Abdominal Pain

Back during residency we used to tell people that 50% of patients who walk in with abdominal pain, walk out without a definite diagnosis. Often we’d recommend a return follow up in 24-48 hours if not entirely better. Today I’m sure we’re doing better with 24/7 high resolution CT and ultrasound availability. However, the range of possibilities remains enormous. When someone says “my belly hurts,” it’s anything from fear of PE class, to too much turkey, to too much marijuana, to ruptured aorta, etc.

Red Flags:

• Fever
• Vomiting (especially absent diarrhea)
• Bloody vomit or BMs
• Nothing similar in the past
• No appetite
• Diabetes
• On dialysis
• Jaundice
• Cancer
• Associated light headedness or syncope
• Frail/elderly
• Immunocompromised
• Pregnant

Happy Words

• Similar to past episodes with known diagnosis (like gastritis)
• Slowly improving already
• Better with Tums
• “Vomiting and diarrhea right after eating the caesar salad.”
• “I no longer have an appendix, gall bladder, uterus or ovaries.”
• “I ran out of my Prilosec.”
• “I have an exam tomorrow and I’ve been awake all night and hydrating with Coke.”
• “While studying at the Frontier I ate their green chili deluxe cheese Taco, then drank a bottle of red wine to calm down at home, then passed out, then woke up late for my exam with a sore stomach, and now can I please have a doctor’s note?”

Unlike for headaches, “worst belly pain of my life” really doesn’t push us in any direction. Patients who wheel in with belly pain generally rate it a 10/10 and look miserable. Magnitude of pain doesn’t help nearly as much as history and location of pain. The exam itself adds really only a little more than history. Abdominal scar patterns from past surguries can be particularly useful.

I remember a surgeon once splitting belly pain between “writhing and rigid.” Those who can’t stay still on the gurney are writhing, and in this category he listed kidney stones, aortic aneurysm and mesenteric ischemia. The last one is rare, and is described as “pain out of proportion to exam.” This makes sense, because the problem isn’t inflammation, but rather lack of intestinal blood flow… analogous to a heart attack or stroke.

“Rigid” abdominal pain means that it hurts to twist, bounce or move, and the problem is typically due to inflammation, which causes pain when organs slide past one another. These patients will do whatever possible to limit that movement, and rigidly contracted abdominal muscles helps to hold those organs in place. For parents at home, a good test is to ask junior to jump up and down a few times. If no problem, then there’s likely time to think.

Location of pain is another useful bit of history. Here are the regional categories and diagnostic tests they may trigger. (It helps to drill an imaginary hole and add “-itis” to whatever organs/tissues you may find… gastritis, pancreatitis, cholecystitis, hepatitis, pleuritis, etc.)

  1. Epigastric – (upper belly just below the ribs)
    Your doc may request a CBC, CMP, lipase level and may offer viscous lidocaine, Maalox, Pepcid … maybe an EKG too for elderly, diabetic, females … maybe an ultrasound to look at the gall bladder and liver. (Diagnosis of “gastritis” will probably get you home fastest.)
  2. Right upper quadrant – (top right below the ribs)
    Approach similar to epigastric, with ultrasound more likely to hunt for cholelithiasis (gall stones) and cholecystitis. It’s important to know that very rarely do gall stones themselves lead to rapid surgery. So if this is your known problem, expect disappointment if you come to an ER hoping for immediate surgery.
  3. Right lower quadrant – (bottom right)
    Expect a CBC and urinalysis at least, and a pregnancy test for women with a sliver of a pregnancy chance. You’ll be lucky to escape without a CT, unless you say the magic words: “I don’t have an appendix.” While bread and butter for surgeons, it’s far better to catch appendicitis early than late. For women, ectopic pregnancy, twisted ovary or tuboovarian abscess are other considerations.
  4. Suprapubic – (right over the bladder)
    I believe l speak for most of us in healthcare in saying we love cystitis. “Dirty urine” in a non pregnant woman, with no fever or back pain, is turn and burn medicine. No scans required and a variety of antibiotics are quite effective.
    Vaginal complaints, however, may send you down the long road earning you a pelvic exam along with antibiotics for both you and your partner.
    In men, we think of STDs too. If you say things right, a rectal exam may earn you a diagnosis of prostatitis as well.
  5. Left lower quadrant – (bottom left)
    Similar path for right lower quadrant pain, with maybe a little less urgency. Diverticulitis is a common finding on CT, which is generally treated with antibiotics.
  6. Left upper quadrant – (left upper and below the ribs)
    Remarkably rare and generally boring. For those with mononucleosis, sometimes a large spleen may prove interesting. Sometimes kidney pathology can appear here. Or stomach gas perhaps?
  7. Periumbilical – (around the belly button)
    We often wonder if this could be early appendicitis. Other rarities may include twisted intestine (“volvulus”) , mesenteric ischemia, aortic dissection… black widow spider bite?… oh yes.
  8. Flanks – (sides)
    Kidney stones or infections? Urinalysis with CT very often provides clarity.

By now, most of you are bored and have stopped reading. Some ER docs and surgeons are cringing. Obviously I can’t make you an abdominal pain expert with a fb post. But just try now to imagine emergency medicine pre-CT? Ultrasound has improved care enormously as well. I’ve only scratched the surface.

Now bringing it home to Pre-R… The thing we lack most in ERs is time. Not only are we tasked with nailing diagnoses and making people better, these have to happen fast. As such, we often order everything at once. Blood and urine tests, CT/ultrasound, pain meds and saline are frequently ordered together.

However, despite all this, in most cases saline (+/- Pepcid, Maalox, Toradol, Zofran) are the solution. It’s fairly amazing to me how much people can improve from misery to all better after a relatively short time, with the majority of people eventually going home.

So all that said, if belly pain is your problem and you want to have a chat, then give call. If no red flags and you’d like to try saline and some simple therapies first, maybe we can help. If not, then head to an ER and buckle up for a ride.

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