Abdominal pain

Abdominal Pain

Acute abdominal pain can be caused by a spectrum of conditions. A primary care nurse practitioner should hold an in-depth knowledge and skill set that will enable her to distinguish between the primary and secondary causes of abdominal pain, make diagnosis, and to plan appropriate referral. Collecting the patient history pertaining to duration, location of pain, activities that aggravate pain, pattern of pain, changes in GI/ GU habits, presence of constitutional symptoms, comorbidities, dietary habits, family history etc.are some of the most important aspects of patient assessment. According to a systematic study report in 2014, the most common causes of abdominal pain were the following: gastroenteritis (7.2–18.7%), irritable bowel disease (2.6–13.2%), urological cause (5.3%) and gastritis (5.2%). About 1 in 10 abdominal pain patients suffers from an acute cause of abdominal pain such as appendicitis (1.9%), diverticulitis (3.0%), biliary/pancreatic (4.0%) or neoplastic (1.0%) diseases needing immediate therapy (2).

  • The following sections will discuss common causes of abdominal pain, assessment, diagnosis, and appropriate investigations as recommended.

    • Pathophysiology of Abdominal pain

    Visceral peritoneum is innervated by autonomic nerves. Stretching, pulling, and contracting of bowel causes diffuse, non-localized, dull, crampy, periodic abdominal pain which is not associated with any movements of the patient. In contrast to this, parietal peritoneum is innervated by somatic nerves. Cuts, structural changes, inflammation in the bowel etc. will cause sharp, well localized, excruciating, persistent, abdominal pain. Peritoneal signs will be present in appendicitis, cholecystitis, diverticulitis, acute pancreatitis, perforated ulcer, and bowel infarction. Acute abdominal pain can also be due to other causes such as nephrolithiasis, reproductive tract conditions, and urinary tract issues. Collect a detailed medical history to verify whether the abdominal pain is associated with history of IBS , IBD, recent travel, or food intake.It is very important for a primary care provider to carefully evaluate the location and nature of pain to make appropriate clinical decisions. Any patients who exhibit red flags, need to be referred to an acute care facility on a timely fashion (3, 4).

    Stage-1

    Stage-1

    Stage-2

    Stage 2

    Assessment, diagnosing, and management of abdominal pain (2,4).

    RUQ pain

    When RUQ pain is reported, watch for any pulmonary, cardiac signs/ symptoms . In case of any tachypnoea, hypoxia, or chest pain, make a referral to the nearest emergency room to rule out pneumonia, pulmonary embolus, or cardiac ischemia. If any associated urinary symptoms are present, preform a urinalysis. Patients with colic pain should be assessed for hepatobiliary causes or nephrolithiasis.

    RLQ pain

    RLQ pain, fever, positive Psoas sign, rigidity, and rebound tenderness require further investigation, preferably CT exam to rule out appendicitis (preferred over ultrasound). RLQ pain with no signs or symptoms suggestive of appendicitis require further urine, colon, or pelvic examination. Any suspected cases of appendicitis need to be assessed in an acute care setting. Patients who are at risk of pelvic inflammatory disease, should be evaluated for the same.

    LLQ pain

    Patients with known history of diverticular disease and physical examination findings that are suggestive of acute diverticulitis, will require antibiotic therapy. You may offer antibiotic therapy in a community setting, depending on the patient’s clinical status (mild diverticulitis with no redflags). If diagnosis is unclear, perform CT examination. In case of any abdominal distension, rectal bleeding, any s/o hypovolemia, send patient to emergency room. Also, pay special attention to rule out PID, STD, ureter calculi, ovarian torsion, abscess, cystic rupture, ectopic pregnancy etc. If you are working in a primary care setting where you may experience delay in obtaining images/ investigation reports, consider sending to emergency room as necessary.

    LUQ pain

    LUQ pain can be caused by many conditions; therefore, CT is more beneficial as it provides imaging of pancreas, spleen, kidneys and vasculature. An endoscopy is essential if signs of esophageal or gastric pathology is suspected. Verify if any H-Pylori screening was done previously, for patients with persisting GERD/ gastritis symptoms.

    The following table entails the location of pain and corresponding possible diagnosis.

    (Table 1) diagnosis table

    Abdominal exams and other resources

    McBurney’s -Tenderness on deep pressure at McBurney’s gives presumptive evidence of an appendicitis.

    >Psoas sign-pain on extension of rt thigh, seen in appendicitis

    Murphy’s sign- Ask the patient to breath out after gently placing the hand on RUQ along midclavicular line; during inspiration, if the pt holds breath due to tenderness, it may indicate cholecystitis.

    Obturator sign-Pain on internal flexion of rt thigh, present in appendicitis

    Rovsing’s sign- Pain in rt lower quadrant (iliac fossae) with palpation of left quadrant-seen in appendicitis.

    Dunphy’s sign- Increased pain with coughing, seen in appendicitis

    Carnett’s sign: increased abdominal wall pain when patient in supine lifts off head and shoulder (abdominal wall pain)

    Constipation and abdominal distension strongly suggest bowel obstruction. An abdominal x- ray could be an easiest, and economic option to diagnose in the community setting (if safe to wait for results).

    Ultrasound is a reliable investigation for RUQ pain; CT is recommended for rt& left lower quadrant pain.

    In special population (seniors, women) always consider genitourinary causes of abdominal pain.

    Patients with peritonitis want to remain still, where as colic pain will make it difficult to stay still.

    In peptic ulcer disease, pain is relieved by food.

    To learn more about Irritable Bowel Syndrome management, read the article below: https://www.aafp.org/afp/2012/0901/p419.html

    To learn more about assessment and management of diverticulitis, read the article: https://www.aafp.org/afp/2013/0501/p612.html

    To know more about dyspepsia, ordering endoscopy, PPI treatment, h- pylori testing, follow the link: http://www.cmaj.ca/content/187/4/276

    Stage -3

    Concrete Experimentation

    Stage 3

    SOAP Notes (example)

    c/o generalized abdominal cramps x 2 days

    recent h/o viral URTI

    no recent travelling history

    diarrhea x 2-3 times/ day

    no melena, nausea, vomiting, or hematochezia

    no fever, chills or urinary symptoms

    no past h/o IBS, IBD

    o/e

    nad

    Abdo: soft, non-distended, non-tender, no CVA tenderness, no guarding/rebound, no peritoneal signs, no mass/HSM

    Psoas, Obturator, Carnette’s sign- negative

    No s/o dehydration

    A

    Possible viral gastro enteritis

    P

    Reassurance given

    Discussed s/s that requires immediate medical attention

    If any fever, rigid abdomen, worsening of symptoms, fever, urinary symptoms, blood in stool or vomitus, should seek immediate medical help

    Discussed dehydration prevention

    If no improvement in 24-48 hrs, rtc for f/u

    Reflection—Stage-4

    Stage4

    Write a reflective journal, explaining your learning your experience on managing abdominal pain, by using Kolb’s learning cycle. What are the aspects of abdominal pain management that you require further training on?

    Reference

    1.

    Snyder, M.,Nellis, Do., Guthrie, M., & Cagle, S., Acute Appendicitis: Efficient Diagnosis and Management. American Family Physician. 2018 Jul 1;98(1):25-33. retrieved from https://www.aafp.org/afp/2018/0701/p25.html

    2.

    Brekke, M., &Eilertsen, R. K. (2009). Acute abdominal pain in general practice: tentative diagnoses and handling. A descriptive study. Scandinavian journal of primary health care, 27(3), 137-40. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3413184/

    3

    Viniol, A., Keunecke, C., Biroga, T., Stadje, R., Dornieden, K., Bosner, S., Banzhoff, N., Haasenritter, J.,Becker, A., Studies of the symptom abdominal pain—a systematic review and meta-analysis. Family Practice, Volume 31, Issue 5, 1 October 2014, Pages 517–529. https://doi.org/10.1093/fampra/cmu036

    4

    Cartwright, S., Knudson, M., Evaluation of acute abdominal pain in adults. American Fam Physician. 2008 Apr 1;77(7):971-978. Retrieved from https://www.aafp.org/afp/2008/0401/p971.html