Red Flags of Abdominal Pain
- duration of pain > 48 hours
- pain followed by vomiting
- hx of abdominal surgery
- peritoneal signs - guarding, rebound tenderness, rigidity (warrants surgical consult)
- fever, chills, leukocytosis, absent bowel sounds
Organic vs. Functional Chronic Abdominal Pain
Organic - clear cause; anatomic, physiologic, or metabolic cause
Functional - no cause despite evaluation; CAPS (centrally mediated abdominal pain syndrome) - not r/t food or defecation, r/t altered pain perception and pain modulation circuits
Why psychosocial assessment with chronic abdominal pain?
- PTSD, abuse, depression, and anxiety are linked with abdominal pain
- make sure and assess relationships and how school is going with adolescents
Pain assessment with abdominal pain
- timing - eating, defecation, last known intake?
- location - radiation, changed?
- quality, quantity, setting
- associated symptoms - menstruation, fever, chills, diarrhea, n/v
- aggravating and alleviating factors
Characteristics of abdominal pain: visceral pain
dull and poorly localized
Characteristics of abdominal pain: parietal pain
sharp and localized
Characteristics of abdominal pain: colicky pain
comes and goes
seen with kidney stones, bowel obstruction, ileus, etc.
Characteristics of abdominal pain: burning pain
caused by irritation from gastric contents
seen with GERD, PUD, dyspepsia, etc.
Murphy’s test (inspiratory arrest)
- used to test gallbladder (i.e., acute cholecystitis)
- hand at right costal margin and press down. ask patient to take deep breath in
- positive Murphy’s sign if patient abruptly stops taking breath d/t pain
Cullen’s Sign
- ecchymosis around umbilicus
- could signal ruptured ectopic pregnancy, acute necrotizing pancreatitis
Grey-Turner’s Sign
- ecchymosis of lower abdomen, flank, or back
- occurs with abdominal or retroperitoneal hemorrhage
McBurney’s Sign
- pain when pressing down in RLQ
Abdominal Pain - pelvic exam components
Cervical Motion Tenderness (CMT) - can indicate peritoneal infection
Adnexal Tenderness - pain in pelvic region, including uterus, ovaries, and fallopian tubes
Elderly considerations with presentation
- atypical presentation
- lack of overt clinical features d/t age-related body system changes (vague complaints, decreased immune response, changes in PNS/CNS)
- more comorbidities affects ability to mount characteristic physiologic response
- dementia = hard to assess
- medications may prevent normal physiological responses (ie, beta blockers)
Abdominal Pain - potential labs
- CBC, CMP
- HCG - on all women of childbearing years
- amylase and lipase (lipase elevated longer so more accurate)
- UA - especially for lower abdominal complaints
- stool for occult blood
- lactic acid
Abdominal pain - potential imaging
- abdominal XR (air under diaphragm - pneumoperionteum = perforation somewhere and need surgical consult)
- chest XR
- CT
- US
Abdominal pain - general management
- Keep NPO
- depends on dx
Serotonin 5-HT3-receptor antaongists anti-emetic
- ondansetron (Zofran)
- granisetron
- dolesetron
Corticosteroid anti-emetic
- dexamethasone
- given mainly for post-op n/v
Dopamine antagonist anti-emetics
- prochlorperazine (Compazine)
- promethazine (Phenergan)
Symptoms of Dyspepsia
- epigastric pain or burning (chronic or recurrent)
- early satiety
- nausea
- bloating
- anorexia
Alarm Symptoms of GI Complaints
- dysphagia or odynophagia
- unintentional weight loss
- anemia
- hematemesis
- melena
- recurrent vomiting
- palpable mass
- jaundice
Most common cause of dyspepsia
NSAIDs and H. pylori
How to test for H. pylori
- urea breath test
- stool antigen
