Abdominal Pain

Initial assessment

• ABC’s
• Pain out of control – may need to give small doses of narcotic in order to be able to take a history and do a physical exam
• IV, O₂

History

• Onset: sudden (specific event – torsion, rupture, stone, obstruction) versus gradual
• Location
  • RUQ
  • LUQ
  • Epigastric
  • RLQ
  • LLQ
  • Suprapubic
• Duration
• Severity
• Character
• Alleviating/Aggravating factors
• Radiation
• Symptoms associated – GI, urinary, gynaecologic (LMP)

Physical exam

• Obviously a complete abdominal exam is necessary in all cases
• Rectal exam
• Pelvic exam
• Genitalia
• Respiratory
• Cardiovascular

Differential diagnosis

By system

• GI
• Urinary
• Gynecologic/Genitalia
• Respiratory
• Cardiovascular
• MSK

By process

• Vascular (ischemia, embolism, infarction, hemorrhage)
• Infection
• Perforation
• Obstruction
• Inflammation
• Torsion

By location (not exhaustive…)

• RUQ
  • Gallbladder and biliary tree
    • Biliary colic
    • Acute cholecystitis
    • Ascending cholangitis
  • Pancreas
    • Pancreatitis (i.e.gallstone)
  • Liver
  • Lung
    • RLL pneumonia
  • Bowel
    • Appendix (high)
• Epigastric
  • Stomach and duodenum
    • Gastritis
    • PUD
  • Pancreas
  • Heart
    • MI inferior
  • Aorta
    • AAA, rupture
• LUQ
• • Stomach
  • Pancreas
  • Lung
• RLQ
  • GI
    • Appendix
  • GU
    • Stone
    • Pyelonephritis
    • Ectopic
    • Torsion/Epididymitis
    • Cyst rupture
• LLQ
  • GI
    • Diverticulitis
  • GU

Investigations

• Investigations should be guided by the history and physical exam
• Bloodwork
  • CBCD, electrolytes, glucose, urea, Cr
  • LFTs, lipase, lactate (increases during underperfusion/ischemia)
  • Quantitative serum beta HCG
  • Type/Screen, crossmatch
• Urinalysis
• Imaging
  • 3 views of the abdomen
  • Ultrasound
  • CT

Pain management and symptom control

• Buscopan 10-20mg IV
• Morphine 2.5-10mg IV
• Hydromorphone (Dilaudid) 0.5-2mg IM/SC/IV
• NSAIDS: Toradol 30mg IV, Voltaren supp.
• Gravol or Maxeran for nausea and emesis
• PO – Tylenol #3, percocet, Ibuprofen