Bread and Butter Abdominal Ailments for Medical Students in the ED

Abdominal pain is the most common chief complaint for adult patients in the ED. [1]  It’s one of the presenting symptoms that can run the gamut between largely benign to imminently lethal, making it imperative for medical students to be able to triage and assess it appropriately. 

Key Concepts

1. Quickly rule out life-threatening emergencies that require immediate resuscitation. Think aortic aneurysm dissection, bowel perforation, STEMI (especially in elderly female patients!), ruptured ectopic pregnancy, etc.  These are the “can’t miss” diagnoses! Some good tests to consider in this phase include looking for peritoneal signs (i.e. rebound tenderness), getting an EKG if you have a high suspicion for cardiac involvement, or using ultrasound to assess for free fluid. Make sure to have patients change into a gown so that you can more fully assess for bruising and skin changes.

2. Build a differential (and keep it broad!); remember that abdominal pain doesn’t necessarily mean the pain is coming from the abdomen (for example, consider pulmonary emboli, pneumonia, herpes zoster).

3. Decide on further testing, including lab work and imaging based on your clinical suspicion for particular diagnoses.

4. Present your patient to a resident/attending.  Make sure your HPI covers associated symptoms, onset, and location.  Your presentation should cover the most important history and physical exam elements of the top diagnoses on your differential and therefore the tests and imaging you want for the patient.

5. Recognize and appreciate the limitations of your tests and get comfortable with the diagnosis of “nonspecific abdominal pain” once the bad stuff has been ruled out.

6. Discuss treatment options as well as disposition for your patient once labs and imaging have returned.

7. Be your patient’s advocate!  Take the lead on calling consults, hunting down imaging, and noticing if orders didn’t go through.  Introduce yourself to the patient’s nurse, discuss your impression and plan, and report back to your residents or attendings with new laboratory/imaging findings or changes in your physical exam. 

Generating a Differential

Seeing a patient with abdominal pain can be daunting, especially when the pain is non-specific or your HPI and physical exam don’t yield many answers.  Consider the patient’s age, sex, and medical/surgical history to start building your differential, then recommend tests and imaging based on those diagnoses.  Keep in mind pretest probabilities for your differential, and get appropriate labs or imaging if history and physical exam alone can’t rule out a potential diagnosis. Remembering which conditions present in which abdominal quadrants before seeing the patient helps me think about the differential diagnoses before seeing the patient.  If the pain is diffuse, think about diagnoses such as aortic aneurysm or dissection, bowel obstruction, diabetic ketoacidosis, mesenteric ischemia, pancreatitis, or gastroenteritis.

Labs to Consider

• A Complete Blood Count and Complete Metabolic Profile are generally routine on all abdominal pain patients.

• Lipase: if the patient has a history of heavy alcohol use, gallstones, past episodes of pancreatitis or if your physical exam reveals significant epigastric pain with palpation.

• Hepatic function tests: if history reveals past alcohol or IV drug-use or physical exam shows right upper quadrant tenderness or a palpable liver edge.

• Urinalysis: if history includes urinary symptoms or if physical exam shows suprapubic tenderness.

• Beta-hCG: for all pre-menopausal patients with a uterus (even if they say there is NO chance they could be pregnant).

• Troponin: if patient has cardiac history, has other risk factors for acute coronary syndrome (think diabetes, renal disease, or smoking), or is having associated chest, jaw, or arm pain.

Imaging to Consider

●      Upright abdominal XR: If pneumoperitoneum is suspected from a perforated ulcer or you have a very high probability for a small bowel obstruction.

●      Abdominal ultrasound: Complete a bedside abdominal aortic ultrasound if the patient has risk factors, or a FAST exam if a ruptured ectopic pregnancy is suspected. You can also use ultrasound testing for evaluation of biliary pathology as well as ovarian/testicular torsion. Click here to learn how to perform an FAST exam.

●      Abdominal CT:  For patients in whom the diagnosis is still unknown and their abdominal pain is concerning for a pathology that could be potentially included or excluded based on CT results.

Watch out for these pathologies on imaging! These are some of those diagnoses in a patient with abdominal pain that you can’t miss as an emergency physician:

Figure 1: Upright abdominal XR showing small bowel obstruction.  Note the distended loops of bowel and air-fluid levels indicated by the arrows.[2]

Figure 2: Longitudinal view of the abdominal aorta showing a focal area of enlargement at the arrows, consistent with AAA.[3]

Make sure to continue to follow your patients to discharge or admission, and communicate often with both the patient and their family regarding next steps and proper follow-up. 

Case Study

Triage Note: 52 year old male with past medical history significant for nephrolithiasis and cholecystitis presents with 2 days of “stabbing” suprapubic abdominal pain accompanied by mild nausea.

You scan the board in the ED.  A 52 year old male patient was roomed 4 minutes ago and has a chief complaint of “abdominal pain.” You sign up for the patient and head towards his room, walking yourself through possible diagnoses in your mind on your way there.

The triage complaint leaves much to the imagination, and diagnoses like gastritis, cholecystitis, small bowel obstruction, and abdominal aortic aneurysm start swirling in your mind.  You reach the door of his room and see a middle-aged male sitting in bed and wincing occasionally with slight movement.  Upon first glance, he does not appear acutely ill.  You start by getting a history from him: “I woke up yesterday morning with a sharp pain in my belly, kind of around this area,” motioning to his lower left quadrant.  He states that the pain is accompanied by some nausea, but he has not vomited. He explains that he was not straining or lifting at the time of onset of the pain.  The pain has steadily increased over the past 48 hours to the point now where it is difficult for him to walk.  The pain is constant, but worsens with movement.  He has tried taking ibuprofen for the pain with no change in his symptoms.  He denies fevers, chills, vomiting, loss of appetite, diarrhea, constipation, pain with urination, or blood in his stool or urine.  He has never experienced pain like this before.  He is up to date on colonoscopies, and his last colonoscopy was normal aside from diverticula in his sigmoid colon.

 He has a past medical history significant for nephrolithiasis and cholecystitis and a past surgical history significant for a cholecystectomy in 2013.  He does not take any medications and has no known drug allergies. He lives with his wife, with whom he is monogamous.  He drinks alcohol occasionally, and does not smoke or use other drugs.

You next move on to the physical exam, first noting his triage vitals: BP: 138/80; pulse: 93; temp: 97.8; RR: 16; SpO2: 99%

On physical exam, you record the following: non-focal cardiopulmonary exam.  Abdominal exam shows good bowel sounds with tenderness to deep palpation over the entire lower abdomen, worse in the left lower quadrant.  No pulsatile abdominal mass palpated. Skin exam reveals no bruising or color change. Genital exam normal.

Putting it All Together

At this point, you reassure your patient and head back out to the hallway to start thinking about your assessment and plan.  Once you gather your thoughts, you find your attending and give them a summary of your findings:

“This is a 52 year old male coming in for lower abdominal pain with tenderness that is most pronounced in his left lower quadrant.  His story and physical exam may support several diagnoses, including diverticulitis, kidney stone, gastroenteritis, ulcerative colitis, and urinary tract infection in decreasing likelihood. The most worrisome diagnoses for this patient include intestinal obstruction and AAA dissection. To further narrow our differential and decide on a treatment modality, we should order a CBC, CMP, UA, AAA ultrasound and abdominal CT.  If his lab work and imaging return normal, we can help treat his pain while he’s here in the ED and plan to discharge him home with outpatient follow up.  If his CT shows diverticulitis or his CBC shows overt infection, we can treat him with antibiotics as an inpatient or outpatient depending on the severity of the infection.”

Case Outcome

The abdominal CT showed uncomplicated diverticulitis!  The patient was discharged home with a course of antibiotics and instructions to follow up with his primary care provider in the next 3-4 days.


Edited by Jeffrey A Holmes, MD

References

1. Silverio, Luz. “Abdominal Pain.” Default, SAEM, 1 Sept. 2019.

2. Stoker, Jaap, and et al. “Imaging Patients with Acute Abdominal Pain.” Radiology, RSNA, 1 Oct. 2009. [Full Text]

3. Sparks, Amy R., et al. “Imaging of Abdominal Aortic Aneurysms.” American Family Physician, 15 Apr. 2002.[Pdf]