Helen F. Brown MS, APRN -BC, ACNP, FNP Doctors Emergency Services, PA

Emergency Department Anne Arundel Medical Center Clinical Instructor

Georgetown University School of Nursing and Health Studies

Washington, DC

Develop a differential diagnosis for a patient with abdominal pain, including extra -abdominal causes.

Recognize warning signs and symptoms of potential abdominal catastrophes.

Identify high risk patient populations for potentially lethal intra -abdominal disease.

List the pitfalls commonly encountered in the evaluation of abdominal pain .

The Mysterious

Box

Abdominal pain is a frequent chief complaint

OR

A component of a constellation of symptoms

unexpectedmake the difference between life and death.

Clinical manifestations range from simple to complex .

The challenge is recognizing and differentiating

the serious

from the benign.

Facts

75% of abdominal pain is non-surgical

10 % patients seen in the ED have life threatening cause for the abdominal pain and require surgery.

The accuracy of initial impression is ~ 50-65% when compared to the final diagnosis.

Kamin, R., Nowicki, T., Courtney, D., Powers, R. (2003).

Acute Abdomen in ICU

Potential complication in acute/critically ill population

Absent or atypical presentation

Delay in diagnosis and treatment

Increase in morbidity and mortality

Those at greatest risk

Admission with a primary diagnosis other than abdominal pain

Frustrations

Large spectrum of diseases with varying acuity.

The presentation of acute life threatening and benign processes overlap.

Need to consider extra-abdominal causes of pain.

Even common cause of abdominal pain

Evaluation consumes time and resources.

Frequently remains undiagnosed.

Where do we start?

Acutely ill? Toxic appearing? Severe pain acute surgical abdomen?

Peritonitis, obstruction, perforation, mesenteric ischemia

Vital Signs

Febrile, tachycardia, hypo or hypertensive, orthostatic

Lab Data

Leukocytosis, metabolic acidosis, azotemia

Acute Care Management resuscitation, pain management and continue gathering data.

The History.

Assess the pain

Quality

Visceral dull, aching or colicky, poorly localized.

Parietal - sharp, stabbing, well localized.

Referred aching, perceived near body surface.

Abdominal Pain

Acute Surgical Abdomen

Early Surgical

consultation

Non Surgical Intra-abdominal Process

Uncommon presentation

of a common problem

Common presentation of

an uncommon problem

Referred Pain from Extra abdominal cause

Manifestation of a systemic illness

High Risk Population

Older Adult

Immunocompromised

Bariatric Surgery

Post Procedure

Pregnancy

Female Male

Younger Younger

Location

Timing

Symptom Cluster

HCG + or -

Most diagnoses are made in the ED

Not in the inpatient setting or operating room

Advance made in radiographic imaging

Increase options for management

Non invasive surgical procedures

Interventional radiology

The Case of 2 Cases

Different Ages

Different Gender

Similar Clinical Presentations

Similar Differentials

Similar Diagnoses

Let the FUN Begin

67% of Elders with abdominal pain are admitted vs. 7.5% of Younger adults with abdominal pain

7% of Elders with abdominal pain admitted ICU vs..

1% of Younger adults with abdominal pain

33% EMS transport AGING vs. 8% others ELDER = 50% more dx tests

ELDER = 20% longer LOS

The AGING abdomen with pain will have a higher rate of incorrect diagnosis and higher mortality rate than the younger abdomen

Marco, C, Schoenfeld,, C., & Keey, J. (2000)

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The YOUNGER ABD

Straight forward

Clinical presentation usually stronger & very specific

Usually seek STAT care

Usually able to provide accurate hx

Minimal or no

co-morbidities

Usually no risk for serious health outcomes

The OLDER ABD

An atypical presentation

Clinical presentation usually milder & less specific

Usually delay in seeking care

Accurate hx can be difficult to obtain

Co-morbidities

Increased risk for serious outcomes

Common Etiology of the Abdominal Pain in ELDERS

21% = Biliary Disease

16% = Indeterminate

12% = Bowel Obstruction

7% = Perforated Viscus

7% = Pancreatitis

6% = Diverticulitis

4% = Appendicitis

4% = Incarcerated Hernia

4% = Renal Colic

2% = Vascular

Common etiology of abdominal pain YOUNGER adults

40% = Undifferentiated abdominal pain (UDAP) 32% = Appendicitis 6% = Biliary disease 4% = Gynecologic 2% = Bowel obstruction 2% = Pancreatitis 12% = Urinary tract

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Case #1 Lily, a 72 yr old w/f, presented to the

ER 4 days ago for LLQ pain radiating to L flank She returns today because of continued pain

described as severe when her pain med wears off

Prior evaluation consisted of CBC, Chem 7,

urinalysis, and non-contrast CT of abdomen/pelvis

to exclude renal calculi or AAA

All studies were negative except urine

+ RBC 8-10

D/C diagnosis = Suspected Renal Calculi

Plan = Fluids, Strain Urine, Rest, Percocet 1 every 6

hrs PRN Pain, and FU with PCP if needed

Case #1: Physical Exam

WD, WN older female appears uncomfortable VS: 97.5, 98, 18, 164/95, 96% RA,

8/10 for pain scale ABD: ND, no visible pulsations/hernias,

NABS, no bruits, tender LLQ, + CVAT, no rebound or guarding

Pelvic: deferred

Rectal: tone intact, no masses, heme -

Biliary Disease

PUD

Bowel Obstruction

Pancreatitis

Appendicitis

Diverticular Dz

Mesenteric Ischemia

Still Renal Calculi? What NEXT Diagnostic Steps?

CV Dz

Aortic Dissection

Aortic Aneurysm

MI

Urogenital Dz

Renal Calculi, BPH

UTI, Pyelonephritis

Non-Abdominal Dz

DKA, Hypercalcemia, Pneumonia, PE, Shingles