Abdominal Pain Clinical Reasoning

Question 1

what are some causes of RUQ pain?

Answer 1

Biliary disease (cholelithiasis, cholecystitis)
Pancreatitis (also epigastric)
Renal colic (usually flank pain) – from kidney stone, infection
Hepatitis

Question 2

what are some causes of LUQ pain?

Answer 2

Renal colic (usually flank pain)
Splenic infarct or rupture

Question 3

what are some causes of epigastric pain?

Answer 3

Peptic ulcer
Pancreatitis
Biliary disease (cholelithiasis, cholecystitis)
GERD

Question 4

what are some causes of diffuse periumbilical pain?

Answer 4

Appendicitis (later RLQ)
Bowel obstruction
Mesenteric ischemia (acute or chronic)
Abdominal aortic aneurysm
Gastroenteritis
IBD
IBS
Splenic rupture

Question 5

what are some causes of RLQ pain?

Answer 5

Appendicitis
Diverticulitis
Cecal volvulus
Ovarian disease (cyst, mass, torsion)
Ectopic pregnancy
PID

Question 6

what are some causes of LLQ pain?

Answer 6

Diverticulitis
Ovarian disease (cyst, mass, torsion)
Ectopic pregnancy
Sigmoid volvulus
PID

Question 7

when should you check CVA tenderness?

how do you assess this?

Answer 7

• when you suspect pyelonephritis (renal tenderness)

- make a fist and gently hit the area over the costovertebral angle on both the right and left side

Question 8

what does rebound tenderness tell you? how do you assess for rebound tenderness?

Answer 8

-Rebound tenderness is a sign of peritoneal irritation

• It is elicited by palpating deeply and slowly.
• The palpating hand is then quickly removed.
• If the pain is greatest when you release the pressure suddenly, the patient has rebound tenderness

Question 9

what tests can you perform for a patient who you suspect has ascites? describe how to perform them

Answer 9

1. shifting dullness: Have the patient lie supine, then determine the borders of dullness and tympany. The area of tympany is present above the area of dullness. The patient is then asked to turn on the side, and the examiner again determines the borders of tympany and dullness. If ascites is present, the “dullness” will shift to the dependent position. The area around the umbilicus that was initially tympanic will become dull.
2. fluid wave: Another examiner or the patient’s own hand is placed in the middle of the patient’s abdomen. The examiner then taps one flank while palpating the other side. Detection of the fluid wave suggests ascites

Question 10

when should you test for Murphy’s sign? how do you do this?

Answer 10

when right upper quadrant pain and tenderness suggest cholecystitis

• Place your fingers under the right costal margin and ask the patient to take a deep breath
• A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy’s sign of acute cholecystitis.

Question 11

when should you test for Psoas sign? how do you do this?

Answer 11

when you suspect appendicitis

• The examiner places hand above the patient’s right knee.
• Ask the patient to flex the right hip against resistance.
• Increased abdominal pain indicates a positive psoas sign.
• An alternative is to ask the patient to lie on the left side and passively extend the right hip backwards. Again, increased pain is a positive psoas sign.

Question 12

when should you test for Obturator sign? how do you do this?

Answer 12

when you suspect appendicitis

• Rotate the leg internally at the hip.
• Increased abdominal pain indicates a positive obturator sign.

Question 13

when should you perform inguinal palpation?

Answer 13

when you suspect hernias or inguinal lymphadenopathy

Question 14

when a patient presents with appendicitis, what are next steps for management?

Answer 14

send them to ER!

get a CT scan to rule out appendicitis if diagnosis is uncertain
give IV fluids and antibiotics
surgery likely

Question 15

classic picture of appendicitis

Answer 15

migration of pain from periumbilical reaction to RLQ to McBurney point (2/3 of way between belly button & iliac crest)

positive psoas/obturator signs on exam

patients often complain of bloating + anorexia

Question 16

classic picture of biliary disease

Answer 16

episodic, crampy pain that begins an hour or so after eating
pain commonly wakes patients from sleep
pain may radiate to back/shoulder
pain assoc w/ nausea and vomiting
Murphy sign is positive

Question 17

when a patient presents with cholelithiasis/cholecystitis, what are next steps for management?

Answer 17

send them to the ER
send them to get an ultrasound
may need surgery

Question 18

how can you tell cholelithiasis and cholecystitis apart?

Answer 18

cholecystitis will present with the same symptoms as cholelithiasis, but also FEVER and persistent rather than episodic symptoms

Question 19

what is the typical presentation of acute pancreatitis?

Answer 19

constant moderate-to-severe intensity abdominal pain that starts in the epigastrium and may radiate to the back

assoc w/ nausea, vomiting, low-grade fever and abdominal distention

Question 20

what is the most common cause of acute pancreatitis?

Answer 20

alcohol abuse and choledocholithiasis (drinking + obstruction of pancreatic outflow)

Question 21

when a patient presents with acute pancreatitis, what are next steps for management?

Answer 21

• send them to the ER

- they will need to be monitored closely (admitted to hospital)

Question 22

what is the typical presentation of large bowel obstruction?

Answer 22

waves of severe crampy abdominal pain, diffuse/poorly localized pain, vomiting, abdominal distention, constipation/inability to pass flatus later in course

Question 23

when a patient presents with large bowel obstruction, what are next steps for management?

Answer 23

get imaging (CT or xray) to confirm, then likely surgery

Question 24

what is the typical presentation of small bowel obstruction?

Answer 24

waves of severe crampy abdominal pain, diffuse/poorly localized pain, vomiting, abdominal distention, constipation/inability to pass flatus later in course
pts often have prior abdominal surgery (surgery means SBO is more likely than LBO)

Question 25

when a patient presents with small bowel obstruction, what are next steps for management?

Answer 25

get imaging (CT) to confirm SBO, then patient may need surgery

Question 26

what is the typical presentation of acute mesenteric ischemia?

Answer 26

abrupt onset of acute, severe abdominal pain that seems out of proportion to a benign physical exam. seen more in patients with risk factors for embolization (afib)
vomiting, diarrhea
patient looks very ill

Question 27

when a patient presents with acute mesenteric ischemia, what are next steps for management?

Answer 27

get a CT angiogram, then revascularization + surgery to resect necrotic bowel

Question 28

what is the typical presentation of ischemic colitis?

Answer 28

left sided abdominal pain (mild) with bloody or maroon stools or diarrhea
abdominal tenderness but NOT rebound tenderness

Question 29

risk factors for ischemic colitis

Answer 29

age >60
hemodialysis
CV disease
htn
DM
hypoalbulinemia
medications that induce constipation

Question 30

when a patient presents with ischemic colitis, what are next steps for management?

Answer 30

colonoscopy to diagnose, then supportive therapy

Question 31

what is the typical presentation of abdominal aortic aneurysm?

Answer 31

male patient with a history of smoking

triad of severe abdominal pain, pulsatile abdominal mass and hypotension

Question 32

when a patient presents with abdominal aortic aneurysm, what are next steps for management?

Answer 32

screening + elective surgery if necessary, since ruptured AAA have very high mortality

Question 33

what is the typical presentation of nephrolithiasis?

Answer 33

rapid onset of excruciating back and flank pain, which may radiate to abdomen or groin
pts moving constantly in an attempt to find a comfortable position

Question 34

when a patient presents with nephrolithiasis, what are next steps for management?

Answer 34

get a CT scan to confirm diagnosis, pain control, stone passage

Question 35

what is the typical presentation of irritable bowel syndrome?

Answer 35

years of intermittent (mostly lower) abdominal pain accompanied by diarrhea, constipation or both
crampy pain that is relieved with defecation

Question 36

what needs to be done before diagnosing someone with IBS?

Answer 36

rule out more serious causes like IBD, colon cancer

Question 37

what alarm symptoms should you look out for before diagnosis when you suspect IBS?

Answer 37

positive fecal occult blood or rectal bleeding
anemia
unintentional/unexplained weight loss
fever
family history of colorectal cancer, IBD, celiac
recent antibiotic use

Question 38

what is the typical presentation of chronic mesenteric ischemia?

Answer 38

recurrent postprandial abdominal pain in first hour after eating, food fear, weight loss
epigastric or periumbilical abdominal pain

Question 39

risk factors for chronic mesenteric ischemia

Answer 39

tobacco use history
peripheral vascular disease
coronary artery disease
htn

Question 40

treatment for chronic mesenteric ischemia

Answer 40

revascularization surgery

Question 41

what is the typical presentation of diverticulitis?

Answer 41

constant gradually increasing LLQ pain, present for several days. may present with diarrhea or constipation and fever
on physical, may see rebound tenderness and guarding

Question 42

when a patient presents with diverticulitis, what are next steps for management?

Answer 42

CT to confirm diagnosis
colonoscopy later down the line to rule out colon cancer
outpatient management w/ antibiotics for mild case, may need to be hospitalized if pts can’t tolerate oral intake

Question 43

what is the typical presentation of ovarian torsion?

Answer 43

sudden-onset, unilateral pelvic pain, nausea, and vomiting. may be accompanied by urinary urgency

Question 44

what is the typical presentation of ectopic pregnancy?

Answer 44

amenorrhea, abdominal pain, and vaginal bleeding. Can rupture and result in life-threatening intraperitoneal hemorrhage