This is a lecture by Dr. Jim Holliman from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

1. Project: Ghana Emergency Medicine Collaborative
Document Title: Management of Patients with Abdominal Pain in the
Emergency Department
Author(s): Jim Holliman, M.D., F.A.E.C.P.
License: Unless otherwise noted, this material is made available under
the terms of the Creative Commons Attribution Share Alike-3.0
License:
http://creativecommons.org/licenses/by-sa/3.0/
We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your
ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly
shareable version. The citation key on the following slide provides information about how you may share and
adapt this material.
Copyright holders of content included in this material should contact open.michigan@umich.edu with any
questions, corrections, or clarification regarding the use of content.
For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use.
Any medical information in this material is intended to inform and educate and is not a tool for selfdiagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.
Please speak to your physician if you have questions about your medical condition.
Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
1

2. Attribution Key
for more information see: http://open.umich.edu/wiki/AttributionPolicy
Use + Share + Adapt
{ Content the copyright holder, author, or law permits you to use, share and adapt. }
Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105)
Public Domain – Expired: Works that are no longer protected due to an expired copyright term.
Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain.
Creative Commons – Zero Waiver
Creative Commons – Attribution License
Creative Commons – Attribution Share Alike License
Creative Commons – Attribution Noncommercial License
Creative Commons – Attribution Noncommercial Share Alike License
GNU – Free Documentation License
Make Your Own Assessment
{ Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. }
Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in
your jurisdiction may differ
{ Content Open.Michigan has used under a Fair Use determination. }
Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your
jurisdiction may differ
Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that
your use of the content is Fair.
2
To use this content you should do your own independent analysis to determine whether or not your use will be Fair.

3. Management of Patients
with Abdominal Pain in
the Emergency Department
Jim Holliman, M.D., F.A.C.E.P.
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences
Clinical Professor of Emergency Medicine
George Washington University
Bethesda, Maryland, U.S.A.
3

4. Abdominal Pain
Lecture Outline
•
•
•
•
•
•
Recognition & resuscitation for lifethreatening causes of abd. pain
Physical exam features
Choosing diagnostic tests
Initial treatment
Differential diagnosis
Key points about the most common
specific causes
4

5. Abdominal Pain : Diagnostic &
Treatment Priorities
•
•
•
•
•
•
First : recognize presence of shock or intraabdominal
bleeding
Second : start resuscitative measures for shock or
bleeding (if these are present)
Third : determine if the abdomen is the source of the
shock or bleeding
Fourth : determine if emergency laparotomy is
needed
Fifth : complete the secondary survey (head to toe
exam) ; obtain needed lab or radiographic studies
Sixth : Conduct frequent reassessments of the patient
5

6. General Approach to the Patient
Presenting with Abdominal Pain
•
•
•
•
Evaluate & treat the ABC's (Airway, Breathing,
Circulation) first in same sequence as for any other
emergency patient
Determine if an immediate life-threatening cause of
abd. pain may be present & if there is any history of
possible abd. trauma
Start resuscitation and emergently consult a surgeon
if an emergent laparotomy is needed
Complete the secondary survey, treat pain, and
decide what other diagnostic tests will be needed
6

7. 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)
7

8. Ruptured Abdominal Aortic
Aneurism (AAA)
•
•
•
•
•
•
•
•
More common in males > 65 years of age
May present initially as back or groin pain
Typically would have epigastric or periumbilical pain radiating to
back
May present in shock from intraperitoneal rupture
(retroperitioneal rupture may initially be contained)
Often can feel pulsating supraumbilical mass (if you can feel the
aortic pulse width > 4 cm : suspect AAA)
Can sometimes make this Dx from lateral X-ray of abd.
Bedside ultrasound (U/S) is best Dx test for unstable patient
Abd. CT scan is best Dx test for stable patient (surgeon may also
want angiography preop if patient is stable)
8

9. Source Undetermined
Ultrasound showing 7.5 cm AAA with intraluminal clot
9

10. Source Undetermined
CT scan of AAA (L = lumen, T = thrombus)
10

11. Emergency Management of
Ruptured AAA
•
•
•
•
•
•
Oxygen & IV fluid resuscitation (normal saline or
lactated Ringer's) if systolic BP < 100 mm Hg (but
do not "overresuscitate" ; do not increase the BP
to over 120 systolic because higher BP may cause
increased bleeding)
Type and cross for at least 6 units of blood
Insert foley catheter
Obtain an electrocardiogram
Emergently consult a surgeon
Notify the operating room
11

12. Ruptured Spleen or Liver
•
•
•
Usually due to trauma, but can be spontaneous
from malaria, mononucleosis, or hematologic
diseases
Patient may present with shock ; may also have
referred pain to shoulder (Kehr's sign)
Dx and Rx considerations & sequence same as for
ruptured AAA (IV fluid, Type & cross, U/S or CT,
call surgeon, etc.)
12

13. Ruptured Ectopic Pregnancy
•
•
•
•
•
•
Most common cause of pregnancy-related death in
U.S.A.
May NOT have missed menstrual period
Typically have severe sudden onset lower abd. pain
+/- shock
Should obtain stat serum or urine HCG test in any
female of reproductive age with abd. pain
Pelvic U/S is Dx test of choice
Rx : Oxygen, IV fluid (NS or LR), Type & cross at least
2 units, emergently consult surgeon or obstetrician
13

14. Bowel Infarction
•
•
•
•
Due to clot embolus or thrombosis in mesenteric
artery
Most patients have severe coronary artery disease
(this can be a post-MI complication)
May have "pain out of proportion to findings" (may
not demonstrate much tenderness)
Physical exam may show signs of peritonitis,
hypoactive bowel sounds, blood in rectum or
guiac positive stool
14

15. Bowel Infarction (cont.)
•
•
•
•
Usual lab findings :
• High WBC
• Severe lactic acidosis (anion gap > 18)
Plain X-ray film findings :
• Free air, air in portal vein, air in bowel wall
("pneumatosis intestinalis")
May need emergent angiography for Dx
Rx : Oxygen, IV fluid resuscitation, IV broad
spectrum antibiotics, consult surgeon
15

16. Source Undetermined
Non-occlusive mesenteric ischemia in 84-year-old man with abdominal 16
pain

17. Angiogram (arrow
shows superior
mesenteric artery
clot) of a 65 year
old male with
bowel ischemia
Source Undetermined
17

18. Perforated Viscus
•
•
•
Causes :
• Blunt or penetrating trauma, tumors,
inflammaory bowel disease, typhoid fever,
amebiasis, other parasites
Typically see free air under diaphragm on plain
films (Chest X-ray is most sensitive to see small
amounts of air)
Rx : Oxygen, IV fluids, IV broad spectrum
antibiotics (such as cefoxitin & metronidazole),
emergently consult surgeon
18

19. Free air under the
diaphragm from a
perforated peptic
ulcer
Source Undetermined
19

20. Source Undetermined
Chest X-ray showing colonic interposition (NOT free air) 20

21. Abdominal film
showing the
“Rigler double
wall sign” of free
intraperitoneal
air (can see both
inside and
outside wall of
bowel)
Source Undetermined
21

22. Acute Myocardial Infarction (MI) as
a Cause of Abdominal Pain
•
•
•
•
•
Suspect in adult patient with upper abd. pain but
no or minimal abd. tenderness
Inferior MI commonly presents as "indigestion" ;
may also have emesis
MI may also secondarily occur from shock due to
an intraabdominal cause (such as intraluminal
bleed, etc.)
Dx by EKG +/- enzymes ; need Chest X-ray also
Rx : Oxygen, IV line, nitrates, aspirin, consider
thrombolytics, etc., & admit to monitor bed unit
22

23. Now That Immediate Life-Threatening Causes of Abd.
Pain Have Been Reviewed, Next the Lecture Will
Review History and Exam for the Stable Patient
•
History items to ask the patient with abd. pain :
• Time and rapidity of onset
• Character of pain (burning, cramping, etc.)
• Associated symptoms
• Signs of bleeding (dark vomitus or stool)
• Prior surgeries & illnesses
• Last menstrual period
• Medications (especially steroids, aspirin, warfarin)
• Alcohol intake
• Unusual ingestion or foreign travel
23

24. Physical Exam for the Patient
with Abdominal Pain
•
•
•
•
•
•
Need complete set of vital signs
Look in nose and mouth for sites of bleeding
(swallowed blood may mimic an intraluminal bleed)
Look at skin for stigmata of liver disease or signs of
coagulapathy
Careful chest & lung exam (basilar pneumonias can
present as abd. pain)
Palpate and observe the back
Genital and rectal exam (& stool guiac) should usually
be routine
24

25. Exam of the Abdomen in the
Patient with Abdominal Pain
•
•
•
Inspection : Look for :
• Scars from prior surgeries
• Distension
• Localized swelling or mass
• Eccymoses or erythema
• Visible peristalsis
Auscultation with stethescope
• Listen for bowel sounds & bruits
Palpation & percussion
25

26. Interpretation of Bowel Sounds
(Associated, but not Definite, Diagnoses)
•
•
•
•
High pitched or "tinkling" : bowel obstruction
Continuous & hyperactive : acute
gastroenteritis
Absent : ileus or peritonitis (need to listen for
at least one minute)
Audible without stethescope : "borborygmi"
26

27. Percussion of the Abdomen
•
•
•
•
Should tap with 2 fingers on all 4
quadrants
If tympanitic : implies bowel
obstruction
If dull, implies intraabdominal bleding
or fluid (such as ascites)
If tender, correlate with tender areas
noted on palpation
27

28. Palpation of the Abdomen
•
•
•
•
•
Should be done following inspection & auscultation
Assess for tenderness, guarding, mass, crepitus,
referred tenderness
Differentiate lower rib tenderness from true upper abd.
tenderness
Don't need to directly assess rebound ; just wiggle
abdomen from the side & check for referred tenderness
(direct rebound is cruel if peritonitis is present)
Don't forget leg maneuvers (psoas, obturator, & heel tap
signs)
28

29. Lab Studies for Patients with
Abdominal Pain
•
•
•
Use selectively ; not all are needed for
all patients
For example, for young adults with
simple acute viral gastroenteritis or
food poisoning, usually no lab studies
are needed (they may just need IV
fluids & parenteral antiemetics)
Draw with the initial venipuncture if an
IV line is to be established
29

30. List of Lab Studies to Consider for
Patients with Abdominal Pain
•
•
•
•
•
•
•
•
•
•
•
•
•
Type and Cross (the most important if patient has shock)
Complete blood count (CBC)
Urine or serum pregnancy test (HCG)
Serum amylase, lipase
Urinalysis, urine culture and sensitivity
Liver function tests (bilirubin, SGOT, SGPT, alk. phos.)
Electrolytes, glucose, creatinine, blood urea nitrogen (BUN)
Serum alcohol, serum or urine drug screen
Serum medication levels (such as digoxin)
Clotting studies (platelet count, protime, PTT, fibrinogen)
Cardiac enzymes (if coronary ischemia suspected)
Blood culture (if sepsis or bacteremia suspected)
Nonemergent tumor markers (CEA, AFP)
30

31. Interpretation of Lab Studies for
Abdominal Pain
•
WBC typically elevated (+/- "left-shifted") in any
cause of peritonitis & in bowel infarction & in
spleen & liver bleeding
• However often NOT elevated appropriately in :
•
the elderly
•
immunocompromised patients
•
patients on chronic corticosteroid Rx
31

32. Interpretation of Lab Studies for
Abdominal Pain (cont.)
•
•
•
Hematocrit may be normal in early stages of even
severe hemorrhage
BUN to creatinine ratio of > 20 to 1 may indicate
upper gastrointestinal (GI) bleed with digestion
of blood in upper GI tract
Degree of elevation of amylase or lipase does not
always correlate with severity of panceatitis or of
pancreatic injury
• Amylase may also be chronically elevated in
patients with renal dysfunction
32

33. Plain Radiographs for
Abdominal Pain
•
•
If needed, usually the 3 view "Acute Abdomen Series " is
best (upright Chest X-ray, upright and flat plate of the
abd.)
• Chest X-ray best shows small amounts of free air
• Upright abd. film best shows bowel air-fluid levels
(indicating bowel obstruction or ileus if multiple)
• Look also for abnormal calcifications
"KUB" film is oriented to include all the pelvis, whereas
"abd. flat plate" is oriented to include the diaphragms
(so these two are different for a tall patient)
33

34. Diagnostic Ultrasound for
Abdominal Pain
•
Dx test of choice for :
• Unstable patient in shock & suspected
intraabdominal bleed
• Gallstones (cholecystitis)
• Ectopic pregnancy
• Other complications of pregnancy
(placenta previa, abruptio, etc.)
• Renal or ureteral stones in the pregnant
patient
34

35. Source Undetermined
Ultrasonogram, transverse view, reveals marked thickening of gallbladder
wall (white arrows), cholelithiasis with shadowing (black arrows), and
35
pericholecystic fluid consistent with acute cholecystitis.

36. Source Undetermined
Impacted stone in distal common bile duct in elderly patient with obstructive
jaundice and sepsis. Longitudinal sonogram reveals markedly dilated common
36
bile duct (CD) from a stone (arrow) with shadowing. P, portal vein

37. Disadvantages of Diagnostic
Ultrasound
•
•
•
•
Visualization may be limited by bowel gas or
obesity
Good interpretation requires experience
Not good at showing retroperitoneal
conditions
May not directly visualize solid organ
lacerations
37

38. Use of Computed Tomography
(CT) for Abdominal Pain
•
•
Noncontrast spiral scan is now method of
choice for ureteral calculi (replaces
intravenous pyelogram or IVP)
Using both IV and oral (or via nasogastric
tube) contrast can then show appendicitis,
diverticulitis, etc.
• However even with greater use of CT for
appendicitis, overall accuracy of this Dx
in the E.D. has not improved
38

39. Other Diagnostic Studies to
Consider for Abdominal Pain
•
If contrast CT not available :
• Gastrografin Upper GI study for suspected :
•
Stomach or bowel perforation
•
Diaphragm rupture
•
Duodenal hematoma
• Never do barium GI study if any chance of
barium leak (causes severe peritonitis)
• Intravenous pyelogram (IVP) for suspected :
•
Ureteral stone or injury
•
Renal mass
39

40. Other Diagnostic Studies to Consider
for Abdominal Pain (cont.)
•
•
•
•
Retrograde urethrogram / cystogram for
suspected urethral or bladder injury
Fistulogram for any suspected abdominal
wall fistula
Technetium bleeding scan to localize
intraluminal GI bleed
Angiography for preop planning of surgery
for stable patient with AAA, or for
suspected arterial bleed or mesenteric
ischemia
40

41. Source Undetermined
Acute gangrenous cholecystitis in 82-year-old woman with history of
gallstones had right upper quadratic pain, nausea, vomiting, and fever.
DISIDA scan demonstrated non-visualization of gallbladder (GB) and
increased radioactivity in adjacent right lobe of liber (curved arrow) from
41
reactive hyperemia.

42. Post-Exam "Procedures" to Consider for
the Patient with Abdominal Pain
•
•
•
Insertion of foley catheter
• Indicated for monitoring of any unstable patient or if
urinary retention suspected
Insertion of nasogastric (NG) tube (see next slide)
Paracentesis (needle aspirate of abd. fluid)
• Indicated for :
• Suspected infected ascites (check cell count &
culture)
• Relieving tense ascites
• Sometimes can make Dx of bowel perforation or
intraabd. bleed
42

43. Usefulness Of NG Tube Suction for
the Patient with Abdominal Pain
•
•
•
•
•
•
Allows decompression of stomach
Lessens risk of aspiration
Can remove some of residual toxins in
stomach
May demonstrate upper GI bleeding
Required before peritoneal lavage
Contraindicated if nasal or midface
fractures or severe coagulapathy
(insert via mouth instead)
43

44. General Mechanisms Causing
Abdominal Pain
•
Pain originating in the abdomen
• Peritonitis
• Distension of hollow viscera
• Ischemia
•
•
•
Pain referred to the abdomen from
another part of the body
Metabolic disorders
Neurogenic disorders
44

45. Acute Cholecystitis
GI Reflux
Angina
Pancreatic
Pain
Cholocystitis
Splenic
Infarct
Pleuritic Pain
Sources of
Referral
Abdominal
Pain
Appendicitis
Diverticulitis
Renal Colic
45
Lena Carleton, University of Michigan

46. Causes of Referred Abdominal
Pain from Chest Conditions
•
•
•
•
•
Acute coronary syndromes (and "angina
equivalents")
Pneumonia (especially basilar)
Spontaneous pneumothorax
Pulmonary embolus (rare cause)
Pericarditis
46

47. Metabolic Causes of Abdominal
Pain
•
•
•
•
•
•
Diabetic ketoacidosis
Hyperlipidemia (often with pancreatitis)
Acute prophyrias
Black Widow spider bites
Scorpion bites
Sickle cell crisis (sequestration in spleen
or liver, or vaso-occlusive)
47

48. Neurogenic Causes of
Abdominal Pain
•
Herpes zoster (Shingles)
• Pain often present several days before
characteristic dermatomal vesicles appear
•
•
Thoracic or lumbar spinal disc disease or
compression
Syphilis ("tabetic crisis")
48

49. Preston Hunt, Wikimedia Commons
Patient with Herpes Zoster (“Shingles”) of the abdomen
49

50. Trauma-Related Causes of
Abdominal Pain
•
May present delayed, or from seemingly minor
trauma in the elderly :
• Ruptured spleen or liver
• Bowel or stomach perforation
• Pancreatic contusion or transection
• Ruptured bladder
• Mesenteric hematoma
• Abdominal wall hematoma (U/S is good at
diagnosing this)
50

51. Pregnancy-Related Causes of
Abdominal Pain
•
•
•
•
•
Ectopic (usually tubal) pregnancy
False labor (Braxton-Hicks contractions)
Active labor
Abruptio placentae (note that placenta
previa which can cause severe bleeding is
usually painless)
Septic abortion
51

52. Genitourinary Tract Causes of
Abdominal Pain
•
•
•
•
•
•
•
•
Cystitis
Pyelonephritis
Ureterolithiasis
Perinephric abscess (may see gas around kidney
on KUB film)
Renal infarction (as from sickle cell disease)
Psoas abscess
Testicular torsion
Urinary retention (as from prostatic hypertrophy)
52

53. Peritonitis Causing Abdominal Pain
•
•
•
•
•
Definition : inflammation of the peritoneum
Causes : exposure of peritoneum to gastric acid, bile, urine,
blood, pancreatic enzymes, bacteria, stool, or exogenous toxins
Complications : fluid & electrolyte disorders, "third spacing" of
fluid causing hypovolemia & shock, paralytic ileus
Symptoms and signs : abdominal pain, rebound tenderness,
abdominal muscle guarding or rigidity, fever, emesis, decreased
bowel sounds, abdominal distention
Key Rx : IV fluid resuscitation, IV antibiotics (usually), EARLY
PAIN RELIEF WITH NARCOTICS, try to determine the most likely
cause, emergently consult a surgeon
53

54. List of Most Common Causes of
Acute Abdominal Pain in Adults
•
•
•
•
•
•
•
•
Acute gastroenteritis
Acute cholecystitis
• Acute cholangitis
Acute appendicitis
Acute diverticulitis
Acute gastritis or peptic
ulcer
• Acute esophagitis
Acute panceatitis
Bowel obstruction
Inflammatory Bowel
Disease
•
•
•
•
•
•
•
•
•
Acute salpingitis (pelvic
inflammatory disease)
Acute pyelonephritis
Acute cystitis
Ureterolithiasis
Urinary retention
Acute viral hepatitis
Mesenteric ischemia
Ovarian cysts
Complications of
pregnancy
54

55. Caveat About Workup of
Abdominal Pain in the E.D.
•
•
Several large studies show that even after
complete workup, 60 % of E.D. patients with
abdominal pain do not have a specific
diagnosis
For most of these patients, it is appropriate
just to treat their symptoms (pain meds,
antispasmodics, antiemetics, etc.) and
perform further diagnostic tests only if their
pain does not resolve in one to 2 days
55

56. Acute Gastroenteritis
•
•
•
•
•
Present with nausea / emesis / diarrhea
Usually viral or reaction to food
If bacterial, usually have abd. tenderness +/lower GI bleeding
If abd. nontender and diarrhea is nonbloody,
usually do not need lab studies
Rx with IV LR 1 to 5 liters, oral, rectal, or
parenteral antiemetics, +/- antidiarrheals
56

57. Choices for AntiEmetics in the E.D.
•
•
•
•
My favorite : hydroxyzine (Atarax, Vistaril)
• Antihistamine, also an antianxiety agent
• Very low incidence of side effects
• 25 to 50 mg IM or PO q 6 hours
Promethazine (Phenergan)
• Some risk of dystonic reactions & sedation
• 25 to 50 mg q 6 hours IV, IM, PO, or PR
Prochlorperazine (Compazine)
• 40 to 50 % incidence of dystonic reactions
• 10 to 25 mg q 6 hours IV, IM, PO, or PR
Metclopromide (Reglan) : 5 to 20 mg q 4 hrs. IV, IM, or PO
57

58. Choices for AntiDiarrheals in the
E.D.
•
•
•
•
•
Do not use these in patients with tender abdomen
or toxicity
Lomotil (diphenoxylate and atropine)
• 2 tabs PO, then one after each diarrheal stool
up to 8 per day
Loperamide (Imodium)
• 2 mg tabs, same dosing as Lomotil
Codeine 15 to 60 mg PO q 4 hours
Donnatal elixir 2 tsp PO q 6 hours (good antispasmodic)
58

59. Acute Cholecystits
•
•
•
•
•
•
•
Usual clinical profile is obese female > age 40
May cause more complications in diabetics
Usually RUQ +/- epigastric tenderness and emesis
U/S is best Dx test
LFT's usually normal ; lipase & amylase elevated if secondary
panceatitis (common duct stone)
If cholangitis (severe RUQ tenderness, fever, emesis, usually
elevated LFT's, +/- air in biliary tree on X-ray) : consult surgery
emergently
Rx : IV fluids, NPO at first, pain meds, surgery consult unless
quickly resolves
59

60. Source Undetermined
Gallstone ileus in 75-year-old woman with intermittent abdominal distention,
nausea and vomiting for 2 weeks. Supine abdominal film shows distended
60
small bowel loops and faint lamellated gallstone in right pelvis.

61. Source Undetermined
Emphysematous cholecystitis (arrows show gas around the
61
gallbladder)

62. Acute Appendicitis
•
•
•
•
•
•
Accuracy of Dx on clinical grounds alone is not
good
Usually periumbilical pain, then migrates to RLQ
Usually anorexia, nausea, +/- low grade fever
KUB film rarely shows diagnostic appendicolith in
RLQ
U/S and CT can make definitive Dx
Consult surgeon if suspected
62

63. Acute Diverticulitis
•
•
•
•
•
More common after age 45
Typically pain & tenderness in LLQ, but
can be diffuse
Can result in inflammatory mass in
LLQ or perforation
CT with contrast is best Dx test
Milder cases can be discharged on oral
antibiotics
63

64. Acute Gastritis ; Peptic Ulcer
•
•
•
•
Typically epigastric pain & tenderness
If perforation or severe bleeding, may
require laparotomy
Definitive Dx by endoscopy preferred
over Upper GI contrast study, but not
needed for many patients
Rx with H2 blockers such as ranitidine
(in addition to IV fluids, etc. for severe
cases)
64

65. Acute Pancreatitis
•
•
•
•
Usually diffuse abd. pain + back pain,
emesis, elevated amylase & lipase
Often attributed to gallstones or alcohol,
but many cases idiopathic
Can have severe complications :
• Hypovolemia, ARDS, hypocalcemia,
retroperitoneal bleeding or abscess
CT is Dx method of choice
65

66. Bowel Obstruction
•
•
Can be either large or small bowel
Most common causes :
• Adhesions from prior surgery, incarcerated
hernia, cancer, volvulus, mass of parasites,
inflammatory bowel disease
•
•
Plain X-ray films are key Dx test
If possible associated bowel necrosis
(infarction), consult surgeon emergently
66

67. Plain film
showing small
bowel
obstruction from
adhesions in a
72 year old male
Source Undetermined
67

68. Source Undetermined
Upright film showing multiple air-fluid levels from small bowel
68
obstruction

69. Upright film of
sigmoid volvulus in a
67 year old male
69
Source Undetermined

70. Supine film showing
sigmoid volvulus in a
67 year old male
Source Undetermined
70

71. Upright film showing
cecal volvulus in a 62
year old male
Source Undetermined
71

72. Inflammatory Bowel Disease
•
Two types :
• Ulcerative colitis
• Crohn's Disease
•
•
Ulcerative colitis can sometimes have
complication of "toxic megacolon"
Complications of either type may need
Rx with high dose IV steroids in
addition to other usual Rx's
72

73. Acute Salpingitis (Pelvic
Inflammatory Disease)
•
•
•
•
•
Typically present as severe lower abd. pain &
vaginal discharge
Get cervical cultures as part of workup
Usually caused by gonococcus or chlamydia,
but can involve other bacteria
Rx : IV antibiotics, pain meds
Admit to hospital if :
• Toxic, pregnant, immunosuppressed,
suspected tubo-ovarian abscess
73

74. Acute Pyelonephritis
•
•
Usually have dysuria & back pain &
CVA tenderness, but can show
projected anterior abd. tenderness
Admit to hospital for IV antibiotics if :
• Toxic, hypotensive, persistent emesis,
pregnant, immunosuppressed, chronic
or structural renal disease, failure of
outpatient Rx, diabetic, age < 2 or > 60
74

75. Ureterolithiasis
•
•
•
•
•
Commonly have sudden back or flank and/or abd.
pain +/- groin radiation, but not much tenderness
Need early Rx with pain meds (parenteral NSAID such
as ketorolac 30 mg IV is most effective) ; IV morphine
if more analgesia needed
Noncontrast spiral CT is Dx method of choice
• IVP or U/S are alternatives
Should "cover" with antibiotic (such as Bactrim or
Cipro) if any bacteria noted on urinalysis
Over 90 % of patients can be discharged from E.D.
75

76. Urinary Retention
•
•
•
•
•
Most common in elderly men with benign
prostatic hypertrophy
Can occur also from acute prostatitis
Rx with foley catheter
If bladder residual > 100 cc, should leave
foley catheter in at least 24 hours to allow
bladder to recover its muscle tone
Routine use of coverage antibiotics while
foley is in is debated
76

77. Acute Viral Hepatitis
•
•
•
•
Incidence greatly decreased by use of
Hep B and A vaccines
Typically present with nausea, emesis,
+/- RUQ pain, +/- jaundice
Need to check serologies on close
contacts of index case
Admit to hospital if encephalopathic, GI
bleed, increased protime,
hypoglycemic
77

78. Ovarian Cysts and
Complications of Pregnancy
•
•
•
U/S is Dx method of choice for these
Ovarian cysts typically have lower abd.
pain & lateralizing tenderness +/adnexal mass on exam
If large amount of blood in pelvis or
suspected ovarian torsion on U/S,
emergently consult surgeon or
obstetrician
78

79. Some Caveats About Abdominal Pain
•
Don't hesitate to treat the patient's abd. pain
early, even if consulting a surgeon
• It has been definitively shown that pain meds
make the physical exam of the abd. pain
patient MORE reliable
•
•
Don't forget to consider child abuse or
trauma as a cause for abd. pain
Repeated physical exams over time may be
needed to clarify the Dx
79

80. "Secondary" Aspects to
Remember for Abdominal Pain
•
•
•
•
•
•
Oxygen if any possible major systemic
compromise
Question patient about prior anesthetic
complications if surgery anticipated
Additional doses of pain meds as needed
Tetanus immunization if associated skin
injury
Antibiotics (+/- cultures if indicated)
Tell the patient & family what is going on
80

81. Abdominal Pain
Summary
•
•
•
•
•
Assess the ABC's & provide emergent
Rx if life-threatening cause suspected
Complete exam prior to deciding on
other Dx tests
Focus on the most likely Dx's initially
Decide early if surgical consult or
hospital admission needed
Don't forget "secondary" treatments
81