ldquoTell me more about your painhelliprdquo

Location

Quality

Severity

Onset

Duration

Modifying factors

Change over time

Differential Diagnosis

bull Appendicitis

bull Biliary colic cholecystitis cholangitis

bull Bowel obstruction

bull Diverticulitis

bull Ectopic pregnancy

bull Gastroenteritis

bull Intussuception

bull Mesenteric Ischemia

bull Ovarian torsion

bull Pancreatitis

bull Pelvic Inflammatory Disease (PID)

bull Perforated peptic ulcer

bull Ruptured or leaking abdominal aortic aneurysm (AAA)

bull Testicular torsion

bull Ureteral colic

bull Volvulus

Immediate Life-Threatening Causes of Abdominal Pain

These must be recognized from the primary survey

Ruptured abdominal aortic aneurism (AAA)

Rupture of the spleen or liver

Ruptured ectopic pregnancy

Bowel infarction

Perforated viscus

Acute myocardial infarction (MI)

Immediate Life-Threatening Causes of Abdominal Pain

These must be recognized from the primary survey

Ruptured abdominal aortic aneurism (AAA)

Rupture of the spleen or liver

Ruptured ectopic pregnancy

Bowel infarction

Perforated viscus

Acute myocardial infarction (MI)

What kind of tests should you order

Depends what you are looking for

Abdominal series 3 views upright chest flat view of

abdomen upright view of abdomen

Limited utility restrict use to patients with suspected obstruction or free air

Ultrasound Good for diagnosing AAA but not

ruptured AAA

Good for pelvic pathology

CT abdomenpelvis Noncontrast for free air renal colic

ruptured AAA (bowel obstruction)

Contrast study for abscess infection inflammation unknown cause

MRI Most often used when unable to

obtain CT due to contrast issue

Labs

CBC ldquoWhatrsquos the white countrdquo

Chemistries

Liver function tests Lipase

Coagulation studies

Urinalysis urine culture

GCChlamydia swabs

Lactate

Plain Films Small bowel obstruction

Cecal Volvulus and Sigmoid Volvulus

Pneumoperitoneum

Ultrasound Cholecystitis

Ovarian Torsionhellip

Ultrasound showing 75 cm AAA with intraluminal clot

CT of Rupturing AAA

Patient with Herpes Zoster (ldquoShinglesrdquo) of the abdomen

Pearls Pitfalls and Mythsbull Do not restrict the diagnosis solely by the

location of the pain

bull Consider appendicitis in all patients with abdominal pain and an appendix especially in patients with the presumed diagnosis of gastroenteritis PID or UTI

bull Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain

bull The WBC count is of little clinical value in the patient with possible appendicitis

bull Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative

bull Pain medications reduce pain and suffering without compromising diagnostic accuracy

bull An elderly patient with abdominal pain has a high likelihood of surgical disease

bull Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain

bull A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis they need an operation

bull The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA

Disposition

Non-specific abdominal painNo source is identified

Vital signs are normal

Non specific abdominal exam no evidence of peritonitis or severe pain

Patient improves during ED visit

Patient able to take fluids

Have patient return to ED in 12-24 hours for re-examination if not better or if they develop new symptoms

Disposition

bull Surgical consultation

bull Serial evaluation

bull Discharge

ن ومن يتق هللا يجعل له مخرجا ويرزقه م)صدق هللا العظيم( حيث اليحتسب

AND WHOSOEVER FEARS ALLAH AND KEEPS

HIS DUTY TO HIM GOD WILL MAKE A WAY

FOR HIM TO GET OUT (from ever difficulty)

AND WILL PROVIDE ( HIM l HER ) FROM

(SOURCES ) HE l SHE NEVER COULD

IMAGINE( THE NOBLE QURAN )

Plain Films Small bowel obstruction

Cecal Volvulus and Sigmoid Volvulus

Pneumoperitoneum

Ultrasound Cholecystitis

Ovarian Torsionhellip

Ultrasound showing 75 cm AAA with intraluminal clot

CT of Rupturing AAA

Patient with Herpes Zoster (ldquoShinglesrdquo) of the abdomen

Pearls Pitfalls and Mythsbull Do not restrict the diagnosis solely by the

location of the pain

bull Consider appendicitis in all patients with abdominal pain and an appendix especially in patients with the presumed diagnosis of gastroenteritis PID or UTI

bull Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain

bull The WBC count is of little clinical value in the patient with possible appendicitis

bull Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative

bull Pain medications reduce pain and suffering without compromising diagnostic accuracy

bull An elderly patient with abdominal pain has a high likelihood of surgical disease

bull Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain

bull A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis they need an operation

bull The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA

Disposition

Non-specific abdominal painNo source is identified

Vital signs are normal

Non specific abdominal exam no evidence of peritonitis or severe pain

Patient improves during ED visit

Patient able to take fluids

Have patient return to ED in 12-24 hours for re-examination if not better or if they develop new symptoms

Disposition

bull Surgical consultation

bull Serial evaluation

bull Discharge

ن ومن يتق هللا يجعل له مخرجا ويرزقه م)صدق هللا العظيم( حيث اليحتسب

AND WHOSOEVER FEARS ALLAH AND KEEPS

HIS DUTY TO HIM GOD WILL MAKE A WAY

FOR HIM TO GET OUT (from ever difficulty)

AND WILL PROVIDE ( HIM l HER ) FROM

(SOURCES ) HE l SHE NEVER COULD

IMAGINE( THE NOBLE QURAN )

Cecal Volvulus and Sigmoid Volvulus

Pneumoperitoneum

Ultrasound Cholecystitis

Ovarian Torsionhellip

Ultrasound showing 75 cm AAA with intraluminal clot

CT of Rupturing AAA

Patient with Herpes Zoster (ldquoShinglesrdquo) of the abdomen

Pearls Pitfalls and Mythsbull Do not restrict the diagnosis solely by the

location of the pain

bull Consider appendicitis in all patients with abdominal pain and an appendix especially in patients with the presumed diagnosis of gastroenteritis PID or UTI

bull Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain

bull The WBC count is of little clinical value in the patient with possible appendicitis

bull Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative

bull Pain medications reduce pain and suffering without compromising diagnostic accuracy

bull An elderly patient with abdominal pain has a high likelihood of surgical disease

bull Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain

bull A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis they need an operation

bull The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA

Disposition

Non-specific abdominal painNo source is identified

Vital signs are normal

Non specific abdominal exam no evidence of peritonitis or severe pain

Patient improves during ED visit

Patient able to take fluids

Have patient return to ED in 12-24 hours for re-examination if not better or if they develop new symptoms

Disposition

bull Surgical consultation

bull Serial evaluation

bull Discharge

ن ومن يتق هللا يجعل له مخرجا ويرزقه م)صدق هللا العظيم( حيث اليحتسب

AND WHOSOEVER FEARS ALLAH AND KEEPS

HIS DUTY TO HIM GOD WILL MAKE A WAY

FOR HIM TO GET OUT (from ever difficulty)

AND WILL PROVIDE ( HIM l HER ) FROM

(SOURCES ) HE l SHE NEVER COULD

IMAGINE( THE NOBLE QURAN )

Pneumoperitoneum

Ultrasound Cholecystitis

Ovarian Torsionhellip

Ultrasound showing 75 cm AAA with intraluminal clot

CT of Rupturing AAA

Patient with Herpes Zoster (ldquoShinglesrdquo) of the abdomen

Pearls Pitfalls and Mythsbull Do not restrict the diagnosis solely by the

location of the pain

bull Consider appendicitis in all patients with abdominal pain and an appendix especially in patients with the presumed diagnosis of gastroenteritis PID or UTI

bull Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain

bull The WBC count is of little clinical value in the patient with possible appendicitis

bull Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative

bull Pain medications reduce pain and suffering without compromising diagnostic accuracy

bull An elderly patient with abdominal pain has a high likelihood of surgical disease

bull Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain

bull A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis they need an operation

bull The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA

Disposition

Non-specific abdominal painNo source is identified

Vital signs are normal

Non specific abdominal exam no evidence of peritonitis or severe pain

Patient improves during ED visit

Patient able to take fluids

Have patient return to ED in 12-24 hours for re-examination if not better or if they develop new symptoms

Disposition

bull Surgical consultation

bull Serial evaluation

bull Discharge

ن ومن يتق هللا يجعل له مخرجا ويرزقه م)صدق هللا العظيم( حيث اليحتسب

AND WHOSOEVER FEARS ALLAH AND KEEPS

HIS DUTY TO HIM GOD WILL MAKE A WAY

FOR HIM TO GET OUT (from ever difficulty)

AND WILL PROVIDE ( HIM l HER ) FROM

(SOURCES ) HE l SHE NEVER COULD

IMAGINE( THE NOBLE QURAN )

Ultrasound Cholecystitis

Ovarian Torsionhellip

Ultrasound showing 75 cm AAA with intraluminal clot

CT of Rupturing AAA

Patient with Herpes Zoster (ldquoShinglesrdquo) of the abdomen

Pearls Pitfalls and Mythsbull Do not restrict the diagnosis solely by the

location of the pain

bull Consider appendicitis in all patients with abdominal pain and an appendix especially in patients with the presumed diagnosis of gastroenteritis PID or UTI

bull Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain

bull The WBC count is of little clinical value in the patient with possible appendicitis

bull Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative

bull Pain medications reduce pain and suffering without compromising diagnostic accuracy

bull An elderly patient with abdominal pain has a high likelihood of surgical disease

bull Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain

bull A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis they need an operation

bull The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA

Disposition

Non-specific abdominal painNo source is identified

Vital signs are normal

Non specific abdominal exam no evidence of peritonitis or severe pain

Patient improves during ED visit

Patient able to take fluids

Have patient return to ED in 12-24 hours for re-examination if not better or if they develop new symptoms

Disposition

bull Surgical consultation

bull Serial evaluation

bull Discharge

ن ومن يتق هللا يجعل له مخرجا ويرزقه م)صدق هللا العظيم( حيث اليحتسب

AND WHOSOEVER FEARS ALLAH AND KEEPS

HIS DUTY TO HIM GOD WILL MAKE A WAY

FOR HIM TO GET OUT (from ever difficulty)

AND WILL PROVIDE ( HIM l HER ) FROM

(SOURCES ) HE l SHE NEVER COULD

IMAGINE( THE NOBLE QURAN )

Ovarian Torsionhellip

Ultrasound showing 75 cm AAA with intraluminal clot

CT of Rupturing AAA

Patient with Herpes Zoster (ldquoShinglesrdquo) of the abdomen

Pearls Pitfalls and Mythsbull Do not restrict the diagnosis solely by the

location of the pain

bull Consider appendicitis in all patients with abdominal pain and an appendix especially in patients with the presumed diagnosis of gastroenteritis PID or UTI

bull Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain

bull The WBC count is of little clinical value in the patient with possible appendicitis

bull Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative

bull Pain medications reduce pain and suffering without compromising diagnostic accuracy

bull An elderly patient with abdominal pain has a high likelihood of surgical disease

bull Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain

bull A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis they need an operation

bull The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA

Disposition

Non-specific abdominal painNo source is identified

Vital signs are normal

Non specific abdominal exam no evidence of peritonitis or severe pain

Patient improves during ED visit

Patient able to take fluids

Have patient return to ED in 12-24 hours for re-examination if not better or if they develop new symptoms

Disposition

bull Surgical consultation

bull Serial evaluation

bull Discharge

ن ومن يتق هللا يجعل له مخرجا ويرزقه م)صدق هللا العظيم( حيث اليحتسب

AND WHOSOEVER FEARS ALLAH AND KEEPS

HIS DUTY TO HIM GOD WILL MAKE A WAY

FOR HIM TO GET OUT (from ever difficulty)

AND WILL PROVIDE ( HIM l HER ) FROM

(SOURCES ) HE l SHE NEVER COULD

IMAGINE( THE NOBLE QURAN )

Ultrasound showing 75 cm AAA with intraluminal clot

CT of Rupturing AAA

Patient with Herpes Zoster (ldquoShinglesrdquo) of the abdomen

Pearls Pitfalls and Mythsbull Do not restrict the diagnosis solely by the

location of the pain

bull Consider appendicitis in all patients with abdominal pain and an appendix especially in patients with the presumed diagnosis of gastroenteritis PID or UTI

bull Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain

bull The WBC count is of little clinical value in the patient with possible appendicitis

bull Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative

bull Pain medications reduce pain and suffering without compromising diagnostic accuracy

bull An elderly patient with abdominal pain has a high likelihood of surgical disease

bull Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain

bull A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis they need an operation

bull The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA

Disposition

Non-specific abdominal painNo source is identified

Vital signs are normal

Non specific abdominal exam no evidence of peritonitis or severe pain

Patient improves during ED visit

Patient able to take fluids

Have patient return to ED in 12-24 hours for re-examination if not better or if they develop new symptoms

Disposition

bull Surgical consultation

bull Serial evaluation

bull Discharge

ن ومن يتق هللا يجعل له مخرجا ويرزقه م)صدق هللا العظيم( حيث اليحتسب

AND WHOSOEVER FEARS ALLAH AND KEEPS

HIS DUTY TO HIM GOD WILL MAKE A WAY

FOR HIM TO GET OUT (from ever difficulty)

AND WILL PROVIDE ( HIM l HER ) FROM

(SOURCES ) HE l SHE NEVER COULD

IMAGINE( THE NOBLE QURAN )

CT of Rupturing AAA

Patient with Herpes Zoster (ldquoShinglesrdquo) of the abdomen

Pearls Pitfalls and Mythsbull Do not restrict the diagnosis solely by the

location of the pain

bull Consider appendicitis in all patients with abdominal pain and an appendix especially in patients with the presumed diagnosis of gastroenteritis PID or UTI

bull Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain

bull The WBC count is of little clinical value in the patient with possible appendicitis

bull Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative

bull Pain medications reduce pain and suffering without compromising diagnostic accuracy

bull An elderly patient with abdominal pain has a high likelihood of surgical disease

bull Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain

bull A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis they need an operation

bull The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA

Disposition

Non-specific abdominal painNo source is identified

Vital signs are normal

Non specific abdominal exam no evidence of peritonitis or severe pain

Patient improves during ED visit

Patient able to take fluids

Have patient return to ED in 12-24 hours for re-examination if not better or if they develop new symptoms

Disposition

bull Surgical consultation

bull Serial evaluation

bull Discharge

ن ومن يتق هللا يجعل له مخرجا ويرزقه م)صدق هللا العظيم( حيث اليحتسب

AND WHOSOEVER FEARS ALLAH AND KEEPS

HIS DUTY TO HIM GOD WILL MAKE A WAY

FOR HIM TO GET OUT (from ever difficulty)

AND WILL PROVIDE ( HIM l HER ) FROM

(SOURCES ) HE l SHE NEVER COULD

IMAGINE( THE NOBLE QURAN )

Patient with Herpes Zoster (ldquoShinglesrdquo) of the abdomen

Pearls Pitfalls and Mythsbull Do not restrict the diagnosis solely by the

location of the pain

bull Consider appendicitis in all patients with abdominal pain and an appendix especially in patients with the presumed diagnosis of gastroenteritis PID or UTI

bull Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain

bull The WBC count is of little clinical value in the patient with possible appendicitis

bull Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative

bull Pain medications reduce pain and suffering without compromising diagnostic accuracy

bull An elderly patient with abdominal pain has a high likelihood of surgical disease

bull Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain

bull A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis they need an operation

bull The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA

Disposition

Non-specific abdominal painNo source is identified

Vital signs are normal

Non specific abdominal exam no evidence of peritonitis or severe pain

Patient improves during ED visit

Patient able to take fluids

Have patient return to ED in 12-24 hours for re-examination if not better or if they develop new symptoms

Disposition

bull Surgical consultation

bull Serial evaluation

bull Discharge

ن ومن يتق هللا يجعل له مخرجا ويرزقه م)صدق هللا العظيم( حيث اليحتسب

AND WHOSOEVER FEARS ALLAH AND KEEPS

HIS DUTY TO HIM GOD WILL MAKE A WAY

FOR HIM TO GET OUT (from ever difficulty)

AND WILL PROVIDE ( HIM l HER ) FROM

(SOURCES ) HE l SHE NEVER COULD

IMAGINE( THE NOBLE QURAN )

Pearls Pitfalls and Mythsbull Do not restrict the diagnosis solely by the

location of the pain

bull Consider appendicitis in all patients with abdominal pain and an appendix especially in patients with the presumed diagnosis of gastroenteritis PID or UTI

bull Do not use the presence or absence of fever to distinguish between surgical and medical causes of abdominal pain

bull The WBC count is of little clinical value in the patient with possible appendicitis

bull Any woman with childbearing potential and abdominal pain has an ectopic pregnancy until her pregnancy test comes back negative

bull Pain medications reduce pain and suffering without compromising diagnostic accuracy

bull An elderly patient with abdominal pain has a high likelihood of surgical disease

bull Obtain an ECG in elderly patients and those with cardiac risk factors presenting with abdominal pain

bull A patient with appendicitis by history and physical examination does not need a CT scan to confirm the diagnosis they need an operation

bull The use of abdominal ultrasound or CT may help evaluate patients over the age of 50 with unexplained abdominal or flank pain for the presence of AAA

Disposition

Non-specific abdominal painNo source is identified

Vital signs are normal

Non specific abdominal exam no evidence of peritonitis or severe pain

Patient improves during ED visit

Patient able to take fluids

Have patient return to ED in 12-24 hours for re-examination if not better or if they develop new symptoms

Disposition

bull Surgical consultation

bull Serial evaluation

bull Discharge

ن ومن يتق هللا يجعل له مخرجا ويرزقه م)صدق هللا العظيم( حيث اليحتسب

AND WHOSOEVER FEARS ALLAH AND KEEPS

HIS DUTY TO HIM GOD WILL MAKE A WAY

FOR HIM TO GET OUT (from ever difficulty)

AND WILL PROVIDE ( HIM l HER ) FROM

(SOURCES ) HE l SHE NEVER COULD

IMAGINE( THE NOBLE QURAN )

Disposition

Non-specific abdominal painNo source is identified

Vital signs are normal

Non specific abdominal exam no evidence of peritonitis or severe pain

Patient improves during ED visit

Patient able to take fluids

Have patient return to ED in 12-24 hours for re-examination if not better or if they develop new symptoms

Disposition

bull Surgical consultation

bull Serial evaluation

bull Discharge

ن ومن يتق هللا يجعل له مخرجا ويرزقه م)صدق هللا العظيم( حيث اليحتسب

AND WHOSOEVER FEARS ALLAH AND KEEPS

HIS DUTY TO HIM GOD WILL MAKE A WAY

FOR HIM TO GET OUT (from ever difficulty)

AND WILL PROVIDE ( HIM l HER ) FROM

(SOURCES ) HE l SHE NEVER COULD

IMAGINE( THE NOBLE QURAN )

Disposition

bull Surgical consultation

bull Serial evaluation

bull Discharge

ن ومن يتق هللا يجعل له مخرجا ويرزقه م)صدق هللا العظيم( حيث اليحتسب

AND WHOSOEVER FEARS ALLAH AND KEEPS

HIS DUTY TO HIM GOD WILL MAKE A WAY

FOR HIM TO GET OUT (from ever difficulty)

AND WILL PROVIDE ( HIM l HER ) FROM

(SOURCES ) HE l SHE NEVER COULD

IMAGINE( THE NOBLE QURAN )

ن ومن يتق هللا يجعل له مخرجا ويرزقه م)صدق هللا العظيم( حيث اليحتسب

AND WHOSOEVER FEARS ALLAH AND KEEPS

HIS DUTY TO HIM GOD WILL MAKE A WAY

FOR HIM TO GET OUT (from ever difficulty)

AND WILL PROVIDE ( HIM l HER ) FROM

(SOURCES ) HE l SHE NEVER COULD

IMAGINE( THE NOBLE QURAN )