00:02
Hi, we're gonna be talking about
the approach to abdominal pain
for patients who present
to the emergency department.
00:10
So abdominal pain
in the emergency department,
it's actually the most common
chief complaint
in the United States.
00:16
So this is the most common thing
that you're going to be seeing
coming through the doors
of the ED.
00:21
It represents approximately 25%
of ED visits.
00:25
And it's the percentage of
non injury abdominal pain visits,
which is actually on the rise.
00:30
So this is something that
potentially can increase in numbers
over the next few years,
rather than decrease.
00:36
So we're going to be seeing
lots of patients coming in
with discomfort in their abdomen.
00:42
Now, again, we always want
to make sure
when we're thinking about
presenting complaints
in patients presenting
to the emergency department
that we always go back
to the basics,
and that is airway,
breathing, and circulation.
00:54
Now, you might be thinking
that airway and breathing
might not necessarily
play a role here.
00:59
But due to the fact that there's
such a wide range of things
that can cause abdominal pain,
we actually always want
to make sure
that we're thinking
in this stepwise fashion.
01:08
Because if we start to not think
in that stepwise fashion,
that's when we get ourselves
into trouble.
01:12
Circulation can definitely
play a role here,
especially in settings
where you're concerned
that someone could have
a life threatening cause
of their abdominal pain,
such as a triple A.
01:21
So we always want to make sure
that we're thinking about this.
01:27
One of the biggest challenges
when patients come
to the emergency department
for abdominal pain
is that there is such
a wide range of things
that can be causing
the abdominal pain.
01:38
And they vary from things
that are benign.
01:41
Things like GERD or
Gastroesophageal Reflux.
01:45
A viral illness,
but for the most part,
most patients can really tolerate
on their own.
01:50
They may be uncomfortable.
01:51
They might have some belly pain
and some vomiting and diarrhea,
but for the most part,
patients will be okay.
01:57
Then they range
to more serious things
such as appendicitis,
bowel obstruction, diverticulitis,
pancreatitis, and kidney stones.
02:05
And these potentially
have very serious implications.
02:09
Some of these require
surgical interventions.
02:11
Some of these require admission
to the hospital
for IV antibiotics,
IV fluid replacement,
pancreatitis
can become very severe,
and can really cause
serious problems
for patients down the line.
02:25
Kidney stones
can lead to obstruction
and urinary tract infections,
which can then lead
to sepsis.
02:32
So we definitely need
to make sure
that we're thinking about these
more serious causes.
02:36
And then if that's not enough,
we move on to the fact
that abdominal pain
can actually be related
to life threatening conditions.
02:44
So an abdominal aortic aneurysm
can cause abdominal pain.
02:47
And that is obviously something
that can be
very, very serious
and life threatening for a patient.
02:53
Patients can bleed out very rapidly
from abdominal aortic aneurysms
that rupture.
02:58
A ruptured ectopic pregnancy
also poses significant challenges.
03:04
Perforation of the GI tract,
that's something that requires
emergent surgical intervention.
03:09
The patient needs to go
to the operating room emergently.
03:13
So when we're
thinking about patients
who come into the
emergency department
with belly pain,
we have to be thinking about this
whole spectrum of things.
03:20
We can't just be thinking about
the benign things
or the life threats.
03:23
We have to be thinking about
all the things that are benign,
more serious, and then
those life threatening conditions.
03:30
Because if we're not
thinking broadly in this situation,
that's how we run into problems.
03:34
And we can get come up
with a misdiagnosis.
03:36
We come up
with an incorrect diagnosis.
03:39
So always maintaining
that high level of suspicion.
03:43
You know, there are also
extra abdominal things
that can cause abdominal pain,
So things outside the belly.
03:48
So as if things weren't complicated
enough already,
we're going to go ahead
and complicate them even further.
03:54
Myocardial infarction
is a classic example
of extra abdominal things
presenting with belly pain.
04:01
Classically,
inferior wall MI's,
so an inferior wall
myocardial infarction
is the classic thing
that we think about
presenting with
epigastric, abdominal pain,
and nausea and vomiting.
04:11
And I would say,
you could probably ask
every emergency medicine
physician
if they've ever seen an inferior MI
present with primarily
abdominal pain symptoms?
And I would say,
that we would all say yes.
04:21
I can think of a handful of times
that patients were presenting
with epigastric belly pain,
got an EKG
and it turned out to be
an ST elevation MI
in the inferior distribution.
04:33
You always just have to keep it
in the back of your mind
that epigastric pain
can potentially be an MI,
especially in the appropriate
patient population.
04:43
And especially if your patient
appears ill,
If they're diaphoretic,
if they're sweaty, if they're pale,
those are the patients
so you want to get that EKG
a little bit more rapidly.
04:54
Ketoacidosis is another
very serious and life threatening
condition
that can potentially cause
abdominal pain.
05:02
So classically,
diabetic ketoacidosis.
05:04
So diabetic patient
that is having ketoacidosis
that is producing ketone bodies
and their blood is acidotic.
05:13
By similar pathway,
alcoholic ketoacidosis
can cause abdominal pain
as well.
05:18
Diabetic patients, patients who
drink alcohol regularly.
05:21
you want to be thinking about this
and you want to be potentially
working your patient up for it.
05:27
Pneumonia,
especially in pediatrics.
05:29
So especially for those
younger kids
can present
just with abdominal pain.
05:34
So we thinking about
pneumonia.
05:36
Herpes Zoster or Shingles
can actually present with pain
in lots of different areas.
05:41
So sometimes it's like a red herring
and chest pain presentations.
05:44
Sometimes it's a red herring
and abdominal pain presentations
as well.
05:49
This is a time
where you want to make sure
you ask a patient,
"Have you seen a rash on your body?"
And also where you want to sometimes
inspect the abdomen.
05:57
Again, this is something where
every so often
you go ahead and you take a look
at the belly.
06:02
And you see in that
dermatomal distribution,
shingles in that area
where that patient is
complaining of pain.
06:09
So just make sure you keep it
in the back of your mind
and that you're thinking about that
when someone comes in
complaining of pain.
06:14
You know, the classic pain
with herpes zoster is kind of like
people describe it as an
itchy burning sort of a discomfort.
06:20
So even more so when they describe
their pain in that way.
06:23
Other things...
06:24
Glaucoma.
06:26
I know that seems like
a total outlier,
but someone having
elevated intraocular pressure
can cause abdominal pain.
06:32
This is why it's really important
to talk with our patients.
06:36
Find out if they're having pain
in their eye.
06:38
Malignancies potentially.
06:40
Henach-Schonlein purpura.
06:41
More common in pediatrics,
but can be seen in adult patients.
06:45
The classic association
with that
is that patients will have
a purpura rash
most commonly
on the lower extremities.
06:52
And then testicular
and ovarian torsion.
06:55
We'll be talking about
those concepts
in another lecture.
06:58
But it's important to always ask
about any pain
in the testicles,
especially for those
adolescent male patients.