Chronic Abdominal Pain Flashcards
(15 cards)
When considering the location of abdominal pain what are things to consider?
Anatomy!
Liver - RUQ and epigastric
Gallbladder - RUQ
Stomach - Epigastric and LUQ
Spleen - LUQ
Pancreas - epigastric and LUQ
Colon - outskirts (ascending RUQ, transverse periumbilical, descending LLQ)
Appendix - RLQ
Small intestine - Periumbilical and suprapubic regions
Also consider referred pain
By definition how long has chronic abdominal pain been occurring?
What body systems could cause abdominal pain?
What are the two etiological divisions of chronic abdominal pain?
at least 6 months of continuous or intermittent pain
GU, GI, and gynecologic tracts
Divided into organic and functional etiologies
What are important questions in a history to ask when considering chronic abdominal pain?
Description: sharp/aching/gnawing
Location/Radiation
Onset: acute/chronic
Intensity: severity 1-10
Duration/Progression: persistent, worsening, chronic
Associated Sx: n/v/d, heartburn, melena, hematochezia, hematemesis, diaphoresis, cough, cold sx, fever, vaginal discharge, LNMP, etc
Aggravating/Alleviating: pain with movement (peritoneal), with food (mesenteric eschemia), bowel movements
Last colonoscopy/EGD
Surgeries/meds/allergies
What are important exams during a physical exam for chronic abdominal pain?
Vital signs
Chest exam
Abdominal Exam
OMT exam
Rectal exam - microscopic blood
What are 4 types of abdominal pain and how do they present?
Visceral : originating from abdominal organs covered by peritoneum (deep pain)
Colic : crampy, intermittent pain
Parietal pain : irritation of parietal peritoneum, more easily localized
Referred : pain in one area goes to another
What are some emergent/urgent physical exam findings?
Rebound
Guarding
Distension
Abnormal Vital Signs
Blood in stool (cancer, PUD, IBD)
Where are some common areas of referred pain?
Referral to right shoulder - liver and gallbladder
Referral to left shoulder - lung and diaphragm and pancreas
Referral down left arm - heart
Referral to inner thighs - ovaries, fallopian tubes, and uterus
What is involved in a lab workup of chronic abdominal pain, and what do these tell you?
CBC (complete blood count) - white count, infection bacterial vs viral, HGB, HCT
CMP (complete metabolic panel) - includes liver function including AST/ALT/alkphos/bilirubin, kidney function including BUN and creatinine, potassium, sodium, chloride
UA (urinalysis) - sugar, protein, infection
Amylase/lipase - pancreas
Thyroid studies - constipation can be result of thyroid problem
Pregnancy test
What are possible imaging orders for abdominal pain?
US transabdominal/vaginal - gallbladder
CT with/without contrast (IV, oral, rectal) - kidney stones
Xray (flat and upright) - constipation
What are important things to rule out when working up abdominal pain?
Ruptured AAA - low BP, decompensated, known AA then collapse, anemic
Aortic dissection
Perforated bowel - distended, guarding, rebound
Volvulus
Mesenteric ischemia
Torsion
Incarcerated hernia
Pregnancy
Cancer
What is IBS?
What symptoms typically accompany this?
How is it diagnosed?
What are 3 alarm features that would indicate the need for further testing?
IBS: functional GI disorder characterized by abd pain and altered bowel habit in the abscence of a specific pathology
Constipation/Diarrhea or both
Diagnosis per Rome criteria
recurrent abd pain (at least 1 day per week for 3 months, and onset at least 6 months before diagnosis)
Abd pain + at least 2 of the following: pain with defecation, change in frequency of stool, change in form of stool
Without warning signs: over 50 with no previous work up or ca screening, GI bleeding, nocturnal pain or defecation, weight loss, family hx of colorectal cancer of OBD, mass or lymphadenopathy, iron-deficiency anemia
Alarm features that require lab testing and diagnostic imaging
weight loss
iron deficiency anemia
Family hx of organic GI illnesses (cancer, IBD, celiac sprue)
What are typical symptoms and lab findings with chronic pancreatitis?
abd pain; jaundice; elevated amylase, lipase or hepatic transaminase levels; weight loss
What are common symptoms of diverticular disease and diverticulitis?
Diverticular disease: LLQ abd pain, can be worse with eating and relieved by BM, bloating, constipation or diarrhea, small pellet-like stools
Diverticulitis: constant pain in LLQ, fever, malaise, nausea, vomiting
What is celiac disease?
What are the symptoms?
How is it diagnosed?
Chronic disorder of digestive tract with inability to tolerate gliadin (alcohol soluble fraction of gluten)
Sx: abdominal pain, diarrhea, weight loss, fatigue, gas pain
Dx:
blood antibody testing - IgA anti-tissue transflutaminase antibody (IgA TTG) and endomysial antibody
endoscopy (upper endoscopy with at least 6 duodenal biopsies)
What is eosinophilic esophagitis?
How is this diagnosed?
Eosinophilic esophagitis (EoE)
Clinically presents with esophageal dysfunction with histological inflammation limited to the esophagus
Guidelines for diagnosis
sx of esophagus dysfunction: dysphagia, food impaction, chest pain
eosinophil-predominant inflammation
eosinophils limited to esophagus that persist after PPI trial
Exclusion of secondary causes of eosinophilia
