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

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