acute cholangitis
Persistent RUQ pain, fever, jaundice (Charcot’s triad)
Acute Cholecystitis
Persistent(>4h), severe RUQ pain, fever, Murphy’s sign
Acute pancreatitis
Severe epigastric pain radiating straight through to back (2º cholelithiasis, alcohol abuse)
Acute gastritis
Aspirin, NSAID use, steroid use, gnawing epigastric pain
Peptic ulcer disease
Intermittent burning epigastric pain that improves (duodenal ulcer) or worsens (gastric ulcer) with food
intake (2º H. pylori infection, NSAID, steroid use)
Malignancy (gastric, pancreatic,
biliary)
Chronic pain, weight loss, fatigue
Fitz-Hugh-Curtis syndrome
RUQ pain, history of recent pelvic inflammatory disease( either Chlamydia trachomatis or Neisseria
gonorrhoeae), fever, “violin string” adhesions between liver and diaphragm
Myocardial infarction
Epigastric pain (referred pain), diabetes, cardiovascular disease, hypercholesterolemia
Acute hepatitis
Hepatitis A (recent foreign travel, IVDA, raw shellfish, fecal-oral)
Hepatic abscess
RUQ pain, high fever, hepatomegaly(bacterial or amoebic
Acute pyelonephritis
Costovertebral angle tenderness, dysuria, hematuria

9. LUQ

• Gastric Ulcer
• Splenic abscess
• Splenic Laceration
• Splenic Infarction
• Lower Lobe Pneumonia
• Lower Lobe Pulmonary infarction(Pulmonary Embolism)
• Empyema
• Ureteric Colic
• Pyelonephritis

10. RLQ

• Acute appendicitis
• Colitis
• IBD
• Epiploic appendagitis
• Neutropenic enterocolitis
• Ureteric Colic (nephrolithiasis)
• Ectopic pregnancy
• Ovarian torsion
• Ruptured ovarian cyst
• Pelvic Inflammatory Disease
• Testicular torsion

11.

RLQ
Diagnosis
Key History and Physical Findings
Inflammatory Bowel Disease
(IBD)
Abdominal pain, severe cramps, weight loss, bloody diarrhea, anemia, enterocutaneous fistula/anal
fissures (Crohn’s), toxic megacolon (Ulcerative Colitis).
Pancreatitis
Epigastric pain radiating to the back, nausea, vomiting, anorexia, fever, tachycardia; often associated
with cholelithiasis (gallstones) or alcohol abuse.
Cholecystitis
Right upper quadrant (RUQ) pain radiating to the back, nausea, vomiting, fever; Murphy’s
sign (palpation of RUQ during inspiration stops inspiration secondary to pain).
Appendicitis
Anorexia, vague periumbilical abdominal pain, vomiting, localized right lower quadrant pain
(McBurney’s point), Rovsing’s sign, psoas sign.
Gastroenteritis
Nausea, vomiting, watery diarrhea (viral), bloody diarrhea (certain bacteria), myalgia, fever.
Nephrolithiasis
Colicky flank pain that may radiate to inner thigh or genitals, nausea, vomiting, dysuria, hematuria.
Perforated Duodenal Ulcer
Sudden onset of epigastric pain, rigid abdomen, history of dyspepsia, NSAID use, recurrent ulcers, H.
pylori infection. (Also known as Valentino’s syndrome).
Pyelonephritis
Costovertebral angle (CVA) tenderness, fever, pain on urination, vomiting.
Sigmoid Diverticulitis
Pain in left lower quadrant (LLQ), fever, leukocytosis, nausea, diarrhea, constipation; common in elderly.
Cecal Diverticulitis
Congenital solitary diverticulum.
Meckel's Diverticulitis
"Rule of 2’s": males 2x more common, occurs within 2 ft of ileocecal valve, 2 types of tissue
(pancreatic/gastric), found in 2% of population, presents at 2 years of age (with painless rectal bleeding).

12.

Diagnosis
History and Physical
Pelvic Inflammatory Disease (PID)
Often involves Neisseria gonorrhoeae or Chlamydia infection. Symptoms include purulent cervical
discharge, cervical motion tenderness, adnexal tenderness, and dysuria.
Ovarian Torsion
Characterized by the acute onset of severe pelvic pain, often with a palpable adnexal mass and a history
of ovarian cysts.
Mittelschmerz
Physiologic, recurrent mid-cycle pain. It is typically mild, unilateral, and lasts from a few hours to a few
days; the pelvic exam is usually normal.
Ruptured Ectopic Pregnancy
Typically presents 6–8 weeks after the last normal menstrual period. Key signs: abdominal pain,
amenorrhea, vaginal bleeding, breast tenderness, and anemia (rarely hemorrhagic shock).
Diagnosis
History and Physical Findings
Mesenteric lymphadenitis
Often follows a concomitant or recent Upper Respiratory Infection (URI); characterized by high fever,
enlarged/inflamed/tender lymph nodes in the small bowel mesentery, and generalized abdominal pain.
Yersinia enterocolitica
(Pseudoappendicitis)
Presents with Right Lower Quadrant (RLQ) pain, fever, vomiting, and bloody diarrhea. Often associated with a
history of "sick contacts" (e.g., infected children at daycare).
Pneumococcal pneumonia
Though a lung infection, it may be associated with nausea, vomiting, and diffuse abdominal pain in children.
Gastroenteritis
Typically involves nausea, vomiting, and diarrhea (watery if viral, bloody if certain bacteria). Often accompanied by
myalgia and fever.
Intussusception
Notable for nausea, vomiting, and crampy abdominal pain. Classic signs include "red currant jelly" stool and a
"sausage-shaped mass" in the abdomen (frequently seen in 12-month-old infants).

13. LLQ

• Diverticulitis
• Colitis
• IBD
• Epiploic appendagitis
• Ureteric Colic (nephrolithiasis)
• Ectopic pregnancy
• Ovarian torsion
• Ruptured ovarian cyst
• Pelvic Inflammatory Disease
• Testicular torsion

14.

Epigastrium
Periumbilical
Suprapubic
Diffuse abdominal pain
Acute esophagitis
Acute gastritis
Acute pancreatitis
Myocardial infarction
Acute mesenteric ischemia
AAA
PUD
Pericarditis
GERD
Aortic dissection
Functional dyspepsia
Mallory Weiss syndrome
Acute appendicitis (early)
Aortic dissection
Mesenteric ischemia
AAA
Ectopic pregnancy
PID
Cystitis (UTI)
Prostatitis
Endometriosis
Acute urinary retention
Diabetic ketoacidosis
Sickle cell crisis
Porphyria
Cocaine use
Opioid withdrawal
Cannabinoid hyperemesis syndrome
Endometriosis
Retroperitoneal hematoma
Acute adrenal insufficiency
Diverticulitis
Bowel obstruction
Bowel perforation (peritonitis)
Mesenteric ischemia (peritonitis)
Irritable bowel syndrome
Constipation
Gastroenteritis
Spontaneous bacterial peritonitis

15.

16.

17.

18.

19.

Appendicitis
CLINICAL FEATURES
DIAGNOSTIC FINDINGS
• RLQ, epigastric, and/or
periumbilical pain (migrating
abdominal pain)
• Fever
• Nausea, anorexia
• Guarding, tenderness,
and rebound tenderness in
the RLQ
• McBurney’s point
• Neutrophilic leukocytosis
• Abdominal CT scan with IV
contrast : distended appendix with
periappendiceal fat stranding
• Abdominal ultrasonography :
noncompressible, aperistaltic,
distended appendix, probe
tenderness in the RLQ, Target sign

20.

GI Tract Perforation
CLINICAL FEATURES
DIAGNOSTIC FINDINGS
• Sudden onset of diffuse
abdominal pain
• Nausea, vomiting
• Constipation/obstipation
• Diffuse abdominal guarding,
rigidity, and rebound
tenderness
• Absent bowel sounds
• Loss of liver dullness
on RUQ percussion
• Abdominal xray:
pneumoperitoneum

21.

Diverticulitis
CLINICAL FEATURES
DIAGNOSTIC FINDINGS
• Fever
• LLQ pain
• Constipation
• Tender mass in LLQ
• Labs: ↑ WBC
• CT abdomen and pelvis with IV
contrast: colonic diverticula with
pericolic mesenteric fat stranding

22.

Mechanical bowel obstruction
CLINICAL FEATURES
DIAGNOSTIC FINDINGS
• Colicky abdominal pain
• Obstipation/bloating
• Progressive nausea and
vomiting (late finding)
• Diffuse abdominal
distention, tympanic
abdomen, collapsed rectum
• Tinkling bowel sounds
• History of abdominal surgery
• X-ray abdomen
• Dilated bowel loops proximal to
the obstruction
• Rectal air shadow absent
• Multiple air-fluid levels
• CT abdomen with IV contrast
• Similar findings as on x-ray
• Transition point at site of
obstruction

23.

Acute Mesenteric Ischemia
CLINICAL FEATURES
• Age > 60 years, embolic risk
factors (e.g., atrial
fibrillation, thrombophilia),
cardiovascular disease
• Pain out of proportion to
findings
• Severe, diffuse abdominal
pain and distention
• Vomiting, diarrhea
• Melena, hematochezia
DIAGNOSTIC FINDINGS
• Labs: lactic
acidosis, hyperkalemia, leukocytosis
• X-ray abdomen: normal (early
stages), pneumatosis
intestinalis (late stages)
• CT angiography: mesenteric arterial
narrowing or occlusion, thickening of
bowel wall, nonenhancing segments
of solid organs or of the bowel
wall, pneumatosis intestinalis

24.

Choledocholithiasis
CLINICAL FEATURES
DIAGNOSTIC FINDINGS
• RUQ pain
• Features of obstructive
jaundice
• Nausea, vomiting
• Normal abdominal
examination
• Labs: ↑ ALP, AST, ALT, total bilirubin
• Abdominal ultrasound
• Dilated common bile
duct (CBD)
• Intrahepatic biliary dilatation
• Echogenic structure within
the CBD with shadowing
• EUS: stone within the CBD
• MRCP or ERCP: filling defect in the
contrast-enhanced duct

25.

Acute Pancreatitis
CLINICAL FEATURES
DIAGNOSTIC FINDINGS
• Severe epigastric pain that
radiates to the back
(circumferential pain)
• Nausea, vomiting
• Epigastric tenderness,
guarding, rigidity
• Hypoactive bowel sounds
• Possibly fever
• ↑ Lipase, amylase
• Hypocalcemia (poor prognostic
indicator)
• Abdominal ultrasound: pancreatic
edema, peripancreatic
fluid, gallstones
• Abdominal CT with IV
contrast : pancreatic edema,
peripancreatic fat
stranding, gallstones

26.

Peptic Ulcer Disease
CLINICAL FEATURES
DIAGNOSTIC FINDINGS
• Epigastric pain
• Duodenal
ulcer: pain relieved with
food; weight gain
• Gastric
ulcer: pain exacerbated by
food; weight loss
• Signs of GI bleed
• History of NSAID intake
• Anemia, positive FOBT (in cases of
bleeding ulcer)
• Urea breath test for H. pylori:
positive in most cases of PUD
• EGD: Mucosal erosions and/or Ulce
rs are required for a definitive
diagnosis

27.

Ruptured AAA (or impending rupture)
CLINICAL FEATURES
DIAGNOSTIC FINDINGS
• Age > 50 years
• Sudden, severe central
abdominal, chest, and/or back
pain
• Hypotension, shock
• Pulsatile mass in the midline of
the abdomen
• Grey Turner sign and/or Cullen
sign
• History
of atherosclerosis, hypertensio
n, and/or smoking
• Imaging is only recommended in
hemodynamically-stable patients
with a low pretest
probability of ruptured AAA.
• Abdominal ultrasound: aortic
dilatation, periaortic
fluid, intraperitoneal free fluid
• CT/MR angiography: retroand intraperitoneal hemorrhage;
localization of the ruptured/leaking
site

28.

29.

Aortic Dissection
CLINICAL FEATURES
DIAGNOSTIC FINDINGS
• Sudden onset of severe, sharp
tearing chest or
abdominal pain that radiates
to the back
• Hypotension, syncope,
neurological symptoms
• Asymmetrical blood
pressure, pulse deficit
• New diastolic murmur (due
to aortic regurgitation)
• Symptoms
of myocardial ischemia
• Elevated D-dimer
• ECG: nonspecific STsegment changes
• CXR: widening of the aorta
• CT angiography of
chest/abdomen/pelvis: intimal flap
with false lumen
• Transesophageal
echocardiography (TEE): proximal
aortic dissection,
tamponade, aortic regurgitation

30.

Acute Coronary Syndrome
CLINICAL FEATURES
• Heavy, dull,
pressure/squeezing
sensation
• Substernal or
epigastric pain with
radiation to left shoulder
• Nausea, vomiting
• Diaphoresis, anxiety
• Dizziness, lightheadedness, s
yncope
DIAGNOSTIC FINDINGS
• ECG: nonspecific changes, STsegment elevation/depression, Twave inversions, Q waves
• Increased or normal troponin
• TTE: hypokinesis, regional wall
motion abnormalities

31.

Ruptured Ectopic Pregnancy
CLINICAL FEATURES
DIAGNOSTIC FINDINGS
• Sudden severe lower
abdominal pain
• Vaginal
bleeding or amenorrhea
• Lower abdominal
guarding and tenderness
• Cervical motion tenderness,
closed cervix
• Enlarged uterus
• Tachycardia, hypotension
• ↑ β-hCG
• Transabdominal/transvaginal
ultrasound
• Free fluid within Morison
pouch and/or pouch of Douglas
• Empty uterine cavity,
thickened endometrial lining
• Adnexal mass
• Tubal ring sign

32.

Ovarian Torsion
CLINICAL FEATURES
DIAGNOSTIC FINDINGS
• Sudden onset unilateral
lower abdominal or pelvic
pain
• Nausea, vomiting
• Unilateral iliac fossa
tenderness
• Pelvic (or transvaginal) ultrasound with
Doppler velocimetry:
enlarged, edematous ovaries with
decreased blood flow
• Pelvic CT scan with IV contrast
• Unilateral thickened ovarian tube,
enlarged ipsilateral ovary, and
decreased enhancement of ipsilatera
l ovary
• Twisted vascular pedicle (whirlpool
sign)

33.

Pyelonephritis
CLINICAL FEATURES
DIAGNOSTIC FINDINGS
• High fever, chills
• Flank pain with costovertebr
al angle tenderness (usually
unilateral, may be bilateral)
• Dysuria, urinary frequency,
urgency
• Labs
• ↑ WBC, CRP, ESR
• Positive urinalysis
• Positive urine culture
• Renal ultrasound: edema and
focal hypoechogenic areas
• CT pelvis with IV contrast: focal
area(s) of hypoenhancement that
extend to the cortical periphery

34.

Nephrolithiasis
CLINICAL FEATURES
DIAGNOSTIC FINDINGS
• Severe unilateral and colicky
flank pain (renal colic)
• Hematuria
• Nausea, vomiting
• Dysuria, frequency, and
urgency
• Urine dipstick and urinalysis: gross
or microscopic hematuria
• Urine microscopy: to detect crystals
• Abdominopelvic CT:
Nonenhanced CT scan is the gold
standard.
• Ultrasound: method of choice for
patients in whom radiation exposure
should be minimized (e.g., pregnant
patients, children, recurrent stone
formers)

35.

36.

BRAINSTORMERS!

37.

1. A 69-year-old man is brought to the emergency department because of a 30minute history of severe abdominal pain radiating to his left flank. He is weak
and has been unable to stand since the onset of the pain. He vomited twice on
the way to the hospital. He has not passed stools for 3 days. He has
hypertension, coronary heart disease, and peptic ulcer disease. He has smoked
one-half pack of cigarettes daily for 46 years. Current medications include
enalapril, metoprolol, aspirin, simvastatin, and pantoprazole. He appears ill. His
temperature is 37°C (98.6°F), pulse is 131/min, respirations are 31/min, and
blood pressure is 82/56 mm Hg. Pulse oximetry on room air shows an oxygen
saturation of 92%. Examination shows a painful pulsatile abdominal mass. The
lungs are clear to auscultation. Cardiac examination shows no abnormalities.
Intravenous fluid resuscitation is begun. Which of the following is the most
appropriate next step in management?
• A. Intravenous ampicillin/sulbactam therapy
• B. Supine and erect x-rays of the abdomen
• C. CT scan of the abdomen and pelvis with contrast
• D. Open emergency surgery
• E. Transfusion of packed red blood cells

38.

2. A 35-year-old man comes to the physician because of a 2-month history of
upper abdominal pain that occurs immediately after eating. The pain is sharp,
localized to the epigastrium, and does not radiate. He reports that he has been
eating less frequently to avoid the pain and has had a 4-kg (8.8-lb) weight loss
during this time. He has smoked a pack of cigarettes daily for 20 years and drinks
3 beers daily. His vital signs are within normal limits. He is 165 cm (5 ft 5 in) tall
and weighs 76.6 kg (169 lb); BMI is 28 kg/m2. Physical examination shows mild
upper abdominal tenderness with no guarding or rebound. Bowel sounds are
normal. Laboratory studies are within the reference ranges. This patient is at
greatest risk for which of the following conditions?
A Malignant transformation
B Biliary tract infection
C Gastric perforation
D Pseudocyst formation
E Intestinal fistula formation
F Pyloric scarring
G Gastrointestinal bleeding
H Subhepatic abscess formation

39.

3. A 71-year-old man with hypertension is taken to the emergency
department after the sudden onset of stabbing abdominal pain that
radiates to the back. He has smoked 1 pack of cigarettes daily for 20 years.
His pulse is 120/min and thready, respirations are 18/min, and blood
pressure is 82/54 mm Hg. Physical examination shows a periumbilical,
pulsatile mass and abdominal bruit. There is epigastric tenderness. Which
of the following is the most likely underlying cause of this patient's current
condition?
A. Coronary artery narrowing
B. Aortic wall stress
C. Mesenteric atherosclerosis
D. Gastric mucosal ulceration
E. Abdominal wall defect
F. Portal vein stasis

40.

4. A 60-year-old woman comes to the physician because of intermittent abdominal pain for the past month.
The patient reports that her pain is located in the right upper abdomen and that it does not change with food
intake. She has had no nausea, vomiting, or change in weight. She has a history of hypertension and
hyperlipidemia. She does not smoke. She drinks 1–2 glasses of wine per day. Current medications include
captopril and atorvastatin. Physical examination shows a small, firm mass in the right upper quadrant.
Laboratory studies are within the reference range. A CT scan of the abdomen is shown. This patient's
condition puts her at greatest risk of developing which of the following?
A. Gallbladder adenocarcinoma
B. Gallbladder perforation
C. Pancreatic adenocarcinoma
D. Hepatocellular carcinoma
E. Pyogenic liver abscess

41.

5. A 15-year-old girl is brought to the physician by her mother for a 2-day
history of abdominal pain, nausea, vomiting, diarrhea, and decreased
appetite. Her last menstrual period was 3 weeks ago. Her temperature is
38.1°C (100.6°F). Abdominal examination shows tenderness to palpation
with guarding in the right lower quadrant. Laboratory studies show a
leukocyte count of 12,600/mm3. Which of the following is the most likely
underlying cause of this patient's condition?
A. Bacterial mesenteric lymphadenitis
B. Pseudomembranous plaque formation in the colon
C. Diverticular inflammation in the colon
D. Congenital anomaly of the omphalomesenteric duct
E. Lymphoid tissue hyperplasia
F. Gestation in the fallopian tube

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