Abdominal Pain: The Saint-Chopra Guide to Inpatient Medicine, 4th Edition

December 8, 2019

– Hello, my name is Dr. Vineet Chopra and I’m here today to talk
to you about abdominal pain. This is coming from the Saint-Chopra Guide
to Inpatient Medicine that I wrote with my
colleague and research mentor Dr. Sanjay Saint. This is the Fourth Edition and this video is a brief overview of one of the chapters in the book. We hope you like it. Abdominal pain is challenging because there are so
many potential diagnoses that can relate to pain in the belly. It’s also challenging because
the signs and symptoms are often non-specific. They can vary from mild to severe symptoms and the signs can be
either present or absent. The key challenge with abdominal pain is that life-threatening
conditions can hide in the abdomen and the consequences of
wrongly attributing the pain to something benign can be catastrophic. So what we tell learners and what’s important for you to know is that we always want
you to respect the belly. If there’s anything a good
diagnostician will be humbled by, it’s abdominal pain. So really think about this in a systematic and in a very thoughtful way. How do you approach abdominal pain? Well, we want you to think
about a three-step approach but you need first with
systemic signs and symptoms. So when you think about a
person with abdominal pain you should ask are there
other systemic causes that may be driving this pain? For example if the patient
has strangely colored urine and has abdominal pain,
maybe they have porphyria. If they hail from the Mediterranean area and their family has a history of recurrent abdominal pain crisis, could they have familial
Mediterranean fever and do they need further testing for that. Also remember to look
for endocrine changes either in the skin or
changes in their blood sugar because Addison’s disease
and diabetic ketoacidosis can often present also
with abdominal pain. And think about uremia in
patients with kidney disease as a cause of nausea,
vomiting, abdominal pain, especially if their kidney
function has deteriorated. The point here is never think about abdominal pain in isolation. Always think about it in the context of how is the patient presenting and what are the comorbidities. The other thing to always
remember is referred pain. So pain at the abdominal pain can come from different sites in the body and the most common sites are
the thorax and the pelvis. We want you to think about
pneumonia as a common cause especially of upper quadrant pain and that’s because basilar pneumonia, those involving the bases of the lungs, can often cause pleural
inflammation which can rub against either the liver capsule
or the splenic capsule to refer to right or
left upper quadrant pain. In fact, I’ve seen this several times. So a febrile patient with
cough and sputum production who presents with right
upper quadrant pain should make you think a little bit about potential pulmonary
causes of referred pain. I also wanna highlight
myocardial infarction as one of those causes of abdominal pain that you should probably never forget. So in an elderly patient or in a diabetic who is presenting with abdominal
pain without a clear cause, always think about the heart. And remember in women do not forget the pelvic inflammatory
diseases and ovarian torsion all of which can also
cause abdominal pain. The most helpful approach, however, is to consider the abdominal
organs based upon anatomy and always think about infection,
obstruction, or ischemia as you work through the
location of the organs and why they may be having the pain. So let’s walk through this
given the following grid. The first thing to think about
is the location of the pain. So if somebody presents with
right upper quadrant pain, we want you to think about
the liver and the gallbladder as the two organs in that area. So inflammation or infection
of those two organs can cause pain. So think hepatitis,
hepatic tumor or abscesses, cholecystitis and even stone disease like choledocholithiasis can
end up causing cholangitis or other causes of abdominal pain in the right upper quadrant. Someone who’s got HIV, don’t
forget AIDS cholangiopathy as a cause of abdominal pain as well. If the pain is epigastric, remember that’s the stomach,
the pancreas, the duodenum, and the abdominal aorta, so ask yourself, is this patient potentially
suffering from gastritis? Could they have peptic ulcer disease? Is the pain really sharp and stabbing? Does it go to the back? Could they have an
abdominal aortic aneurysm? Do they have a history of alcohol intake? Could this be pancreatitis
or stone disease? Again, remember cardiac disease as a potential cause of
epigastric pain as well. Pain in the left upper quadrant
is almost always the spleen so look for splenic enlargement, hook under the ribcage
if you can’t feel it. Think about a splenic infarct in somebody who may
otherwise be bacteremic or be at risk for splenic infarction. And think about abscesses as well. In an older patient who
has known splenomegaly who become suddenly hypotensive, never forget splenic rupture. It is a life-threatening condition and something that should
be always be on your mind especially in the setting
of known spleen enlargement. Left or right lower quadrant pain can refer to a number of organs, specifically the appendix
and the intestines. In women you should think about the ovary and the fallopian tubes
and in men the testes. Also remember the genito-urinary system including the kidney and the ureters. So diseases such as
appendicitis, diverticulitis, ovarian cyst or torsion, in younger women think
about ectopic pregnancy or pelvic inflammation disease
if they’re sexually active, and in men don’t forget
to look for epididymitis and testicular torsion as
causes of abdominal pain. If somebody has a history of stone disease or is at risk of stone formation, think about nephrolithiasis and don’t forget to look at flank pain in the patient who may
have pyelonephritis. Periumbilical pain is one
of those interesting ones because it can refer
to the small intestine, the appendix especially
when appendicitis begins before it localizes to
the parietal peritoneum and the visceral peritoneum
in the right lower quadrant, and the abdominal aorta. So when you see periumbilical pain, think about bowel obstruction,
think about appendicitis, and don’t forget ischemic bowel disease. Hypogastric pain or pain
in the hypogastric area could refer to the bladder, in women the uterus and the ovaries and the fallopian tubes are also at play, think about cystitis,
urethritis, nephrolithiasis, PID and endometriosis especially
if it’s pain in that area. So I like this location-based approach mapping to the underlying organs and again this is a very
systematic way of thinking about the causes and the
potential organs involved with abdominal pain. You also wanna try to
elicit certain symptoms that may have help you
increase the likelihood of certain conditions
in organ involvement. So somebody has suprapubic
pain or hypogastric pain with dysuria and frequency, maybe they’ve got a kidney
or a bladder infection. If somebody presents with
nausea, vomiting, and diarrhea, is it possible that they
have some type of gastritis or maybe they’ve got pancreatitis. The diarrhea from pancreatitis may just be chronic
pancreatitis and malabsorption. Jaundice and itching in the
patient with abdominal pain should make you think about liver disease. If it’s a younger patient, think about stone disease
from the gallbladder that may be causing
obstructive cholangiopathy. Pain that gets better
when someone stands up is almost always pancreatic pain so think about the pancreas. In an abrupt onset of pain in the midline that is completely out
of proportion to the exam should make you think about ischemia specifically the mesenteric blood vessels. So look for risk factors
around cardiac dysrhythmias or an embolic disease that
may be causing that as well and think about serum
lactate as a diagnostic test. Remember pain exacerbated by the flexion of the abdominal muscles refers to pain from the abdominal wall, that could be all related to
some type of abdominal trauma or there may be an
intraabdominal cause of that in the wall itself. Make sure to look for that
when you’re thinking about flexion of the abdominal musculature. So what’s our approach to the patient? We always begin with a good history, this is key in abdominal pain, ask for when the pain
began, what exacerbated it, what they were doing at the
time, what makes it better, what’s the site, what’s the
radiation, what’s the severity, and ask if they’ve had this before or if other family members have had it. Do a good physical exam especially if somebody
has severe abdominal pain. It’s not difficult to do so
don’t forget to flex the knees, relax the abdominal muscles
and do a good auscultation to look for bowel sounds but also for tenderness
and rebound and guarding. Get your usual labs, your CBC, your basic, and lactate if you’re
thinking about ischemia. Don’t forget an ECG and a chest x-ray especially if you’re
thinking about referred pain. I wanna point in a word
here for abdominal CT scan because a lot of learners are reluctant and sometimes hesitate to
pull the trigger on a CT. Remember that an abdominal CT
is better than an ultrasound for evaluating most
intra-abdominal structures. And what I commonly see
is too much hesitation in ordering the CAT scan and
potentially missing diagnoses. I always say if the bowel
is of primary concern and you’re worried about contrast, sometimes you can avoid the contrast especially if the creatinine is elevated. But remember the ideal study
is oral and IV contrast study because it allows you to
look at the bowel walls, intra-abdominal pathologies
and also abscesses which you will miss if
you don’t use contrast. In a patient who has
unexplained belly pain and especially if they’re elderly, move to the CAT scan early and quickly. It will save you a lot of pain and trouble in managing that patient. So that’s it, thank you. I hope you liked this brief
overview of abdominal pain. If you like this talk
and want to read more, please consider purchasing the Saint-Chopra Guide
to Inpatient Medicine. You can use the promo
code here to save 30%. And I hope you have a wonderful day. Thanks very much for your attention.

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