Abdominal Pain 1 Given a patient with abdominal pain, paying particular attention to its location and chronicity: a) Distinguish between acute and chronic pain. Arbitrary number cannot be used to distinguish between acute and chronic pain. Pain of less than a few days duration that has worsened progressively until the time of presentation may be classified as acute. Pain that has remained unchanged for months or years may be classified as chronic. Pain that does not clearly fit either category might be called subacute and requires consideration of the differential diagnoses for both acute and chronic pain. b) Generate a complete differential diagnosis (ddx). GI tract Inflammatory: gastroenteritis, appendicitis, gastritis, esophagitis, diverticulitis, Crohn's disease, ulcerative colitis, microscopic colitis Obstruction: hernia, intussusception, volvulus, post-surgical adhesions, tumours, superior mesenteric artery syndrome, severe constipation, hemorrhoids Vascular: embolism, thrombosis, hemorrhage, sickle cell disease, abdominal angina, blood vessel compression (such as celiac artery compression syndrome), Digestive: peptic ulcer, lactose intolerance, coeliac disease, food allergies Bile system Inflammatory: cholecystitis, cholangitis Obstruction: cholelithiasis, tumours Liver Inflammatory: hepatitis, liver abscess Pancreatic Inflammatory: pancreatitis Renal and urological Inflammation: pyelonephritis, bladder infection Obstruction: kidney stones, urolithiasis, Urinary retention, tumours Vascular: left renal vein entrapment Gynaecological or obstetric Inflammatory: pelvic inflammatory disease Mechanical: ovarian torsion Endocrinological: menstruation, Mittelschmerz Tumors: endometriosis, fibroids, ovarian cyst, ovarian cancer Pregnancy: ruptured ectopic pregnancy, threatened abortion Abdominal wall muscle strain or trauma neurogenic pain: herpes zoster, radiculitis in Lyme disease, abdominal cutaneous nerve entrapment syndrome (ACNES), Referred pain from the thorax: pneumonia, pulmonary embolism, ischemic heart disease, pericarditis from the spine: from the genitals: testicular torsion Metabolic disturbance uremia, diabetic ketoacidosis, porphyria, adrenal insufficiency, narcotic withdrawal Blood vessels aortic dissection, abdominal aortic aneurysm Immune system sarcoidosis vasculitis Idiopathic irritable bowel syndrome (affecting up to 20% of the population, IBS is the most common cause of recurrent, intermittent abdominal pain) c) Investigate in an appropriate and timely fashion. Initial diagnostic testing — may consider following investigations Complete blood count with differential, Electrolytes, BUN, creatinine, and glucose, Aminotransferases, alkaline phosphatase, and bilirubin, Lipase, Urinalysis, Ferritin, Anti- tissue transglutaminase, Pregnancy test in women of childbearing potential Plain film 3 views of abdomen / CT (gas pattern, free air) Ultrasound (gallbladder disease, gynecological problems) Gastroscopy/colonoscopy (AAA, appendicitis) 2 In a patient with diagnosed abdominal pain (e.g., gastroesophageal reflux disease, peptic ulcer disease, ulcerative colitis, Crohn’s disease), manage specific pathology appropriately (e.g., with. medication, lifestyle modifications). GERD - Lifestyle modifications , Head of bed elevation, avoidance of reflux-inducing foods (fatty foods, chocolate, peppermint, and excessive alcohol, Weight loss avoidance of meals before bedtime Medications - Proton pump inhibitors H2 Antagonist (Ranitidine, Cimetidine, Famotidine, Nizatidine ) Prokinetic agents (bethanechol, metoclopramide) PUD - Eradication of H. pylori Antisecretory therapy after H. pylori eradication with Proton pump inhibitors and H2 Antagonist Inflammatory Bowel Disease - 5-aminosalicylate (5-ASA) Sulfasalazine , mesalamine, olsalazine, balsalazide Prednisone Cyclosporine hydrocortisone (100 mg IV q8h), antibiotics in colitis flare - metronidazole , ciprofloxacin anti-TNF - Infliximab 3 In a woman with abdominal pain: a) Always rule out pregnancy if she is of reproductive age. b) Suspect gynecologic etiology for abdominal pain. c) Do a pelvic examination, if appropriate. Ectopic Pregnancy, Adnexal Masses, Corpus luteum hematoma, Ruptured ovarian cyst, Ovarian torsion, Acute Pelvic Inflammatory Disease, Endometriosis, Primary Dysmenorrhea, Secondary Dysmenorrhea, Adhesions Interstitial Cystitis 4 In a patient with acute abdominal pain, differentiate between a surgical and a non-surgical abdomen. Obstruction — pain, anorexia, bloating, nausea, vomiting (bilious or feculent), and obstipation Distension, high-pitched or absent bowel sounds. Peritonitis - , abdominal wall rigidity, percussion/rebound tenderness, involuntary guarding, diminished bowel sounds 5 In specific patient groups (e.g., children, pregnant women, the elderly), include group-specific surgical causes of acute abdominal pain in the ddx. Trauma - hemorrhage from solid organ laceration or fluid loss, organ ischemia from vascular injury, and infection from perforated hollow viscus In neonates - volvulus (as a complication of malrotation) and necrotizing enterocolitis .Intussusception (invagination of a part of the intestine into itself, causing obstruction Among children of all ages, appendicitis can cause peritoneal irritation and focal tenderness. Obstruction as the result of adhesions from previous surgery or inflammation, complications of Hirschsprung disease, perforated ulcer, and primary bacterial peritonitis (usually as a complication of nephrotic syndrome. Incarcerated inguinal hernia diabetic ketoacidosis, hemolytic uremic syndrome. ruptured ectopic pregnancy. Ischemic bowel, aortic dissection, rupture of AAA 6 Given a patient with a life-threatening cause of acute abdominal pain (e.g., a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): a) Recognize the life-threatening situation. b) Make the diagnosis. c) Stabilize the patient. d) Promptly refer the patient for definitive treatment. Conventional angiography Angiography remains the criterion standard for the diagnosis of AAA Computed tomography Preoperative CT scanning helps more clearly define the anatomy of the aneurysm and other intra- abdominal pathologies. Nonenhanced CT scanning is used to size aneurysms. Diagnostic Tests for Detecting Ectopic Pregnancy Diagnostic test Sensitivity (%) Specificity %) Transvaginal ultrasonography with beta-hCG level greater than 1,500 67 to 100 100 (virtual mIU per mL (1,500 IU per L) certainty) Beta-hCG levels do not increase appropriately 36 63 to 71 Single progesterone level to distinguish ectopic pregnancy from 15 > 90 nonectopic pregnancy Single progesterone level to distinguish pregnancy failure from viable 95 40 intrauterine pregnancy 7 In a patient with chronic or recurrent abdominal pain: a) Ensure adequate follow-up to monitor new or changing symptoms or signs. b) Manage symptomatically with medication and lifestyle modification (e.g., for irritable bowel syndrome). Dietary modification - lactose free diet , Exclusion of gas-producing foods , (beans, onions, celery, carrots, raisins, bananas, apricots, prunes, brussel sprouts, wheat germ, pretzels, and bagels) Food allergies, Gluten sensitivity, Carbohydrate malabsorption, increase in the intake of fiber Psychosocial therapies Medications - Antispasmodic agents (hyoscine, cimetropium, pinaverium, dicyclomine) Antidepressants (amitriptyline, imipramine, nortriptyline, and desipramine Paroxetine, fluoxetine, sertraline) 5- serotonin 3 receptor antagonists (alosetron, cilansetron, ondansetron and granisetron) c) Always consider cancer in a patient at risk. Risk factors for colorectal cancer, Hereditary CRC syndromes, Familial adenomatous polyposis, MYH-associated polyposis, Lynch syndrome, Alcohol, Obesity, Age, Inflammatory bowel disease, 8 Given a patient with a diagnosis of inflammatory bowel disease (IBD) recognize an extra intestinal manifestation Musculoskeletal Peripheral arthritis Sacroiliitis Ankylosing spondylitis Osteoporosis Dermatologic Erythema nodosum Pyoderma gangrenosum Aphthous stomatitis Ocular Uveitis Scleritis Episcleritis Hepatobiliary Disease Primary sclerosing cholangitis Vascular Thromboembolic events Renal Nephrolithiasis .