Abdominal Pain

00:01 All right. Now, we’re going to be discussing abdominal pain.

00:04 And first, I want to discuss some general principles about the approach to abdominal pain because it’s such a broad subject.

00:12 So, really, I like to think of abdominal pain as splitting into three separate categories.

00:17 First is upper gastrointestinal disorders.

00:20 Next is lower gastrointestinal disorders.

00:23 And then there's another group of non-gastrointestinal disorders that can also cause abdominal pain.

00:29 So, in upper GI, the common things I think about include gastroesophageal reflux disease, gastritis, gastric or duodenal ulcers, biliary colic, pancreatitis and malignancy.

00:45 For lower GI, different here.

00:47 Now, we’re getting more into functional bowel disorders.

00:51 Inflammatory bowel disease, that may be upper GI too, but most types of inflammatory bowel disease are noted to be lower GI.

01:01 Diverticulosis, really common as you get older.

01:03 Mechanical obstruction, less common, but can be an emergency.

01:06 Of course, malignancy.

01:08 And of course, appendicitis and other emergency as well.

01:11 And then, if it doesn't quite fit into one of these two categories, it's not just about the gastrointestinal system, right? So, the genitourinary system.

01:22 I think that kidney stones can be the great pretender.

01:24 They can mimic a bunch of different conditions and are often missed.

01:28 Urinary tract infections and pyelonephritis, less so.

01:31 That's a little bit more straightforward.

01:34 Similarly, reproductive disorders, particularly among women, such as endometriosis, ovarian cysts or fibroids, really common disorders that can promote abdominal pain.

01:45 Usually more of a typical pattern that you might see with a gynecological condition, but not always, and certainly can be mistaken for some of those lower GI problems too.

01:55 Also, certainly, women can have both disorders at once as well.

01:58 And of course, think about malignancy as well.

02:00 And that’s typically going to be malignancy of the reproductive tract.

02:06 Rarely chest structures can promote pain in the upper abdomen which might even radiate to the level of the umbilicus.

02:11 Myocardial infarction and pneumonia/empyema can possibly present this way.

02:18 So, here are some tricks to help differentiate abdominal pain.

02:22 First of all, you’re going to look at demographic factors.

02:25 If they are using a lot of alcohol and smoking and caffeine, lot of risk factors there for upper GI disorders, in particular, things like ulcers and gastritis and GERD.

02:36 In terms of past medical history, many times, this isn’t the first time the patient has had abdominal pain.

02:43 So, really going back, maybe it was 14 years ago, but they did have an ulcer diagnosed under endoscopy because it was bleeding.

02:50 Also surgical history becomes very, very important for these patients.

02:54 I find patients, even among those who have had laparoscopic surgery, it never is quite the same.

03:00 And every now and then, you just move a certain way and you get a tug from that laparoscopic cholecystectomy or appendectomy scar that you have, and that's not that unusual.

03:10 That's why surgeries are very important.

03:11 And medications that can promote - some medications promote abdominal pain directly.

03:16 Many are constipating, I think of opioids.

03:18 Medications like NSAIDs can promote ulcers and bleeding.

03:22 So, taking a good complete history with the specific areas of focus is important.

03:27 The physical examination, unlike that history, is probably less helpful overall because it may be that they are, say, tender in the epigastrium, and so you think, well, it could be more of a gastritis, a pancreatitis.

03:42 But just remember that a good percentage of cases of biliary colic present with epigastric pain too.

03:49 And so, it really comes down to the history.

03:51 And then let's discuss labs and imaging.

03:54 So, in general, the broad labs, like a CBC, a complete blood count may not be very helpful.

04:03 It’s better to target certain things.

04:05 So, if I'm really worried about a patient with epigastric pain and a long history of drinking, certainly a lipase would be indicated.

04:12 A patient with potential biliary colic, I’m going to check liver enzymes.

04:16 And I almost always wound up examining the liver and kidney function among these patients.

04:22 It's just part of the routine.

04:23 But, yeah, do try to focus your laboratory evaluation.

04:27 As in everything, broadly hunting doesn't necessarily get you closer to a strong diagnosis and can bring up a bunch of other disorders that have nothing to do with the reason you're examining the patient in the first place.

04:43 And in terms of imaging, I don't think that most patients need just plain radiography.

04:49 Those with suspected bowel obstruction certainly can benefit.

04:54 That's a very small percentage of ambulatory patients.

04:57 Ultrasound is a great tool.

05:00 Generally has less complications versus CT and it’s actually superior, as you probably know, for biliary tract as well as imaging of the reproductive system.

05:09 No radiation, so it's a superior thing often to start with before necessarily going to CT scanning.

05:17 And then finally, regarding imaging, sometimes I can use abdominal symptoms as a means to an end, which is completing just general screening exam.

05:26 So, patients who are having inferior abdominal pain, and it’s like, well, I did recommend a colonoscopy for you for the past couple of years, maybe it’s time to think about that now because it's the gold standard for diagnosing diverticulosis if there is a - if there is a colon cancer, it’s going to find it.

05:45 Same thing with cervical cancer screening.

05:46 Now, do I think the abdominal pain is due to a cervical lesion or cervical cancer that we haven’t found? Probably not.

05:54 But I am going to be doing a GYN exam anyway, pelvic exam.

05:58 So, therefore, checking for cervical cancer at the same time can get two needs done.

06:03 It gets the patient evaluated, as they should be, for their pain.

06:06 Also, it's a chance to complete that cervical cancer screening, get them up to date.

06:10 So, that's just general principles.

06:14 We are going to be talking about applications and I look forward to doing that next using some cases that you can think about as we go through.