So, we’ve discussed the principles behind
abdominal pain and its workup previously.
Now, we’re going to talk about
cases to try to drive those points home.
So, we’re going to start.
We have a few to get through.
And definitely think as you –
as we move through these,
what you would do and there's some questions.
Feel free to pause any time if you
want to really think through the case.
So, we’re going to start with central abdominal pain.
I’ve got a 45-year-old woman.
She has a one-month history
of central abdominal pain.
It’s worse with food and it’s cramping in nature.
That's the history we’ve got.
We also know that it does not radiate
and it can promote mild nausea when it’s severe.
So, based on what we discussed regarding
principles and getting a good history in particular,
which of the following questions will be the
highest yield to further evaluate this patient?
A, do you have any blood in your stool?
B, do you have a family history
of inflammatory bowel disorders?
C, tell me about surgeries that you’ve had.
Or D, do you have any pain –
do you have pain over your spine as well?
So, we have a one-month history
of central abdominal pain.
It could be upper or lower GI.
It’s worse with food and cramping in nature.
That’s kind of hard to really
give much of a differential,
but doesn't radiate and
she has some mild nausea,
which – that could be just
related to the pain.
To me, these questions
are all legitimate questions.
The one that sticks out to me is,
if she has had a surgery,
this is kind of vague abdominal pain is
pretty common after a major bowel surgery.
Maybe she had a bleeding
ulcer that had to go through repair.
She had a history of complicated pancreatitis,
or whatever it may be, if she has a history
of abdominal surgery or surgeries,
that's going to give me some light that maybe this is related
to some kind of postsurgical influence and complication.
Maybe it's a partial small bowel
obstruction or maybe it's just adhesions
within her abdominal cavity that’s promoting the pain.
The other questions are certainly legitimate,
but not as high a yield as talking
about previous surgeries.
So, I thought her pain sounded a
little bit more upper GI in nature.
Maybe it's more of an acid-related disorder.
I did mention how biliary colic can be epigastric.
And so, the other things to ask that,
I think, are particularly impactful when you
have an upper gastrointestinal disorder,
many patients have tried antacids,
many have tried over-the-counter proton pump inhibitors.
If it did not get better after taking a
proton pump inhibitor for a week,
say, at least improve a little bit,
it's probably not an acid-related disorder in my opinion.
It’s time to look elsewhere.
Think about biliary colic, pancreatitis,
some of the other things that cause upper GI problems.
And then think about the patient's
risk factors for acid-related disorders
versus cholelithiasis because they are different.
For acid-related disorders,
using lots of caffeine,
using lots of alcohol,
previous history of acid-related disorders.
Cholelithiasis, overweight and obese,
female, 40 years old, those things can be telling as well.
All right. Let’s move on to case number two.
Now, we’re talking about inferior abdominal pain.
A 25-year-old woman presents with persistent
inferior abdominal pain over three weeks.
It has been associated with several
episodes of hematochezia
or blood in the stool, gross red blood.
The pain is a dull ache.
She has fatigue and occasional tactile fever.
So, this is definitely, with that short history,
giving me a strong inclination as to
what the patient actually has.
And so, what should you
consider regarding this case?
A bleeding peptic ulcer is likely given her age.
A rectal examination should not be performed.
A trial of proton pump inhibitors with
reevaluation in two weeks is warranted.
She needs immediate laboratory
work and probable colonoscopy.
And it’s D because I'm really worried about this patient
and the particular risk for inflammatory bowel disease.
Let’s go through some explanation on this case.
So, first of all,
it sounds like a lower GI problem.
She's having – the pain is lower in her abdomen
and she has hematochezia as well.
Remember, bleeding from an ulcer
would often present as melena,
not bright red blood.
It would look black, not red.
Yet hematochezia, oftentimes
it’s concerning always,
and we have to include terrible things like inflammatory
bowel disease and malignancy on a differential,
but usually it's due to very simple disorders
such as hemorrhoids or fissures,
but those things, of course, aren't
associated with abdominal pain.
So, therefore, if you have the two,
abdominal pain with hematochezia,
it’s more ominous than either alone.
And then the fact that she has some fever,
she's only 25 years old,
it all does point towards inflammatory bowel disease.
So, when I talk about needing a laboratory workup,
she needs a CBC as well as
some measure of inflammation
and there are some specific serologic markers
for both Crohn's disease and ulcerative colitis,
but she needs to be referred
to GI promptly and urgently,
so she can get a colonoscopy with biopsy.
That's going to be diagnostic for her.
And then she can be put on
disease modifying therapy,
important in cases of inflammatory bowel disease.
If she has something more rare,
an arteriovenous malformation,
it’d be very rare in a woman who doesn’t have a strong
family history of colorectal cancer to develop cancer,
but that's what colonoscopy is for as well.
It will diagnose those conditions as well.
Okay. Let's look at cramping
and intermittent abdominal pain now.
So, I’ve got a 40-year-old female,
complains of inferior abdominal pain for two weeks.
It’s cramping and intermittent.
It's worse with activity and unchanged with food.
She has some mild dysuria and constipation.
She's had menorrhagia with her last two menses.
So, she's 40 years old and has actually a variety of
different symptoms in addition to her abdominal pain.
And so, which of the following
batteries of test is most appropriate?
Urine pregnancy test?
How about a CBC, a sed rate,
and a CT of the abdomen?
Or a faecal occult blood colonoscopy, CBC,
or a pelvic examination followed
by a CT of the abdomen?
Which is the most appropriate
in this case for initial analysis?
It’s this one.
So, I think – let's discuss the case
a little bit and we’ll go through it.
So, she does have multiple
potential causes for her pain.
This could very well be a non-GI cause of abdominal pain.
And that's why it's important to perform
the simplest and do the basics first.
And that means –
and this is one of my pearls,
is whenever there is the remotest possibility of pregnancy,
even in patients with a tubal
ligation in their history,
getting urine pregnancy test is very low cost,
but it can be incredibly high yield when it’s positive.
And what you don't want to do is start sending the patient
down a road of potentially getting a CAT scan
or other testing which could harm a potential fetus
without knowing that she's not pregnant.
So, she's only 40. Definitely worth a pregnancy test.
In this case, urinalysis as well.
Simple test to do.
It can help with the potential for a UTI.
She did have some dysuria.
Or a kidney stone.
This could also be a kidney stone.
And sensitivity is not nearly 100%,
but again, in office, you get results in
minutes and it can be high-yield.
If there's a lot of blood that
returns on the urinalysis
and the lady is not having
her menses at this time,
certainly makes you think that this is
going to be a genitourinary disorder.
And then finally,
I’ll always do a pelvic examination
for low abdominal pain
when there is no clear-cut diagnosis.
But in general, it's a good idea at
least to do a bimanual examination.
In this case, an ultrasound of the pelvis may be helpful
for the possibilities of endometriosis and uterine fibroids.
And a CT is going to be less
diagnostic for those conditions.
So, start with an ultrasound.
So, those three cases, I think,
emphasize some the points on upper,
lower and non-GI sources of pain.
And hopefully, that helps you in your clinical acumen.
I'm sure you will see cases of abdominal pain and
the differential featured on your examination.
And you'll see questions just like
the ones I just posed to you
and you should feel better prepared to answer them.