Evaluation of Abdominal Pain

1
Evaluation of Abdominal Pain
John E. Carroll, M.D.
Assistant Professor of Medicine
Division of Gastroenterology
Georgetown University Hospital
2
24 Causes of Abdominal Pain
3
Causes of Abdominal Pain
1. Adhesions

• Hx Intermittent pain. Non-localized No sig.
  aggravating/alleviating Factors Hx of ABD
  surgery or ABD infection
• PE Unimpressive Normal BS
• Labs None (all normal)
• Imaging None (all normal)
• Key.. Clinical Suspicion

4
Causes of Abdominal Pain
2. Small Bowel Obstruction

• Hx Sudden onset. Severe pain Mid abdominal
  location Significant vomiting Hx of prior
  surgery
• PE Distended. Diffusely tender High Pitched
  BS
• Labs None (hypokalemic alkalosis)
• Imaging Plain ABD film (air fluid levels)
• Key Exam and ABD film

5
Causes of Abdominal Pain
3. Partial SBO

• Hx Intermittent pain Diffuse - mid
  abdomen Hx of prior surgery More
  nausealess vomiting
• PE Non-specific Less distended . Less
  tender High pitched - normal BS
• Labs None (normal)
• Imaging Plain ABD film (sparse AFLs)
• Key. Hx, Exam and ABD film

6
Causes of Abdominal Pain
4. Ileus

• Hx Non specific ABD pain Mid-abdominal
  location Nausealess vomiting No need for
  prior surgery Debillitated state. Certain
  medications.
• PE Absent BS
• Labs None (normal)
• Imaging Plain ABD film (distended bowel)
• Key Exam and ABD film

7
Causes of Abdominal Pain
5. Colonic Obstruction

• Hx Severe, unremitting ABD pain Fairly sudden
  onset Decreased stool output
• PE Unremarkable Slightly
  distended Tympanic
• Labs None (normal)
• Imaging Plain ABD film (no air in rectal
  vault) CT (mass with proximal bowel dilation)
• Key Clinical Suspicion and imaging studies

8
Causes of Abdominal Pain
6.

• Hx Severe epigastric pain Risk factors
  (ETOH, gallstones)
• PE Severe epigastric tenderness
• Labs Amylase, Lipase
• Imaging CT
• Key Labs and CT

9
Causes of Abdominal Pain
6. Acute Pancreatitis

• Hx Severe epigastric pain Risk factors
  (ETOH, gallstones)
• PE Severe epigastric tenderness
• Labs Amylase, Lipase
• Imaging CT
• Key Labs and CT

10
Causes of Abdominal Pain
7.

• Hx Known pancreatitis ETOH, idiopathic,
  medications
• PE Moderate epigastric tenderness Less tender
  than in acute pancreatitis
• Labs Amylase, Lipase Less elevated than in
  acute pancreatitis
• Imaging CT (calcifications, atrophic
  gland) ERCP (ductal changes) MRCP (ductal
  changes) EUS (parenchyma and ductalchanges)
• Key Imaging studies

11
Causes of Abdominal Pain
7. Chronic Pancreatitis

• Hx Known pancreatitis ETOH, idiopathic,
  medications
• PE Moderate epigastric tenderness Less tender
  than in acute pancreatitis
• Labs Amylase, Lipase Less elevated than in
  acute pancreatitis
• Imaging CT (calcifications, atrophic
  gland) ERCP (ductal changes) MRCP (ductal
  changes) EUS (parenchyma and ductalchanges)
• Key Imaging studies

12
Causes of Abdominal Pain
8. Pancreatic Pseudocyst

• Hx Known pancreatitis ABD pain in chronic
  pancreatitis unresolving acute pancreatitis
• PE Non-specific
• Labs Non-specific
• Imaging CT (pseudocyst size) (pseudocyst
  wall) (internal cyst texture)
• Key CT

13
Causes of Abdominal Pain
9. Pancreatic Cancer (body)

• Hx Persistent, gradual pain May have
  fatigue, anorexia, wt. loss
• PE Unremarkable
• Labs CA 19-9 otherwise normal
• Imaging CT (mass) ERCP (pancreatic duct
  narrowing) EUS (mass, vascular, ductal changes)
• Key Imaging studies and CA 19-9

14
Causes of Abdominal Pain
10. Peptic Ulcer Disease

• Hx Gradual moderate epigastric pain NSAID use
• PE Unremarkable Slight epigastric
  tenderness
• Labs None (normal)
• Imaging UGI series Upper endoscopy
• Key Upper endoscopy

15
Causes of Abdominal Pain
11. Perforated PUD

• Hx Sudden onset severe epigastric pain
• PE Rigid ABD Severe diffuse tenderness
• Labs None
• Imaging Plain ABD film (free air) CT (free
  air)
• Key Exam and Imaging studies

16
Causes of Abdominal Pain
12. Cholangitis

• Hx Vague ABD pain Recent biliary
  manipulation Known hepatobiliary malignancy
• PE Toxic appearing. Fever. Tachycardia. Jaund
  iced Epigastric/RUQ tenderness
• Labs WBC, bilirubin, bicarb
• Imaging Non-specific
• Key Clinical history, exam and labs

17
Causes of Abdominal Pain
13. Cholecystitis

• Hx Sudden onset RUQ pain May be a pleuritic
  component
• PE RUQ tenderness Murphys sign
• Labs WBC, bilirubin, alk phos
• Imaging RUQ U/S (peri-cholecystic
  fluid) (thickened GB wall)
• Key Exam and U/S

18
Causes of Abdominal Pain
14. Biliary Colic

• Hx Intermittent epigastric pain Moderate to
  severe in intensity Occurs spontaneously Sel
  f limiting after 2-3 hours Risk factors for
  lithogenic bile
• PE Normal
• Labs None (normal)
• Imaging RUQ U/S (cholelithiasis)
• Key Clinical history and RUQ U/S

19
Causes of Abdominal Pain
15. Biliary Dyskinesia

• Hx Postprandial component nausea RUQ
  pain
• PE Unremarkable
• Labs None (normal)
• Imaging HIDA scan
• Key Clinical history and HIDA scan

20
Causes of Abdominal Pain
16. Choledochal cyst

• Hx ABD pain Moderate RUQ
• PE Unremarkable
• Labs Normal
• Imaging CT ERCP U/S EUS
• Key Imaging studies

21
Causes of Abdominal Pain
17. Appendicitis

• Hx Sudden onset Severe pain RLQ
• PE Fever Localized RLQ tenderness
• Labs WBC
• Imaging CT (appendiceal thickening)
• Key History, exam, labs, CT

22
Causes of Abdominal Pain
18. Diverticulitis

• Hx Sudden onset Severe pain LLQ
• PE Fever Severe tenderness LLQ
• Labs WBC
• Imaging CT (peri-colonic stranding)
• Key CT

23
Causes of Abdominal Pain
19. Ischemic Bowel

• Hx Poorly localized Non-specific nausea and
  pain Followed by bloody diarrhea Elderly
  patient Known atherosclerotic disease
• PE Unremarkable
• Labs None (normal)
• Imaging None (normal)
• Key Clinical history

24
Causes of Abdominal Pain
20. Celiac Artery Compression Syndrome (median
arcuate ligament syndrome)

• Hx Intermittent ABD pain Epigastric
  location Weight loss No
  aggravating/alleviating factors
• PE Unremarkable
• Labs None (normal)
• Imaging Angiography (breathing sequences)
• Key Clinical suspicion and angiography

25
Causes of Abdominal Pain
21. Peritonitis

• Hx Severe, diffuse ABD pain Recent
  interventional procedure Ascites
• PE Diffusely tender Rebound
  tenderness Guarding
• Labs WBC, bicarb
• Imaging None
• Key Physical exam

26
Causes of Abdominal Pain
22. Perforated Viscus

• Hx Recent interventional procedure Inflammator
  y bowel disease Known intra-abdominal
  malignancy
• PE Rigid abdomen Diffusely
  tender Rebound tenderness
• Labs WBC, bicarb
• Imaging Plain ABD film (free air) CT (free
  air)
• Key Clinical history, exam and imaging

27
Causes of Abdominal Pain
23. Crohns Disease

• Hx Sudden onset severe pain Mid-abdomen
  location Associated with nausea
• PE Non-specific tendeness Rebound
  tenderness Guarding
• Labs WBC
• Imaging CT (stranding, inflammatory
  mass) SBFT (fibrostenotic disease)
• Key Imaging studies

28
Causes of Abdominal Pain
24. Ulcerative Colitis

• Hx Progressive diarrhea Blood and
  mucous Diffuse, non-localized pain
• PE Toxic appearing Fever.
  Tachycardia Severe diffuse tenderness Rebou
  nd tenderness. Guarding
• Labs WBC, bicarb
• Imaging Plain ABD film (toxic
  megacolon) CT (diffusely thickened wall)
• Key Clinical history, exam, imaging studies

29
The Acute Abdomen
Problem perforated viscus uncontrolled ABD
infection/inflammation Evaluation Rigid
ABD Peritoneal signs Culprits bowel
perforation progressive peritonitis acute
appendicitis
30
24 Causes of Abdominal Pain
-Adhesions -Cholecystits -Small Bowel
Obstruction -Biliary Colic -Partial
SBO -Biliary Dyskinesia -Ileus -Choledochal
cyst -Colonic Obstruction -Appendicitis -Acute
Pancreatitis -Diverticulitis -Chronic
Pancreatitis -Ischemic Bowel -Pancreatic
Pseudocyst -Celiac Comp. Synd. -Pancreatic
Cancer -Peritonitis -Peptic Ulcer
Disease -Perforated Viscus -Perforated
PUD -Crohns Disease -Cholangitis -Ulcerative
Colitis