Abdominal Pain

Abdominal pain has a wide differential. It is broadly classified into acute and chronic. Although a clear differentiation is not well defined it is generally accepted that >6 weeks is deemed chronic. It is also important to recognize an acute/surgical abdomen in a timely fashion and arrange appropriate speciality involvement. In women with abdominal pain always suspect a gynecologic etiology of the abdominal pain, rule on pregnancy ,and do a pelvic examination if appropriate.

History

 * ChLORIDE FPP: characteristic, location, onset, radiation, intensity, duration, events preceding, frequency, provoking factors, palliating factors
 * Fever, N/V, weight loss, night sweats, rash
 * History of trauma
 * Bowel movements/flatus/diarrhea/constipation blood in stool/ caliber of stool
 * Urinary symptoms: hematuria, urge, frequency, dysuria, discharge
 * LMP (female), PV discharge, sexual partners, pregnancy
 * PMHx: ischemic risk factors, MI, pancreatitis, nephrolithiasis, IBD, ectopic, PID, AAA, diverticulitis
 * Past Surgical Hx: bowel surgeries (gallbladder/appendix, etc)
 * Past Obs/Past Gyne History
 * Medications: NSAID, steroids, OCP/mirena
 * Social history: smoking, ETOH, rec drugs

Physical

 * ABCs + Vitals
 * General: dehydration, discomfort
 * Abdominal exam: ausculate for bowel sounds), percuss, palpation (light/deep)- masses, rebound, guarding, peritoneal signs
 * +/- Genitals: pelvic, testicles
 * +/- DRE: masses, rectal tone, blood
 * +/- Extra-stigmata of liver disease

RUQ

 * Hepatitis, gall bladder disease, right lower lobe pneumonia, intestinal ischemia, appendicitis, liver abscess, liver/pancreatic/biliary cancer, pyelonephritis, urinary calculi, trauma or MSK pain, abdominal abscess, herpes zoster, dyspepsia

Epigastric

 * Dyspepsia, PUD, GERD, gastritis, myocardial infarction, pneumonia, pancreatitis, pancreatic Ca, gall bladder disease, esophageal rupture, gastric volvulus, aortic dissection

LUQ

 * Gastritis, pancreatitis, PUD, LLL pneumonia, MI, pyelonephritis, ruptured spleen, splenic infarct, diverticulitis, trauma/MSK

Periumbilical

 * obstruction, gastroenteritis, pancreatitis, aortic dissection, MI, early appendicitis

RLQ

 * Appendicitis, IBD, IBS, PID, ovarian torsion, ruptured ovarian cyst, tubo-ovarian abscess, endometriosis, ectopic, mittelschmerz, cystitis, hernia, testicular torsion, epididymitis, prostatisis, diverticulitis, urinary calculi, obstruction, AAA, mesenteric adenitis, trauma/MSK, abdominal abscess

LLQ

 * Diverticulitis, colitis, constipation, obstruction, IBS, gyne (ovarian torsion/cyst/PID, ectopic, endometriosis, mittelschmerz), intestinal ischemia, cystitis, hernia, testicular (torsion, epididymitis), prostatitis, urinary calculi, trauma/MSK, AAA

GI Tract

 * Infectious/Inflammatory: IBD, gastroenteritis, gastritis, esophagitis, appendicitis, colitis, diverticulitis
 * Obstruction: small bowel obstruction, large bowel obstruction, malignancies, volvulus, hernia, intussusception, constipation, adhesions
 * Digestion: peptic ulcer disease, lactose intolerance, celiac disease, food allergies, functional dyspepsia
 * Other: hemorrhoids, mesenteric ischemia, IBS

Hepatobiliary

 * Hepatic: hepatitis, hepatic abscess, malignancy, hepatic vein thrombosis
 * Gallbladder: cholelithiasis, cholecystitis, choledocholithiasis, malignancy
 * Pancreas: pancreatitis, pseudocyst, malignancy

Renal/Bladder/Urinary System

 * Pyelonephritis, kidney stones, cystitis, urinary retention, malignancy
 * Testicular torsion, epididymitis, prostatitis

Gynecologic

 * PID, ovarian torsion, tubo-ovarian abscess, ovarian cyst, endometriosis, fibroids, ectopic, spontaneous abortion, menstruation, mittelschmerz, malignancy, uterine rupture

Vascular

 * AAA, aortic dissection, vasculitis, thrombosis/embolism, mesenteric ischemia

Other

 * MSK pain/strain/trauma
 * Neurogenic pain: zoster, nerve entrapment
 * Referred pain: pneumonia, PE, MI, pericarditis, spine, testicles
 * Metabolic: DKA, uremia, withdrawal

Investigations

 * Depend on history and physical
 * Can include: CBC, lytes, BUN, Cr, LFTs, bilirubin,lipase, amylase,glucose, lactate, T+S, TTG, anti-IgA, ESR/CRP, urine R+M, urine C+S, urine or serum BhCG, +/- septic w/u
 * Plain film (3 views of abdomen): free air, obstruction
 * Ultrasound: biliary tree, liver, gynecologic, testicular, AAA, hydronephrosis, appendicitis (young,thin)
 * CT adbdomen
 * Further investigations: ERCP/MRCP, MRI abdo, colonoscopy, endoscopy

Crohn's disease

 * Pathophysiology: transmural inflammation of GI tract
 * Clinical: crampy abdominal pain, prolonged diarrhea +/- blood (often occult), fatigue, weight loss, +/- fever
 * Can be associated with:
 * strictures and SBO
 * fistulas (communications often between intestine and bladder/skin/bowel/vagina - enterovesical/enterocutaneous/enteroenteric/enterovaginal)
 * abscess
 * perianal disease: pain, drainage, anal fissure, perirectal abscesses, anorectal fistulas
 * malabsorption (bile acids)
 * Other GI involvement: amphthous ulcers, odynophagia, dysphagia
 * Extraintestinal manifestions: arthritis (sacroilitis, ankylosing spondylitis), eye (uveitis, iritis, episcleritis), skin (erythema nodosum, pyoderma gangrenosum, primary sclerosing cholangitis, renal stones, osteoporosis, vitamin B12 deficiency, venous/arterial thromboembolism, cholelithiasis, Fat soluble vitamin malabsorption (ADEK), pulmonary (bronchiectasis, ILD)
 * Investigations:
 * CBC, lytes, Cr, Liver enzymes, blood glucose, ESR, CRP, iron studies, B12, albumin (CRP levels correlate with crohn's activity)
 * Consider celiac serology, stool testing for culture, ova and parasites, c.diff (pending history)
 * Colonscopy with biopsy 
 * CT: strictures
 * MRI: perianal fistulas
 * Small bowel disease: upper GI series with small bowel follow-through (barium study - string sign, cobblestoning), CT, CTE, MRI, MRE, enterocysis
 * Prognosis: May have slight increase risk of colorectal cancern, no change in mortality. Typical course: exacerbations and remissions. Not medically or surgically curable
 * Treatment:
 * Depends on severity
 * Adults: Crohn's Disease Activity Index (CDAI) and the Harvey-Bradshaw Index (HBI)
 * Pediatrics: Pediatric Ulcerative Colitis Activity Index (PUCAI)
 * 5 -ASA (mild-moderate) - although poor evidence (Sulfasalazine, mesalamine). Recommended as maintenance therapy.
 * Steroids (flare-up): prednisone/budesonide
 * Immunosupressants: azathioprine (imuran), MTX - treat active inflammation, maintain remission
 * Antibiotics (Metronidazole) for decrease disease activity, perianal disease, fistula, abscess
 * Immunomodulators/biologics: infliximab - remicade, adalimumab - Humira
 * Surgical: obstruction, fistula
 * Other:
 * Antidiarrheal medications — loperamide, cholestyramine (chronic watery diarrhea or previous ileal resections)Ileal disease - risk of lactose intolerance
 * Routine:
 * Diet counseling/supplementation: Ensure adequate calcium, Vitamin D, Magnesium, Zinc, B12, iron
 * Osteoporosis prevention: smoking cessation, calcium, Vit D, exercise, +/- bisphosphonate
 * Immunizations UTD, yearly influenza
 * Screening for colon cancer - colonoscopy q 5-10 years
 * Prior to starting biologics: hepatitis serology,+/- HIV, CBC, metabolic profile with LFTS, Cr, screen for latent TB, immunizations >3 months prior to starting

Ulcerative Colitis


Gastroesophageal Reflux

 * Clinical: epigastric/retrosternal burning discomfort, worse after meals (especially fatty/spicy/caffeine), worse with lying down/bending over, +/- regurge symptoms, waterbrash, dysphagia
 * Extra-esophageal complications: cough, dental erosions, pulmonary fibrosis (rare), bronchitis, laryngitis, dental erosions, sinusitis
 * Red flags: GI bleeding, anemia, vomiting, dysphagia, chest pain, weight loss
 * Pathophysiology: lower esophageal sphincter dysfunction, delayed gastric emptying


 * Complications: esophagitis, peptic stricture, Barrett's esophagus (increase risk of adenocarcinoma)
 * Diagnosis: based on history and improvement with treatment. Further investigation if atypical symptoms, not relieved with medication, red flags. Consider endoscopy in patients with > 10 years of reflux.
 * CBC (R/O anemia)
 * GOLD STANDARD - 24 hour pH monitoring (rarely completed)
 * Endoscopy (biopsy): atypical symptoms, alarm symptoms, failure to respond to treatment after 4-8 weeks of treatment, dysphagia that does not resolve within 2-4 weeks of PPI
 * Treatment:
 * Non-pharm: avoid spicy/citris foods, fatty foods, chocolate, caffeine, ETOH, smoking. Lose weight. Elevate head of bed. Small, frequent meals. Avoid lying down for > 2 hours post meal. Consider changing medications that affect LES tone.
 * Pharm: antacids, H2 antagonists(e.g. ranitidine), PPI (e.g. pantoprazole), pro-kinetic agents (e.g.metoclopramide)
 * R/A PPI in 4-8 weeks. Consider titration and then D/C at that point.
 * Risk of chronic PPI use: osteoporosis, hip #, community acquired pneumonia, c.difficile, gastric acid rebound on discontinuation, iron deficiency, low magnesium, B12 deficiency

Peptic Ulcer Disease

 * Clinical: upper abdominal pain gnawing/burning, pain improved with meals,pain occuring 2-5 hours after a meal,nocturnal pain, nausea, bloating, early satiety
 * Red flags: vomiting, UGIB, anemia, abdominal mass, unexplained weight loss, dysphagia
 * Etiology: NSAIDs (often gastric), helicobacter pylori (often antral or duodenal), acid secreting tumors.
 * Complications: UGIB, perforation, gastric outlet obstruction
 * Investigations:
 * CBC (R/O anemia) +/- FOBT
 * H.Pylori: serum ELISA test (serology), Urea breath test, stool antigen test, endoscopic biopsy
 * Serum ELISA testing least accurate and only useful for initial infection
 * Endoscopy (>50 years old, alarm symptoms, fail treatment therapy, NSAID use)
 * Acute ill CXR upright to r/o free air (perforation)


 * Treatment:
 * non-pharm: avoid ETOH, smoking, NSAIDs
 * PPI or H2 receptor antagonist x 4 weeks then R/A
 * H.Pylori treatment: combination therapy with a PPI BID (triple therapy)
 * Amoxicillin 1000mg PO BID + Clarithromycin 500mg PO BID x 1 week
 * Clarithromycin 500mg PO BID + Metronidazole 500mg PO BID x 1 week
 * Second line: PPI BID + Metronidazole** 500mg PO BID + Amoxicillin 1000mg PO BID (note Levofloxacin 500 mg PO daily can be substituted for metronidazole in treatment refractory H. pylori)
 * Quadruple therapy: PPI + bimuth + metronidazole + tetracycline x 10-14 days
 * ​ Endoscopic: bleeding sites can be ligated, clips placed, epinephrine injected
 * Refractory: surgical options
 * Post-treatment:
 * If asymptomatic - no further investigations
 * If remains symptomatic retest using urea breath test >30 days (2 weeks off PPI, 1 month of abx)

Risk factors

 * F's: Fat, female, fertile, forties

Cholilithiasis (gallstones)

 * Only 10% of people with gallstones will display symptoms

Biliary colic

 * Clinical: RUQ pain, usually constant in nature, intense/dull discomfort, pain often associated with diaphoresis, N/V,not relieved with movement/bowel movement, often precipitated by eating a fatty meal, post-prandial pain, lasts on average 30minutes- <6 hours, afebrile, normal physical examination, normal laboratory values
 * Pathophysiology: stone forced into gallbladder outlet, leading in increase in gallbladder pressure. As gallbladder relaxes, stone moves out of outlet.
 * Investigations: ultrasound, (if negative and classic symptoms usually repeat U/S in 2-3 weeks). If negative could consider endoscopic ultrasound, r/o other non-biliary tree pathology
 * Management: conservative management with close follow up or referral to general surgery for cholecystectomy
 * Complications of cholecystectomy: bleeding, abscess formation, bile leak, biliary injury, bowel injury, chronic diarrhea

Acute Cholecystitis

 * Clinical: biliary colic complicated by infection and inflammation of gall bladder. Assc with N/V/fever, localized peritonitis, + Murphy's sign, elevated WBC/LFTs
 * Investigations: ultrasound (GB thickening, pericholecystic fluid), +/- blood cultures
 * Management: admit, consult general surgery, NPO, correct electrolyte disturbances, IV fluids, analgesia, +/- Abx, NG insertion (if persistent emesis), cholecystectomy or gallbladder drainage procedures
 * Selection and timing of definitive management depends on severity of symptoms, duration of symptoms, and surgical risk
 * Antibiotic options:
 * Ceftriaxone 1g IV q24h + Metronidazole 500mg IV/PO q8h
 * Ciprofloxacin 400mg IV/500mg PO q8h + Metronidazole 500mg IV/PO q8h

Choledocholithiasis

 * Presence of gallbladder stones in common bile duct


 * Clinical: biliary type pain, elevated cholestatic liver enzymes (GGT, ALP), AST/ALT (elevated early), jaundice, courvoisier sign (palpable gallbladder often associated with malignancy)
 * Uncomplicated: afebrile, N CBC
 * Complicated: acute cholangitis (fever, elevated WBC), gallstone pancreatitis (elevated lipase)


 * Investigations: CBC, LFTs, bilirubin, +/- blood cultures, Ultrasound (bile duct dilatation >6mm)
 * Further imaging: endoscopic ultrasound, MRCP, ERCP
 * Management:
 * High risk: ERCP + elective cholecystectomy. Other option: cholecystectomy with intraoperative with interoperative cholangiography - followed by intraoperative or post-op ERCP
 * Moderate risk: pre-op endoscopic ultrasound or MRCP
 * Low risk: direct to cholecystectomy

Ascending Cholangitis

 * Complete obstruction of infected biliary tree
 * Etiology of obstruction: gallstones, strictures, malignancy, stent
 * Charcot's triad: RUQ pain, fever, jaundice
 * Reynold's Pentad: fever, RUQ pain, jaundice, shock, confusion
 * Investigations: Elevated CBC, elevated LFTs, + blood cultures, Ultrasound (duct dilatation)
 * Treatment: urgent endoscopic decompression (drainage), + broad spectrum ABx (same as cholecystitis)+ monitoring/treatment of sepsis

Pancreatitis

 * Etiology: I GET SMASHED: idiopathic, gallstones, ETOH, Tumors, Scorpion bite, microbiology (mumps), Autoimmune, Surgery/Trauma (ERCP), Hypertriglyceridemia/hypercalcemia/hypotherapy, Emboli/ischemia, Drugs
 * Clinical: N/V, fever, epigastric pain radiating to the back, loss of appetite, hemodynamic instability, jaundice, cullen's sign (hemorrhagic blue discolaration of umbilicus), grery turner (flank discoloration)
 * Complications: ARDS, pleural effusion, pseudocyst, pancreatic abscess, pancreatic necrosis, chronic pancreatitis

Diverticulitis

 * Imaging: CT abdo
 * Management:
 * Mild/moderate: fluid -->DAT, PO Abx (cipro/flagyl)
 * Moderate/severe: requires imaging, consult general surgery, Abx, NPO

Appendicitis

 * Epidemiology: M>F, highest incidence age 10-30s
 * History: Periumbulical pain--> RLQ pain, fever, anorexia, N/V
 * Physical: fever, RUQ tenderness
 * McBurney's point (maximal tenderness 2 inches from ASIS on straight line from ASIS to umbilicus
 * Rovsing's sign: pain in RLQ with palpation to LLQ
 * Psoas sign (retrocecal appendix): RLQ pain with passive right hip extension
 * Obturator sign (pelvic appendix): flex right hip/knee + internal rotation = RLQ pain
 * Investigations/Imaging:
 * Blood work: mild leukocytosis with left shift, T+S
 * CT abdomen
 * Ultrasound (not as specific) - could consider first line
 * Management:
 * Abx - cipro/flagyl or ceftriaxone/flagyl
 * NPO, IVF, analgesics
 * Consult general surgery for appendectomy

Resources
http://www.aafp.org/afp/2007/1001/p1005.html