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