Pocket Emergency Medicine (Pocket Notebook Series) 3rd Ed.

ABDOMINAL PAIN

Approach

• Assess nature of pain: Location, acute or chronic, constant or intermittent, relation to eating, associated sxs such as fever, nausea, vomiting, dysuria, change in bowel habits

• Always ask about previous abdominal surgeries

• Labs depend on presentation. Consider: CBC, BMP, UA, LFTs, lipase, hCG, lactate

• In the elderly, low threshold to evaluate for AAA w/ bedside U/S & ACS w/ EKG

RIGHT UPPER QUADRANT PAIN

Cholelithiasis

Presentation

• Acute, severe, intermittent RUQ pain, +N/V, a/w fatty meals

• In biliary colic, sxs generally resolve completely in b/w episodes

• Mild RUQ tenderness but no fever or Murphy’s sign

• In choledocholithiasis & cholecystitis, sxs will become constant

Evaluation

• nl labs in biliary colic

• Biliary colic is a clinical Dx & U/S is not required in ED unless ruling out other Dx, or in pt w/ intractable pain. RUQ U/S spec/sens is 90–95% for stones.

Treatment

• NSAIDs, opiate analgesics, antiemetics; elective surgical management

Disposition

• If pain controlled, d/c home w/ surgery f/u to consider cholecystectomy

Pearls

• 80% of stones are of mixed composition w/ cholesterol having the highest concentration

• RFs include female gender, increasing age & parity, & obesity

Choledocholithiasis

Presentation

• Biliary colic that becomes constant, often jaundiced

• Mild RUQ tenderness but no fever or Murphy’s sign

Evaluation

• Obstructive LFT pattern, U/S shows dilated CBD >6 mm

Treatment

• ERCP-guided stone removal or cholecystectomy

Disposition

• Admit medicine

Cholecystitis

Presentation

• Acute, severe, RUQ pain, that becomes constant, fever, nausea, vomiting

• RUQ tenderness; Murphy’s sign (arrest of inspiration w/ RUQ palpation), or Sonographic Murphy’s sign (pain w/ palpation of visualized gallbladder w/ U/S probe); fever

Evaluation

• CBC (elevated WBC ± left shift), LFTs (may be elevated but are often nl), RUQ U/S: The presence of stones, thickened gallbladder wall (>3 mm), & pericholecystic fluid has a PPV of >90%

• HIDA scan: Used if U/S is equivocal, best sens/spec

Treatment

• 2nd- or 3rd-generation cephalosporin (E. coli, Enterococcus, Klebsiella) broaden coverage if septic

• Surgical consult for cholecystectomy; may do percutaneous drain if poor surgical candidate

Disposition

• Admit for surgical management

Cholangitis

Presentation

• Charcot’s triad: RUQ pain, jaundice, fever (present in 70% of pts)

• Reynold’s pentad: Charcot’s triad +shock & MS changes (present in 15% of pts)

Evaluation

• Labs: ↑ WBC, ↑ LFTs, positive blood cultures

• U/S/CT not very sens; can be suggestive

• ERCP is diagnostic & can be therapeutic if obstructing stone is found

Treatment

• Broad-spectrum abx for gram-negative enterics (eg, E. coli, Enterobacter, Pseudomonas): Piperacillin/tazobactam OR ampicillin/sulbactam OR ticarcillin/clavulanate OR ertapenem OR metronidazole + (ceftriaxone OR ciprofloxacin)

Disposition

• Admission to medicine for IV abx ± ERCP w/ surgery consultation

Pearls

• 80% pts respond w/ conservative mgmt & abx w/ elective biliary drainage

• 20% require urgent ERCP biliary decompression, percutaneous drainage, or surgery

• 5% mortality

EPIGASTRIC PAIN

Pancreatitis

Definition

• Inflammation of the pancreas

Etiology

• Alcohol (30%), gallstones (35%), idiopathic (20%) hypertriglyceridemia (TG >1000), hypercalcemia, drugs (thiazides, furosemide, sulfa, ACE-I, protease inhibitors, estrogen), obstructive tumors, infection (EBV, CMV, HIV, HAV, HBV, coxsackievirus, mumps, rubella, echovirus), trauma, post-ERCP, ischemic

Presentation

• Acute onset epigastric pain radiating to the back, nausea, vomiting

• Often h/o previous pancreatitis, alcohol abuse, gallstones

• May be ill appearing, tachycardic, epigastric ttp, guarding, ↓ bowel sounds (adynamic ileus)

Evaluation

• Increased amylase >3× nl (suggestive but not spec for pancreatitis)

• Increased lipase >2.5× nl

• If severe: ↑ WBC, ↑ BUN, ↑ glucose, ↓ HCT, ↓ calcium (see Ranson criteria)

• CT scan: 100% spec but low sens. Not required; should be obtained only to r/o cx (acute fluid collection, pseudocyst, necrosis, abscess)

• Abdominal U/S: May be used to evaluate for gallstones, CBD dilatation or pseudocyst

Treatment

• Aggressive IV fluids; NPO initially, but early enteral nutrition if tolerated

• IV analgesia (risk of sphincter of Oddi spasm w/ morphine is unsupported), antiemetics

• Prophylactic abx have unclear benefit; may use for severe necrotizing pancreatitis

• Surgery required only for débridement of infected necrosis, or cholecystectomy if 2/2 stone

Disposition

• Admission for supportive care if severe or not tolerating PO

• Several scoring systems exist to help determine floor vs. ICU. Ranson criteria widely used (see below) but limited evidence to support utility (Crit Care Med 1999;27(10)2272).

LOWER QUADRANT/PELVIC PAIN

Appendicitis

Definition

• Inflammation of the appendix

History

• Classically, dull vague periumbilical pain which then migrates to the RLQ & becomes sharp & localized

• Nausea, vomiting, anorexia, fever

• Greatest at 10–30 y of age but can occur at any time

Physical Findings

• RLQ (McBurney’s point) tenderness, localized rebound & guarding

• Psoas sign: Pain w/ active flexion against resistance or passive extension of the right leg

• Obturator sign: Pain w/ internal rotation of the flexed right hip

• Rovsing sign: RLQ pain w/ palpation of the LLQ

Evaluation

• Labs: Leukocytosis (not sens or spec); cannot r/o w/ nl WBC. Check hCG.

• U/S: Less sens than CT but high spec. Consider esp in children.

• Abdominal CT w/ IV ± oral or rectal contrast (94% sens & 95% spec)

• MRI is a useful modality in pregnancy

• In cases w/ strong clinical e/o appendicitis & low suspicion of alternate etiology, it may be reasonable to proceed w/ laparoscopy w/o imaging

Management

• Abx: Cefoxitin, cefotetan, fluoroquinolone/metronidazole, OR piperacillin–tazobactam

• Admission for surgical removal

Pearl

• Patients at extremes of age are more likely to have atypical presentations & present w/ perforated appendicitis. Very thin young patients may have nl CT w/ appendicitis.

Hernia

Definition

• Defect in the abdominal wall that allows protrusion of abdominal contents

• Reducible hernia: Can be pushed back in

• Incarcerated hernia: Cannot be reduced

• Strangulated hernia: Incarcerated hernia w/ vascular compromise (ischemia)

History

• Bulging mass in inguinal area, femoral area, or scrotum (men)

Physical Findings

• Painful mass in abdominal wall or groin

• Strangulated: Tender, fever, ± cellulitis, blue discoloration or associated peritonitis

Evaluation

• If concern for strangulated hernia, consider CBC, lactate

• CT scan required if concern for strangulated hernia

Management

• Attempt reduction w/ generous analgesia/anxiolysis, pt in Trendelenburg

• If easily reduced, d/c w/ analgesic, stool softener, & surgery f/u

• If not reducible or if strangulated, start abx & surgical admission for operative intervention

Pearl

• Be cautious about reducing a hernia that has been irreducible by the patient for more than 12 h & is difficult to reduce in the emergency department b/c bowel may be compromised. Consult surgery for these cases; may need observation.

Diverticulitis

Definition

• Inflammation of diverticulum (sac-like protrusion in the wall of the bowel)

• Complicated diverticulitis: Associated perforation, obstruction, abscess, or fistula

Presentation

• LLQ pain, fever, nausea, constipation

• Mild LLQ tenderness, 50% of pts have heme-positive stool

• Complicated may have peritonitis, septic shock

Evaluation

• Clinical Dx if mild sxs & typical presentation

• Labs: Increased WBC (increased in 31–64% of patients)

• CT only needed if concern for complicated diverticulitis. Oral contrast may reveal pericolonic inflammation/stranding, abscess, or free air if perforation present.

Treatment

• Mild: PO metronidazole + (quinolone or TMP-SMX), OR amoxicillin–clavulanate

• Severe: NPO, IV fluids, IV ampicillin–sulbactam OR piperacillin–tazobactam OR ceftriaxone/metronidazole OR quinolone/metronidazole OR carbapenem

• Surgery is required if medical therapy fails, free air is present, large abscess that can’t be drained percutaneously, & recurrent dz (≥2 episodes)

Disposition

• If mild, d/c w/ abx, cathartic, analgesia w/ GI f/u. If severe, admit.

Pelvic Inflammatory Disease/Tubo-ovarian Abscess

Definition

• Polymicrobial infection of the upper female genital tract commonly a/w sexually transmitted organisms (gonorrhea, chlamydia), but not exclusively

• Cx include abscess, perihepatitis (Fitz-Hugh–Curtis), sepsis, chronic pain, increased risk of ectopic pregnancy, infertility

History

• Women w/ lower abd pain, vaginal d/c, dysuria, dyspareunia, nausea ± fevers

• RFs: Age <25, multiple sexual partners, unprotected sex, h/o PID, IUD placement in the last month, recent instrumentation of the cervix, douching, smoking

Physical Findings

• Lower abdominal tenderness, cervical d/c, cervical motion tenderness, adnexal tenderness/fullness

• Clinical exam has sens of 50–75%; presentation is often atypical

Evaluation

• Labs: Always check pregnancy test; cervical cultures, UA, CBC (not sens)

• Abdominal CT or pelvic U/S only required if TOA is suspected (unilateral tenderness or palpable mass, systemically ill)

Treatment (CDC. MMWR 2012;61:581)

• Low threshold for empiric tx: Minimum criteria in sexually active young women or others at risk are pelvic pain & cervical, uterine or adnexal tenderness

• Outpt: Ceftriaxone 250 mg IM × 1 + doxycycline for 14 d

• Consider adding metronidazole for anaerobes, esp if recent gynecologic instrumentation

• Azithromycin is considered insufficient for PID; may be used in isolated cervicitis or 2nd line

• If severe PCN allergy, options are hospitalization or azithromycin 2 g AND levofloxacin

• Inpt: (Cefotetan or cefoxitin) + doxycycline OR clindamycin + gentamicin

Disposition

• Admit if toxic appearing, severe vomiting, failure to outpt therapy, pregnancy, immunocompromised, young age, poor f/u w/i 72 h

• Discharged pts need f/u in 3 d to ensure sx resolving. Partners should be referred for rxn.

Pearls

• Given ↑ resistance to antibiotic regimens, CDC updates recommendations frequently

• PID in pregnancy is rare but does happen; alternative diagnoses should be considered

DIFFUSE PAIN

Abdominal Aortic Aneurysm

Definition

• Dilation of the abdominal aorta (true aneurysm, involves all layers of the vessel wall)

History

• Older patient w/ low back pain, abdominal pain, or flank pain (may mimic renal colic), syncope

Physical Findings

• Pulsatile mass (often not present)

• Ruptured AAA: Hypotension, abdominal tenderness, decreased femoral pulses mottling, decreased urine output due to obstructive uropathy

• Extension into SMA/IMA/celiac arteries leads to bowel ischemia

• Extension to renal artery leads to renal failure, colic, may cause obstructive uropathy

• Extension to spinal arteries causes neuro deficits, specifically T10–T12 spinal ischemia

• Extension to iliac vessels causes peripheral limb ischemia

Evaluation

• Abdominal CT or U/S only if hemodynamically stable

• Bedside U/S may reveal enlarged aorta & free fluid

Treatment

• Stable, nonruptured: Surgical or endovascular repair required if >5.5 cm (1%/y risk of rupture if >5 cm) or rapidly growing; usually arranged as outpt

• Unstable or ruptured: Immediate surgical repair, allow permissive hypotension (SBP 90 s)

Disposition

• Surgical admission for ruptured AAA or vascular sequelae

Pearls

• RFs: Smoking, HTN, hyperlipidemia, age ≥65 y, male (5×), FH

• 50% mortality if AAA is ruptured at presentation

Small Bowel Obstruction

Definition

• Mechanical obstruction of nl intestinal transit leading to bowel dilation

History

• Diffuse, colicky abdominal pain, nausea, vomiting, abdominal distension, h/o abdominal surgeries/prior obstructions/hernia, obstipation

Physical Findings

• Diffuse abdominal tenderness, distension, high-pitched bowel sounds

Evaluation

• Supine & upright abdominal x-rays (47–76% sens): Multiple air–fluid levels, >3 cm small bowel dilation, more than 3 mm small bowel wall thickening

• Abdominal CT (64–100% sens) can be diagnostic & used to characterize the obstruction (level, severity, cause)

Treatment

• NPO, bowel rest, gastric decompression w/ NGT placement

• IV fluids, analgesia, antiemetics

• Surgical consultation

Disposition

• Surgical admission

Large Bowel Obstruction/Volvulus

Definition

• Mechanical obstruction of the large bowel

• Volvulus: LBO caused by twisting of the large bowel on itself (10% of cases)

History

• Insidious onset of diffuse, colicky abdominal pain, constipation, N/V

Physical Findings

• Diffuse abdominal tenderness, distension, bowel sounds present early

Evaluation

• Supine & upright abdominal x-rays: Dilated large bowel. In volvulus: Single dilated loop of large bowel (80% sens for sigmoid volvulus, 50% sens for cecal volvulus).

• Abdominal CT w/ rectal contrast: Oral contrast should be avoided

Treatment

• IV fluids & correction of electrolyte abnormalities

• Rectal tube & NGT for relief of sxs

• Surgical consultation for likely operative reduction (particularly for cecal volvulus)

Disposition

• Surgical admission

Pearls

• Sigmoid volvulus most common in ill, debilitated elderly patients, or patients w/ psychiatric/neurologic disorders

• Cecal volvulus common in young adults, classically marathon runners

Perforated Viscus

Definition

• Perforation of hollow viscus leading to abdominal free air, intraluminal spillage

History

• Acute onset, severe abdominal pain, worse w/ movement, anorexia, vomiting

Physical Findings

• Acute peritonitis: Rigidity, tap tenderness, rebound, hypotension, sepsis

Evaluation

• Supine & upright abdominal x-rays: Free air seen (70–94% sens)

• Abdominal CT: Definitive study but not required for operative management

Treatment

• Immediate surgical consult

• Abx: Ampicillin–sulbactam OR cefotetan OR ampicillin/flagyl/gentamicin

Disposition

• Surgical admission

Pearl

• Chronic steroids can mask sxs

Mesenteric Ischemia

Definition

• Insufficient perfusion of the mesentery & intestine

• Etiologies: SMA embolism (50%), transient hypoperfusion (25%), SMA thrombosis (10%), venous thrombosis (10%), focal segmental ischemia of the small bowel (5%)

History

• RFs: Age, AF, vascular dz (coronary, peripheral), CHF (↓ forward flow)

• May have h/o prior abdominal angina: Postprandial pain, food aversion

• Acute typical presentation is persistent abdominal pain, anorexia, vomiting, bloody stools

Physical Findings

• Ill appearing, pain out of proportion to exam, tachycardia, fever, occult blood in stools. Late signs include peritonitis, shock.

Evaluation

• Early surgical eval

• Labs: May be nl, increased WBC/amylase/LDH/lactate (late), metabolic acidosis

• Abdominal x-ray: nl prior to infarction, “thumbprinting” of the intestinal mucosa later

• Abdominal CT: Colonic dilation, bowel wall thickening, pneumatosis of the bowel wall

• CT angiography: More sens than CT alone

• Angiography: Gold standard

Treatment

• IV fluids, avoid pressors if possible

• Abx: Ampicillin/gentamicin/metronidazole OR piperacillin/tazobactam OR levofloxacin/flagyl

• Intra-arterial thrombolysis or embolectomy for arterial embolism

• Anticoagulation for arterial & venous thrombosis & embolic dz

Disposition

• Surgical admission

Pearl

• 20–70% morality; improved if Dx made prior to infarct

Spontaneous Bacterial Peritonitis

Definition

• Infection of the ascitic fluid in patients w/ severe chronic liver dz

History

• Fever, abdominal pain, new or worsening ascites, hepatic encephalopathy

Physical Findings

• Stigmata of liver failure, diffuse abdominal pain, ascites

Evaluation

• Labs: PT/INR, PTT, platelets prior to paracentesis

• Paracentesis: >250 PMN, blood:ascites pH gradient >0.1, culture

Treatment

• Abx: Cefotaxime 2 g IV OR levofloxacin 750 mg IV; if prior quinolone prophylaxis, add vancomycin

• Albumin 1.5 g/kg at Dx & 1 g/kg for 3 d shows survival benefit

Disposition

• Medical admission

Pearls

• 70% GNR (E. coli, Klebsiella), 30% GPC (S. pneumoniae, Enterococcus)

• Clinical signs may be unreliable; have low threshold for paracentesis

• Occurs in 20% of cirrhotics

INFLAMMATORY BOWEL DISEASE (ULCERATIVE COLITIS AND CROHN’S DISEASE)

Definition

• Ulcerative colitis (UC): Idiopathic inflammation of the colonic mucosa

• Crohn’s dz (CD): Idiopathic transmural inflammation of the GI tract

History

• Women, 20–30 y/o, weight loss, vomiting, abdominal pain/diarrhea (grossly bloody in UC) that flares w/ emotional stress, infections, acute illness, pregnancy, abx, withdrawal from steroids

Physical Findings

• Diffuse abdominal tenderness (focal RLQ tenderness in CD), heme-positive stools 20% of pts have extraintestinal sxs, perianal dz (seen in CD); fissures, fistulas, abscess, rectal prolapse

Evaluation

• Labs: Low HCT (from chronic blood loss), increased WBC, hypokalemia (from diarrhea)

• Plain abdominal x-ray: If perforation, obstruction, or toxic megacolon suspected

• Abdominal CT: May r/o cx (eg, abscess, obstruction, fistula)

• Outpt colonoscopy: If Dx not known & once acute flare resolved

Treatment

• IV fluids, bowel rest, surgical consult, steroids, ± mesalamine

Disposition

• Admit for severe dz or acute complication