Abdominal Pain (Case 19)

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Chapter 26
Abdominal Pain (Case 19)

Shamina Dhillon MD, Henry Schoonyoung MD, and Jessica L. Israel MD

Case: A 54-year-old man with a history of hypertension, diabetes mellitus, and hyperlipidemia presents to the emergency department (ED) complaining of progressive epigastric pain for the last 2 days. The pain initially woke him from a deep sleep. He describes his discomfort as “sharp” and states it has worsened in intensity over the last few hours. He also complains of nausea and has had two episodes of clear vomiting. He has been unable to tolerate any solid food since the onset of the pain. He is passing gas and recalls his last bowel movement was earlier in the day. He has never had symptoms like this before. He denies any fevers or chills. He has had no sick contacts. He is not a heavy drinker and reports only drinking one glass of wine with dinner 5 days ago. He quit smoking several years ago.

On physical exam, his temperature is 100.4° F. His heart rate is 110 beats per minute (bpm) and blood pressure (BP) is 151/92 mm Hg. The patient’s sclerae are mildly icteric, but there is no overall evidence of jaundice. His abdomen is soft with mild distension. He has significant tenderness in the epigastrium and right upper quadrant (RUQ) to palpation but without any guarding or rebound.

Differential Diagnosis

Perforated viscus

Cholecystitis

Acute mesenteric ischemia

Diverticulitis

Appendicitis

Pancreatitis

Choledocholithiasis

 

Speaking Intelligently

When evaluating a patient with abdominal pain, a detailed history about the character, duration, and quality of pain is imperative. It is important to discern exactly how and when the pain started and inquire about its location; this can give you important clues as to the underlying diagnosis. A nocturnal component to the pain often suggests an organic or serious cause. It is also important to inquire about exacerbating and alleviating factors, as well as any association of the pain with nausea, vomiting, fevers, or chills, and if ingestion of food worsens the pain.

PATIENT CARE

Clinical Thinking

• When evaluating a patient with abdominal pain, it is important to determine if the symptom is acute or chronic.

• A patient with a 6-month history of pain is less likely to have an acute abdomen.

• A good clinician must always be on the lookout for the possibility of an abdominal disorder requiring surgery, which would require urgent intervention; time may be critically important in these cases.

History

• Pain that is sudden in onset or wakes a person from sleep usually signifies an acute abdominal process. It is thus important to ask the patient what he or she was doing when the pain began.

• It is also imperative to determine if the pain was mild and progressively worsened, or if it was severe at onset.

• Ask patients to rate their pain on a scale of 1 to 10.

• Pain associated with nausea and vomiting can be seen in patients with pancreatitis.

• Fever and chills are associated with cholecystitis.

Physical Examination

• The most urgent assessment during a physical exam is to determine if there are signs of peritonitis, including a careful assessment for rebound tenderness and guarding.

Absent bowel sounds may also signify a more critical intra-abdominal pathology.

• The location of tenderness can be important to elucidate a particular etiology for the patient’s symptoms. For example, right lower quadrant (RLQ) pain is often seen in patients with appendicitis, and left lower quadrant (LLQ) tenderness is closely associated with diverticulitis.

Tachycardia and hypotension can be signs of both pain and volume depletion.

Tests for Consideration

White blood cell (WBC) count: This can signify either infection or an intense inflammatory response.

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Liver function tests: Aspartate aminotransferase (AST), alanine transaminase (ALT), alkaline phosphatase, prothrombin time (PT), partial thromboplastin time (PTT), amylase, and lipase

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IMAGING CONSIDERATIONS

→ Plain abdominal radiographs: This is most important for evaluating for free air in the abdomen, which implies perforation and the need for urgent surgery.

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→ CT scan: This is best done with both oral and IV contrast. If perforation is suspected, a water-soluble oral contrast agent is often used.

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Clinical Entities Medical Knowledge

Perforated Viscus

This is a transmural injury of an organ resulting in perforation through the serosa. Common etiologies of perforation include ulcer disease in the duodenum or stomach, intestinal ischemia, and diverticular transmural inflammation.

TP

Patients present with sudden onset of acute pain. On physical examination, most patients will have signs of peritonitis such as rebound or guarding. It is important to recognize these findings, as some patients will require emergent surgical intervention.

Dx

The abdominal exam is often the most telling. Patients are extremely uncomfortable and lying still. They will often have pain when going over bumps in the stretcher or ambulance. Abdominal imaging will show free air. If a CT scan is done, it can show extravasation of contrast at the point of perforation.

Tx

The treatment is surgical repair. These patients also require antibiotics (targeted principally against gram-negative bacilli and anaerobes) as well as fluid resuscitation. See Cecil Essentials 34, 37.

 

Cholecystitis

The hallmark of this disease is gallbladder inflammation, most often secondary to gallstones. Acute cholecystitis can be associated with cystic duct obstruction. On a pathologic spectrum, the disease can manifest as mild edema, acute inflammation, or necrosis and gangrene of the gallbladder. The clinician should be aware of the possibility of acalculous cholecystitis. This entity is clinically similar to acute cholecystitis but is not associated with gallstones. Acalculous cholecystitis is usually found in the critically ill patient.

TP

Acute cholecystitis presents as steady RUQ pain with fever and leukocytosis. The pain can also be located in the epigastrium, and it can radiate to the patient’s right shoulder or back. The pain may be associated with nausea, vomiting, and anorexia. On exam, patients are usually ill-appearing and tachycardic. A Murphy sign may be positive.

Dx

Patients with uncomplicated cholecystitis do not always have elevated bilirubin, because the common bile duct is not obstructed. Mild elevation in serum aminotransferases can be seen. An ultrasound often shows gallbladder wall thickening >4 mm, along with gallstones and pericholecystic fluid. A hepatobiliary iminodiacetic acid (HIDA) scan may be helpful to rule out choledocholithiasis; a positive test will show no visualization of the gallbladder after IV injection of the isotope due to obstruction of the cystic duct.

Tx

The treatment of acute cholecystitis consists of IV hydration, correction of electrolyte abnormalities, and analgesia. IV antibiotics should target common biliary pathogens including Klebsiella, Enterococcus, Enterobacter, Escherichia coli, and anaerobes. Early cholecystectomy (now almost always performed laparoscopically) is ideal, and surgical consultation should be obtained. See Cecil Essentials 46.

 

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Choledocholithiasis