SIU School of Medicine

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Department of Internal Medicine

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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