Its the damned belly that gives y g man his worst troubles ED - PDF document

“It’s the damned belly that gives y g man his worst troubles” ED Evaluation of Abdominal -Homer H Pain Kathleen Jobe, MD Kathleen Jobe, MD Division of Emergency Medicine Division of Emergency Medicine Division of Emergency Medicine Division of Emergency Medicine University of Washington University of Washington Epidemiology Diagnosis  One of the most common presenting One of the most common presenting complaints: 4- complaints: 4 p -8% of adult ED visits. 8% of adult ED visits.  Abdominal pain of unknown etiology  “Abdominal pain of unknown etiology” “Abdominal pain of unknown etiology” Abdominal pain of unknown etiology  Admission rates of 18 Admission rates of 18- -42% in adults, much 42% in adults, much higher rates in the elderly higher rates in the elderly higher rates in the elderly higher rates in the elderly  In 42% of patients etiology is unknown. In 42% of patients etiology is unknown. Immediate Life Threat “Beauty cannot disguise y g  Abdominal aortic aneurysms Abdominal aortic aneurysms nor music melt,  Splenic rupture  Splenic rupture Splenic rupture Splenic rupture A A pain undiagnosable i di bl  Ectopic pregnancy Ectopic pregnancy but felt” but felt  Myocardial infarction M Myocardial infarction M di l i f di l i f ti ti - AM Lindbergh

Extra Abdominal Causes of Extra Abdominal Causes of Extra Abdominal Causes of Abdominal Pain Abdominal Pain  Systemic  Systemic Systemic Systemic  Toxic  Toxic Toxic Toxic  Genitourinary Genitourinary  Abdominal Wall Pain  Abdominal Wall Pain  DKA DKA  Methanol Methanol  Testicular torsion Testicular torsion  Herpes zoster Herpes zoster   Heavy metals Heavy metals y  AKA  AKA AKA AKA  Renal colic Renal colic  Muscle hematoma Muscle hematoma   Scorpion bites Scorpion bites  Uremia Uremia  Infectious Infectious  Muscle spasm Muscle spasm   Lactrodectus bite Lactrodectus bite  Sickle cell disease Sickle cell disease  Strep pharyngitis Strep pharyngitis  Thoracic Thoracic  SLE SLE  Rocky Mtn. Spotted Rocky Mtn. Spotted  Acute coronary syn Acute coronary syn  Vasculitis Vasculitis Fever Fever Fever Fever  Pneumonia P P Pneumonia i i  Glaucoma Glaucoma  Mononucleosis Mononucleosis  PE PE  Hyperthyroidism Hyperthyroidism  Thoracic disc disease  Thoracic disc disease Thoracic disc disease Thoracic disc disease History History Disease Spectrum by Age Disease Spectrum by Age  Diagnosis Diagnosis Age < 50 Age < 50 Age > Age > 50 50  Quality of Pain  Quality of Pain Quality of Pain Quality of Pain  Cholecystitis  Cholecystitis Cholecystitis Cholecystitis 6% 6% 6% 6% 21% 21% 21% 21%  Nonspecific Nonspecific 40% 40% 16% 16%  Onset Onset  Appendicitis Appendicitis 32% 32% 15% 15%  Bowel obst B Bowel obst B l b l b 2% 2% 2% 2% 12% 12% 12% 12%  Severity S S Severity i i  Pancreatitis Pancreatitis 2% 2% 7% 7%  Associated symptoms Associated symptoms  Diverticular disease Diverticular disease <0.1% <0.1% 6% 6%  Cancer Cancer <0.1% <0.1% 4% 4%  Hernia Hernia <0.1% <0.1% 3% 3%  Vascular  Vascular Vascular Vascular <0.1% <0.1% <0 1% <0 1% 2% 2% 2% 2% History (continued) The importance of positioning  Gyn history Gyn history- -Sexual activity, LMP, Sexual activity, LMP, contraception, gravida/para status. contraception, gravida/para status. p p , g , g p p  Recurrence of symptoms Recurrence of symptoms  PMH  PMH PMH-Surgeries, Chronic illnesses, Risk PMH Surgeries Chronic illnesses Risk Surgeries Chronic illnesses Risk Surgeries, Chronic illnesses, Risk factors factors  Medications M di M di Medications ti ti

Physical Exam Ph sical E am Physical Exam  Vitals signs Vitals signs  Location of Tenderness Location of Tenderness  Original study of McBurney’s point Original study of McBurney’s point  Temperature variable sens. and spec. for Temperature variable sens. and spec. for p p p p t t tenderness had n=10 tenderness had n=10 d d h d h d 10 10 intra- intra -abdominal infection abdominal infection  80% of patients with appendicitis have 80% of patients with appendicitis have  Majority of elderly patients with acute  Majority of elderly patients with acute Majority of elderly patients with acute Majority of elderly patients with acute tenderness to palpation in the RLQ tenderness to palpation in the RLQ tenderness to palpation in the RLQ tenderness to palpation in the RLQ cholecystitis and appendicitis are afebrile. cholecystitis and appendicitis are afebrile.  Guarding Guarding  Involuntary guarding (rigidity) greatly  Involuntary guarding (rigidity) greatly Involuntary guarding (rigidity) greatly Involuntary guarding (rigidity) greatly increases the likelihood of surgical disease increases the likelihood of surgical disease  Voluntary guarding not predictive Voluntary guarding not predictive Physical Exam Physical Exam  General appearance General appearance  Peritoneal Signs Peritoneal Signs  ‘You can observe a lot just by watching’  You can observe a lot just by watching ‘You can observe a lot just by watching’ You can observe a lot just by watching  Cough test is 80  Cough test is 80 Cough test is 80-95% sensitive for Cough test is 80 95% sensitive for 95% sensitive for 95% sensitive for surgically proven peritonitis surgically proven peritonitis -Yogi Berra Yogi Berra  ‘Heel drop’ was 93% sensitive for  Heel drop was 93% sensitive for ‘Heel drop’ was 93% sensitive for Heel drop was 93% sensitive for appendicitis appendicitis  Less sensitive in the elderly L L Less sensitive in the elderly iti iti i th i th ld l ld l Physical Exam  Specific PE signs Specific PE signs  Murphy’s Murphy’s- - • Useful in diagnosing cholecystitis and biliary colic Useful in diagnosing cholecystitis and biliary colic • Sensitivity of 97% and negative predictive value of 93% Sensitivity of 97% and negative predictive value of 93% for cholecystitis. for cholecystitis. • Specificity of <50% for cholecystitis Specificity of <50% for cholecystitis  Psoas Psoas • Sensitive and specific for psoas muscle abcess • Sensitive and specific for psoas muscle abcess Sensitive and specific for psoas muscle abcess Sensitive and specific for psoas muscle abcess • Appendicitis Appendicitis - -95% spec, 16% sens in one small study 95% spec, 16% sens in one small study

Physical Exam Carnett’s sign  Rosving’s Rosving’s  Carnett’s Carnett’s  95% accuracy in 95% accuracy in  Obturator  Obturator Obturator Obturator distinguishing distinguishing  Boas sign Boas sign abdominal wall abdominal wall pain from visceral pain from visceral i f i f i i l l pain pain Pelvic Examination Rectal Examination  Greatest value is in detection of heme + stools Greatest value is in detection of heme + stools  Valuable in all women with abdominal pain Valuable in all women with abdominal pain  Routine use in the evaluation of abdominal pain is Routine use in the evaluation of abdominal pain is unsupported in the literature unsupported in the literature  Fitz Fitz- -Hugh Hugh- -Curtis Curtis  Literature is scant Literature is scant  PID vs. appendicitis PID vs. appendicitis  Rectal provided no additional information in Rectal provided no additional information in  Appendicitis may cause CMT (30% of cases) Appendicitis may cause CMT (30% of cases) pp pp y y ( ( ) ) the patient with appendicitis the patient with appendicitis the patient with appendicitis the patient with appendicitis  Appendicitis may cause hematuria (20 Appendicitis may cause hematuria (20- -30% of 30% of  Useful in diagnosis of prostatis, perirectal Useful in diagnosis of prostatis, perirectal cases) cases) abcess, stool impactions, foreign body and abcess, stool impactions, foreign body and abcess, stool impactions, foreign body and abcess, stool impactions, foreign body and GI bleed. GI bleed.  >95% of women with PID will have pus at the >95% of women with PID will have pus at the cervical os. cervical os. Serial Exams Diagnostic Studies  Useful in a subset of patients Useful in a subset of patients  Adjuncts to history and physical Adjuncts to history and physical  May be done on an outpatient basis  May be done on an outpatient basis May be done on an outpatient basis May be done on an outpatient basis  Most overused:  Most overused: Most overused: Most overused: depending on individual patient depending on individual patient  CBC, electrolytes, LFT’s, radiographs CBC, electrolytes, LFT’s, radiographs  Most underused M M Most underused t t d d d d  bHCG, UA, EKG bHCG, UA, EKG