Hi, we’re gonna be talking about the approach to abdominal pain
for patients who present to the emergency department.
So abdominal pain in the emergency department,
it’s actually the most common chief complaint in the United States.
So this is the most common thing that you’re gonna to be seeing
coming through the doors of the ED.
It represents approximately 25% of ED visits
and it’s the percentage of non-injury abdominal pain visits
which is actually on the rise.
So this is something that potentially can increase in numbers
over the next few years rather than decrease.
So we’re gonna be seeing lots of patients coming in
with discomfort in their abdomen.
Now again, we always wanna make sure when we’re thinking about
presenting complaints in patients presenting to the emergency department
that we always go back to the basics.
And that is airway, breathing, and circulation.
Now, you might be thinking that airway and breathing might not necessarily play a role here
but due to the fact that there’s such a wide range of things that can cause abdominal pain,
we actually always wanna make sure that we’re thinking in this step wise fashion
because if we start to not think in that step wise fashion,
that’s when we get ourselves into trouble.
Circulation can definitely play a role here
especially in settings when you’re concerned
that someone could have a life threatening cause of their abdominal pain
such as a triple A.
So we always wanna make sure that we’re thinking about this.
One of the biggest challenges when patients come to the emergency department
for abdominal pain is that there is such a wide range of things
that can be causing the abdominal pain
and they vary from things that are benign,
things like GERD or Gastroesophageal reflux.
A viral illness that for the most part,
most patients can really tolerate on their own.
They may be uncomfortable, they might have some belly pain,
and some vomiting and diarrhea but for the most part, patients will be okay.
Then they range to more serious things such as appendicitis,
bowel obstruction, diverticulitis, pancreatitis, and kidney stones.
And these potentially have very serious implications.
Some of these require surgical interventions,
some of these require admission to the hospital for IV antibiotics,
IV fluid replacement, pancreatitis can become very severe
and can really cause serious problems for patients down the line.
Kidney stones can lead to obstruction and urinary tract infections
which can then lead to sepsis, so we definitely need to make sure
that we’re thinking about these more serious causes
and then if that’s not enough, we move on to the fact
that abdominal pain can actually be related to life threatening conditions.
So an abdominal aortic aneurysm can cause abdominal pain,
and that is obviously something
that can be very, very serious and life threatening for a patient.
Patients can bleed out very rapidly from abdominal aortic aneurysms that rupture.
A ruptured ectopic pregnancy also poses significant challenges.
Perforation of the GI tract,
that’s something that requires emergent surgical intervention.
The patient needs to go to the operating room emergently.
So when we’re thinking about patients
who come into the emergency department with belly pain,
we have to be thinking about this whole spectrum of things.
We can’t just be thinking about the benign things or the life threats,
we have to be thinking about all the things that are benign,
more serious, and then those life threatening conditions
because if we’re not thinking broadly in this situation,
that’s how we run into problems and we come up with a misdiagnosis,
we come up with an incorrect diagnosis.
So always maintaining that high level of suspicion.
There are also extra abdominal things that can cause abdominal pain,
so things outside the belly.
So as if things weren’t complicated enough already,
we’re gonna go ahead and complicate them even further.
Myocardial infarction is a classic example of extra abdominal things
presenting with belly pain.
Classically, inferior wall MIs, so an inferior wall myocardial infarction
is the classic thing that we think about
presenting with epigastric abdominal pain and nausea and vomiting,
and I would say you could probably ask every emergency medicine physician
if they’ve ever seen an inferior MI
present with primarily abdominal pain symptoms
and I would say that we would all say yes.
I can think of a handful of times that patients were presenting
with epigastric belly pain, got an EKG,
and it turned out to be an ST elevation MI and the inferior distribution.
You always just have to keep it in the back of your mind
that epigastric pain can potentially be an MI
especially in the appropriate patient population
and especially if your patient appears ill.
If they’re diaphoretic, if they’re sweaty, if they’re pale,
those are the patients who you wanna get that EKG a little bit more rapidly.
Ketoacidosis is another very serious and life threatening condition
that can potentially cause abdominal pain.
So classically, diabetic ketoacidosis.
So a diabetic patient that is having ketoacidosis.
That is producing ketone bodies, and their blood is acidotic,
by a similar pathway, alcohol and ketoacidosis
can cause abdominal pain as well.
Diabetic patients, patients who drink alcohol regularly,
you wanna be thinking about this
and you wanna be potentially working your patient up for it.
Pneumonia, especially in pediatrics.
So especially for those younger kids
can present just with abdominal pain,
so we’re thinking about pneumonia.
Herpes Zoster or shingles can actually present with pain in lots of different areas,
so sometimes it’s like a red herring in chest pain presentations,
sometimes it’s a red herring in abdominal pain presentations as well.
This is the time where you wanna make sure you ask a patient,
have you seen a rash on your body?
And also where you wanna sometimes inspect the abdomen.
Again, this is something where every so often,
you go ahead and you take a look at the belly
and you see in that dermatomal distributions
shingles in that area where that patient is complaining of pain.
So just make sure you keep it in the back of your mind
and that you’re thinking about that when someone comes in complaining of pain.
The classic pain with herpes zoster is kind of like
people describe it as an itchy burning sort of a discomfort,
so even more so when they describe their pain in that way.
Other things, glaucoma, I know that seems like a total outlier
but someone having elevated intraocular pressure can cause abdominal pain.
This is why we – it’s really important to talk with our patients,
find out if they’re having pain in their eye.
Henoch-Schonlein purpura are more common in pediatrics
but can be seen in adult patients.
The classic association with that is that patients will have a purpuric rash
most commonly on the lower extremities.
And then testicular and ovarian torsion.
We’ll be talking about those concepts in another lecture
but it’s important to always ask about any pain in the testicles
especially for those adolescent male patients.