Acute abdominal pain

A C U T EA C U T E
ABDOMINAL PAINABDOMINAL PAIN

INTRODUCTIONINTRODUCTION
Abdo.Abdo. is bounded by diaphragm, & bony pelvis. Pain can ariseis bounded by diaphragm, & bony pelvis. Pain can arise
from abdo. wall; butfrom abdo. wall; but APAP means pain in abdo. organsmeans pain in abdo. organs
Technically, the lowermost abdo. is pelvis, which containsTechnically, the lowermost abdo. is pelvis, which contains
UB & rectum; & prostate in men; & uterus,UB & rectum; & prostate in men; & uterus, tubes, &tubes, &
ovaries in women. Often, it is difficult to know if lowerovaries in women. Often, it is difficult to know if lower
APAP is coming from pelvis (is coming from pelvis (pelvic painpelvic pain) or not) or not
APAP is common in children & often needs urgent evaluation.is common in children & often needs urgent evaluation.
It isIt is typically self-limited minortypically self-limited minor d., (constipation, AGE,d., (constipation, AGE,
or viral syn.)or viral syn.)
Challenge is to identify those few with life-threatening d.Challenge is to identify those few with life-threatening d.
DxDx is often suggested by the child'sis often suggested by the child's age & CFage & CF
AP: abdo. pain. CF: clinical features. UB: urinary bladder. AGE: ac. gastroenteritisAP: abdo. pain. CF: clinical features. UB: urinary bladder. AGE: ac. gastroenteritis

What causes AP?What causes AP?
APAP is c/byis c/by inflam./stretching/distention/ischemiainflam./stretching/distention/ischemia
ButBut APAP also can occur without a clear causealso can occur without a clear cause (IBS).(IBS). ThisThis
often is referred to asoften is referred to as functional painfunctional pain
C/ofC/of APAP is Dx by its characteristics, PE, & testsis Dx by its characteristics, PE, & tests
Occasionally,Occasionally, surgerysurgery is necessary for Dxis necessary for Dx
DxDx is oftenis often challengingchallenging because:because:
a. characteristics of pain may be atypicala. characteristics of pain may be atypical
b. and may change over timeb. and may change over time
c. tests are not always abnormal &c. tests are not always abnormal &
d. diseases may mimic each otherd. diseases may mimic each other

Mechanism of A.P.Mechanism of A.P.
Hemorrhage:Hemorrhage: AAA, ruptured ovarian cysts/ectopic preg.,AAA, ruptured ovarian cysts/ectopic preg.,
rectus sheath haematoma, traumarectus sheath haematoma, trauma
Perforation:Perforation: PUD, diverticular d., Crohn, UC, GB, ectopicPUD, diverticular d., Crohn, UC, GB, ectopic
preg., appendicitis, obs. bowelpreg., appendicitis, obs. bowel
Obstruction:Obstruction: rrenal/biliary colic, adhesion, bands, hernias,enal/biliary colic, adhesion, bands, hernias,
Crohn, inflam. strictureCrohn, inflam. stricture,, volvulus (sigmoid & caecal)volvulus (sigmoid & caecal)
 Inflammation:Inflammation: manymany
 InfarctionInfarction: obs., spleen, SCD, testicles: obs., spleen, SCD, testicles
AAA: aneurysm of abdo. Aorta. Preg.: pregnancy.AAA: aneurysm of abdo. Aorta. Preg.: pregnancy.
PUD: peptic ulcer d. UC: ulcerative colitis. SCD: sickle c.d.PUD: peptic ulcer d. UC: ulcerative colitis. SCD: sickle c.d.

NEUROLOGIC BASIS OF A.P.NEUROLOGIC BASIS OF A.P.
Pain receptors in abdo. are located onPain receptors in abdo. are located on serosa, mesentery, &serosa, mesentery, &
mucosamucosa.. Mucosal receptors respond mainly to chemicalMucosal receptors respond mainly to chemical
stimuli; but others respond to mechanical & chemical ..stimuli; but others respond to mechanical & chemical ..
3 categories:3 categories: visceral, parietal (somatic), & referredvisceral, parietal (somatic), & referred
Visceral painVisceral pain is usuallyis usually poorly localizedpoorly localized; mostly in midline; mostly in midline
(bilateral innervation). In appendicitis, exact site of AP(bilateral innervation). In appendicitis, exact site of AP
is clear once parietal peritoneum (somatic) is inflamedis clear once parietal peritoneum (somatic) is inflamed
Parietal painParietal pain is well localized, discrete,is well localized, discrete, sharp, intensesharp, intense
Visceral pain may beVisceral pain may be referredreferred usually in dermatomesusually in dermatomes
sharing the same spinal cord level as the visceral inputssharing the same spinal cord level as the visceral inputs
Usually fUsually fore-gut pain comes in epigastrium, mid-gutore-gut pain comes in epigastrium, mid-gut
peri-umbilical & hind-gutperi-umbilical & hind-gut lower abdomenlower abdomen

VisceralVisceral
 Midline painMidline pain
 Steady dull ache or vague discomfort to excruciating orSteady dull ache or vague discomfort to excruciating or
colicky paincolicky pain
 Poorly localizedPoorly localized
 Epigastric region:Epigastric region: stomach, duodenum, biliary tractstomach, duodenum, biliary tract
 Periumbilical:Periumbilical: small bowel, appendix, cecumsmall bowel, appendix, cecum
 Suprapubic:Suprapubic: colon, sigmoid, GU tractcolon, sigmoid, GU tract
ParietalParietal
 Involves parietal peritoneumInvolves parietal peritoneum
 Localized, sharp intense painLocalized, sharp intense pain
Tenderness & guarding which progress to rigidity &Tenderness & guarding which progress to rigidity &
rebound as peritonitis developsrebound as peritonitis develops

Non-specific APNon-specific AP
 No source is identifiedNo source is identified
 Vitals are normal, not ill, able to take fluidsVitals are normal, not ill, able to take fluids
 No evidence of peritonitis or severe painNo evidence of peritonitis or severe pain
 Pt. improves during ED visitPt. improves during ED visit
 Have pt. return to ED in 12-24h for re-exam. if notHave pt. return to ED in 12-24h for re-exam. if not betterbetter
or if new symptomsor if new symptoms
Half the time you will send the pt. home with a Dx ofHalf the time you will send the pt. home with a Dx of
NSAP;NSAP; 90% will be better or asymptomatic at 2-3w90% will be better or asymptomatic at 2-3w

Acute abdomen:Acute abdomen: acute onset of AP:acute onset of AP:
a potential emergencya potential emergency,,
may reflect a major problem in an organmay reflect a major problem in an organ
InIn IBSIBS AP may be c/by contraction of gut muscles orAP may be c/by contraction of gut muscles or
hyper-sensitivehyper-sensitive normalnormal intestinal activitiesintestinal activities
SymptomsSymptoms a/witha/with APAP may include:may include:
 bloating, belching, retching, indigestion, ANVDbloating, belching, retching, indigestion, ANVD
 flatus, fartingflatus, farting
 discomfort, distension, constipationdiscomfort, distension, constipation
 GERD, heartburnGERD, heartburn
 chest or pelvic discomfortchest or pelvic discomfort
AAP: acute abdo. Pain. ANVD: anorexia, nausea, vomiting, diarrheaAAP: acute abdo. Pain. ANVD: anorexia, nausea, vomiting, diarrhea

Referred painReferred pain (not a sign)(not a sign) may be sharp & localized or as a vaguemay be sharp & localized or as a vague
aching sensation. Irritation of parietal pleura is perceived as abdo.aching sensation. Irritation of parietal pleura is perceived as abdo.
wall pain & cholecystitis as shoulder or scapular painwall pain & cholecystitis as shoulder or scapular pain

DD of AP:DD of AP: It’s Huge!It’s Huge!
 Gastritis, ileitis, colitis, esophagitisGastritis, ileitis, colitis, esophagitis
 PUD, cholelithiasis, cholecystitisPUD, cholelithiasis, cholecystitis
 Hepatitis, pancreatitis, cholangitisHepatitis, pancreatitis, cholangitis
 Splenic infarct, ruptureSplenic infarct, rupture
 Pancreatic psuedocystPancreatic psuedocyst
 Perforation, gut obs., volvulusPerforation, gut obs., volvulus
 Diverticulitis, appendicitisDiverticulitis, appendicitis
 Ovarian cyst, - torsion, testicularOvarian cyst, - torsion, testicular
torsion, mens., UTItorsion, mens., UTI
 Hernias: incarceratedHernias: incarcerated
 Kidney stones, APN, HDNKidney stones, APN, HDN
 IBD, AGE, enterocolitis, pseudomemb.IBD, AGE, enterocolitis, pseudomemb.
or, ischemia colitis, constipationor, ischemia colitis, constipation
 Tumors, Meckel's diverticulumTumors, Meckel's diverticulum
 Epididymitis, prostatitis, orchitis,Epididymitis, prostatitis, orchitis,
cystitiscystitis
 AAA, ruptures aneurysm, dissectionAAA, ruptures aneurysm, dissection
 Mesenteric ischemiaMesenteric ischemia
 Helminths, PorphyriasHelminths, Porphyrias
 Abdo. compartment syn.Abdo. compartment syn.
 PneumoniaPneumonia
 Abdo. wall syn: muscle strain,Abdo. wall syn: muscle strain,
hematomas, traumahematomas, trauma
 Neuropathic: radicular painNeuropathic: radicular pain
 Nonsp. AP, IBSNonsp. AP, IBS
 GAS pharyngitis, TSSGAS pharyngitis, TSS
 Rocky Mountain SFRocky Mountain SF
 Black widow envenomationBlack widow envenomation
 Drugs: cocaine induced-ischemia,Drugs: cocaine induced-ischemia,
erythromycin, tetracyclines, NSAIDserythromycin, tetracyclines, NSAIDs
 Mercury salts, lead poisoningMercury salts, lead poisoning
 Electrical injury, mushroomElectrical injury, mushroom
 Opioid withdrawal syn.Opioid withdrawal syn.
 DKA, alcohol ketoacidosisDKA, alcohol ketoacidosis
 Adrenal crisis, thyroid stormAdrenal crisis, thyroid storm
 Hypo- & hypercalcemiaHypo- & hypercalcemia
 Sickle cell crisis, vasculitisSickle cell crisis, vasculitis
 Ectopic preg., PID, urinary retentionEctopic preg., PID, urinary retention
 Ileus, Ogilvie synIleus, Ogilvie syn

Certain d. occur more commonly at specific agesCertain d. occur more commonly at specific ages
Pain may also be classified as surgical or medicalPain may also be classified as surgical or medical
For all ages, GE & appendicitis are the commonest medicalFor all ages, GE & appendicitis are the commonest medical
& surgical c/of AAP, respectively& surgical c/of AAP, respectively
Malrotation with midgut volvulus is the single mostMalrotation with midgut volvulus is the single most
devastating abdo. surgical emergency of childhooddevastating abdo. surgical emergency of childhood
Life-threatening c/of AP:Life-threatening c/of AP: trauma, obs., & peritonitis.trauma, obs., & peritonitis.
Peritonitis may be 2y to inflam. or perforationPeritonitis may be 2y to inflam. or perforation
AP can also be classified based on the site. Hepatic & GB d.AP can also be classified based on the site. Hepatic & GB d.
usually present with RUQ pain. Appendicitis classicallyusually present with RUQ pain. Appendicitis classically
presents with migration of pain to the RLQ.presents with migration of pain to the RLQ.
Gastritis/PUD may present with LUQ painGastritis/PUD may present with LUQ pain

C/of acute AP by ageC/of acute AP by age
<2y 2-11y

Double bubble (figure of 8) without distal bowel gas:Double bubble (figure of 8) without distal bowel gas:
confirms Dx of duodenal atresia & no further imaging isconfirms Dx of duodenal atresia & no further imaging is
needed. In extreme prematures the Dx can be moreneeded. In extreme prematures the Dx can be more
challenging as duodenum has not had enough time to dilatechallenging as duodenum has not had enough time to dilate

A typical case of NEC with pneumatosis intestinalis. Horizontal beamA typical case of NEC with pneumatosis intestinalis. Horizontal beam
image there is no sign of free airimage there is no sign of free air
Normal XRNormal XR

NEC:NEC: air in portal vein (arrow)air in portal vein (arrow) (pneumoportogram)(pneumoportogram) & peripheral& peripheral
portal branches: seen on XR & USportal branches: seen on XR & US

What are the findings & what is your Dx.?What are the findings & what is your Dx.?
1.1. Multiple dilated small bowel loopsMultiple dilated small bowel loops
2.2. Pneumatosis intestinalisPneumatosis intestinalis
3.3. PneumoperitoneumPneumoperitoneum

2w old M: vomits & vomits without effort, dehydrated,2w old M: vomits & vomits without effort, dehydrated,
constipated. What is the Dx?constipated. What is the Dx?

Single muscle wall > 3mm (most reliable)Single muscle wall > 3mm (most reliable)
Total transverse diameter > 14mmTotal transverse diameter > 14mm
Length pyloric canal > 15mmLength pyloric canal > 15mm

Most Common Causes in the EDMost Common Causes in the ED
Non-specific APNon-specific AP 34%34%
AppendicitisAppendicitis 28%28%
Biliary tract d.Biliary tract d. 10%10%
SBOSBO 4%4%
Gyne. d.Gyne. d. 4%4%
PancreatitisPancreatitis 3%3%
Renal colicRenal colic 3%3%
Perforated ulcerPerforated ulcer 3%3%
CancerCancer 2%2%
Diverticular d.Diverticular d. 2%2%
OtherOther 6%6%

HistoryHistory
How did the pain begin?How did the pain begin?
 If it comes on suddenly, this may suggest a problemIf it comes on suddenly, this may suggest a problem
with an organ (interruption of BF/obs. of BD bywith an organ (interruption of BF/obs. of BD by
a gallstone)a gallstone)
Site of pain?Site of pain?
 AppendicitisAppendicitis typically causes pain in the middle, &typically causes pain in the middle, &
then moves to RIFthen moves to RIF
 DiverticulitisDiverticulitis typically causes pain in the LLQ. wheretypically causes pain in the LLQ. where
most colonic diverticuli are locatedmost colonic diverticuli are located
 Pain fromPain from GBGB typically is felt in the middle, uppertypically is felt in the middle, upper
abdo. or RUQabdo. or RUQ
BF: blood flow. Bangladesh: bile duct. RIF: right iliac fossa. LLQ: left lower quadrantBF: blood flow. Bangladesh: bile duct. RIF: right iliac fossa. LLQ: left lower quadrant

Is the AP severe, crampy, steady; or does itIs the AP severe, crampy, steady; or does it
wax & wane?wax & wane?
 Obs. of gutObs. of gut initially causes waves of cramps. Trueinitially causes waves of cramps. True
cramps suggests vigorous contractions of gutcramps suggests vigorous contractions of gut
 Obs. of the BDObs. of the BD by gallstones typically causesby gallstones typically causes
constant upper belly pain for 30min–several hrsconstant upper belly pain for 30min–several hrs
 Ac. pancreatitisAc. pancreatitis typically causes severe steady paintypically causes severe steady pain
in the upper abdo. & upper backin the upper abdo. & upper back
 Pain ofPain of ac. appendicitisac. appendicitis is severe & steadyis severe & steady
The character of pain may change over time: obs. of BDThe character of pain may change over time: obs. of BD
sometimes progresses to inflam. of GB with/-out inf.sometimes progresses to inflam. of GB with/-out inf.
changing to inflammatory painchanging to inflammatory pain

How long does the pain last?How long does the pain last?
 PainPain ofof IBSIBS typicallytypically waxes & waneswaxes & wanes over mo-yrs & mayover mo-yrs & may
last for years/decadeslast for years/decades
 Biliary colicBiliary colic lasts no more thanlasts no more than several hoursseveral hours
 The pain ofThe pain of pancreatitispancreatitis lastslasts one or more daysone or more days
 Pain ofPain of GERD/PUDGERD/PUD - typically occurs- typically occurs over a weeks orover a weeks or
monthsmonths f/by periods of weeks or months off/by periods of weeks or months of
decrease (periodicity)decrease (periodicity)
 Functional painFunctional pain may show thismay show this periodicityperiodicity
What makes the pain worse?What makes the pain worse?
 Pain due to inflam. typically is aggravated byPain due to inflam. typically is aggravated by sneezing,sneezing,
coughing or any jarringcoughing or any jarring motion. Pts. prefer to lie still.motion. Pts. prefer to lie still.
Liver pain is increased byLiver pain is increased by joltingjolting

Diseases can mimic one anotherDiseases can mimic one another
IBSIBS can mimic bowel obs., cancer, ulcer, GB attacks, orcan mimic bowel obs., cancer, ulcer, GB attacks, or
even appendicitiseven appendicitis
CrohnCrohn can mimic appendicitiscan mimic appendicitis
Inf. of the R kidneyInf. of the R kidney can mimic ac cholecystitiscan mimic ac cholecystitis
A rupturedA ruptured R ovarian cystR ovarian cyst can mimic appendicitis; while acan mimic appendicitis; while a
ruptured L ovarian cyst can mimic diverticulitisruptured L ovarian cyst can mimic diverticulitis
Kidney stonesKidney stones can mimic appendicitis or diverticulitis. Thecan mimic appendicitis or diverticulitis. The
characteristics of the pain may changecharacteristics of the pain may change
PancreatitisPancreatitis can involve whole abdo.can involve whole abdo.
Biliary colicBiliary colic may cause cholecystitismay cause cholecystitis

What relieves the pain?What relieves the pain?
 Pain of IBS & constipation often is relievedPain of IBS & constipation often is relieved by bowelby bowel
movementsmovements
 Pain in obs. of upper GIT may be relieved byPain in obs. of upper GIT may be relieved by vomitingvomiting
 AntacidsAntacids may temporarily relieve ulcer painmay temporarily relieve ulcer pain
Pain that awakens from sleep is more likely to be due toPain that awakens from sleep is more likely to be due to
non-functional causes & is more significantnon-functional causes & is more significant
Other associated SS:Other associated SS:
 FeverFever suggests inflam. or inf.suggests inflam. or inf.
 Diarrhea or PR hgeDiarrhea or PR hge suggests an intestinal causesuggests an intestinal cause
 Fever & diarrheaFever & diarrhea suggest enteritissuggest enteritis


RelevantRelevant ROSROS
General:General: F, tachycardia, fast br., lightheadednessF, tachycardia, fast br., lightheadedness
GIT:GIT: past abdo. surgeries, GB d., ulcers; Family H/of IBD, ANVD,past abdo. surgeries, GB d., ulcers; Family H/of IBD, ANVD,
hematemesis, constipation, bloody stools, melenahematemesis, constipation, bloody stools, melena
GUT:GUT: LUTS, UTI, hematuria, vaginal discharge/bleeding in female,LUTS, UTI, hematuria, vaginal discharge/bleeding in female,
past surgeries, h/o kidney stonespast surgeries, h/o kidney stones
Gynecology:Gynecology: last menses, sexual activity, contraception, PID, STDs,last menses, sexual activity, contraception, PID, STDs,
ovarian cysts, past gyne. surgeries, pregnanciesovarian cysts, past gyne. surgeries, pregnancies
Vascular:Vascular: MI, heart disease, a-fib, anticoagulation, CHF, PVD,MI, heart disease, a-fib, anticoagulation, CHF, PVD,
Family Hx of AAAFamily Hx of AAA
Other d.:Other d.: DM, organ transplant, HIV/AIDS, cancerDM, organ transplant, HIV/AIDS, cancer
Medications:Medications: NSAIDs, H2 blockers, PPIs, immunosuppression,NSAIDs, H2 blockers, PPIs, immunosuppression,
coumadincoumadin

Check in Physical ExamCheck in Physical Exam
General: ABCGeneral: ABC, diaphoresis, distress/discomfort, is the pt. lying still, diaphoresis, distress/discomfort, is the pt. lying still
or moving around in the bedor moving around in the bed
Vitals, dehydrationVitals, dehydration
Cardiac:Cardiac: aarrhythmias.rrhythmias. Lungs:Lungs: ppneumonianeumonia
Abdo.:Abdo.: Tenderness & s/of inflam. inTenderness & s/of inflam. in LIFLIF often meansoften means diverticulitisdiverticulitis
That inThat in RIFRIF often meansoften means appendicitisappendicitis
Guarding/rigidity: voluntary:Guarding/rigidity: voluntary: diminished by having flexed kneesdiminished by having flexed knees
Involuntary: peritoneal irritationInvoluntary: peritoneal irritation
Inflam inInflam in RIFRIF, with/-out a mass, also may be found in Crohn's, with/-out a mass, also may be found in Crohn's
S/of inflam. by special maneuversS/of inflam. by special maneuvers
MassMass suggests a tumor, organomegaly, abscess (tender)suggests a tumor, organomegaly, abscess (tender)
Bloody stoolBloody stool may signify ulcer, Ca colon, colitis/ischemiamay signify ulcer, Ca colon, colitis/ischemia

Abdominal Findings …Abdominal Findings …
Rebound:Rebound: present in 25% without peritonitispresent in 25% without peritonitis
Pain referred to the point of maximum tendernessPain referred to the point of maximum tenderness
when palpating an adjacent quadrant (Rovsing’s sign)when palpating an adjacent quadrant (Rovsing’s sign)
Look for:Look for: aortic aneurysm, organomegaly, hernias, renal angleaortic aneurysm, organomegaly, hernias, renal angle
hyperactive BS increase likelihood of SBO fivefoldhyperactive BS increase likelihood of SBO fivefold
Percuss for tympaniPercuss for tympani
 Rectal examRectal exam
 Little evidence thatLittle evidence that tendernesstenderness adds any useful info.adds any useful info.
beyond abdo. exam. Gross blood/melena: GIBbeyond abdo. exam. Gross blood/melena: GIB
Pelvic exam:Pelvic exam: Vaginal discharge, Adenexal mass or fullnessVaginal discharge, Adenexal mass or fullness
GIB: gastrointestinal bleedingGIB: gastrointestinal bleeding

Lab. testsLab. tests
CBC, liver enzymes, pancreatic amylase & lipase,CBC, liver enzymes, pancreatic amylase & lipase,
preg. test & urinalysis are frequently donepreg. test & urinalysis are frequently done
Leucocytosis suggests inflam./inf.Leucocytosis suggests inflam./inf.
Anemia may indicate a bleedAnemia may indicate a bleed
Liver enzymes may rise in GB attacks or ac. hepatitisLiver enzymes may rise in GB attacks or ac. hepatitis
Hematuria suggests kidney stonesHematuria suggests kidney stones
WBC in stool suggest inv. diarrheaWBC in stool suggest inv. diarrhea
A positive preg. may suggest an ectopic preg.A positive preg. may suggest an ectopic preg.
OBT:OBT:

ImagingImaging
Plain AXRPlain AXR may show fluid & air levels (obs.). Perforationmay show fluid & air levels (obs.). Perforation
may have air under diaphragm. AXR may show kidneymay have air under diaphragm. AXR may show kidney
stone; calcifications in chr. pancreatitisstone; calcifications in chr. pancreatitis
Ba XRBa XR of upper GI series with a small bowel follow-throughof upper GI series with a small bowel follow-through
can be helpful in PUD, inflam., & blockage in gutcan be helpful in PUD, inflam., & blockage in gut
USGUSG is useful in gallstones, cholecystitis, appendicitis, oris useful in gallstones, cholecystitis, appendicitis, or
ruptured ovarian cysts, ectopic preg.ruptured ovarian cysts, ectopic preg.
CTCT is useful in pancreatitis, Ca. pancreas, appendicitis,is useful in pancreatitis, Ca. pancreas, appendicitis,
diverticulitis, abscess, Crohn. By special CT scans ofdiverticulitis, abscess, Crohn. By special CT scans of
abdo.abdo. BV can detect d. of arteriesBV can detect d. of arteries
MRIMRI is useful in many of the same conditions as CTis useful in many of the same conditions as CT

Capsule enteroscopyCapsule enteroscopy is helpful in Crohn's, tumors, &is helpful in Crohn's, tumors, &
bleeding not seen on XR/CTbleeding not seen on XR/CT
EndoscopyEndoscopy
 EsophagogastroduodenoscopyEsophagogastroduodenoscopy for ulcers, gastritis, Cafor ulcers, gastritis, Ca
 Colonoscopy/flexible sigmoidoscopyColonoscopy/flexible sigmoidoscopy is useful foris useful for
colitis, Cacolitis, Ca
 Endoscopic ultrasound (EUS)Endoscopic ultrasound (EUS) is useful for Ca panc. oris useful for Ca panc. or
gallstones if standard US/CT/MRI failgallstones if standard US/CT/MRI fail
 Balloon enteroscopy,Balloon enteroscopy, the newest technique allowsthe newest technique allows
endoscopes to be passed through the mouth orendoscopes to be passed through the mouth or anusanus
& into the small gut where small intestinal& into the small gut where small intestinal c/of pain orc/of pain or
bleeding can be diagnosed,bleeding can be diagnosed, biopsied, & treatedbiopsied, & treated
Surgery.Surgery. Sometimes, Dx requires exam of abdo. eitherSometimes, Dx requires exam of abdo. either
by laparoscopy or surgeryby laparoscopy or surgery

Case #1Case #1
A 10-w-o F admitted with an 8h h/of lethargy, V, refusal to
feed, very sleepy & a high pitched cry. Vomited x3, last
vomit was greenish. No F, constipation or diarrhoea
She is bottle fed
PE: lethargic, pale & quiet. HR was 134/min & BP 85/42.
Abdo. was scaphoid & soft with normal BS. No masses
Later she passed a small amount of blood PR & had a
palpable mass in epigastrium
What is the Dx?
BS: bowel sound

Labs:Labs:
RBGRBG was 7.6 mmol/l was 7.6 mmol/l
ABG & urea & electrolytesABG & urea & electrolytes normalnormal
CBC:CBC: neutrophilia (neutrophilia (10.9×109/l)10.9×109/l)
Blood & CSFBlood & CSF cultures were negativecultures were negative
Urine dipstick & CSFUrine dipstick & CSF microscopy, biochemistry normalmicroscopy, biochemistry normal
CRPCRP <0.5mg/l<0.5mg/l
ClottingClotting screen was normalscreen was normal
Plain AXR:Plain AXR: dilated loops of bowel centrally (SBO) & lack ofdilated loops of bowel centrally (SBO) & lack of
gas in the rectumgas in the rectum
Abdominal ultrasound:Abdominal ultrasound: ileo-colic intussusceptionileo-colic intussusception

Plain AXR:Plain AXR:
dilated loops ofdilated loops of
bowel centrallybowel centrally
& no gas in& no gas in
rectumrectum

Abdo. US: dilatedAbdo. US: dilated
bowel in thebowel in the
epigastrium withepigastrium with
sandwich sign ofsandwich sign of
bowel within bowelbowel within bowel

DX:DX: intussusceptionintussusception
Differential diagnosisDifferential diagnosis
Sepsis, intussusception & malrotation with volvulus.Sepsis, intussusception & malrotation with volvulus.
DD of fresh PR bleeding in an un-well child could include aDD of fresh PR bleeding in an un-well child could include a
bleeding d. & NECbleeding d. & NEC
TreatmentTreatment
Surgical reduction of intussusception following failedSurgical reduction of intussusception following failed
air/fluid enemaair/fluid enema

DiscussionDiscussion
For this child with nonsp. SS,For this child with nonsp. SS, sepsissepsis is considered untilis considered until
proven otherwise. Lethargy & pallor may indicateproven otherwise. Lethargy & pallor may indicate sepsis butsepsis but
lethargy with a high pitched cry: CNS d.lethargy with a high pitched cry: CNS d.
Here, sudden onset made sepsis less likelyHere, sudden onset made sepsis less likely
Bilious VBilious V in an infant <3mo: sepsis or obs. especially mid-in an infant <3mo: sepsis or obs. especially mid-
gut volvulus. Bilious V isgut volvulus. Bilious V is surgicalsurgical unless provenunless proven
otherwise. V is most consistent with intussusceptionotherwise. V is most consistent with intussusception
(non-bilious in 60% cases)(non-bilious in 60% cases)
Usual h/of intermittent crying with drawing up of legs isUsual h/of intermittent crying with drawing up of legs is
absent here.absent here. She was quiet & reacted minimally.She was quiet & reacted minimally.
Bleeding PR (Bleeding PR (currant jellycurrant jelly) is usually late. Combination) is usually late. Combination ofof
bleeding PR & a mass narrowed down DX. A surgicalbleeding PR & a mass narrowed down DX. A surgical
cause was confirmed with AXR. USG was DXcause was confirmed with AXR. USG was DX

Learning pointsLearning points
Intussusception is rare in <3mo, but do occurIntussusception is rare in <3mo, but do occur
Dx in infants <3mo can be challenging since majority willDx in infants <3mo can be challenging since majority will
present with nonspecific SSpresent with nonspecific SS
Intussusception should be included in DD when an infantIntussusception should be included in DD when an infant
<3mo presents with pallor, V & lethargy acutely even<3mo presents with pallor, V & lethargy acutely even
withwith nono abdominal signsabdominal signs
Non-bilious V do not exclude intussusception inNon-bilious V do not exclude intussusception in <3mo age<3mo age

Case #2Case #2
10yo M with one day of AP, generalized at first, now worse in10yo M with one day of AP, generalized at first, now worse in
RIF & radiates to Rt. groin. He vomited x2. No D, F,RIF & radiates to Rt. groin. He vomited x2. No D, F,
dysuria. Anorexicdysuria. Anorexic
Past Hx: negativePast Hx: negative
P. Surgical Hx: negativeP. Surgical Hx: negative
Meds: noneMeds: none
No Known Drug AllergyNo Known Drug Allergy
Family Hx: non-contributoryFamily Hx: non-contributory

Physical Exam.Physical Exam.
T: 37.8,T: 37.8, HR: 110,HR: 110, BP 118/76, BR: 18BP 118/76, BR: 18
O2: 100% room airO2: 100% room air
Uncomfortable appearing, slightly paleUncomfortable appearing, slightly pale
Abdomen: soft, non-distended, tender to palpation in RLQAbdomen: soft, non-distended, tender to palpation in RLQ
with mild guarding; hypoactive BS.with mild guarding; hypoactive BS. Psoas and RovsingPsoas and Rovsing
signs are positivesigns are positive
Genital exam: normalGenital exam: normal
What is DD & what do you do next?What is DD & what do you do next?

What tests should you order?What tests should you order?
What you look for!What you look for!
AXRAXR
 3 views: upright chest, flat view of3 views: upright chest, flat view of
abdo., upright view of abdo.abdo., upright view of abdo.
 Restrict to suspected obs./free airRestrict to suspected obs./free air
UltrasoundUltrasound
 Good for AAA but not rupturedGood for AAA but not ruptured
AAAAAA
 Good for appendicitis, pelvic patho.Good for appendicitis, pelvic patho.
CT abdo/pelvisCT abdo/pelvis
 Free air, renal colic, ruptured AAA,Free air, renal colic, ruptured AAA,
bowel obs.bowel obs.
 ContrastContrast for abscess, inf., inflam,for abscess, inf., inflam,
unknown causeunknown cause
MRIMRI
 Most often used when unable toMost often used when unable to
obtain CT due to contrast issueobtain CT due to contrast issue
LabsLabs
 CBCCBC
 ChemistriesChemistries
 LFT, lipaseLFT, lipase
 Coagulation studiesCoagulation studies
 Urinalysis, urine cultureUrinalysis, urine culture
 GC/Chlamydia swabsGC/Chlamydia swabs
 LactateLactate

AppendicitisAppendicitis
Classic (66%)Classic (66%)
 Periumbilical painPeriumbilical pain
 ANV, pain localizes to RLQANV, pain localizes to RLQ
 64% of appendices are64% of appendices are
retrocecal & cause painretrocecal & cause pain in thein the
flank; 4% are in RUQflank; 4% are in RUQ
 A pelvic appendix can causeA pelvic appendix can cause
suprapubic pain, dysuriasuprapubic pain, dysuria
 Males may have pain in testiclesMales may have pain in testicles
Findings:Findings: depends on durationdepends on duration
 Rebound, voluntary guardingRebound, voluntary guarding
 Psoas, obturator, Rovsing signPsoas, obturator, Rovsing sign
 Fever (a late finding)Fever (a late finding)
Urinalysis abnormal inUrinalysis abnormal in 40%40%
CBC is not sensitive/CBC is not sensitive/
specificspecific
Abdominal XRAbdominal XR
 Appendiceal fecalith or gas,Appendiceal fecalith or gas,
localized ileus, blurredlocalized ileus, blurred
Rt. psoas muscle, free airRt. psoas muscle, free air
CT scanCT scan
 Pericecal inflam, abscess,Pericecal inflam, abscess,
periappendiceal phlegmon,periappendiceal phlegmon,
fluid collection, localizedfluid collection, localized
fat strandingfat stranding

Appendicitis: Psoas SignAppendicitis: Psoas Sign

Obturator SignObturator Sign
Passively flex Rt hip & knee; thenPassively flex Rt hip & knee; then
internally rotate the hipinternally rotate the hip

Case #3Case #3
46 yo M46 yo M with Hx of alcohol abuse with 3d severe upperwith Hx of alcohol abuse with 3d severe upper
abdo. pain, vomiting, feverabdo. pain, vomiting, fever
Medical Hx: negativeMedical Hx: negative
Surgical Hx: negativeSurgical Hx: negative
Allergies: NKDAAllergies: NKDA
Social Hx: homeless, heavy alcohol use, smokes 2ppd, noSocial Hx: homeless, heavy alcohol use, smokes 2ppd, no
drug usedrug use

Case #3 ExamCase #3 Exam
Looking Ill, in painLooking Ill, in pain
T: 37.4,T: 37.4, HR: 115,HR: 115, BP: 98/65, BR: 22BP: 98/65, BR: 22
O2 sat: 95% room airO2 sat: 95% room air
CV: normal HSCV: normal HS
Lungs: clearLungs: clear
Abdomen: mildly distended, moderately tender epigastric,Abdomen: mildly distended, moderately tender epigastric,
+ voluntary guarding+ voluntary guarding
Rectal: heme neg. stoolRectal: heme neg. stool
What is your DD & what next?What is your DD & what next?

PancreatitisPancreatitis
Risk FactorsRisk Factors
 AlcoholAlcohol,, gallstonesgallstones
 DrugsDrugs
 Amiodarone, antivirals,Amiodarone, antivirals,
diuretics, NSAIDs,diuretics, NSAIDs,
antibiotics, more…..antibiotics, more…..
 Severe hyperlipidemiaSevere hyperlipidemia
 Procedures, idiopathicProcedures, idiopathic
CFCF
 Epigastric constant, severeEpigastric constant, severe
boring pain, radiates toboring pain, radiates to
backback
 N/V, bloatingN/V, bloating
 LGF, tachycardia,LGF, tachycardia,
hypotensionhypotension
 Atelectasis, pleural effusionAtelectasis, pleural effusion
 Peritonitis – late findingPeritonitis – late finding
 IleusIleus
 Cullen sign:Cullen sign: BluishBluish
discoloration arounddiscoloration around
umbilicusumbilicus
 Grey Turner signGrey Turner sign
Bluish discoloration ofBluish discoloration of
the flanksthe flanks
Cullen and Grey Turner signsCullen and Grey Turner signs

PancreatitisPancreatitis
DiagnosisDiagnosis
 Lipase:Lipase: elevated >2 timeselevated >2 times
normal.normal. Sensitivity &Sensitivity &
specificity >90%specificity >90%
 AmylaseAmylase
 NonspecificNonspecific
 Don’t botherDon’t bother……
 USGUSG
 CT scanCT scan
 Insensitive in early or mildInsensitive in early or mild
 Useful for complicationsUseful for complications
TreatmentTreatment
 NPO. IV fluidNPO. IV fluid
 Maintain urineMaintain urine
100ml/hr100ml/hr
 NGTNGT
 No ABT unless severe d.No ABT unless severe d.
 E coli, Klebsiella,E coli, Klebsiella,
enterococci, staph.,enterococci, staph.,
pseudomonaspseudomonas
 Mild disease, tolerating oralMild disease, tolerating oral
fluidsfluids
 Discharge on liquid dietDischarge on liquid diet
 Follow up in 24-48hFollow up in 24-48h

Case #4Case #4
60yo M60yo M with CAD onwith CAD on aspirinaspirin & Clopidogrel with several& Clopidogrel with several
days of dull upper AP & now worsened “in entiredays of dull upper AP & now worsened “in entire
abdo.” today. Some relief with food until today, nowabdo.” today. Some relief with food until today, now
worse after eating lunchworse after eating lunch
Med Hx: CAD, HTN, CHFMed Hx: CAD, HTN, CHF
Surg Hx: appendisectomySurg Hx: appendisectomy
Meds:Meds: AspirinAspirin, Clopidogrel, Metoprolol, Lasix, Clopidogrel, Metoprolol, Lasix
Social hx: smokes 1ppd, denies alcohol or drug use, lonelySocial hx: smokes 1ppd, denies alcohol or drug use, lonely

General: ill-appearingGeneral: ill-appearing
T: 99.1,T: 99.1, HR: 100,HR: 100, BP: 90/45, BR: 22BP: 90/45, BR: 22
CV: normalCV: normal
Abdo.:Abdo.: mildly distended & diffusely tender, +rebound &mildly distended & diffusely tender, +rebound &
guardingguarding
Rectal: blood-streaked stoolRectal: blood-streaked stool

Perforated Peptic UlcerPerforated Peptic Ulcer
Abrupt severe epigastric pain f/by peritonitisAbrupt severe epigastric pain f/by peritonitis
IV, oxygen, monitorIV, oxygen, monitor
CBC, LipaseCBC, Lipase
AXRAXR:: Lack of free air does NOT rule out perforationLack of free air does NOT rule out perforation
Broad-spectrum antibioticsBroad-spectrum antibiotics
Surgical consultationSurgical consultation

Peptic Ulcer Disease, perforationPeptic Ulcer Disease, perforation
Risk FactorsRisk Factors
 H. pylori, NSAIDs, SmokingH. pylori, NSAIDs, Smoking
 HereditaryHereditary
CFCF
 Burning epigastric painBurning epigastric pain
 Sharp, dull, achy, or “empty” orSharp, dull, achy, or “empty” or
“hungry” feeling“hungry” feeling
 Relieved by milk, food, antacidsRelieved by milk, food, antacids
 Awakens at nightAwakens at night
 Atypical presentations in elderlyAtypical presentations in elderly
Physical FindingsPhysical Findings
 Epigastric tendernessEpigastric tenderness
 Severe, generalized painSevere, generalized pain
may indicate perforationmay indicate perforation
with peritonitiswith peritonitis
 Occult or gross blood perOccult or gross blood per
rectum or NGT if bleedingrectum or NGT if bleeding
 Loss of hepatic dullnessLoss of hepatic dullness

Peptic Ulcer DiseasePeptic Ulcer Disease
DiagnosisDiagnosis
 OBTOBT
 CBCCBC
 Anemia fromAnemia from
chronicchronic bloodblood
lossloss
 LFTsLFTs
 Evaluate for GB, liverEvaluate for GB, liver
& pancreatic disease& pancreatic disease
 Definitive DxDefinitive Dx is by EGDis by EGD
or upper GI Ba studyor upper GI Ba study
Empiric treatmentEmpiric treatment
 Avoid tobacco, NSAIDs,Avoid tobacco, NSAIDs,
aspirinaspirin
 PPI or H2 blockerPPI or H2 blocker
Immediate referral to GI if:Immediate referral to GI if:
 >45 years>45 years
 Weight lossWeight loss
 Long h/o symptomsLong h/o symptoms
 AnemiaAnemia
 Persistent ANVPersistent ANV
 Early satietyEarly satiety
 GIBGIB

Case #5Case #5
15yo healthy F to ED c/o ANV since yesterday along with15yo healthy F to ED c/o ANV since yesterday along with
generalized AP. No fever. Last stool 2d ago. No flatusgeneralized AP. No fever. Last stool 2d ago. No flatus
Med Hx: negativeMed Hx: negative
Surg Hx: openSurg Hx: open appendisectomyappendisectomy 6mo ago6mo ago
Meds: none, Allergies: NKDAMeds: none, Allergies: NKDA
Social Hx: denies alcohol, tobacco or drug useSocial Hx: denies alcohol, tobacco or drug use

General: mildly obese female, vomitingGeneral: mildly obese female, vomiting
T: 36.9,T: 36.9, HR: 120,HR: 120, BP: 130/85, BR: 25BP: 130/85, BR: 25
O2 sat: 97% at room airO2 sat: 97% at room air
Abdo.:Abdo.: moderately distended, mildly tender diffuselymoderately distended, mildly tender diffusely,,
hypoactive BS,hypoactive BS, no rebound or guardingno rebound or guarding

Upright abd x-rayUpright abd x-ray

large bowel obstructionlarge bowel obstruction

Bowel ObstructionBowel Obstruction
Mechanical/non-Mechanical/non- causescauses
 Adhesions from previousAdhesions from previous
surgerysurgery
 Hernia incarcerationHernia incarceration
CFCF
 Crampy, intermittent painCrampy, intermittent pain
 Periumbilical or diffusePeriumbilical or diffuse
 Inability to have BM orInability to have BM or
flatusflatus
 ANV, bilious vomitingANV, bilious vomiting
 BloatingBloating
 Sensation of fullnessSensation of fullness
 DistentionDistention
 TympanyTympany
 Absent, high pitched orAbsent, high pitched or
tinkling BS or “rushes”tinkling BS or “rushes”
 Abdo. tenderness: diffuse,Abdo. tenderness: diffuse,
localized, or minimallocalized, or minimal

Bowel Obstruction …Bowel Obstruction …
DiagnosisDiagnosis
AXR:AXR: Flat, upright, & CXRFlat, upright, & CXR
 Air-fluid levels, dilatedAir-fluid levels, dilated
loopsloops
Lack of gas in distal bowel &Lack of gas in distal bowel &
rectumrectum
CBC & electrolytesCBC & electrolytes
 dyselectrolytemiasdyselectrolytemias
WBC >20,000 suggestsWBC >20,000 suggests
bowel necrosis, abscess orbowel necrosis, abscess or
peritonitisperitonitis
CTCT
 Identify c/of obstructionIdentify c/of obstruction
 Delineate partial fromDelineate partial from
complete obstructioncomplete obstruction
TreatmentTreatment
 Fluid resuscitationFluid resuscitation
 NGTNGT
 AnalgesiaAnalgesia
 Surgical consultSurgical consult
 ABTABT

Case #6Case #6
40 yo40 yo obeseobese F with one day H/of upper AP after eating,F with one day H/of upper AP after eating,
no radiation, is intermittent cramping pain, +N/V, nono radiation, is intermittent cramping pain, +N/V, no
diarrhea, subjective F. No prior similar symptomsdiarrhea, subjective F. No prior similar symptoms
Med Hx: deniesMed Hx: denies
Surg Hx: deniesSurg Hx: denies
No meds or allergiesNo meds or allergies
Social Hx: no alcohol, tobacco or drug useSocial Hx: no alcohol, tobacco or drug use

Moderately obese, no acute distressModerately obese, no acute distress
T: 100.4,T: 100.4, HR: 96,HR: 96, BP: 135/76, BR: 18BP: 135/76, BR: 18
Abdo: non-distended, moderately tender RUQ, +Murphy,Abdo: non-distended, moderately tender RUQ, +Murphy,
normal BSnormal BS

CholecystitisCholecystitis
CFCF
RUQ/epigastric painRUQ/epigastric pain
Radiation to the back orRadiation to the back or
shouldersshoulders
Dull & achyDull & achy →→ sharp &sharp &
localizedlocalized
Pain lasting >6hPain lasting >6h
ANVANV
Fever, chillsFever, chills
Physical FindingsPhysical Findings
Epigastric or RUQ painEpigastric or RUQ pain
Murphy’s signMurphy’s sign
Patient appears illPatient appears ill
Peritoneal signs suggestPeritoneal signs suggest
perforationperforation

CholecystitisCholecystitis
DiagnosisDiagnosis
 CBC, LFTs, LipaseCBC, LFTs, Lipase
 Elevated al. phos.Elevated al. phos.
 Elevated lipase suggests gallstoneElevated lipase suggests gallstone
pancreatitispancreatitis
 RUQ USRUQ US
Thick GB wallThick GB wall
Pericholecystic fluidPericholecystic fluid
Gallstones or sludgeGallstones or sludge
Sonographic Murphy signSonographic Murphy sign
 HIDA scanHIDA scan
more sensitive & specific than USmore sensitive & specific than US
 H&P & lab. findings have a poorH&P & lab. findings have a poor
predictive valuepredictive value –– if you suspectif you suspect
it, get the USit, get the US
TreatmentTreatment
 Surgical consultSurgical consult
 IV fluidsIV fluids
 Correct electrolyteCorrect electrolyte
abnormalitiesabnormalities
 ABTABT
 CeftriaxoneCeftriaxone
 If septic, broaden coverageIf septic, broaden coverage
 NGT if intractable vomitingNGT if intractable vomiting

Case #7Case #7
34 yo healthy M with 4h H/of sudden left flank pain, +NV;34 yo healthy M with 4h H/of sudden left flank pain, +NV;
no prior H/of similar symptoms; no F. +difficultyno prior H/of similar symptoms; no F. +difficulty
urinating, no hematuria. Feels like has to urinate buturinating, no hematuria. Feels like has to urinate but
cannotcannot
PMHx: negPMHx: neg
Surg Hx: negSurg Hx: neg
Allergies: NKDAAllergies: NKDA
Social Hx: occasional alcohol, denies tobacco or drug useSocial Hx: occasional alcohol, denies tobacco or drug use

Writhing around on stretcher in pain, +diaphoreticWrithing around on stretcher in pain, +diaphoretic
T: 98.9,T: 98.9, HR: 110,HR: 110, BP: 150/90, BR: 20BP: 150/90, BR: 20
O2 sat: 99% at room airO2 sat: 99% at room air
CV: tachycardic, heart sounds normalCV: tachycardic, heart sounds normal
Abdo.: soft; non-tenderAbdo.: soft; non-tender
Back: mild left CVA tendernessBack: mild left CVA tenderness
Genital exam: normalGenital exam: normal
Neuro exam: normalNeuro exam: normal

Renal ColicRenal Colic
CFCF
 Ac. severe, dull, achy visceralAc. severe, dull, achy visceral
painpain
 Flank painFlank pain
 Radiates to abdo. or groinRadiates to abdo. or groin
including testiclesincluding testicles
NV & sometimes diaphoresisNV & sometimes diaphoresis
Fever is unusualFever is unusual
Waxing & waning symptomsWaxing & waning symptoms
Physical FindingsPhysical Findings
Non/mild tender tendernessNon/mild tender tenderness
 Anxious, pacing, writhing inAnxious, pacing, writhing in
bed – unable to sit stillbed – unable to sit still

Renal ColicRenal Colic
DiagnosisDiagnosis
 Urinalysis: RBCsUrinalysis: RBCs
WBCs suggest inf. or other causeWBCs suggest inf. or other cause
(appendicitis)(appendicitis)
 CBCCBC
 If inf. suspectedIf inf. suspected
BUN/CreatinineBUN/Creatinine
 In older ptsIn older pts
 If patient has single kidneyIf patient has single kidney
 If severe obs. is suspectedIf severe obs. is suspected
 CT scanCT scan
 In older pts. or withIn older pts. or with
comorbidities (DM, SCD)comorbidities (DM, SCD)
 Not necessary in young pts. orNot necessary in young pts. or
patients with h/o stonespatients with h/o stones
that pass spontaneouslythat pass spontaneously
TreatmentTreatment
 IV fluidIV fluid
NarcoticsNarcotics
NSAIDS (NSAIDS (If no renal insufficiency)If no renal insufficiency)
 Strain all urineStrain all urine
 Follow up with urology in 1-2wFollow up with urology in 1-2w
 If stone > 5mm, admit & urologyIf stone > 5mm, admit & urology
consultconsult
 If toxic appearing or inf foundIf toxic appearing or inf found
IV ABTIV ABT
Urologic consultUrologic consult

Ovarian TorsionOvarian Torsion
Acute severe pelvic painAcute severe pelvic pain
May wax & waneMay wax & wane
Possible H/of ovarian cystsPossible H/of ovarian cysts
Menstrual cycle: midcycleMenstrual cycle: midcycle
also possibly in pregalso possibly in preg
Can have variable exam:Can have variable exam:
 ac., rigid abdo., peritonitisac., rigid abdo., peritonitis
 FeverFever
 TachycardiaTachycardia
 Decreased BSDecreased BS
May mimic appendicitisMay mimic appendicitis
Obtain USGObtain USG
LabsLabs
CBC, beta-hCG,CBC, beta-hCG,
electrolytes, T&Selectrolytes, T&S
IV fluidsIV fluids
NPONPO
Pain medicationsPain medications
Gyne consultGyne consult

Testicular TorsionTesticular Torsion
 Sudden severe testicular painSudden severe testicular pain
 If repairedIf repaired within 6hwithin 6h of insult,of insult,
salvage rates of 80-100%salvage rates of 80-100%
are typical;are typical; decline todecline to
nearlynearly 0% at 24h0% at 24h
 5-10% of torsed testes5-10% of torsed testes
spontaneously detorse, butspontaneously detorse, but
the risk of retorsion at athe risk of retorsion at a
later date remains highlater date remains high
 Most occur in <20yoa but 10% ofMost occur in <20yoa but 10% of
affected are >30yaffected are >30y
 DetorsionDetorsion
 Emergent urology consultEmergent urology consult
 Ultrasound with dopplerUltrasound with doppler

Abdominal Pain in the ElderlyAbdominal Pain in the Elderly
 Mortality rate for AP in theMortality rate for AP in the
elderly is 11-14%elderly is 11-14%
 Perception of pain is alteredPerception of pain is altered
 Altered reporting of pain:Altered reporting of pain:
stoicism, fear,stoicism, fear,
communication problemscommunication problems
Most common causes:Most common causes:
CholecystitisCholecystitis
AppendicitisAppendicitis
Bowel obstructionBowel obstruction
DiverticulitisDiverticulitis
Perforated PUPerforated PU
Don’t miss these:Don’t miss these:
AAA, ruptured AAAAAA, ruptured AAA
Mesenteric ischemiaMesenteric ischemia
Myocardial ischemiaMyocardial ischemia
Aortic dissectionAortic dissection

Appendicitis: do not exclude it because of prolonged SS.Appendicitis: do not exclude it because of prolonged SS.
Only 20% will have F, NV, RLQ pain &Only 20% will have F, NV, RLQ pain & ↑↑WBCWBC
Ac. Cholecystitis: the commonest surg. emergency in themAc. Cholecystitis: the commonest surg. emergency in them
Perforated PU: only 50% report a sudden onset of pain. InPerforated PU: only 50% report a sudden onset of pain. In
one series, missed Dx of PPU was leading c/of deathone series, missed Dx of PPU was leading c/of death
Mesenteric ischemia: Dx only 25% of the time. Early DxMesenteric ischemia: Dx only 25% of the time. Early Dx
improves survival. Overall survival is 30%improves survival. Overall survival is 30%
Increased frequency of AAAIncreased frequency of AAA
AAA may look like renal colic in elderlyAAA may look like renal colic in elderly
AP in the Elderly …AP in the Elderly …

Mesenteric IschemiaMesenteric Ischemia
Consider this in all elderly with risk factorsConsider this in all elderly with risk factors
 AF, recent MI, atherosclerosis, CHF, digoxin therapyAF, recent MI, atherosclerosis, CHF, digoxin therapy
 Hypercoagulability, prior DVT, liver d.Hypercoagulability, prior DVT, liver d.
Severe pain, often refractory to analgesicsSevere pain, often refractory to analgesics
ANV are common. 50% will have diarrheaANV are common. 50% will have diarrhea
Relatively normal abdo. examRelatively normal abdo. exam
Embolism: ac. onset (more gradual if thrombosis)Embolism: ac. onset (more gradual if thrombosis)
Eventually stools will be guiaic-positiveEventually stools will be guiaic-positive
Metabolic acidosis & extreme leukocytosis with bowelMetabolic acidosis & extreme leukocytosis with bowel
necrosisnecrosis
Dx requires mesenteric angiography or CT angiographyDx requires mesenteric angiography or CT angiography

Abdominal Aortic AneurysmAbdominal Aortic Aneurysm
Risk increases with age, women >70, men >55Risk increases with age, women >70, men >55
Sudden significant AP in 80% (not back pain!)Sudden significant AP in 80% (not back pain!)
Back pain in 50%Back pain in 50%
Atypical locations of pain: hips, inguinal area, ext. genitaliaAtypical locations of pain: hips, inguinal area, ext. genitalia
Syncope can occur. Hypotension may be presentSyncope can occur. Hypotension may be present
Palpation of a tender, enlarged aorta is an imp. findingPalpation of a tender, enlarged aorta is an imp. finding
May present with hematuriaMay present with hematuria
Suspect it in any older pt. with back, flank or abdominalSuspect it in any older pt. with back, flank or abdominal
pain especially with a renal colic presentationpain especially with a renal colic presentation
USG: can reveal it but is not helpful for rupture. CT withoutUSG: can reveal it but is not helpful for rupture. CT without
contrast for stable patients. High suspicion in ancontrast for stable patients. High suspicion in an

GI BleedingGI Bleeding
UpperUpper
 Proximal to Ligament of TreitzProximal to Ligament of Treitz
PUD most commonPUD most common
 Erosive gastritisErosive gastritis
 Esophagitis; Esophageal & gastric varicesEsophagitis; Esophageal & gastric varices
 Mallory-Weiss tearMallory-Weiss tear
LowerLower
 Hemorrhoids most commonHemorrhoids most common
 DiverticulosisDiverticulosis
 AngiodysplasiaAngiodysplasia

Medical HistoryMedical History
Common Presentation:Common Presentation:
Hematemesis (source proximal to right colon)Hematemesis (source proximal to right colon)
Coffee-ground emesisCoffee-ground emesis
MelenaMelena
Hematochezia (distal colorectal source)Hematochezia (distal colorectal source)
High level of suspicion withHigh level of suspicion with
 Hypotension, tachycardia, angina, syncopeHypotension, tachycardia, angina, syncope
 WeaknessWeakness
 ConfusionConfusion
 Cardiac arrestCardiac arrest

Labs & ImagingLabs & Imaging
Type & crossmatchType & crossmatch: Most important!: Most important!
CBC, BUN, creatinine, electrolytes, coagulation studies,CBC, BUN, creatinine, electrolytes, coagulation studies,
LFTsLFTs
Initial Hct often will not reflect the actual blood lossInitial Hct often will not reflect the actual blood loss
AXR & CXR of limited value for source of bleedAXR & CXR of limited value for source of bleed
Nasogastric (NG) tubeNasogastric (NG) tube
 Gastric lavageGastric lavage
AngiographyAngiography
Bleeding scanBleeding scan
Endoscopy/colonoscopyEndoscopy/colonoscopy

Management in the EDManagement in the ED
 AIRWAYAIRWAY
 ensure airway; prevent aspiration of bloodensure airway; prevent aspiration of blood
 BREATHINGBREATHING
 O2, continuous pulse oximetryO2, continuous pulse oximetry
 CIRCULATIONCIRCULATION
 Cardiac monitoringCardiac monitoring
 CrystalloidsCrystalloids
 General guidelines for BTGeneral guidelines for BT
• Active bleeding. Failure to improve perfusion after 2 L ofActive bleeding. Failure to improve perfusion after 2 L of
crystalloidcrystalloid
• Lower threshold in the elderlyLower threshold in the elderly
 NOT BASED ON INITIAL HEMATOCRIT ALONENOT BASED ON INITIAL HEMATOCRIT ALONE


ManagementManagement
Early GI consultEarly GI consult for severe bleedsfor severe bleeds
Therapeutic Endoscopy:Therapeutic Endoscopy: band ligation or injectionband ligation or injection
sclerotherapysclerotherapy
 Also….electrocoagulation, heater probes, & lasersAlso….electrocoagulation, heater probes, & lasers
Drug Therapy:Drug Therapy: somatostatin, octreotide, vasopressin, PPIssomatostatin, octreotide, vasopressin, PPIs
Balloon tamponade:Balloon tamponade: adjunct oradjunct or
temporizing measuretemporizing measure
Surgery:Surgery: if all else failsif all else fails

ADMITADMIT
 Certain pts. with lower GI bleeding may be dischargedCertain pts. with lower GI bleeding may be discharged
for Outpatient work-upfor Outpatient work-up
Pts. are risk stratified by clinical & endoscopic criteriaPts. are risk stratified by clinical & endoscopic criteria
Independent predictors ofIndependent predictors of adverse outcomesadverse outcomes in upper GIin upper GI
bleeding (Corley & colleagues):bleeding (Corley & colleagues):
 Initial hct. <30%Initial hct. <30%
 Initial SBP <100 mmHgInitial SBP <100 mmHg
 Red blood in the NG lavageRed blood in the NG lavage
 H/of cirrhosis or ascites on examinationH/of cirrhosis or ascites on examination
 H/of vomiting red bloodH/of vomiting red blood

Abdominal Pain Clinical PearlsAbdominal Pain Clinical Pearls
Significant tenderness should never be attributed to GESignificant tenderness should never be attributed to GE
Severe AP should be taken as serious d.Severe AP should be taken as serious d.
Pain awakening from sleep is considered significantPain awakening from sleep is considered significant
Incidence of GE in the elderly is very lowIncidence of GE in the elderly is very low
Always do genital exam when lower AP is present – inAlways do genital exam when lower AP is present – in
males & females, inmales & females, in youngyoung && oldold
In older pts. with renal colic SS, exclude AAAIn older pts. with renal colic SS, exclude AAA

Sudden, severe pain suggests serious dSudden, severe pain suggests serious d
Pain almost always precedes vomiting in surgical causes;Pain almost always precedes vomiting in surgical causes;
converse is true for most gastroenteritis & NSAPconverse is true for most gastroenteritis & NSAP
Ac. cholecystitis is the commonest surgical emergency inAc. cholecystitis is the commonest surgical emergency in
the elderlythe elderly
If the pain of biliary colic lasts >6h, suspect earlyIf the pain of biliary colic lasts >6h, suspect early
cholecystitischolecystitis
A lack of free air on a CXR does NOT rule out perforationA lack of free air on a CXR does NOT rule out perforation
CF of PUD, gastritis, reflux & dyspepsia significantly overlapCF of PUD, gastritis, reflux & dyspepsia significantly overlap
Abdominal Pain Clinical Pearls …Abdominal Pain Clinical Pearls …

MCQMCQ
AP in children is usually self limitingAP in children is usually self limiting
RAP in children is mostly functionalRAP in children is mostly functional
AP away from umbilicus is more significantAP away from umbilicus is more significant
Early appendicitis can be treated conservativelyEarly appendicitis can be treated conservatively
Rebound always means peritonitisRebound always means peritonitis

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