Upper Abdominal Pain

Question 1

What are the classifications of abdominal pain based on location?

Answer 1

Right upper quadrant, epigastric, left upper quadrant, periumbilical, right lower quadrant, and left lower quadrant.

Question 2

What is the first step in evaluating a patient with abdominal pain?

Answer 2

Assess ABCDE to determine if the patient is stable or unstable.

Question 3

What immediate management should be done for an unstable patient with abdominal pain?

Answer 3

Stabilize the airway, provide supplemental oxygen, establish IV access, and continuously monitor hemodynamics.

Question 4

What is the first step in evaluating a stable patient with abdominal pain?

Answer 4

Obtain a focused history and physical exam (H&P).

Question 5

What are the key aspects of history-taking in a patient with abdominal pain?

Answer 5

Location, severity, chronicity, aggravating and alleviating factors, associated symptoms, and recent abdominal or GI procedures (EDG, colonoscopy, recent surgeries, or aortic abdominal aneurysm).

Question 6

What are the physical exam findings of an acute abdomen?

Answer 6

Diffuse tenderness, rebound pain, rigidity, and guarding.

Question 7

What imaging should be obtained to rule out a perforated viscus?

Answer 7

Upright chest x-ray or abdominal x-ray series to check for free air under the diaphragm.

Question 8

Patients with evidence of peritonitis should first have an upright chest X-ray obtained to evaluate for free air. If this is negative, the next best step is … ?

Answer 8

Imaging with CT of the abdomen and pelvis to better differentiate between primary, secondary, and tertiary causes of peritonitis. Primary peritonitis requires paracentesis for definitive diagnosis. Clinical evidence of peritonitis, which is caused by inflammation of the peritoneum is marked by diffuse tenderness, rebound pain, rigidity, guarding, abdominal distention, or diffuse abdominal tenderness. Patients with evidence of peritonitis should first have an upright chest radiograph to evaluate for free air and pneumoperitoneum. If negative, the next best step involves obtaining a CT of the abdomen and pelvis to better differentiate between primary, secondary, and tertiary etiologies of peritonitis.
Depending on the etiology, peritonitis can be divided into primary (caused by intra abdominopelvic fluid), secondary (caused by a process in the gastrointestinal tract), or tertiary (caused by postoperative inflammatory process). Clinical clues that may point to an underlying etiology include early history of the pain (e.g. right sided pain in a young patient may suggest ruptured appendicitis, or left sided pain in an elderly patient may suggest a perforated diverticulitis). Primary peritonitis may be suggested by history of liver disease or endometriosis and should be diagnosed with paracentesis.

Question 9

What are the common causes of acute abdomen requiring emergency surgery?

Answer 9

Perforated viscus, abdominal sepsis, ruptured abdominal aortic aneurysm.

Question 10

What is the role of exploratory laparotomy in acute abdomen?

Answer 10

It is both diagnostic and therapeutic.

Question 11

Right upper quadrant pain is associated with what major conditions?

Answer 11

RIGHT UPPER QUADRANT PAIN:
* Biliary colic
* Cholelithiasis
* Acute cholecystitis
* Acute cholangitis
* Acute hepatitis
* Liver abscess
* Budd-Chiari syndrome
* Portal vein thrombosis
* Pancreatitis
* Duodenal ulcer
* Nephrolithiasis

Question 12

Which labs become critical for diagnosing RUQ pain?

Answer 12

CBC, CMP (LFTs), LIPASE, AMYLASE

Question 13

What is the classic presentation of biliary disease?

Answer 13

Acute onset of pain after eating a fatty meal, nausea, vomiting, and sometimes fever.

Question 14

What are key risk factors for biliary disease?

Answer 14

Female sex, obesity, age over 40.

Question 15

What physical exam finding is associated with acute cholecystitis?

Answer 15

RUQ tenderness with a positive Murphy sign.

Question 16

What are common lab findings in biliary disease?

Answer 16

Leukocytosis with a left shift, elevated LFTs, and normal lipase/amylase.

Question 17

What imaging modality is first-line for suspected biliary disease?

Answer 17

Right upper quadrant ultrasound.

Question 18

What imaging findings suggest biliary disease?

Answer 18

Gallbladder sludge, stones, pericholecystic fluid, thickened gallbladder wall.

Question 19

Gallbladder sludge or stones with no other findings is diagnostic for …?

Answer 19

Biliary colic.

Question 20

Fever, positive Murphy’s sign with pericholecystic fluid or a thickened gallbladder wall, without jaundice is diagnostic for … ?

Answer 20

Cholecystitis.

Question 21

A dilated common bile duct is diagnostic for … ?

Answer 21

Choledocholithiasis.

Question 22

Fever with pericholecystic fluid or a thickened gallbladder wall, with jaundice or hyperbilirubinemia is diagnostic for … ?

Answer 22

Cholangitis.

Question 23

What symptoms are associated with liver disease?

Answer 23

Nausea, vomiting, fever, RUQ tenderness, hepatomegaly, jaundice, altered mental status in extreme cases. Patients may also have substantial risk factors.

RISK FACTORS:
~ SUBSTANCE USE DISORDER
~ IMMUNOSUPPRESSION
~ CANCER
~ HYPERCOAGULABLE STATE

Question 24

What lab findings suggest liver disease?

Answer 24

Leukocytosis with left shift (for an abscess), elevated LFTs, elevated PT/PTT, hyperglycemia, normal lipase and amylase.

Question 25

What imaging should be ordered if liver disease is suspected and biliary disease is ruled out with U/S?

Answer 25

Abdominal CT scan.

Question 26

What CT finding is diagnostic of a liver abscess?

Answer 26

Peripheral rim-enhancing liver lesion in a patient with fever.

Question 27

What CT finding is diagnostic of Budd-Chiari syndrome?

Answer 27

Hepatomegaly and thrombosed hepatic veins.

Question 28

What CT finding is diagnostic of portal vein thrombosis?

Answer 28

Thrombus in the portal vein.

Question 29

What are key risk factors for acute hepatitis?

Answer 29

Recent travel, substance use disorder, immunosuppression, cancer, hypercoagulable states.

Question 30

What are the major causes of liver disease?

Answer 30

acute viral hepatitis, toxin-related hepatitis (eg. acetaminophen), alcoholic hepatitis, or nonalcoholic steatohepatitis.

Question 31

What is the major cause of acute liver failure in the United States?

Answer 31

Toxin-related hepatitis secondary to acetaminophen overdose. This usually requires liver transplant but is treated acutely with oral acetylcysteine.

Question 32

What lab findings suggest acute hepatitis?

Answer 32

Elevated LFTs with fractionated bilirubin changes.

Question 33

Liver disease causes which two labs to be elevated?

Answer 33

**LFT**s (ALT and AST): - ALT is elevated with drugs, virus infections and toxins. - AST is elevated in alcoholism. **Indirect Bilirubin** is elevated in liver disease (Direct Bilirubin is elevated in gallbladder disease)

Question 34

How is viral hepatitis diagnosed?

Answer 34

Viral hepatitis serology (IgM anti-HAV, HBs antigen, anti-HBc antibodies).

Question 35

What are the main causes of epigastric pain?

Answer 35

EPIGASTRIC REGION PAIN: * Acute myocardial infarction * Functional dyspepsia * Acute pancreatitis * Chronic pancreatitis * Peptic ulcer disease * GERD * Gastritis * Gastropareisis

Question 36

A 72-year-old man presents to the emergency department for evaluation of three days of worsening upper abdominal pain and associated vomiting. The patient drinks alcohol daily and has a past medical history of diabetes, hypertension, and gastric ulcers. Temperature is 36°C (96.8°F), blood pressure is 96/66 mmg, pulse is 112/min, respiratory rate is 22/min, and oxygen saturation is 94% on room air. The patient is lying on his left side in the stretcher and appears uncomfortable. Physical examination reveals diffuse tenderness to palpation that is more prominent in the epigastrium and is associated with rebound and guarding. The patient is started on intravenous fluids and his blood pressure improves. He is started on IV pantoprazole, morphine, and empiric antibiotics. A surgery consultation is called. Which of the following is the best next step in management?

Answer 36

This patient presents for evaluation of worsening upper abdominal pain with signs, symptoms, and a physical exam that is suggestive of peritonitis and a possible perforated viscus. Given this patient's history of gastric ulcers and daily alcohol use, he likely has a perforated gastric ulcer. The patient has been stabilized with IV fluids and analgesia, therefore the next best step in management is to obtain an upright chest radiograph to screen for evidence of free air under the diaphragm, and to call for a surgery consult for evaluation and management of an acute abdomen. Upper abdominal pain is a symptom that is associated with many conditions, which can range from benign to serious to life-threatening and requiring surgical intervention. One approach to creating a differential diagnosis for upper abdominal pain is to classify the pain by location-right upper quadrant, epigastric, or left upper quadrant. Right upper quadrant pain may be caused by biliary or hepatic processes, while epigastric pain may be caused by pancreatic or gastric pathology. Left upper quadrant pain typically suggests a splenic process. The first step in management of a patient with upper abdominal pain involves an ABCDE assessment to determine if they are stable or unstable. If the patient is unstable, they require acute management before pursuing a diagnostic workup. Management should involve stabilizing the airway, providing supplemental oxygen, establishing IV access, and continuously monitoring hemodynamics. Unstable patients often have evidence of peritonitis, including diffuse tenderness, rebound tenderness, rigidity, and guarding. These patients should have an upright chest radiograph to screen for free air and a surgical consultation should be called.

Question 37

What are classic symptoms of pancreatitis?

Answer 37

Sudden severe epigastric pain radiating to the back, nausea, vomiting, chills, malaise.

Question 38

What lab findings are indicative of pancreatitis?

Answer 38

Leukocytosis, elevated LFTs, lipase, and amylase.

Question 39

What imaging is done for suspected pancreatitis?

Answer 39

RUQ ultrasound or CT scan.

Question 40

What CT finding suggests pancreatitis?

Answer 40

Enlarged edematous pancreas with peripancreatic inflammation and fluid.

Question 41

What are classic symptoms of gastric conditions (e.g., GERD, gastritis, PUD)?

Answer 41

Burning sensation after eating, bloating, nausea, vomiting, hematemesis.

Question 42

What are key risk factors for gastric conditions?

Answer 42

Alcohol use, chronic NSAID use, steroid use.

Question 43

What is the Carnett sign and how is this used to help diagnose abdominal pathology?

Answer 43

While supine, ask the patient to tense their abdomen while lifting their head or legs. If the pain increases the source of pain is likely in their abdominal wall. A negative sign would indicate that pain is in their abdominal cavity.

Question 44

What imaging should be done before an upper GI endoscopy?

Answer 44

Upright chest x-ray or abdominal x-ray series to rule out perforation.

Question 45

Upper EGD will help to diagnose ... ?

Answer 45

PUD, Gastritis, Duodenitis, GERD.

Question 46

What are the main causes of Left Upper Quadrant pain?

Answer 46

LEFT UPPER QUADRANT PAIN: * Splenomegaly * Splenic infarct * Peptic ulcer * Gastritis * Nephrolithiasis

Question 47

What hematologic conditions cause left upper quadrant pain?

Answer 47

Splenic conditions (splenic abscess, infarction, splenic artery aneurysm) and hematologic disorders (sickle cell anemia, lymphoma).

Question 48

What is the diagnostic workup for suspected hematologic conditions?

Answer 48

Blood smear!

Question 49

What are classic symptoms of splenic pathology?

Answer 49

Abdominal fullness, early satiety, fatigue, referred shoulder pain.

Question 50

What is Kehr's sign?

Answer 50

Referred shoulder pain due to splenic pathology (usually infarction).

Question 51

Why is endocarditis a risk factor for splenic infarctions?

Answer 51

Septic emboli.

Question 52

What lab findings suggest splenic disease?

Answer 52

Leukocytosis, thrombocytopenia due to sequestration.

Question 53

What imaging should be ordered for suspected splenic pathology?

Answer 53

Abdominal ultrasound followed by CT if needed.

Question 54

What CT finding suggests splenic infarction?

Answer 54

Wedge-shaped hypodense lesion.

Question 55

What is characteristic of a splenic abscess?

Answer 55

Riim enhancements and septations.

Question 56

What CT finding suggests a splenic artery aneurysm?

Answer 56

Well-defined, round, hyperdense lesion (surgical emergency).

Question 57

What is the importance of the hepatic and splenic flexures in abdominal pain?

Answer 57

Colon diseases can ALSO present with upper quadrant pain.