Assessment of abdominal pain

What is choledocholithiasis and how does it manifest in patients?

A stone in the common bile duct (CBD). Causes cholestatic jaundice with less severe or possibly even no upper abdominal pain.

What is the Glasgow criteria for assessing prognosis in acute pancreatitis?

-Age >55. -PaO2 < 8kPa (60mmHg). -WBC > 15 x 10^9/L. -Albumin <32g/L. -Serum corrected calcium <8mg/dL. -glucose >180mg/dL. -Urea >45mg/dL after rehydration. -ALT >200 U/L. -LDH >600 U/L. More than 3 of these indicate severe disease.

What is the stepwise algorithm for patient assessment of upper abdominal pain?

1) free air on CXR? NO 2) ECG evidence of ischemia? NO 3) Amylase >500 U/L (WNL = 40-140 U/L) which is roughly 3x ULN? NO 4) Jaundiced? NO 5) inflammatory response with RUQ pain/tenderness? NO 6) biliary colic? NO 7) Consider acute gastritis, PUD, gastroenteritis, non-specific ab pain. If concern, observe and have surgical review.

What is the stepwise algorithm for patient assessment of chronic/relapsing abdominal pain?

1) full clinic assessment, PR exam, CBC, LFTs, ESR, CRP, Ca2+. 2) upper GI symptoms with alarm features? NO 3) lower GI symptoms with alarm features? NO 4) jaundice, abnormal LFTs, hepatomegaly, ascites, or typical history of biliary colic? NO 5) loin pain with mass or hematuria? NO 6) cyclical pain, pelvic mass, dyspareunia or abnormal PV bleeding/discharge. NO 7) Palpable mass, weight loss, systemic upset or unexplained jaundice? NO 8) likely functional disorder like IBS so refer to GI/gyno as appropriate.

What is the stepwise algorithm for patient assessment of upper abdominal pain?

1) known pregnancy, positive pregnancy test, or PV bleeding? NO 2) Pain predominantly in RIF? NO 3) LLQ pain, tenderness and inflammatory response? NO 4) Pelvic exam 5) Gynecological pathway? NO 6) Leukocytes/nitrites on UA? NO 7) consider atypical appendicitis, endometriosis, mesenteric ischemia, etc.

What is the stepwise algorithm for patient assessment of general abdominal pain?

ABCDE 1) Evidence of shock? NO 2) generalized peritonitis? NO Full clinical assessment: 3) intestinal obstruction? NO 4) acute and/or bloody diarrhea? NO 5) unilateral loin or flank pain? NO 6) Pain localized to upper or lower abdomen? NO 7) Consider mesenteric ischemia, CD, gastroenteritis, IBS, DKA, pancreatitis? Surgical review +/- CT abdomen if any concerns.

What is IBS and how does it manifest in patients?

Ab pain relieved by defecation or is associated with alterations of bowel habit. Symptoms tend to follow a relapsing and remitting course. Symptoms often exacerbated by psychological stress. ESSENTIAL TO RULE OUT ORGANIC CAUSES, including IBD, malignancy, celiac disease, and tropical sprue (flattening of villi and inflammation of small bowel lining).

Ruling out miscellaneous causes in chronic/relapsing ab pain assessment:

Abdominal CT if palpable mass, weight loss, or unexplained jaundice. In those significant weight loss or other major constitutional upset such as fevers, night sweats, or very high ESR, CT May reveal evidence of lymphoma, solid organ malignancy, or inflammatory disease such as Crohns or abscesses. Consider chronic pancreatitis in those with chronic alcohol excess or steatorrhea. Fecal elastase, ab CT, and potential specialist referral for further assessment. If relationship between eating and pain then exclude mesenteric ischemia via CT mesenteric angiography. Consider Crohn's through enteroscopy, barium follow through, or small bowel MRI if a young patient with: -unexplained mouth ulcers. -increased ESR/CRP. -extraintestinal manifestations. Or -persistent RLQ tenderness. If none of the above is present, then IBS is likely.

Ruling out biliary colic in upper ab pain assessment:

Abdominal USS can help confirm diagnosis by finding gallstones, but keep in mind that asymptomatic gallstones are very common and may not be the issue at hand. History is critical to help make this decision. Look for the following: -pain onset a few hours after meal (May waken the Latino from sleep). -duration 6 hours or less followed by complete resolution of symptoms. -main site is epigastrium or RUQ +/- radiation to the back. -constant, vague, aching or cramping discomfort. -history of similar episodes. If suggestive history then arrange abdominal USS.

Ruling out pain predominantly in RIF in lower ab pain assessment:

Acute appendicitis is highly likely if absence of previous appendectomy with: -migration of pain from the periumbilical region to the RLQ. -RLQ tenderness or signs of local peritonism. Mild fever, increased WBC, and increased CRP often accompany appendicitis. If diagnostic then refer to on-call surgeon, especially if <12 hours of onset of symptoms. Ab USS and CT are good options for confirming diagnosis of appendicitis.

How does PUD typically manifest?

Almost all duodenal ulcers and 70% of gastric ulcers from H. Pylori. Recurrent episodes of burning or gnawing discomfort. Relationship to food. Dyspeptic symptoms: nausea, belching, relief with antacids.

Ruling out lower GI symptoms with alarm symptoms in chronic/relapsing ab pain assessment:

Arrange lower GI endocscopy in anyone with: -rectal bleeding -palpable rectal mass. -iron deficiency anemia. ->45 with change in bowel habit. -weight loss with change in bowel habit. Consider flexible sigmoidoscopy in <45 and colonoscopy in >45.

Ruling out pregnancy and PV bleeding in lower ab pain assessment:

Bedside pregnancy test in any pre-menopausal or perimenopausal women with acute lower ab pain. -if positive or vaginal bleeding request urgent gyno review with trans abdominal +/- transvaginal USS to exclude ectopic pregnancy. —if negative but bleeding or missed period then consider sending blood for lab assessment for beta hCG. Request for gyno review in anyone with known intra-uterine who've developed low ab pain.

What is IBD and how does it manifest in patients?

CD or UC can cause cramping lower ab pain, usually associated with bloody diarrhea.

Considering other causes for general ab pain patient assessment after exhausting other steps in our algorithm:

CT angiography is a good idea for suspicion of mesenteric ischemia if our patient has severe diffuse pain, shock, or unexplained lactic acidosis. —this goes more so for elderly or those with vascular disease/a-fib. Both gastroenteritis and hypercalcemia may cause ab discomfort with conspicuous vomiting and minimal abdominal signs. Measure serum calcium and ask about infectious contacts and recent ingestion of suspicious foodstuffs.

How is visceral pain characterized?

Conducted by ANS fibers. May be from distention, spasm, inflammation, ischemia, or nociception. Typically dull and poorly localized. Not associated with abdominal guarding or rigidity. In contrast, somatic pain is sharp, localized well, constant, and often associated with tenderness and guarding.

What are the 3 respective regions that viscera can be described as?

Epigastric - liver, stomach and gallbladder. Midgut - small intestine all the way through the transverse colon. Hindgut (suprapubic region) - descending colon through the anus.

What are the indicators of systemic inflammation?

Fever (>38 Celsius). Increased CRP (>10mg/L). Note that a marginal CRP (ie <30mg/L) is not compelling enough by itself to indicate major inflammatory process. WBC >11x10^9/L or <4x10^9/L.

What are the common pain radiation spots associated with gallbladder pain, diaphragmatic pain, and ureteric pain, respectively?

Gallbladder pain - right and middle epigastric area up to the xyphoid process. Also the bottom tip of the right scapula. Diaphragmatic pain - right shoulder. Ureteric pain - from the left testicle up through the left inguinal canal that ends at the left hip.

What is the difference between gastric and duodenal ulcers with respect to food?

Gastric pain occurs several minutes after eating. Duodenal pain occurs hours after eating and may be relieved by food.

Ruling out jaundice in upper ab pain assessment:

Get an urgent abdominal USS for all those with acute epigastric pain and jaundice presentation to look for biliary obstruction or hepatitis. We are to assume biliary sepsis initially if patient is unwell with high fever +/- rigors or cholestatic jaundice. Give IV ABX and, if dilated CBD, refer for immediate surgery to further investigate and biliary decompression.

Ruling out gynecological pathology in lower ab pain assessment:

Have high suspicion in any women of child-bearing age with acute pelvic or lower ab pain. Organize urgent USS to find evidence of ovarian torsion or cyst. Request gyno review if suspicious of torsion. If absence of confirmation for ovarian cause, consider acute PID. Suspect if bilateral ab pain and tenderness +/- fever associated with any of the following: -ab vaginal or cervical discharge. -tenderness on moving the cervix during bimanual vaginal exam ('cervical excitation'). -adnexal tenderness on bimanual vaginal exam.

Ruling out shock in overview ab pain assessment:

Hypotension and tissue hypoperfusion. Early features include Increased HR, increased RR, narrow pulse pressure, anxiety, pallor, cold sweat, or lightheadedness upon standing +/- postural hypotension. —If shock, immediately secure two large-bore IV lines, send blood for cross match, U+E, CBC, amylase, and LFTs. Begin aggressive resuscitation. Diagnoses to consider first are those that require immediate surgery: AAA, rupture ectopic pregnancy or ovarian cyst, or splenic rupture. —AAA more likely in a pulsatile abdominal mass or risk factors for AAA (>60 male who has sudden severe ab/back/loin pain quickly followed by rapid hemp dynamic compromise). —Suspect ruptured ectopic pregnancy in any pregnant woman or those of child-bearing age who have had recent lower ab pain or PV bleeding. Perform immediate bedside pregnancy test. —consider splenic rupture in any shocked patient with ab pain who have history of recent trauma like a traffic accident. If any of the three above scenarios are true, immediately arrange surgical review prior to imaging. If none are true get an ECG, CXR, UA, and ABG. Move to next part of stepwise algorithm and refer for urgent surgical review.

Ruling out liver issues in chronic/relapsing ab pain assessment:

If jaundiced in these patients, it suggests: -hepatitis. -choledocholithiasis. -malignancy in liver, pancreas, biliary, etc. A USS May reveal cause, but if inconclusive then a CT or MRCP is required. -If ascites, do ascitic tap and send to microbio and cytology. -USS can find gallstones, but remember that gallstones can be found in asymptomatic patients, so ensure that the current complaint is related. Refer to GI specialist if convincing history of biliary pain in the absence of gallstones, esp. associated with abnormal LFTs or a dilated CBD.

Ruling out upper or lower abdominal specific pain in overview ab pain assessment:

If predominantly RUQ, LUQ, epigastric, or generalized upper ab pain, proceed to upper ab pain algorithm. If vice versa go to the lower ab pain algorithm.

What is ascending cholengitis and how does it manifest in patients?

Infection of biliary tree occurs upstream from a blockage in the CBD (could be gallstone, tumor, liver fluke, etc). Charcot's Triad: -Significant sepsis (Pyrexia) -Jaundice. -Abdominal discomfort.

What is cholecystitis and how does it manifest in patients?

Infection of gall bladder due to gallstone obstruction of cystic duct. Pain persists over time. Associated with fever. MAY BE JAUNDICE in patients with Mirizzi's syndrome (large gallstone and inflamed gallbladder cause extrinsic compression of the common hepatic duct).

What is renal tract disorders associated with ab pain and how does it manifest in patients?

Infrequent, discreet attacks of severe loin pain radiating to the groin +/- hematuria suggests renal stone disease. Chronic dull aching or dragging discomfort may be from cancer, poly cystic kidney disease, or chronic obstruction/pyelonephritis.

What is colon cancer and how does it manifest in patients?

May present with lower colicky (pain that starts and stops abruptly d/t muscular contraction of a hollow tube to squeeze an obstruction out) ab pain (from partial or complete obstruction). History of weight loss. Bowel habits alternating between constipation and diarrhea (as liquid feces bypasses around firmer stool that's held up). Rectal bleeding. Iron-deficiency anemia. Tenesmus (feeling of incomplete defecation) feature of low rectal tumors. Right sided cancers present insidiously with vague pain and iron deficiency anemia b/c the proximal colon is more distensable and has liquid feces and blood loss is occult (shut off from exposure or view). Diagnosed usually by colonoscopy. CT colonography preferred for frail patients.

Ruling out amylase >500 in upper ab pain assessment:

Measure amylase in any case with severe ab pain. Amylase >3x ULN are 95% likely to have pancreatitis; levels >1000 are considered diagnostic. If normal levels but history is characteristic + there is a delay in presentation or history of alcoholism then a pancreatitis case still likely. If diagnosis is considerable, consider CT w/ IV contrast to look for evidence of pancreatic inflammation. If confirmed diagnosis then: -repeatedly evaluate for evidence of complications (shock, hypoxia, ARDS, DIC). -calculate Glasgow (see below). -monitor CRP. Manage all severe or high-risk acute pancreatitis (shock, organ failure, Glasgow 3+, or peak CRP >210mg/dL) in critical care unit. Perform abdominal USS to look for gallstones and an MRCP if there is jaundice or a dilated CBD on the USS. Rarely require stone extraction.

Are most gall stones symptomatic?

No, they are usually asymptomatic.

What is biliary colic and how does it manifest in patients?

Occurs when gallstone obstructs cystic duct leading to gallbladder distention. Usually 1-6 hours after meal. Intense, dull RUQ or epigastric pain with or without radiation to the back or scapula. Pain builds to a crescendo over minutes then lasts up to several hours. NO JAUNDICE, DERANGED LFTs, OR ABDOMINAL SIGNS. Ultrasound can confirm gallstone presence.

Ruling out inflammatory response in upper ab pain assessment:

Once all of the above options have been weeded through, narrow the differential diagnosis by confirming a presence or absence of systemic inflammatory response via: -acute cholecystitis (esp if RUQ pain and tenderness and + Murphy's sign). -pyelonephritis. -hepatitis. Subohrenic collection.

Ruling out cyclical pain, pelvic mass, or any post menopausal patient with PV bleeding or recent-onset persistent lower ab pain in chronic/relapsing ab pain assessment:

Pelvic USS will help conclude presence of any of these diagnoses. If PID, take endocervical or vaginal swabs for gonorrhea and chlamydia. Treat if +. Consider endometriosis in any woman of reproductive age with severe dysmenorrhea or the combination of chronic lower ab pain +: -variation of menstrual cycle. -deep dyspareunia Refer to a gynecologist for further assessment for definitive diagnosis.

Ruling out free air on CXR in upper ab pain assessment:

Perform erect CXR (good way to see any intraperitoneal gas) in all unwell patients with acute upper ab pain. -The presence of free air indicates perforation of a hollow viscus. If peritonitis then secure IV access, cross-match for blood, resuscitate with IV fluids and immediately refer to surgery. If CXR non-diagnostic then move to next step in algorithm for lower ab pain assessment.

What is chronic mesenteric ischemia and how does it manifest in patients?

RARE. Usually in widespread severe atherosclerotic disease. Dull periumbilical or lower ab pain that develops about 30 minutes after eating (abdominal angina). May have bloody diarrhea, which in turn may precipitate anorexia and weight loss. Poor absorption can further increase for cachexia. Diagnosis made by CT mesenteric angiography.

What is chronic pancreatitis and how does it manifest in patients?

Recurrent episodes of acute pancreatitis. Pain may be constant and unremitting or provoked by alcohol or food. MOST CASES FROM CHRONIC ALCOHOL EXCESS. Weight loss. Anorexia. DM in advanced disease (d/t endocrine deficiency). Steatorrhea in advanced cases (d/t exocrine insufficiency). Decreased fecal elastase (a protease) can indicate this pancreatic insufficiency. Diagnosis made via CT but endoscopic ultrasound with biopsy may be needed to rule out malignancy.

Ruling out ECG evidence of ischemia in upper ab pain assessment:

Refer immediately to cardiology if there are features of STEMI. In patients with ST depression, evaluate carefully for hypotension, sepsis, hypoxia, and bleeding before attributing changes to acute coronary event. If non-specific T-wave changes measure cardiac biomakers to assist diagnosis. If any doubt in your diagnosis consult cardiology.

Ruling out loin pain with either a mass or hematuria in chronic/relapsing ab pain assessment:

Renal USS is first line as it can find APKD or chronic hydronephrosis. Consider CT +/- urology referral if the cause remains unclear, esp. in patients >40.

How to characterize ab pain?

SOCRATES S - Site. O - Onset. C - Character. R - Radiation. A - Associated features. T - Timing. E - Exacerbating factors. S - Severity of pain.

What is acute mesenteric ischemia and how does it manifest in patients?

SURGICAL EMERGENCY WITH A HIGH MORTALITY, from mesenteric embolism, thrombosis in situ, or cardiac failure or septic shock. Acute, agonizing, constant diffuse ab pain. Poorly localized with no peritonism. Lactic acidosis.

What is gynecological conditions associated with abdominal pain and how does it manifest in patients?

Sudden lower ab pain in reproductive age women may be ovarian torsion (around a cyst) or ruptured ectopic pregnancy. EITHER SCENARIO ARE SURGICAL EMERGENCIES. Recurrent episodes of acute lower ab pain that regularly occur midway through the menstrual cycle might just be their ovulation manifestation (mittelschmerz). This pain is usual sudden onset as the Graafian follicle ruptured and then subsides over 24 hours.

Ruling out leukocytes/nitrites on UA in lower ab pain assessment:

Suprapubic pain/tenderness is common in UTI but UA should be positive in order to have a robust diagnosis. Acute appendicitis may cause dysuria, frequency, and urgency with positive UA if an inflamed appendix lies adjacent to the bladder or ureter, particularly in males (where cystitis is uncommon).

Ruling out acute and/or bloody diarrhea in overview ab pain assessment:

Suspect gastroenteritis if: -recent onset of acute diarrhea with cramping abdominal pain +/- vomiting suggests infective gastroenteritis. Suspect colitis (infective, inflammatory, or ischemic) if: -bloody diarrhea with cramping lower ab pain +/- tenesmus and features of systemic inflammation. -always consider ischemic in elderly or with known vascular disease/a-fib. If suspected arrange CT mesenteric angiogram. Otherwise send stool for culture.

Ruling out generalized peritonitis in overview ab pain assessment:

Suspect if there is: -severe non-colicky ab pain that is worse on movement. -coughing or deep inspiration. -associated with inflammatory features and generalized abdominal rigidity. -usually lies still taking shallow breaths and in obvious distress or discomfort. RECONSIDER IF PATIENT APPEARS WELL AND MOVING FREELY. Free air under the diaphragm on erect CXR confirms the diagnosis as this is in the majority of cases. If non-diagnostic consider CT with oral and IV contrast. If true, patients require aggressive resuscitation, antibiotics, and immediate surgical referral.

Ruling out intestinal obstruction in overview ab pain assessment:

Suspect if: -ab pain is colicky. -accompanied by vomiting, absolute constipation, and/or ab distention. —high small bowel obstruction pre-emanate with vomiting and pain. —colonic lower lesions have more pronounced constipation and distention. If any of the above present perform an abdominal X-Ra to confirm diagnosis and estimate level of obstruction. Check for incarcerated hernia (herniated tissue is trapped and difficult to be freed) in any suspected bowel obstruction case. Patients may be very dehydrated so check urea and electrolytes (U+E), provide fluid, and consider a urinary catheter. Refer to surgery for further assessment and management.

Ruling out unilateral lion or flank pain in overview ab pain assessment:

Suspect renal tract obstruction (usually due to a calculus) if: -severe colicky loin pain that radiates to the groin +/- testes/labia. -typically writhe in pain, unable to find a comfortable position. -Visible (macroscopic) or dipstick (microscopic) hematuria is present in 90% of cases. -vomiting is common in bouts of pain. Rule out AAA if patient is high risk for it: ultrasound good confirmation that if true will require immediate surgical review. Rule out a stone via ab CT (or IVU if ab CT unavailable) for confirmation. -if stone present, check renal function and signs of infection proximal to stone (fever, WBC, CRP, leukocytes/nitrites on UA). —if proximal infection suspected then take urine and blood cultures, give IV ABX and urgently refer to urology. Suspect pyelonephritis if: -flank pain is non-colicky and associated with inflammatory features, leukocytes/nitrites (produced by bacteria) on urine dipstick, or loin/renal angle tenderness +/- lower UTI symptoms. —if the above is untrue, consider alternative diagnoses such as chilecystitis or appendicitis. Also get blood and urine cultures, start IV antibiotics, and arrange USS to exclude perinephric collection or renal obstruction.

Ruling out LLQ pain, tenderness and inflammatory response in lower ab pain assessment:

This goes especially if these symptoms present at the age of >40 or known diverticula's disease. Arrange urgent CT for rapid confirmation and identify complications (eg abscess).

Ruling out upper GI symptoms with alarm symptoms in chronic/relapsing ab pain assessment:

UGIE if upper ab discomfort +/- any of the following: -weight loss. -dysphagia. -persistent vomiting or early satiety. -ab distention. -hematemesis or iron deficiency anemia. -55+ with new-onset persistent symptoms. If gastric ulcer, biopsy should be taken to exclude malignancy. Prescribe H. Pylori eradication therapy if CLO test positive. Recheck history for NSAID use. Eradicate H. Pylori in any patient with a duodenal ulcer and confirm successful eradication with a urea breath test.

What is acute pancreatitis and how does it manifest in patients?

Usually from gallstones traveling through the CBD and irritating the pancreas or from alcohol directly injuring the pancreas. Severe upper abdominal pain. Often with repeated vomiting. If severe enough could lead to systemic inflammatory response and possible multi organ failure. Serum amylase level??