- Hello, my name is Dr. Vineet Chopra
and I'm here today to talk
to you about abdominal pain.
This is coming from
the Saint-Chopra Guide
to Inpatient Medicine
that I wrote with my
colleague and research mentor
Dr. Sanjay Saint.
This is the Fourth Edition
and this video is a brief overview
of one of the chapters in the book.
We hope you like it.
Abdominal pain is challenging
because there are so
many potential diagnoses
that can relate to pain in the belly.
It's also challenging because
the signs and symptoms
are often non-specific.
They can vary from mild to severe symptoms
and the signs can be
either present or absent.
The key challenge with abdominal pain
is that life-threatening
conditions can hide in the abdomen
and the consequences of
wrongly attributing the pain
to something benign can be catastrophic.
So what we tell learners
and what's important for you to know
is that we always want
you to respect the belly.
If there's anything a good
diagnostician will be humbled by,
it's abdominal pain.
So really think about this in a systematic
and in a very thoughtful way.
How do you approach abdominal pain?
Well, we want you to think
about a three-step approach
but you need first with
systemic signs and symptoms.
So when you think about a
person with abdominal pain
you should ask are there
other systemic causes
that may be driving this pain?
For example if the patient
has strangely colored urine
and has abdominal pain,
maybe they have porphyria.
If they hail from the Mediterranean area
and their family has a history
of recurrent abdominal pain crisis,
could they have familial
Mediterranean fever
and do they need further testing for that.
Also remember to look
for endocrine changes
either in the skin or
changes in their blood sugar
because Addison's disease
and diabetic ketoacidosis
can often present also
with abdominal pain.
And think about uremia in
patients with kidney disease
as a cause of nausea,
vomiting, abdominal pain,
especially if their kidney
function has deteriorated.
The point here is never think
about abdominal pain in isolation.
Always think about it in the context
of how is the patient presenting
and what are the comorbidities.
The other thing to always
remember is referred pain.
So pain at the abdominal pain
can come from different sites in the body
and the most common sites are
the thorax and the pelvis.
We want you to think about
pneumonia as a common cause
especially of upper quadrant pain
and that's because basilar pneumonia,
those involving the bases of the lungs,
can often cause pleural
inflammation which can rub against
either the liver capsule
or the splenic capsule
to refer to right or
left upper quadrant pain.
In fact, I've seen this several times.
So a febrile patient with
cough and sputum production
who presents with right
upper quadrant pain
should make you think a little bit about
potential pulmonary
causes of referred pain.
I also wanna highlight
myocardial infarction
as one of those causes of abdominal pain
that you should probably never forget.
So in an elderly patient or in a diabetic
who is presenting with abdominal
pain without a clear cause,
always think about the heart.
And remember in women do not forget
the pelvic inflammatory
diseases and ovarian torsion
all of which can also
cause abdominal pain.
The most helpful approach, however,
is to consider the abdominal
organs based upon anatomy
and always think about infection,
obstruction, or ischemia
as you work through the
location of the organs
and why they may be having the pain.
So let's walk through this
given the following grid.
The first thing to think about
is the location of the pain.
So if somebody presents with
right upper quadrant pain,
we want you to think about
the liver and the gallbladder
as the two organs in that area.
So inflammation or infection
of those two organs
can cause pain.
So think hepatitis,
hepatic tumor or abscesses,
cholecystitis and even stone disease
like choledocholithiasis can
end up causing cholangitis
or other causes of abdominal pain
in the right upper quadrant.
Someone who's got HIV, don't
forget AIDS cholangiopathy
as a cause of abdominal pain as well.
If the pain is epigastric,
remember that's the stomach,
the pancreas, the duodenum,
and the abdominal aorta, so ask yourself,
is this patient potentially
suffering from gastritis?
Could they have peptic ulcer disease?
Is the pain really sharp and stabbing?
Does it go to the back?
Could they have an
abdominal aortic aneurysm?
Do they have a history of alcohol intake?
Could this be pancreatitis
or stone disease?
Again, remember cardiac disease
as a potential cause of
epigastric pain as well.
Pain in the left upper quadrant
is almost always the spleen
so look for splenic enlargement,
hook under the ribcage
if you can't feel it.
Think about a splenic infarct
in somebody who may
otherwise be bacteremic
or be at risk for splenic infarction.
And think about abscesses as well.
In an older patient who
has known splenomegaly
who become suddenly hypotensive,
never forget splenic rupture.
It is a life-threatening condition
and something that should
be always be on your mind
especially in the setting
of known spleen enlargement.
Left or right lower quadrant pain
can refer to a number of organs,
specifically the appendix
and the intestines.
In women you should think about the ovary
and the fallopian tubes
and in men the testes.
Also remember the genito-urinary system
including the kidney and the ureters.
So diseases such as
appendicitis, diverticulitis,
ovarian cyst or torsion,
in younger women think
about ectopic pregnancy
or pelvic inflammation disease
if they're sexually active,
and in men don't forget
to look for epididymitis
and testicular torsion as
causes of abdominal pain.
If somebody has a history of stone disease
or is at risk of stone formation,
think about nephrolithiasis
and don't forget to look at flank pain
in the patient who may
have pyelonephritis.
Periumbilical pain is one
of those interesting ones
because it can refer
to the small intestine,
the appendix especially
when appendicitis begins
before it localizes to
the parietal peritoneum
and the visceral peritoneum
in the right lower quadrant,
and the abdominal aorta.
So when you see periumbilical pain,
think about bowel obstruction,
think about appendicitis,
and don't forget ischemic bowel disease.
Hypogastric pain or pain
in the hypogastric area
could refer to the bladder,
in women the uterus and the ovaries
and the fallopian tubes are also at play,
think about cystitis,
urethritis, nephrolithiasis,
PID and endometriosis especially
if it's pain in that area.
So I like this location-based approach
mapping to the underlying organs
and again this is a very
systematic way of thinking
about the causes and the
potential organs involved
with abdominal pain.
You also wanna try to
elicit certain symptoms
that may have help you
increase the likelihood
of certain conditions
in organ involvement.
So somebody has suprapubic
pain or hypogastric pain
with dysuria and frequency,
maybe they've got a kidney
or a bladder infection.
If somebody presents with
nausea, vomiting, and diarrhea,
is it possible that they
have some type of gastritis
or maybe they've got pancreatitis.
The diarrhea from pancreatitis
may just be chronic
pancreatitis and malabsorption.
Jaundice and itching in the
patient with abdominal pain
should make you think about liver disease.
If it's a younger patient,
think about stone disease
from the gallbladder
that may be causing
obstructive cholangiopathy.
Pain that gets better
when someone stands up
is almost always pancreatic pain
so think about the pancreas.
In an abrupt onset of pain in the midline
that is completely out
of proportion to the exam
should make you think about ischemia
specifically the mesenteric blood vessels.
So look for risk factors
around cardiac dysrhythmias
or an embolic disease that
may be causing that as well
and think about serum
lactate as a diagnostic test.
Remember pain exacerbated
by the flexion of the abdominal muscles
refers to pain from the abdominal wall,
that could be all related to
some type of abdominal trauma
or there may be an
intraabdominal cause of that
in the wall itself.
Make sure to look for that
when you're thinking about
flexion of the abdominal musculature.
So what's our approach to the patient?
We always begin with a good history,
this is key in abdominal pain,
ask for when the pain
began, what exacerbated it,
what they were doing at the
time, what makes it better,
what's the site, what's the
radiation, what's the severity,
and ask if they've had this before
or if other family members have had it.
Do a good physical exam
especially if somebody
has severe abdominal pain.
It's not difficult to do so
don't forget to flex the knees,
relax the abdominal muscles
and do a good auscultation
to look for bowel sounds
but also for tenderness
and rebound and guarding.
Get your usual labs, your CBC, your basic,
and lactate if you're
thinking about ischemia.
Don't forget an ECG and a chest x-ray
especially if you're
thinking about referred pain.
I wanna point in a word
here for abdominal CT scan
because a lot of learners are reluctant
and sometimes hesitate to
pull the trigger on a CT.
Remember that an abdominal CT
is better than an ultrasound
for evaluating most
intra-abdominal structures.
And what I commonly see
is too much hesitation
in ordering the CAT scan and
potentially missing diagnoses.
I always say if the bowel
is of primary concern
and you're worried about contrast,
sometimes you can avoid the contrast
especially if the creatinine is elevated.
But remember the ideal study
is oral and IV contrast study
because it allows you to
look at the bowel walls,
intra-abdominal pathologies
and also abscesses
which you will miss if
you don't use contrast.
In a patient who has
unexplained belly pain
and especially if they're elderly,
move to the CAT scan early and quickly.
It will save you a lot of pain and trouble
in managing that patient.
So that's it, thank you.
I hope you liked this brief
overview of abdominal pain.
If you like this talk
and want to read more,
please consider purchasing
the Saint-Chopra Guide
to Inpatient Medicine.
You can use the promo
code here to save 30%.
And I hope you have a wonderful day.
Thanks very much for your attention.
