Abdominal Pain

ABDOMINAL PAIN

Rationale

Abdominal pain is a common symptom that can be attributed to a wide variety of acute and chronic disease processes, many of which represent serious medical problems. Mastery of the approach to patients with abdominal pain is important to general internists because they often are the first physicians to evaluate such patients.

Knowledge

Students should be able to define and describe:

Visceral pain

poorly localized but site roughly corresponds to dermatome that innervates the affected organ

characteristics may vary -- dull, cramping, burning

frequently accompanied by secondary autonomic effects:

nausea, vomiting, pallor, diaphoresis, restlessness

patient moves around in an attempt to alleviate discomfort

Somatoparietal pain

more localized and more intense than visceral pain

arises from peritoneal irritation

aggravated by movement -- patient attempts to lie still

Referred pain

usually well localized but felt in areas remote to affected organ

may be felt in skin or in deeper tissues

results from convergence of visceral afferent neurons with somatic neurons from different anatomic regions

Relative likelihood of the common causes of abdominal pain based on the pain pattern and the quadrant in which the pain is located

Key diagnostic criteria for the common causes of abdominal pain based on a focused history, physical exam, laboratory testing and imaging procedures

Symptoms and signs indicative of an acute abdomen

Importance of age and gender on the prevalence of different disease processes that may result in abdominal pain

Skills

Students should demonstrate specific skills, including:

History-Taking Skills: Students should be able to obtain, document, and present an appropriately complete medical history that differentiates among the common etiologies of abdominal pain. The medical history should elicit features of the patient’s abdominal pain including:

chronology

location

radiation

character

intensity

duration

aggravating or alleviating factors

associated symptoms

The medical history of patients with abdominal pain should also contain pertinent information about:

previous abdominal or pelvic surgeries

chronic medical conditions

sexual activity

medications

family history

Physical Exam Skills: Students should be able to perform a focused physical exam in patients who present with abdominal pain in order to:

establish a preliminary diagnosis of the cause

assess the severity of the patients’ presenting symptoms and signs

determine the urgency of implementing diagnostic and treatment plans

The initial physical examination of the patient should include:

a general assessment of the patient’s appearance, position and degree of discomfort

measurement of vital signs including temperature and, when indicated, orthostatic blood pressure and pulse

correct order and technique for examining the abdomen

inspection of the abdomen for surgical scars, distension, asymmetry or cutaneous abnormalities (dilated veins, ecchymoses, dermatomal rash)

auscultation of the abdomen for abnormal bowel sounds and bruits

percussion of the abdomen for detection of hepatomegaly, splenomegaly, abdominal masses or the presence of ascites

palpation of the abdomen for areas of tenderness, signs of peritoneal inflammation, hepatomegaly, splenomegaly, abnormal masses, pulsations or hernias

performance of an adequate rectal and pelvic examination (with supervision)

Differential Diagnosis: Students should be able to generate a prioritized list of the most important and likely causes of a patient’s abdominal pain and recognize specific history and physical exam findings that distinguish between the following diagnoses or conditions:

appendicitis

cholecystitis (biliary colic)

pancreatitis

diverticulitis

peptic ulcer disease including perforation

gastroenteritis

hepatitis

irritable bowel syndrome

small bowel obstruction

acute mesenteric ischemia

inflammatory bowel disease

ruptured abdominal aortic aneurysm

ureteral stones (renal colic)

pelvic inflammatory disease

ruptured ectopic pregnancy

abdominal wall pain

referred pain

Laboratory Interpretation: Students should know the indications for and independently interpret the following specific diagnostic tests and radiographs that are commonly ordered to evaluate patients who present with abdominal pain:

complete blood count

urinalysis

pregnancy test

stool for occult blood

stool for fecal leukocytes

liver enzyme tests

amylase and lipase

abdominal series

Students should be able to define the indications for, and interpret (with consultation) the results of these diagnostic tests and procedures:

abdominal ultrasound

abdominal CT scan

paracentesis

upper GI endoscopy

lower GI endoscopy – sigmoidoscopy and colonoscopy

barium contrast studies

radionuclide scan of the hepatobiliary system

Communication Skills: Students should be able to obtain informed consent for diagnostic and therapeutic procedures commonly used to evaluate and treat patients who present with abdominal pain. Informed consent discussions should use appropriate and understandable language to explain to patients:

indications

risk/benefits and expected outcomes of proposed treatments

interventions or procedures

Basic and Advanced Procedure Skills: Students should be familiar with how to insert a nasogastric tube after explaining the procedure to the patient and obtaining appropriate consent.

Management Skills: Students should be able to:

develop a timely and appropriate initial management plan for diagnosing and treating patients with abdominal pain

recognize the role of narcotic analgesics and empiric antibiotics in treating selected patients who present with acute abdominal pain

determine when to consult a gastroenterologist or involve a surgeon in the management of patients with abdominal pain

describe the indications, contraindications, mechanisms of action, adverse reactions, significant interactions and relative costs of the various treatments, interventions or procedure commonly used to diagnose and treat patients who present with symptoms of abdominal pain.

describe the physiological basis and/or scientific evidence supporting each type of treatment, intervention or procedure

describe how the diagnosis and treatment of abdominal pain in special populations may differ (very elderly, pre-menopausal women, e.g.)

recognize the value of psychotherapy in the management of chronic abdominal pain

demonstrate the ability to access and utilize appropriate information systems and resources to help delineate issues related to abdominal pain

Attitudes and Professional Behaviors

Students should be able to:

recognize the importance of involving a surgeon as soon as possible when a patient is identified as having an acute abdomen.

recognize the importance of patient preferences when selecting among treatment options.

Resources

Clerkship Seminar, “Peptic Ulcer Disease,” T. Engel, MD

Clerkship Seminar, “Abnormal Liver Function Tests,” C. Todd, MD

Clerkship Seminar, “Urinary Tract Infections,” R. Kovach, MD

Clerkship Weekly Article, “Contagious Acute Gastrointestinal Infections,” Musher and Musher, NEJM, December 2002, pp 2417-2427

Internal Medicine Clerkship Guide, Paauw, et al, Mosby 2003, pp 53-63, 87-95, 105-112. 276-290

WagnerJM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA 1996;276:1589-1594.

Lederle F, Simel D. Does this patient have an abdominal aortic aneurysm? JAMA 1999;281:77-82.

Trowbridge RL, Rutkowski ND, Shojania KG. Does this patient have acute cholecystitis? JAMA 289;2003:80-86.

Cope’s Early Diagnosis of the Actue Abdomen (20th edition) William Silen Oxford University Press. 2000.

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