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

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