Abdominal pain

Background

• Elderly pts
  • Surgical emergencies are more common in elderly than in any other pt population
  • Viral gastroenteritis is uncommon
  • Conservative admission strategy is strongly advocated
• Pts with immunosuppression often have delayed or atypical presentations
• Fever is not a reliable marker for surgical disease

Workup

• Urine pregnancy
• CBC
  • Note: WBC cannot exclude surgical disease
• Chem
• LFT
• Lipase
  • May be normal early in course of pancreatitis
• UA/UCx
• Guaiac
• ECG (>40 yo)
• ?CXR
• ?Coags
  • GI bleeding, end-stage liver disease, coagulopathy
• ?Lactate
• ?Abd x-ray
  • Consider for r/o obstruction, perforation, or severe constipation
• ?US
• ?CT

Differential Diagnosis

Killers

1. AAA
2. Mesenteric Ischemia
3. Bowel Perforation
4. Small Bowel Obstruction
5. Sigmoid Volvulus
6. Ectopic Pregnancy
7. Placental Abruption
8. ACS

Diffuse Abdominal pain

• Abdominal aortic aneurysm
  • Aortocaval fistula
• Acute gastroenteritis
• Aortoenteric fisulta
• Appendicitis (early)
• Bowel obstruction
  • Large bowel obstruction
    • Ogilvie's syndrome
  • Small bowel obstruction
  • Malignant bowel obstruction
• Bowel perforation
• Diabetic ketoacidosis
• Gastroparesis
• Hernia
• Hypercalcemia
• Inflammatory bowel disease
• Mesenteric ischemia
  • Mesenteric vein thrombosis
• Pancreatitis
• Peritonitis
• Sickle cell crisis
• Spontaneous bacterial peritonitis
• Volvulus

Epigastric Pain

• Gastroesophageal reflux disease (GERD)
• Peptic ulcer disease with or without perforation
  • Zollinger-Ellison syndrome
• Gastritis
• Pancreatitis
• Gallbladder disease
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis
  • Acalculous cholecystitis
• Myocardial Ischemia
• Splenic Infarctionenlargement/rupture/aneurysm
• Pericarditis/Myocarditis
• Aortic dissection
• Hepatitis
• Pyelonephritis
• Pneumonia
• Pyogenic liver abscess
• Fitz-Hugh-Curtis Syndrome
• Hepatomegaly due to CHF
• Bowel obstruction
• SMA syndrome
• Pulmonary embolism
• Bezoar
• Ingested foreign body

RUQ Pain

• Gallbladder disease
  • Symptomatic cholelithiasis (biliary colic)
  • Choledocholithiasis
  • Acute cholecystitis
  • Ascending cholangitis
  • Acalculous cholecystitis
• Pancreatitis
• Acute hepatitis
• Pancreatitis
• GERD
• Appendicitis (retrocecal)
• Pyogenic liver abscess
• Bowel obstruction
• Cirrhosis
• Budd-Chiari syndrome
• GU
  • Pyelonephritis
  • Kidney stone
  • Fitz-Hugh-Curtis Syndrome
• Other
  • Hepatomegaly due to CHF
  • Peptic ulcer disease with or without perforation
  • Pneumonia
  • Herpes zoster
  • Myocardial ischemia
  • Pulmonary embolism
  • Abdominal aortic aneurysm

LUQ

1. Gastritis/gastric ulcer
2. Herpes Zoster
3. Pancreatitis
4. Splenic rupture/distension
5. Myocardial Ischemia
6. Pneumonia
7. Pulmonary Embolism
8. Splenic Infarction

RLQ Pain

• GI
  • Appendicitis
    • Perforated appendicitis
  • Peritonitis
  • Crohn's disease (terminal ileitis)
  • Diverticulitis (cecal, Asian patients)
  • Inguinal hernia
  • Mesenteric ischemia
  • Ischemic colitis
  • Meckel's diverticulum
  • Neutropenic enterocolitis (typhlitis)
• GU
  • Ectopic
  • Endometriosis
  • Kidney stone
  • Mittelschmerz
  • Ovarian cyst
  • Ovarian torsion
  • PID
  • Pyelonephritis
• Other
  • Abdominal aortic aneurysm
  • Epiploic appendagitis
  • Mesenteric lymphadenitis
  • Herpes zoster
  • Psoas abscess
  • Testicular torsion

LLQ Pain

• Diverticulitis
• Kidney stone
• UTI
• Pyelonephritis
• Ectopic pregnancy
• Infectious colitis
• Inflammatory bowel disease (Crohn's Disease, Ulcerative Colitis)
• Inguinal hernia
• Mesenteric ischemia
• Epiploic appendagitis
• Mittelschmerz
• Ovarian cyst
• Ovarian torsion
• PID
• Psoas abscess
• Testicular torsion
• Appendicitis
• Abdominal aortic aneurysm
• Herpes zoster
• Endometriosis
• Colon cancer
• Irritable bowel syndrome
• Small bowel obstruction

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

• Pregnancy-related
  • Ectopic Pregnancy
  • Spontaneous abortion, threatened or incomplete
  • Septic abortion
• Acute Infections
  • Cervicitis
  • Endometritis
  • Bartholin gland abscess
  • Pelvic inflammatory disease (PID)
  • Tubo-ovarian abscess
• Vulvovaginitis
  • Bacterial Vaginosis
  • Candida Vaginitis
  • Trichomonas
  • Contact Vulvovaginitis
  • Atrophic vaginitis
• Adnexal Disorders
  • Hemorrhage/rupture of ovarian cyst
  • Ovarian torsion
  • Twisted paraovarian cyst
• Other
  • Myoma (degenerating)
  • Genitourinary trauma
  • Ovarian hyperstimulation syndrome
  • Sexual assault
• Recurrent
  • Mittelschmerz
  • Primary/Secondary Dysmenorrhea
  • Pelvic Congestion Syndrome
  • Endometriosis

Genitourinary

• Cystitis
• Pyelonephritis
• Urethritis (e.g. N. gonorrhoeae/Chlamydia)
• Urolithiasis

Gastrointestinal

• Gastroenteritis
• Appendicitis
• Bowel obstruction
• Perirectal abscess
• Diverticulitis
• Inflammatory bowel disease
• Irritable bowel syndrome
• Mesenteric adenitis

Musculoskeletal

• Abdominal wall hematoma
• Psoas hematoma, psoas abscess
• Hernia

Vascular

• Pelvic thrombophlebitis
• Abdominal aortic aneurysm
• Ischemic bowel (Mesenteric Ischemia)

Extra-Abdominal

1. MI
2. Aortic Dissection
3. PNA
4. PE
5. Testicular Torsion
6. Herpes Zoster
7. Muscle spasm
8. Strep Pharyngitis (peds)
9. Mononucleosis
10. DKA
11. ETOH Ketoacidosis
12. Uremia
13. Sickle Cell Crisis
14. SLE
15. Vasculitis
16. Glaucoma
17. Hyperthyroidism
18. Methanol Poisoning
19. Heavy Metal toxicity
20. Addison's Disease
21. Porphyria

See Also

• Abdominal Pain (Geriatrics)
• Abdominal Pain (Peds)
• Abdominal Trauma
• Abdominal pain in pregnancy
• Pelvic Pain

Source

• Tintinalli
• ACEP Geriatric lecture series