Author: Zack (Page 3 of 9)

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There are HUNDREDS of other non-GI/GU causes of abdominal pain…

Acute coronary syndrome (ACS)

• Test with EKG and troponin

• Treat with aspirin and heparin

Acidosis

• Diabetic Ketoacidosis (DKA)
• Respiratory Acidosis (COPD)
• Salicylate Toxicity (Remember MUDPILES)

Abdominal Aortic Aneurysm (AAA)

Additional Reading

• Approach to STEMI (EM Clerkship)
• Approach to Diabetic Ketoacidosis (EM Clerkship)
• Approach to Salicylate Overdose (EM Clerkship)
• Approach to Abdominal Aortic Aneurysm (EM Clerkship)

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Testicular Torsion

History

• Pain in the testicles
• Referred pain in the flank or lower abdomen
• Usually sudden and severe
• Usually WITHOUT urinary symptoms

Exam

• Asymmetric testicular lie
• High riding testicle
• Tenderness and swelling of the testicle itself
• Cremasteric reflex

Testing

• Testicular Ultrasound

Treatment

• Immediate call to urology when suspected
• Manual detorsion (“Open the Book”)

Prostatitis

History

• Pelvic pain
• Pain with sex
• Urinary symptoms
• Fevers and chills

Exam

• Tenderness of the prostate/epididymis/testicle

Testing

• Urinalysis
• Generally a clinical diagnosis

Treatment

• Commonly sexually transmitted in young men
• Commonly E coli in older men
• Bactrim or Fluoroquinolones

Additional Reading

• Testicular Torsion (EM Clerkship)
• EMRA Antibiotic Guide (Amazon)

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Women have two additional diseases that must be added to the differential diagnosis of their abdominal pain. PID and ovarian torsion.

Pelvic Inflammatory Disease (and Tube-Ovarian Abscess)

Deep pelvic infections high in the reproductive tract frequently caused by sexually transmitted infection but can be caused by other infections (especially anaerobic infections) as well

History

• Symptoms
  • Lower Abdominal Pain
  • Fevers
  • Vaginal Symptoms (especially discharge)
• Red Flags
  • High risk sex
  • Delayed presentations
  • IUD (Don’t need to remove if patient has PID, but needs to be noted)

Exam

It is controversial whether all women with pelvic complaints need a full speculum exam (my opinion is that they don’t and that it almost never changes management)

• Bimanual Exam
  • Cervical motion tenderness
  • Adnexal/Uterine tenderness

Testing

• Gonorrhea
• Chlamydia
• CBC
• Ultrasound to evaluate for tubo-ovarian ABSCESS

Treatment

Patients who are septic, unable to keep antibiotics down, getting worse on oral antibiotics, pregnant, immunosuppressed, or with TOA generally get admitted for IV antibiotics.

• Treat chlamydia
  • Doxycycline
• Treat gonorrhea
  • Cefoxitin/cefotetan (2nd generation cephalosporins provides better anaerobic coverage than a third generation cephalosporins)
  • Ceftriaxone
• Treat anaerobes
  • 2nd generation cephalosporin
  • Metronidazole

Ovarian Torsion

Ovary twists on its pedicle and becomes ischemic

NOTE: The ovary actually has a dual arterial blood supply. When the pedicle twists, it’s not the artery is being pinched off that causes ischemia, rather its the venous outflow becoming blocked and resulting in swelling of the ovary and the poor perfusion that results)

History

• Sudden onset pain
• Severe pain with vomiting
• Usually unilateral pain (although 25% have bilateral pain)

Exam

• Peritonitis in the lower abdomen
• Large mass or adnexal tenderness on pelvic exam

Testing

• Pelvic ultrasound (with doppler)
  • Swollen/edematous ovary
  • Large cyst/mass causing the torsion
  • IMPORTANT- You can frequently see normal arterial flow on the doppler (remember DUAL BLOOD SUPPLY)
• CT scan with NORMAL ovaries 100% negative predictive value for torsion in some studies

Treatment

OBGYN consult for surgery

Additional Reading

• Pelvic inflammatory disease review (Medscape)
• Ovarian torsion review (Medscape)

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How to Read a Urinalysis

• Signs of Inflammation
  • Leukocyte Esterace
  • WBCs

Multiple conditions cause inflammation on a urinalysis. Anything that causes nearby inflammation (appendicitis, pelvic infections, diverticulitis) or slows urine output (dehydration, renal disease) can commonly elevate these markers.

• Signs of bacterial presence (not present in ~25% of proven urinary tract infections!!!)
  • Nitrites
  • Bacteria

Asymptomatic Bacteriuria

Generally should NOT be treated with antibiotics. If you were to randomly sample the population you would find bacteria present in approximately…

• 5% of young people
• 20% of old people
• 50% of patients in long term care

When to Diagnose UTI

• Dysuria AND urinary frequency WITHOUT vaginal symptoms (+LR 20)
• Patient self reports that they think their UTI is back (+LR 4)
• Urinalysis shows BOTH signs of inflammation and bacterial presence
• Combine pretest suspicion with urinalysis findings using clinical judgement

Indwelling Foley Catheters

All patients with an indwelling foley will have a grossly abnormal urinalysis and appearance of urine at baseline. The urinalysis is useless and diagnosis can only be made by clinical judgement

Geriatric Patients

Geriatric patients have minimal symptoms regardless of diagnosis. They can have UTI’s with minimal symptoms. However they can also have appendicitis or kidney stones with minimal symptoms (and asymptomatic bacteriuria at baseline). BE CAREFUL.

Additional Reading

• The best UTI resource I have seen (First10EM)

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All women of childbearing age who present with abdominal pain need a pregnancy test

a core teaching of EMergency medicine

Ectopic pregnancy is the leading cause of maternal death in the first trimester

History

• Abdominal pain present in 90% of cases
• Amenorrhea present in 70% of cases
• Vaginal bleeding present in 50% of cases

The biggest red flag with this complaint is history of receiving fertility treatments (increased risk of heterotopic pregnancy)

Exam

• Abdominal tenderness and peritoneal signs
• Adnexal tenderness
• Paradoxical bradycardia (vagal response caused by peritoneal blood)

Testing

• Type and screen
  • Rh- mother requires RhoGam if exposed to fetal blood
  • Transfusion if develops hemorrhagic shock
• Pelvic ultrasound
  • If no intrauterine pregnancy (IUP) is seen in a pregnant patient, regardless of B-hCG level, the patient might have an ectopic pregnancy
• B-hCG quantitative
  • If no IUP is seen and >1500, strongly suspect ectopic pregnancy
  • If no IUP is seen and <1500, ectopic pregnancy is still possibile

Treatment

• If patient has no IUP and hCG >1500, consult OBGYN
• If patient has no IUP and hCG < 1500, disposition based on clinical appearance

Additional Reading

• Ectopic pregnancy overview (Medscape)

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Bowel Perforations

History

Perforation takes time, frequently symptoms were either ignored or not noticed as can occurring in…

• Elderly, diabetic, or immunosuppressed patients (frequently have minimal symptoms)
• Pediatric patients (unable to or scared to mention symptoms)

Exam

Commonly have “peritoneal signs”

• Guarding
• Rebound Tenderness
• Rigidity

Testing

• CT Scan
• X-Ray? (not your primary test, but a common test question will show you an upright chest X-ray and you will see a rim of free air under the diaphragm (should NOT be there in a normal upright X-ray)

Treatment

• Broad spectrum antibiotics
• Stat surgical consult

Volvulus

It is common to first learn this as a pediatric condition (Malrotation with Volvulus) however it is common in adults as well. The two most common subtypes are…

• Cecal Volvulus
• Sigmoid Volvulus

The history exam and testing plan is the same as with bowel obstruction. The primary difference is that volvulus without ischemia/gangrene is frequently treated with colonoscopy which is a GI CONSULTATION rather than surgical consultation.

Additional Reading

• Management of colonic volvulus (PubMed)

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Mesenteric Ischemia

• Celiac truck supplies blood to the stomach and duodenum
• SMA supplies blood to the rest of the small bowel and proximal colon
• IMA supplies blood to the distal colon and rectum

Arterial flow can be blocked because of emboli (atrial fibrillation)

Venous flow can be blocked because of thrombosis (hypercoagulable states)

Effective flow can be severely decreased in shock states (sepsis, hemorrhage)

History

• Atrial fibrillation
• Pain with PO intake (intestinal angina)
• SEVERE pain

Exam

The most classic finding is “Pain out of proportion to exam”

Testing

• Lactic acid reportedly 100% sensitive according to some texts
• CT scan WITH contrast (or even better, a CTA) for additional confirmation if your pretest suspicion is high

Treatment

Analgesics and antibiotics. Surgery consult if intestines necrotic on imaging. Potentially vascular surgery consult as well if intestines salvageable.

Small Bowel Obstruction

• QUESTION: What is the most common cause of mechanical small bowel obstruction?
  • ANSWER: Adhesions

Not all small bowel obstructions are mechanical, don’t forget that ileus can cause a similar pattern as well (electrolyte abnormalities, recent surgery, opiates, multi-system trauma)

History

Severe crampy pain with vomiting, bloating, and decreased bowel movements/flatus. History of multiple abdominal surgeries (high risk for adhesions)

Exam

Abdominal distention and tenderness. If peritoneal signs develop, this is a very bad condition and patient may be developing ischemic/necrotic bowel.

Testing

• Most common test is CT scan with IV contrast
• Abdominal x-ray sometimes gets ordered but has fallen out of favor for multiple reasons (decreased sensitivity, difficulty localizing obstruction, unable to rule out alternative diagnoses
• Using oral contrast with the CT scan is also falling out of favor primarily due to the time constraints demanded of modern medicine.

Treatment

Fluids, Analgesics, Antiemetics +/- Antibiotics if ischemia is developing. Obtain a surgery consult.

• QUESTION: Should you order an NG tube?
  • ANSWER: NG tubes have been reported to be one of the most painful procedures one can endure. On the other hand, you can find online videos of people putting these in without any discomfort. It will end up being a risk/benefit discussion with your attending. The benefit is that decompressing the stomach will frequently improve the patient’s symptoms to a significant extent.

Additional Reading

• American College of Radiology mesenteric ischemia imaging (ACR)
• American College of Radiology small bowel obstruction imaging (ACR)

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Biliary Diseases

• Biliary Colic- A gallstone DOES NOT GET STUCK, but it slowly rolls out of the gallbladder, through the cystic duct, then the common bile duct and pancreatic duct. This results in several hours of crampy “colicky” pain as the stone passes.
• Cholecystitis- A gallstone gets stuck IN THE NECK OF THE GALLBLADDER OR THE CYSTIC DUCT. Pressure builds up in the gallbladder and inflammation worsens as the patient develops persistent pain, fevers, and eventually perforation of the gallbladder wall.
• Choledocolithiasis- A gallstone gets past the neck of the gallbladder and the cystic duct. However, it gets stuck IN THE COMMON BILE DUCT (CBD). The liver can’t drain bile and liver function tests increase.
• Cholangitis- The patient has choledocolithiasis and INFECTION DEVELOPS
• Gallstone Pancreatitis- A gallstone gets past the neck of the gallbladder AND the cystic duct AND the common bile duct but gets stuck in a PANCREATIC DUCT (ugh, so close). Lipase increases.

History

Asymptomatic gallstones

Biliary colic- Crampy RUQ abdominal pain that frequently radiates to right shoulder and resolves after a few hours

Cholecystitis- RUQ abdominal pain persists for more than a few hours and fevers develop.

Cholangitis- RUQ abdominal pain, fevers, and jaundice (Charcots Triad) eventually leading to shock and altered mental status (Reynolds Pentad)

Exam

Murphy’s Sign- Patient has pain and stops inhalation while you palpate under the right costal margin (Note: the same thing should NOT happen when palpating under the left costal margin)

Testing

The most appropriate test for biliary disease is RIGHT UPPER QUADRANT ULTRASOUND. However, CT scan is quite good as well (negative predictive value ~90% and identifies complications and alternative diagnoses well)

Treatment

Asymptomatic gallstones and resolved biliary colic get outpatient surgery referral

Acute cholecystitis needs a surgery consult

Choledocolithiasis, Cholangitis, and Gallstone Pancreatitis needs a GI consult (for MRCP/ERCP)

Pancreatitis

History

Constant epigastric abdominal pain radiating to the back with lots of vomiting and retching

Exam

Mild pancreatitis may have nothing more than some epigastric tenderness. Severe pancreatitis will look a lot like sepsis (hyperthermia, hypotension, altered mental status)

Testing

Patients will have an elevated lipase and abnormal findings on a CT scan with IV contrast

Treatment

Aggressive treatment of pain and nausea and NPO with slow advancing of the diet as tolerated.

Additional Reading

• American College of Radiology biliary disease imaging (ACR)
• American College of Radiology pancreatitis imaging (ACR)