Abdominal PainAbdominal PainAssessment and Diagnosis

Lawrence R. Kosinski,MD,MBA,AGAF

Principles of Gastroenterology for the Nurse Practitioner and Physician AssistantAugust 10-12, 2012g ,

What is Abdominal Pain?An unpleasant experience commonly associated with tissue injury or tissue distressassociated with tissue injury or tissue distress

R t i t l fRepresents an interplay of: pathophysiologic and psychosocial factors

Physiologic Determinantsy gThe nature of the stimuliThe type of receptor involvedModifying influences – psychosocial?

Today’s Algorhithmy g

Anatomic Basis of Abd PainLocation of Sensory Neuroreceptors

Muscularis of hollow visceraOn Serosal StructuresIn the Mesentery

Types of Sensory NeuroreceptorsMyelinated A Delta Fibers: somatoparietal painUnmyelinated C Fibers: visceral pain

Abdominal Pain‐Stimuli

St t hStretchInflammation

Ischemia

Abdominal Pain ‐ Typesyp

VisceralVisceralParietalR f dReferred

Abdominal Pain ‐ Historyy

LocationQualityChronologyChronologyAggravating FactorsA i t d S tAssociated Symptoms

LocationEpigastrium

EsophagusEsophagusStomachDuodenumG llbl ddGallbladderPancreas

PeriumbilicalPeriumbilicalSmall IntestineAscending Colon

Lower AbdomenEntire ColonGyne SourcesGyne Sources

Location

QualityyVisceral Pain

Dull, Cramping, Burning, Gnawingu , C a p g, u g, G a g

Parietal PainSharp and intenseSharp and intense

ExamplesAppendicitisAppendicitisUlcers GnawAneurysms tearAneurysms tear

Pearl #1

The patient with Visceral Pain won’t stop moving

The patient with Parietal Pain doesn’t want to move at all.move at all.

Chronologygy

SuddenSuddenRapidG d lGradual

Case #1Hx: 86 y/o female A/W the acute onset of severe diffuse abdominal pain. No bowel activity. She is lying motionless in the bed and is somewhat lethargic/confused.

Px: T 101, P100, R 20, 180/90Px: T 101, P100, R 20, 180/90Abd: Mildly distended, relatively soft, No BS

Labs: WBC 22K, Hb. 10, PC 110K

Differential Diagnosis of Abd Pain ofSudden Onset (<1 hour)( )

Perforated UlcerRuptured AbcessRuptured HematomaRuptured HematomaEsophageal RuptureDi ti A

Mechanical Process

Dissecting AneurysmEctopic PregnancyMesenteric Infarction

CT Findingg

Diagnosis: SMA Thrombosis with Ischemic Infarction of the Small Bowel

Pearl #2

When you are presented with sudden severe abdominal pain

THINK MECHANICAL PROCESSES: RUPTURERUPTURE

OR INFARCTION

Pearl #3

When pain is out of proportion to physical findings, think:

ISCHEMIA

Case #2Hx: 42 y/o obese female admitted with the several hours of epigastric and RUQ p g Qabdominal pain associated with nausea and vomitingPx: T 100, P 90, R 18, BP: 150/89Abd: Obese soft BS absent Tender to lightAbd: Obese, soft, BS absent. Tender to light palpation in the RUQ

Labs: WBC 13K, Hb 12, AST 180, ALT 160, AP 131

Abdominal Pain ‐ ChronologyRapid Onset (>1 hour)p ( )

All causes of Sudden Pain +Intestinal ObstructionAcute CholecystitisAcute CholecystitisAcute PancreatitisA t Di ti liti

InflammationAcute DiverticulitisUreteral Colic

Ultrasound

Diagnosis: Acute Cholecystitis

Pearl #4Pain of Rapid onset (>1 hour)

THINK OBSTRUCTION OR INFLAMMATIONOBSTRUCTION OR INFLAMMATION

Case #361yo w/m presented two days of LLQ abdominal pain, described as sharp, constant with no radiation. He has had no bowel movement during that time. PMH: Totally negative No medsNo medsPx: T101, VSSAbd: Mildly distended no BS tender in LLQAbd: Mildly distended, no BS, tender in LLQ with guarding

Abdominal Pain – ChronologyGradual Onset

All causes of Sudden and RapidAppendicitisMeckel’s DiverticulitisMeckel s DiverticulitisAbdominal Abcess

Imagingg g

Diagnosis: Diverticulitis with Abcess

Pearl #5

Pain nearly always precedes vomiting with surgical problems whereas with most nonsurgical causes, it follows and vomiting comes first.

Nonsurgical Problem: Vomiting before PainSurgical Problem: Pain before VomitingSurgical Problem: Pain before Vomiting

Abdominal PainAggravating and Alleviating Factorsgg g g

Postural EffectsRemember the Mesentery

Meal Related EffectsRemember the Gastro-colic Reflex

Bowel Related EffectsBowel Related EffectsThey will tell you if the colon is involved

MedicationsMedicationsEspecially those taken at night

Abdominal Examination

InspectionAuscultationPalpationPalpationPercussion

Physical Exam ‐ Inspectiony p

DistentionDistentionScarsE h iEcchymosisVenous PatternStriaJaundice

Abdominal DistentionThink of the 6Fs

FatFluid - AscitesFlatus - GasFlatus GasFetus - PregnancyF Ob ti tiFeces - ObstipationFatal Growths - Tumors

Scars

Ecchymosisy

Grey Turner’s SignGrey Turner s SignCullen’s Sign

Venous Pattern

Caput Medusa

Caput Medusae - flow is towards the legsCaput Medusae flow is towards the legsInferior vena cava obstruction - flow is towards the head

Stria

Physical Exam ‐ Auscultationy

Bowel SoundsNormalHyperactive: Obstruction or ColitisHypoactive: IleusAbsent: Acute Abdomen

Bruits

Physical Exam ‐ Palpationy p

Light PalpationLight PalpationBuild ConfidenceStart away from the painStart away from the painTenderness

Direct TendernessRebound Tenderness

Deep PalpationOrgan Size Masses

Physical Exam ‐ Percussiony

Organ size and DensityOrgan size and DensityTypes of Sounds

Tympani to DullnessTympani to Dullness

AscitesB f l i h i i hBe careful in the patient with abdominal pain

Rectal Examination

Don’t forget a rectalDon t forget a rectal examPelvic AbscessPelvic AbscessMassesV i i iVaricosities

Laboratory Evaluationy

CBC: Anemia, leukocytosis, thrombocytopenia, MCV

CMPRenal Function, Acid Base, LFTs

Amylase/LipaseAmylase/LipasePT/INR: liver disease, WarfarinUrinalysisUrinalysisPregnancy Test

Imagingg g

Obstructive Series: DistentionFree Air

US: CholecystitisPelvic Processes

CT:

Plain X‐raysyUtility

Gas PatternsCalcifications

BenefitsInexpensiveEasy to doN i iNoninvasive

LimitationsLimited Detail of hollow organsLimited Detail of hollow organs

Example 1

Example 2

Example 3

UltrasoundIndications

Evaluation of the Biliary Tree, Liver, Pancreasy , ,Pelvic Organs

BenefitsNoninvasiveNo Radiation doseP ti t T lPatient Tolerance

LimitationsPoor visualization of hollow GI organsPoor visualization of hollow GI organsLimited visualization in obese or distended patients

Nuclear Medicine Studies

IndicationsLiver and Biliary ScanningLiver and Biliary ScanningGI BleedingGastric Emptying

BenefitsNoninvasiveGood Patient Compliance

LimitationsP I i d t ilPoor Imaging detailInconclusive results

Example 1Normal Biliary Imagingy g g

Example 2 Cholecystitisy

CT ScanningIndications

Evaluation of Solid organs, ie: Liver, Pancreas, S lSpleen

Requires IV ContrastBowel Wall Evaluation

Requires Oral Contrast

BenefitsEasily DoneEasily DoneGood Patient Compliance

LimitationsHollow organs not visualized in detailImmobile (Cannot be done at bedside)

CT Overview

Slices

Example 1Cirrhosis with Ascites

Example 2Bowel Wall Infarct

Example 3Retroperitoneal Abcessp

Example 4Crohn’s Disease

Differential Diagnosisg

Epigastric PainGERDPeptic Ulcer DiseaseGastritisPancreatitisIschemia/Infarction

Pearl #8

Bleeders don’t hurt and hurters don’t bleedWhen you see a bleeder that hurts, think ischemia

Differential Diagnosis – RUQ Paing Q

Acute CholecystitisPeptic Ulcer DiseaseHepatic DisordersHepatic DisordersColon Disorders

Differential Diagnosis – LUQ Paing Q

Splenic DisordersColon DisordersIBSIBSPancreatitis

Differential Diagnosis – Periumbilicalg

Intestinal DisordersObstructionIBD

V l Di dVascular DisordersAAAI f tiInfarction

Differential Diagnosis – RLQ Paing Q

Acute AppendicitisMeckel’s DiverticulitisCrohn’s DiseaseCrohn s DiseaseValentino AppendicitisO i C tOvarian CystIBS

Differential Diagnosis – LLQ Paing Q

Colonic DisordersDiverticulitisIBDIBS

Ovarian Disorders

Differential Diagnosis – Suprapubic g p p

Bladder DisordersOvarian CystOvarian CystRuptured Endometrioma

Patience and Wisdom

DISCUSSION

Lawrence R. Kosinski, MD, MBA, AGAFManaging PartnerIllinois Gastroenterology Group745 Fletcher Drive745 Fletcher DriveElgin, Illinois 60123