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Differential Abdominal Pain

Discussion of the different possible diagnosis for when a patient complains of abdominal pain. Directed at Medics for a CE.
by

Amber Teichmiller

on 29 August 2013

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Transcript of Differential Abdominal Pain

Differential Diagnosis of Abdominal Pain
Typical Signs and Symptoms
Pain
Nausea/Vomiting
Changes in bowel habits
Diarrhea
Abdominal distention
Fever
Typical EMS Treatment
IV
Labs
Morphine
Zofran
Four Quadrants with multiple possibilities...


Tour of the Belly!
Right Lower Quadrant

Appendicitis
Kidney stone
Ovarian Cysts
Diverticulitis

Appendicitis
Inflammation of the appendix
RLQ or Umbilical pain
Tenderness (Rebound)
Rovsing's Sign
Fever
Nausea/Vomiting
Decreased appetite
Kidney Stones
Renal Calculus (kidney Pebble)
Flank pain
Radiates to Lower quadrant
Sharp "traveling" pain
Labor pain
Difficulty/pain with urination
Urinary Urgency
Blood in urine
Nausea Vomiting
This is what the fuss is about!?!
Left Lower Quadrant
Diverticulitis
Ovarian Cysts
Kidney stones

Peak incidences in 10-12 year old

Starts as dull pain in umbilical region
Usually progresses in 4-6 hours
Localizing to RLQ of abdomen

Sudden pain relief... May indicate rupture of appendix!
Pain most often in LLQ
Tender
Cramping
Changes in bowel habits
Nausea
Bloating
Mild rectal bleeding
Diverticulitis
Inflammation of intestines
Don't Mock Me!
Colon Cancer
Irritable bowel Syndrome (IBS)
Chron's Disease
IBS
Symptom based diagnosis characterized by chronic abdominal pain, bloating, and alteration of Bowel habits.
Onset is more likely to occur after an infection
or
a stressful life event.
Mild Case:
Diet- Liquid (give intestine a break) then high fiber
Antibiotics- initial IV then PO
Worse Case Scenario:
Surgery- remove portion of intestine (Resection)
Colostomy- (temporary/permanent)
Treatment:
collection of fluid, surrounded by a thin wall, within an ovary
Ovarian Cysts
Get
it
OUT!
And Antibiotics
Treatment
What is it?
Phosphates, oxalates, & Urates
Treatment
Hydration
Medicate: pain/nausea
Strain urine
Lithotripsy
Cystoscopy removal
Crystal aggregation formed in kidneys from dietary minerals in the urine
Dull aching pain in lower abdomen
Increase to sharp pain
Nausea/Vomiting
Bloating
Affects women of all ages
Most common during childbearing years
Can be smaller then a pea
or as big as an Orange!
Sudden improvement of pain
Usually indicates cyst rupture
Usually harmless and resolve on own
Some can cause bleeding (Haemorrhagic cyst)
1/4 of massive cysts become Cancerous
Medicate: pain/nausea
Heat/cold packs
Hormonal contraception
Treatment:
Surgery
considered for Symptomatic Cysts larger then 5cm
RECORD...
In 1905 a record was set and maintains today...
328
pounds!
93 pound cyst
Gallbladder
Liver
Right Upper Quadrant
inflammation of the gallbladder
Cholecystitis
Pain after eating
Nausea/Vomiting
Increased belching
Women
Age- around 40 years
Diet- fat intake
Obesity
Medications- prolonged PPI usage
Risk Factors
Usually caused by
gallstones
(cholelithiasis)
Gallstones...
Bile contains to much cholesterol & not enough bile salts
Decreased Gallbladder motility
Elevated Estrogen levels
Can have them and never know
Have symptoms when stone >8mm
Small as grain sand
Big as golf ball
Treatment
Diet Changes
ERCP
Lithotripsy

Cholecystectomy
Endoscopic Retrograde Cholangiopancreatography
But stones can keep coming back...
Hepatitis: Inflammation of the liver.
Infectious vs non infectious
Acute vs chronic
Cirrhosis: Greek for "yellowish"
Secondary chronic liver disease
Evident by liver tissue replaced
by fibrosis or scar tissue. Causes decreased liver function
Liver Disease
Same for both as cirrhosis is the chronic disease process if hepatitis goes untreated or is irreversible
Infectious: Viral (Hep C)
Non Infectious: ETOH, Medication, Obstruction, Non ETOH fatty liver, Obesity
Liver purpose is for detox, protein synthesis and metabolize lipids and carbs
Beer Goggles...
Acute: "flu like symptoms"
Chronic:Often no symptoms
Signs & Symptoms
Signs: Jaundice, itching, Ascites, Confusion, engorged liver with palpation, bruising
Treat the cause
If enters Cirrhosis stage... typically not reversible!
Treatment
Focus on preventing progression and complications
Paracentisis
Lactulose
Liver Transplant
Diuretics
Causes:
Mid Abdomen
Left Upper Quadrant

Pancreatitis
Bowel Obstruction
Cardiac
Inflammation of pancrease
Pancreatitis
Pancrease
Multifunctional glandular organ that produces insulin to regulate the blood sugar
and secrets digestive enzymes to
small intestine
Pancreatitis occurs when pancreatic enzymes (especially trypsin) that digest food are activated in the pancreas instead of the small intestine
Genetic
Idiopathic
Most common:
Alcohol Consumption
Obstruction (gallstones)
Causes:
Sharp Upper Mid abdominal pain
Increase pain with eating
Nausea/Vomiting
Changes in stool

Signs & Symptoms
Treatment
Treating the Cause:
ETOH- Stop
Smoking-Stop
Dietary Modifications
Remove obstruction- ERCP
Acute treatment:
Pain & Nausea medication
Diet- NPO
Bowel Obstruction
obstruction of the intestines, preventing the normal transit of the products of digestion.
Pain (localized or general)
Nausea/Vomiting
Fecal Emesis
Abdominal distention
Constipation
Medicate: pain & nausea
Narcotics can reduce gut mobility
NG Tube: suction
Diet-NPO
Surgery-Resection
Treatment
Remember that each cardiac patient has their own symptoms...
Cardiovascular
Lower Abdomen
Gender Specific

Urinary Tract Infection
Pregnancy
Epididymitis
Torsion
Ovarian torsion
Refers to the rotation of the ovary to such a degree as to occlude the ovarian artery and/or vein
Testicular torsion
Occurs when the spermatic cord (from which the testicle is suspended) twists, cutting off the testicle's blood supply
Urinary Tract Infection
Symptoms
Urinary Frequency
Pain with urination
Fever
Lower abdominal pain
Flank pain
Hematuria
Warning...
Not always just a simple UTI...

Left untreated can turn in to Pyleonephritis (kidney infection)

Especially in the elderly can quickly turn in to Sepsis

Can mimic Neuro symptoms (Altered mental status)
Suspected
Miscarriage
Ectopic
Pregnancy
How could she not know!?!
Suspected
History is SO important!
Last menstrual period
Gravida/Para
Previous
Miscarriages
Ectopics
Abortions
Current Bleeding/discharge
Known to be pregnant?
Number of Weeks
Miscarriage
Spontaneous end of a pregnancy
Vaginal Bleeding

Lower abdominal Cramping

Fear/Anxiety
Need inform ER if note large clots
Common for excessive bleeding
More intense and frequent cramps
the more likely miscarriage imminent
Anxiety of loss of baby
Fear that did something wrong & of unknown
Ectopic Pregnancy
complication where embryo implants outside of the uterus
Typically implants in fallopian tube
Potentially life threatening event
Typically between 4-8 weeks pregnant
Lower abdominal pain & Minimal Vaginal bleeding
Complications
The most common complication is rupture with internal haemorrhage which may lead to hypovolemic shock
Cullen's sign is superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus.
Can take 24-48 hours to appear
If fallopian tube ruptures can tear the Ovarian artery, causing internal bleeding
Monitor for:
Abdominal Distention
Referred shoulder pain
Hypotension
Treatment
Nothing
Methotrexate
Surgery
inflammation of the epididymis
Epididymitis
Epididymis:
a curved structure at the back of the testicle in which sperm matures and is stored
Symptoms:
Slow onset (several days)
Fever
Swelling to one testicle
Dysuria prior
Urethral discharge prior
Causes:
Typically STD related
2/3 of cases related to Chlamydia
Treatment:
Antibiotics
Torsion
Treatment:
Both instances would require surgical intervention

Both run risk of loosing ovary or testicle
if delay in seeking treatment

If treated in <6 hrs 90% success rate
If treated >12 hrs <50% success rate
12-18 year old boys account for 65% of torsions
Most common on cold nights
Cremasteric Reflex
Signs/Symptoms:
Testicle will rotate toward mid line of body
Testicle usually swollen, tender, and "high riding"
Sometimes able to manually manipulate to untwist
Testicular Torsion
Factoids
Don't forget...
There is always the
unexpected
and
unknown!
Full transcript