ABDOMINAL PAIN

	Location
	Work-up
	Acute pain syndromes
	Chronic pain syndromes

Epigastric Pain

			PUD
			GERD
			MI
			AAA- abdominal aortic aneurysm
			Pancreatic pain
			Gallbladder and common bile duct obstruction

Right Upper Quadrant Pain

			Acute Cholecystitis and Biliary Colic
			Acute Hepatitis or Abscess
			Hepatomegaly due to CHF
			Perforated Duodenal Ulcer
			Herpes Zoster
			Myocardial Ischemia
			Right Lower Lobe Pneumonia

Left Upper Quadrant Pain

			Acute Pancreatitis
			Gastric ulcer
			Gastritis
			Splenic enlargement, rupture or infarction
			Myocardial ischemia
			Left lower lobe pneumonia

Right lower Quadrant Pain

			Appendicitis
			Regional Enteritis
			Small bowel obstruction
			Leaking Aneurysm
			Ruptured Ectopic Pregnancy
			PID
			Twisted Ovarian Cyst
			Ureteral Calculi
			Hernia

Left Lower Quadrant Pain

			Diverticulitis
			Leaking Aneurysm
			Ruptured Ectopic pregnancy
			PID
			Twisted Ovarian Cyst
			Ureteral Calculi
			Hernia
			Regional Enteritis

Periumbilical Pain

			Disease of transverse colon
			Gastroenteritis
			Small bowel pain
			Appendicitis
			Early bowel obstruction

Diffuse Pain

			Generalized peritonitis
			Acute Pancreatitis
			Sickle Cell Crisis
			Mesenteric Thrombosis
			Gastroenteritis
			Metabolic disturbances
			Dissecting or Rupturing Aneurysm
			Intestinal Obstruction
			Psychogenic illness

Referred Pain

	Pneumonia (lower lobes)
	Inferior myocardial infarction
	Pulmonary infarction

TYPES OF ABDOMINAL PAIN

	Visceral
		originates in abdominal organs covered by peritoneum
	Colic
		crampy pain
	Parietal
		from irritation of parietal peritoneum
	Referred
		produced by pathology in one location felt at another location

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WORK-UP OF ABDOMINAL PAIN

	HISTORY
	Onset
	Qualitative description
	Intensity
	Frequency
	Location - Does it go anywhere (referred)?
	Duration
	Aggravating and relieving factors

WORK-UP

	PHYSICAL EXAMINATION
	Inspection
	Auscultation
	Percussion
	Palpation
	Guarding - rebound tenderness
	Rectal exam
	Pelvic exam

WORK-UP

	LABORATORY TESTS
	U/A
	CBC
	Additional depending on rule outs
		amylase, lipase, LFT’s

WORK-UP

	DIAGNOSTIC STUDIES
	Plain X-rays (flat plate)
	Contrast studies - barium (upper and lower GI series)
	Ultrasound
	CT scanning
	Endoscopy
	Sigmoidoscopy, colonoscopy

Common Acute Pain Syndromes

	Appendicitis
	Acute diverticulitis
	Cholecystitis
	Pancreatitis
	Perforation of an ulcer
	Intestinal obstruction
	Ruptured AAA
	Pelvic disorders

APPENDICITIS

	Inflammatory disease of wall of appendix
	Diagnosis based on history and physical
	Classic sequence of symptoms
		abdominal pain (begins epigastrium or periumbilical area, anorexia, nausea or vomiting
		followed by pain over appendix and low grade fever

DIAGNOSIS

	Physical examination
		low grade fever
		McBurney’s point
		rebound, guarding, +psoas sign
	CBC, HCG
		WBC range from 10,000-16,000
		SURGERY

DIVERTICULITIS

	Results from stagnation of fecal material in single diverticulum leading to pressure necrosis of mucosa and inflammation
	Clinical presentation
		most pts have h/o diverticula
		mild to moderate, colicky to steady, aching abdominal pain - usually LLQ
		may have fever and leukocytosis

Slide 20

CHOLECYSTITIS

	Results from obstruction of cystic or common bile duct by large gallstones
	Colicky pain with progression to constant pain in RUQ that may radiate to R scapula
	Physical findings
		tender to palpation or percussion RUQ
		may have palpable gallbladder

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PANCREATITIS

	History of cholelithiasis or ETOH abuse
	Pain steady and boring, unrelieved by position change - LUQ with radiation to back - nausea and vomiting, diaphoretic
	Physical findings;
		acutely ill with abdominal distention, ¯ BS
		diffuse rebound
		upper abd may show muscle rigidity

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PEPTIC ULCER PERFORATION

	Life-threatening complication of peptic ulcer disease - more common with duodenal than gastric
	Predisposing factors
		Helicobacter pylori infections
		NSAIDs
		hypersecretory states

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SMALL BOWEL OBSTRUCTION

	Distention results in decreased absorption and increased secretions leading to further distention and fluid and electrolyte imbalance
	Number of causes
	Sudden onset of crampy pain usually in umbilical area of epigastrium - vomiting occurs early with small bowel and late with large bowel

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RUPTURED AORTIC ANEURYSM

	AAA is abnormal dilation of abdominal aorta forming aneurysm that may rupture and cause exsanguination into peritoneum
	More frequent in elderly
	Sudden onset of excrutiating pain may be felt in chest or abdomen and may radiate to legs and back

Slide 30

PELVIC PAIN

	Ectopic pregnancy
	PID
	UTI
	Ovarian cysts

CHRONIC PAIN SYNDROMES

	Irritable bowel syndrome
	Chronic pancreatitis
	Diverticulosis
	Gastroesophageal reflux disease (GERD)
	Inflammatory bowel disease
	Duodenal ulcer
	Gastric ulcer

IRRITABLE BOWEL SYNDROME

	GI condition classified as functional as no identifiable structural or biochemical abnormalities
	Affects 14%-24% of females and 5%-19% of males
	Onset in late adolescence to early adulthood
	Rare to see onset > 50 yrs old

SYMPTOMS

	Pain described as nonradiating, intermittent, crampy located lower abdomen
	Usually worse 1-2 hrs after meals
	Exacerbated by stress
	Relieved by BM
	Does not interrupt sleep
		critical to diagnosis of IBS

DIAGNOSIS
ROME DIAGNOSTIC CRITERIA

	3 month minimum of following symptoms in continuous or recurrent pattern
	Abdominal pain or discomfort relieved by BM & associated with either:
	Change in frequency of stools
	and/or
	Change in consistency of stools

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DIAGNOSTIC TESTS

	Limited - R/O organic disease
	CBC  with diff
	ESR
	Electrolytes
	BUN, creatinine
	TSH
	Stool for occult blood and O & P
	Flexible sigmoidoscopy

MANAGEMENT

	Goals of management
	- exclude presence of underlying organic
	disease
	- provide support, support, & reassurance
	Dietary modification
	Pharmacotherapy
	Alternative therapies

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CHRONIC PANCREATITIS

	Alcohol major cause
	Malnutrition - outside US
	Patients >40 yrs with pancreatic dysfunction must be evaluated for pancreatic cancer
	Dysfunction between 20 to 40 yrs old R/O cystic fibrosis
	50% of pts with chronic pancreatitis die within 25 yrs of diagnosis

SYMPTOMS

	Pain - may be absent or severe, recurrent or constant
	Usually abdominal, sometimes referred upper back, anterior chest, flank
	Wt loss, diarrhea, oily stools
	N, V, or abdominal distention less reported

DIAGNOSIS

	CBC
	Serum amylase (present during acuteattacks)
	Serum lipase
	Serum bilirubin
	Serum glucose
	Serum alkaline phosphatase
	Stool for fecal fat
	CT scan

MANAGEMENT

	Should be comanaged with a specialist
	Pancreatic dysfunction
	- diabetes
	- steatorrhea & diarrhea
	- enzyme replacement

DIVERTICULOSIS

	Uncomplicated disease, either asymptomatic or symptomatic
	Considered a deficiency disease of 20th century Western civilization
	Rare in first 4 decades - occurs in later years
	Incidence - 50% to 65% by 80 years

SYMPTOMS

	80% - 85% remain symptomless - found by diagnostic study for other reason
	Irregular defecation, intermittent abdominal pain, bloating, or excessive flatulence
	Change in stool - flattened or ribbonlike
	Recurrent bouts of  steady or crampy pain
	May mimic IBS except older age

DIAGNOSIS

	CBC
	Stool for occult blood
	Barium enema

MANAGEMENT

	Increased fiber intake - 35 g/day
	Increase fiber intake gradually
	Avoid
		popcorn
		corn
		nuts
		seeds

GASTROESOPHAGEAL REFLUX DISEASE

	Movement of gastric contents from stomach to esophagus
	May produce S & S within esophagus, pharynx, larynx, respiratory tract
	Most prevalent condition affecting GI tract
	About 15% of adults use antacid > 1x/wk

SYMPTOMS

	Heartburn - most common (severity of does not correlate with extent of tissue damage)
	Burning, gnawing in mid-epigastrium worsens with recumbency
	Water brash (appearance of salty-tasting fluid in mouth because stimulate saliva secretion)
	Occurs after eating may be relieved with antacids (occurs within 1 hr of eating - usually large meal of day)

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DIAGNOSIS

	History of heartburn without other symptoms of serious disease
	Empiric trial of medication without testing
	Testing for those who do have persistent or unresponsive heartburn or signs of tissue injury
	CBC, H. pylori antibody
	Barium swallow
	Endoscopy for severe or atypical symptoms

MANAGEMENT

	Lifestyle changes
		smoking cessation
		reduce ETOH consumption
		reduce dietary fat
		decreased meal size
		weight reduction
		elevate head of bed 6 inches

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MEDICATIONS

	Antacids with lifestyle changes may be sufficient
	H2-histamine receptor antagonists in divided doses
		approximately 48% of pts with esophagitis will heal on this regimen
		tid dosing more effective for symptom relief and healing
		long-term use is appropriate

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MAINTENANCE THERAPY

	High relapse rate - 50% within 2 months, 82% within 6 months without maintenance
	If symptoms return after treatment need maintenance
	Full dose H2RA for most patients with nonerosive GERD
	Proton pump inhibitors for severe or complicated

INFLAMMATORY BOWEL DISEASE

	Chronic inflammatory condition involving intestinal tract with periods of remission and exacerbation
	Two types
		Ulcerative colitis (UC)
		Crohn’s disease

ULCERATIVE COLITIS

	Chronic inflammation of colonic mucosa
	Inflammation diffuse & continuous beginning in rectum
	May involve entire colon or only rectum (proctitis)
	Inflammation is continuous

CROHN’S DISEASE

	Chronic inflammation of all layers on intestinal tract
	Can involve any portion from mouth to anus
	30%-40% small intestine (ileitis)
	40%-45% small & large intestine (ileocolitis)
	15%-25% colon (Crohn’s colitis)
	Inflammation can be patchy

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SYMPTOMS

	Both have similar presentations
	Abdominal pain may be only complaint and may have been intermittent for years
	Abdominal pain and diarrhea present in most pts
	Pain diffuse or localized to RLQ-LLQ
	Cramping sensation - intermittent or constant

Slide 62

PHYSICAL EXAMINATION

	May be in no distress to acutely ill
	Oral apthous ulcers
	Tender lower abdomen
	Hyperactive bowel sounds
	Stool for occult blood may be +
	Perianal lesions
	Need to look for fistulas & abscesses

DIAGNOSIS

	CBC
	Stool for culture, ova & parasites, C. difficile
	Stool for occult blood
	Flexible sigmoidoscopy - useful to determine source of bright red blood
	Colonoscopy with biopsy
	Endoscopy may show “skip” areas
	May be difficult to distinguish one from other

MANAGEMENT

	Should be comanaged with GI
	5-aminosalicylic acid products
	Corticosteroids
	Immunosuppressives
	Surgery

DUODENAL ULCERS

	Incidence increasing secondary to increasing use of NSAIDs,  H. pylori infections
	Imbalance both in amount of acid-pepsin production delivered form stomach to duodenum and ability of lining to protect self

RISK FACTORS

	Stress
	Cigarette smoking
	COPD
	Alcohol
	Chronic ASA & NSAID use

GENETIC FACTORS

	Zollinger-Ellison syndrome
	First degree relatives with disease
	Blood group O
	Elevated levels of pepsinogen I
	Presence of HLA-B5 antigen
	Decreased RBC acetylcholinesterase

INCIDENCE

	About 16 million individuals will have during lifetime
	More common than gastric ulcers
	Peak incidence; 5th decade for men, 6th decade for women
	75%-80% recurrence rate within 1yr of diagnosis without maintenance therapy
	>90% of duodenal ulcers caused by H.pylori

SYMPTOMS

	Epigastric pain
	Sharp, burning, aching, gnawing pain occurring 1! - 3 hrs after meals or in middle of night
	Pain relieved with antacids or food
	Symptoms recurrent lasting few days to months
	Weight gain not uncommon

DIAGNOSIS

	CBC
	Serum for H. pylori
	Stool for occult blood

MANAGEMENT

	2 week trial of antiulcer med - d/c NSAIDs
	If H. pylori present - treat
	If no H. pylori & symptoms do not resolve after 2 wks refer to GI for endoscopy
	Antiulcer meds
		H2RA; associated with 75%-90% healing over 4-6week period followed by 1 yr maintenance
		inhibits P-450 pathway; drug interactions

MANAGEMENT (CONT)

	Proton pump inhibitors
		daily dosing
		documented improved efficacy over H2-RA blockers
	Prostagladin therapy - misoprostol
		use with individuals who cannot d/c NSAIDs

GASTRIC ULCERS

	H. pylori identified in 65% to 75% of patients with non-NSAID use
	5% - 25% of patients taking ASA/NSAID develop gastric ulcers (inhibits synthesis of prostaglandin which is critical for mucosal defense)
	Malignancy cause of

OTHER RISK FACTORS

	Caffeine/coffee
	Alcohol
	Smoking
	First-degree relative with gastric ulcer

SYMPTOMS

	Pain similar to duodenal but may be increased by food
	Location - LUQ radiating to back
	Bloating, belching, nausea, vomiting, weight loss
	NSAID-induced ulcers usually painless - discovered secondary to melena or iron deficiency anemia

DIAGNOSIS

	CBC
	Serum for H. pylori
	Carbon-labeled breath test
	Stool for occult blood
	Endoscopy

MANAGEMENT

	Treat H.pylori if present
	Proton pump inhibitors shown to be superior to H2-RA
	Need to use proton pump inhibitor for up to 8 wks
	Do not need maintenance if infection eradicated and NSAIDs d/c’d
	Consider misoprostol if cannot d/c NSAID