Abdominal Pain

A common problem which may arise under any circumstances is acute abdominal pain. Knowing when such conditions may require a tums vs. evacuation to advanced medical care is essential.

Initial Evaluation of Abdominal Pain Several things can help determine the probable cause of a patient's abdominal pains, knowing the abdominal anatomy is very important:

http://meded.ucsd.edu/clinicalmed/abdomen.htm

Evaluation of the Right Upper Quadrant and common causes of pain:

Gallbladder Disease: More common in women, over 40, or during pregnancy, often with family history of gallbladder disease. Cramping pain below R upper ribs, sometimes radiating into the back/shoulder blades, pain worsens after fatty meals can last min. to hours, bloated feeling, belching & gassy, nausea, pain is made worse with palpation while having the patient take a deep breath. Gallbladder disease is an emergency when symptoms come with high fever, severe pain, severe vomiting, or jaundice (yellowing of skin/eyes).

Liver Disease/Injury: Liver Disease is rarely acute (rapid onset), but can develop rapidly from drug overdose (Tylenol) and acute hepatitis (liver inflammation) from viruses. Liver disease is an emergency when it is associated with high fever, severe pain, severe vomiting, or jaundice (yellowing of skin/eyes). Liver injury can occur from blunt force trauma, often associated with fractured ribs, and can result in blood loss and shock. Emergency: signs of hypovolemic shock

Evaluation of the Epigastric area and common causes of pain (stomach area)

Stomach/Gastric Pain Stomach pain can be caused by simple problems like gastritis from a spicy meal or simple gas pains. These usually resolve quickly with OTC medications. Ulcers are associated with NSAID (Ibuprofin, Naprosyn) use. Pain increases sometimes after meals or on an empty stomach depending where the ulcer is located, and may or may not be relieved with antacids. Stomach ulcers are an emergency when: signs of hypovolemic shock, vomiting blood, black sticky stool, or episodes of fainting.

Pancreas Pain: Acute pancreatitis is associated with alcohol abuse, gallstones, and sometimes trauma. Pain is sudden onset of epigastric abdominal pain that radiates to the back and flanks. The pain usually is constant and boring. Nausea and vomiting are commonly associated symptoms. The symptoms may begin after a heavy meal or after a drinking binge. The abdomen may be distended and tenderness may exist over the upper abdomen. Rarely, the skin overlying the flank or abdominal wall may have a purple hue from hemorrhage. Pancreatitis may follow a mild course in approximately 70-80% of patients, and resolve without intervention other than supportive care. In 20-30% of patients, the disease follows a more severe clinical course. Signs of pancreatic infection and multisystemic organ failure include high fever, loss of consciousness, and septic shock.

Evaluation of the Left Upper Quadrant area and common causes of pain: Spleen Pain

Acute spleen pain is frequently associated with blunt trauma. The spleen filters an estimated 10-15% of total blood volume every minute, and hypovolemic shock (low blood pressure) is a significant risk with splenic injury. Pain presents after trauma, initially with high left upper quadrant tenderness and sometimes left shoulder tenderness. With bleeding into the abdomen, diffuse abdominal pain, peritoneal irritation, and rebound tenderness are more likely. Spleen pain following injury is always an emergency because it is difficult to fully asses without advanced imaging. Signs of hypovolemic shock can progress rapidly over minuets to hours. Emergency surgery may be warranted.

  Note: In the absence of trauma, spleen pain can also be associated with inflammation from infection, rarely an emergency.

Colon Pain

  Colon pain can arise for a number of reasons, including:
  acute diarrhea illness: usually cramping episodic pain with diarrhea
  gas pains: associated with cramping pain and flatulence
  diverticulitis: more commonly presents in LLQ 

Evaluation of the Left Lower Quadrant area and common causes of pain: Colon Pain (as noted above)

  Diverticulitis:  Infection of small pouches in the colon, more common in ages over 60, abdominal pain - occurs mostly in the left lower quadrant and tends to be steady, severe, and deep.  History of fever suggestive of diverticulitis, previous episodes of dull, colicky, and diffuse abdominal pain accompanied with flatulence, distention, and change in bowel habits.  Altered bowel habits including diarrhea, increased constipation, and tenesmus (pain with defecation).  Nausea and vomiting, severe and generalized abdominal pain (diffuse peritonitis), or back or lower extremity pain (perforation). Abdomen may be distended and tympanic (hollow) on examination.  Often treated with antibiotics such as Cipro, Flagyl, or a combination of both.
  Emergency: signs of hypovolemic shock from blood loss, high fever, septic shock

Ovaries (located both the left and right lower quadrants, one on each side)

  Ovarian pain is most commonly caused by ovarian cysts manifest as pelvic discomfort and heaviness.  Ovarian cysts are extremely prevalent, most often occur on one side, affecting an estimated 7% of premenopausal and postmenopausal woman. Furthermore, up to 4% of women will be admitted to the hospital with a diagnosis of ovarian cysts.  There are several types of ovarian cysts, most resolve without intervention, but some can result in hemorrhage and become life-threatening.  Other causes of pain in the ovaries include eptopic pregnancy and torsion, both are emergencies.  All women of child bearing age with abdominal pain should undergo a pregnancy test to rule-out an eptopic pregnancy.  Untreated eptopic pregnancies are commonly fatal.   

Evaluation of the Right Lower Quadrant area and common causes of pain: Appendicitis

     The appendix is a small tube of tissue attached to the beginning of the colon.  Appendicitis occurs when the tube becomes blocked and infection develops.
     Appendicitis occurs in 7% of the US population.   
     Classic history of lack of appetite and periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases.   Migration of pain from the area around the belly button to the RLQ is the most accurate feature of the patient's history.  Markle sign (or jump sign), pain elicited in RLQ when the standing patient drops from standing on toes to the heels with a jarring landing, was studied in 190 patients undergoing appendectomy and found to have a sensitivity of 74%.  Duration of  symptoms is less than 48 hours in approximately 80% of adults but tends to be longer in    elderly persons and in those with a perforated appendix. Approximately 2% of patients report duration of pain in excess of 2 weeks.
     Note:  Acute non-perforated appendicitis can be treated successfully with antibiotics such as a combination of Cipro and Flagyl.   This decision should be made with the consultation of a surgeon when available.
   Emergency: Every case of potential appendicitis should be evaluated at a hospital (when available), septic shock and death can develop as a result of a perforated appendix.

Evaluation of Suprapubic area (just above the pubic bone) and common causes of pain: Bladder The most common cause of bladder pain is Cystitis, a urinary tract infection. Common in females of any age, less common in men, simply due to the length of the urethra. Signs of a UTI also include, pain during urination, the feeling one needs to urinate frequently, pressure pain in the lower back, and sometimes visual blood or foul odor of the urine. UTIs are rarely emergencies, they resolve quickly with antibiotics, and rarely develop into kidney infections if left untreated. Always test for flank pain with the “hammer fist” (costovertebral angle tenderness) test, if this causes pain in the kidney, consider kidney infection. This test is performed with tapping over the kidney region with a closed fist. Note: Urgent Condition: In pregnant women UTI carries a much greater risk of progressing to kidney infection than in non-pregnant women (28 versus 1 percent), and is associated with serious risks to the fetus. UTI's can be treated with several antibiotics, depending upon local bacterial resistance. Common choices include Cipro, Bactrim, Macrobid, and Keflex.

Uterus

  The most common cause of uterus pain is menstruation, associated with cramping and menstrual bleeding.  Rarely becomes an emergency unless excessive heavy bleeding results in hypovolemic shock.  Uterine pain may also be caused from infections, an emergency when present with high fever and septic shock.  Eptopic pregnancy is always an emergency.  Other causes include: normal pregnancy, fibroids, and endometriosis. 
  Note:  Abdominal pain in the female can be one of the most difficult cases to diagnose correctly even in a fully equipped emergency department (ED). The spectrum of gynecological disease is broad, spanning all age ranges and representing various degrees of severity, from benign cysts that eventually resolve on their own to ruptured ectopic pregnancy that causes life-threatening hemorrhage. When in doubt, ship it out.

Generalized Abdominal Pain Abdominal pain that presents in several locations simultaneously is difficult to assess for even a highly trained provider. Common causes include: Gastroenteritis: Usually an infectious viral cause, estimates put diarrhea in the top 5 causes of deaths worldwide, with most occurring in young children in non-industrialized countries. Viral spread from person to person occurs by fecal-oral transmission of contaminated food and water. Some viruses, like noroviruses, may be transmitted by an airborne route. For this reason, it is very important to maintain good sanitation in austere environments. Viral gastroenteritis ranges from a self-limited watery diarrhea illness (usually <1 wk) associated with symptoms of nausea, vomiting, poor appetite, malaise, or fever, to severe dehydration resulting in hospitalization or even death. Gastroenteritis is rarely an emergency unless the development of bloody diarrhea or dehydration results in hypovolemic shock.

Bowel Obstruction: Obstruction of the bowel leads to dilatation of the intestine due to accumulation of GI secretions, and may result in bowel death. If left untreated, this progresses to perforation, peritonitis, and death. BO is characterized with generalized pain, often described as cramp and intermittent and developing to constant pain. Associated symptoms include, nausea, vomiting, diarrhea (early), constipation (a late finding) as evidenced by the absence of flatus (farts) or bowel movements, fever and rapid heart rate. BO is an emergency that requires advanced evaluation, but often resolves with supportive care.

Flank Pain (below the ribs on the lower back) Kidney Stones: The lifetime prevalence of urinary tract stone disease in the United States is approximately 10%. Risk factors include family history, and history of prior stones. Kidney stone pain is characterized by undulating cramps and severe pain and is often associated with nausea and vomiting. Pain may radiate from the flanks into the lower abdomen, and may include the scrotum and pelvis. Visual blood may be seen in the urine. Kidney stones are rarely emergencies unless severe dehydration, or infection (high fever) should develop. If the stone does not pass withing 24-48 hours, and pain is still present, it may be lodged in the ureter and require advanced invasive treatment.

Kidney Infection: Acute pyelonephritis results from bacterial invasion of the kidney. This condition may present with classic symptoms of a UTI, but involve flank pain, high fever, nausea and vomiting. Always test for flank pain with the “hammer fist” (costovertebral angle tenderness) test. Kidney infections require antibiotic treatment, otherwise there is significant risk for septic shock and death. Common antibiotics used include Cipro or Bactrim.

Final Thoughts: In general, seek advanced medical care anytime abdominal pain is constant for more than 4-6 hours, or is accompanied by frequent or projectile vomiting (forceful), or fever. Even the most seasoned emergency department providers have difficulty with making an accurate diagnosis without advanced diagnostic testing.

If located in a remote location, "when in doubt, ship it out".