All right. Now, we’re going to
be discussing abdominal pain.
And first, I want to discuss some general
principles about the approach to abdominal pain
because it’s such a broad subject.
So, really, I like to think of abdominal pain
as splitting into three separate categories.
First is upper gastrointestinal disorders.
Next is lower gastrointestinal disorders.
And then there's another group of non-gastrointestinal
disorders that can also cause abdominal pain.
So, in upper GI,
the common things I think about
include gastroesophageal reflux disease,
gastric or duodenal ulcers,
biliary colic, pancreatitis and malignancy.
For lower GI, different here.
Now, we’re getting more into
functional bowel disorders.
Inflammatory bowel disease,
that may be upper GI too,
but most types of inflammatory bowel
disease are noted to be lower GI.
Diverticulosis, really common as you get older.
Mechanical obstruction, less common,
but can be an emergency.
Of course, malignancy.
And of course, appendicitis and
other emergency as well.
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.
I think that kidney stones
can be the great pretender.
They can mimic a bunch of different
conditions and are often missed.
Urinary tract infections and pyelonephritis, less so.
That's a little bit more straightforward.
Similarly, reproductive disorders,
particularly among women,
such as endometriosis, ovarian cysts or fibroids,
really common disorders that
can promote abdominal pain.
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.
Also, certainly, women can have
both disorders at once as well.
And of course, think about malignancy as well.
And that’s typically going to be
malignancy of the reproductive tract.
So, here are some tricks to
help differentiate abdominal pain.
First of all, you’re going to look
at demographic factors.
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.
In terms of past medical history,
many times, this isn’t the first time
the patient has had abdominal pain.
So, really going back,
maybe it was 14 years ago,
but they did have an ulcer diagnosed
under endoscopy because it was bleeding.
Also surgical history becomes very,
very important for these patients.
I find patients, even among those
who have had laparoscopic surgery,
it never is quite the same.
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.
That's why surgeries are very important.
And medications that can promote – some
medications promote abdominal pain directly.
Many are constipating, I think of opioids.
Medications like NSAIDs can promote ulcers and bleeding.
So, taking a good complete history with
the specific areas of focus is important.
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.
But just remember that a good
percentage of cases of biliary colic
present with epigastric pain too.
And so, it really comes down to the history.
And then let's discuss labs and imaging.
So, in general,
the broad labs, like a CBC,
a complete blood count may not be very helpful.
It’s better to target certain things.
So, if I'm really worried about a patient with
epigastric pain and a long history of drinking,
certainly a lipase would be indicated.
A patient with potential biliary colic,
I’m going to check liver enzymes.
And I almost always wound up examining the
liver and kidney function among these patients.
It's just part of the routine.
But, yeah, do try to focus
your laboratory evaluation.
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.
And in terms of imaging,
I don't think that most patients
need just plain radiography.
Those with suspected bowel
obstruction certainly can benefit.
That's a very small percentage of ambulatory patients.
Ultrasound is a great tool.
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.
No radiation, so it's a superior thing often to start
with before necessarily going to CT scanning.
And then finally, regarding imaging,
sometimes I can use abdominal
symptoms as a means to an end,
which is completing just general screening exam.
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.
Same thing with cervical cancer screening.
Now, do I think the abdominal pain is due to a cervical
lesion or cervical cancer that we haven’t found?
But I am going to be doing a GYN exam anyway,
So, therefore, checking for cervical cancer
at the same time can get two needs done.
It gets the patient evaluated, as
they should be, for their pain.
Also, it's a chance to complete that
cervical cancer screening, get them up to date.
So, that's just general principles.
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.