CT abdomen and pelvis is not the right answer for these causes of abdominal pain. You will run into some these cases…
First off, the immediate life threats:
A 24 year old female presents with sudden onset of severe abdominal pain one hour ago. Vital signs are: T 37, P 115, BP 120/92, RR 22, O2 100% on room air. She appears diaphoretic and apprehensive. She is afraid to move for fear of worsening her pain.
If you do not immediately order a pregnancy test, your patient will die from a ruptured ectopic pregnancy. In any female of childbearing age with sudden onset of severe abdominal or pelvic pain, pregnancy is the most important thing to exclude. Ruptured ectopic pregnancy causes peritonitis. The classic signs of peritonitis are rebound tenderness, rigidity, and guarding; but these are not very sensitive or specific. Alternative signs:
Increase in pain with coughing
Increase in pain with jostling the gurney
Increase in pain with striking the heel
In the above patient, who is already showing signs of peritonitis and early shock (diaphoresis and narrow pulse pressure), if her pregnancy test is positive, consulting OB immediately and readying blood products would be more appropriate than waiting for other test results. Simultaneous bedside ultrasound is a viable option. Do not let the above patient go to radiology, despite the normal blood pressure.
A 72 year old male presents with right flank pain similar to previous episodes of urolithiasis. He is pale and diaphoretic. Vital signs are: T 37.2, P 109, BP 84/61, RR 25, O2 99% on room air.
Renal colic, in emergency medicine, is a condition that causes exsanguination in old people. The next best step is bedside abdominal ultrasound to look for AAA. If there is AAA found on ultrasound in a hypotensive patient, leak or rupture must be presumed. Consult surgery and ready 6-10 units of blood immediately. Do not send this patient to CT. You cannot, on the exam, send patients with SBP < 90 to CT. That is a hard rule.
Here’s quick-and-dirty how you manage AAA:
Radiographic evidence of rupture (on US, this would be positive FAST): immediate surgery
Clinical evidence of rupture (peritonitis or shock): immediate surgery
Hypotensive: immediate surgery
Symptomatic and not hypotensive: emergent surgery consult. CT should be obtained to accurately identify any evidence of leak or rupture. If you think an unruptured AAA is causing symptoms, the patient cannot be safely discharged, regardless of aneurysm size.
Symptomatic, not ruptured on CT, and hypertensive: as symptoms represent rapid expansion, BP must be tightly controlled with esmolol in the same fashion as in aortic dissection
Asymptomatic and aneurysm is >5 cm: consult surgery for recommendations. Close outpatient follow-up is possible, as long as a vascular surgeon is on board.
Asymptomatic and aneurysm is <5 cm: outpatient follow-up with vascular surgeon for repeat US in 3-6 months
A 57 year old male smoker with hypertension presents with epigastric pain and vomiting after eating dinner one hour ago. Vital signs are normal.
If you do not immediately obtain an EKG on this patient, this “biliary colic” will progress to V-fib. Obtain an EKG on all patients with upper abdominal pain who are older than 50, or have known CAD, or multiple cardiac risk factors. When a question stem provides you with past medical history, it usually is for the purpose of helping you with a challenging diagnosis.
Other emergent conditions:
A 13 year old male presents from school after he developed sudden onset of lower abdominal pain while in gym class. There is no history of trauma. The patient is in distress from pain. Vital signs are normal. Abdominal exam is normal.
The next thing to do here is to examine the scrotum. Pediatric testicular torsion frequently presents as abdominal pain because kids are bad at localizing pain, and teenage boys are too embarrassed to say their balls hurt. Remember that the most important part of the exam is to assess for the cremasteric reflex. Presence of this reflex effectively rules out torsion on that side. With bilateral cremasteric reflex intact, the patient is safe to go to radiology for formal evaluation with ultrasound.
If there is absence of this reflex, and the history and exam are suggestive of testicular torsion, provide adequate analgesia and consult urology without getting an ultrasound. Set the appropriate tone at the beginning of the consult and start the conversation with, “This boy is in trouble. I need you to save the day.”
If supporting the scrotum relieves the pain, this is a positive Prehn sign. This does not rule out torsion, but it suggests epididymitis.
A 28 year old female presents with sudden onset of severe right lower quadrant pain that started 4 hours ago. Pain has been constant and increasing in severity. She has associated nausea and vomiting. She denies any fever, urinary, or vaginal symptoms. She has a history of a right ovarian dermoid cyst. Her urine pregnancy is negative.
A 25 year old female who is 16 weeks pregnant presents with sudden onset of severe left lower quadrant pain that started 4 hours ago. She had intrauterine pregnancy confirmed by ultrasound, and her pregnancy has been thus far uncomplicated. She denies any fever, urinary, or vaginal symptoms.
Lower abdominal pain in women of childbearing age is a million times more complicated than brain surgery. The above cases are ovarian torsion until proven otherwise. The risk factor for ovarian torsion is anything that would disturb the normal tranquility of the ovary. The most common disturbance is, of course, pregnancy. But if a question specifically mentions a history of ovarian tumor or cyst, be thinking about ovarian torsion. The best thing to do is to consult OB/Gyn, obtain some form of imaging, and provide analgesia. Nothing is reliable in diagnosing this disease entity. A palpable adnexal mass rarely occurs, and the sensitivity of ultrasound and CT are not very high.
Because this is considered a surgical emergency, the right answer as soon as ovarian torsion comes into your mind as a real possibility is to consult. Because the presentation is vaguer than testicular torsion, it is appropriate to pursue imaging prior to surgery. A popular false belief is that pelvic ultrasound is the most sensitive imaging modality for torsion. CT is more sensitive, but either test is appropriate because you are paying for extra sensitivity with radiation exposure. Completely normal appearing adnexa on either CT or US, in my mind, excludes ovarian torsion. The most common abnormality on imaging is nonspecific ovarian enlargement due to venous engorgement.
A 40 year old female presents with two days of worsening abdominal pain, nausea, and vomiting. Vital signs are: T 36.5, P 92, BP 78/59, RR 19, O2 99% on room air. Her abdomen has normal bowel sounds, and is nontender to palpation. Her skin is cool, not mottled, and appears hyperpigmented. Fingerstick blood glucose is 62.
This patient has acute adrenal insufficiency (AAI). More specifically, she probably has Addisionian crisis. Characteristics of uncontrolled Addison disease include skin hyperpigmentation, generalized weakness, abdominal pain, nausea, vomiting, hyponatremia, and hyperkalemia. The end stage of uncontrolled Addison disease is AAI, which is a shock state that features hypotension that is refractory to fluids and hypoglycemia that is difficult to raise with dextrose. The treatment is IV corticosteroids and antibiotics. Infection is a common trigger for AAI, and sepsis is more fulminant when the adrenals are not working. It is thus vital to empirically start antibiotics and pursue a sepsis workup.
Addison is only responsible for a minority of AAI cases. More common causes include severe infections such as disseminated TB, meningococcemia; and sudden discontinuation of chronic steroid therapy. In a patient with septic shock, the clue for AAI will be refractory hypotension despite fluids and pressors. In a patient with a given PMH of conditions that commonly require large doses of systemic steroids, such as multiple sclerosis, be thinking about AAI when the patient presents with acute abdominal pain and hypotension.
A 21 year old female presents with one week of intermittent right upper quadrant pain and fever. Vital signs are only abnormal for a low-grade fever 38.2 C. Abdominal exam reveals RUQ tenderness. Urine pregnancy is negative. RUQ ultrasound is normal. Hepatic panel is normal.
If you want to play the trust-your-patient game, ask about sexual history and vaginal complaints. The appropriate thing to do on the exam is to perform a pelvic exam. If there is any evidence of cervicitis, adnexal tenderness, or cervical motion tenderness, the diagnosis is pelvic inflammatory disease (PID) with perihepatitis (Fitz-Hugh-Curtis syndrome). In FHCS, the liver and gallbladder or not involved and the hepatic panel is normal. PID is an emergent diagnosis to make in a 21 year old because delay in treatment affects fertility and increases risk of future ectopic pregnancy. Remember that one-time ceftriaxone and azithromycin is sufficient for cervicitis, but PID requires one-time ceftriaxone and 14 days of doxycycline.
Diagnosis seeking behavior
There are far fewer malingerers and drug seekers than most of us believe, and the board exam will reflect that. Always try to find the medical diagnosis. In a patient with recurrent abdominal pain and previous negative workups in the ED that includes multiple CTs, it is not appropriate to order a CT abdomen and pelvis for the same complaints. After routine labs, CT, ultrasound, and endoscopy fail to diagnose recurrent abdominal pain, there are still a few other entities to think about:
A 24 year old female presents with episodic abdominal pain and intractable vomiting. Episodes occur about once a month and last 1-3 days, and she has required hospitalization for IV hydration before. Anti-emetics have not provided relief, and the only thing that alleviates her symptoms is hot showers.
This patient has cyclical vomiting syndrome (CVS). CVS is related to migraines, and CVS may actually evolve to become migraine headaches. Migraine headache therapies work in treating CVS. Prophylactic therapy includes: cyproheptadine, antidepressants, anticonvulsants, and beta-blockers. Abortive therapies include triptans, promethazine, and prochlorperazine. Of course, try Zofran.
The most important intervention is identifying any triggers and avoiding the trigger. In the above case, the CVS may actually be cannabis hyperemesis syndrome (CHS). The alleviation with hot showers has been reported to be specific for CHS, although I have found that many patients with CVS and without CHS report that hot showers help. For the above patient, ask about marijuana use.
A 36 year old male presents with acute onset of severe colicky epigastric pain. He has multiple visits to the ED over the past 2 years with negative workups. These visits are sometimes accompanied by neurological signs and symptoms that include delirium, blindness, and bilateral lower extremity weakness. Symptoms improved spontaneously, but he has been hospitalized multiple times, including to the psychiatric floor. Currently, the patient is severely agitated, complaining that his legs are too weak to walk, and that there are bugs crawling in his penis.
The above case provides enough cues to be a classic case of acute intermittent porphyria (AIP). AIP is caused by a defect in heme metabolism, causing a buildup of porphyrin and its precursors. This is important to know because the ED test to order that can quickly make this diagnosis is a urine porphobilinogen. In a minority of cases, there is so much of this shit, the urine appears grossly bloody. The routine UA will show a (false) positive urobilinogen.
AIP patients present with paroxysmal bouts of severe pain with bizarre neuropsychiatric findings that commonly land these patients in a psych room before the proper diagnosis is made. AIP can be associated with almost any neurological symptom, including seizure and cortical blindness. The most common, however, is an ascending motor weakness that can mimic Guillain-Barre syndrome (GBS). Psychotic breaks and autonomic instability can also accompany AIP.
AIP is triggered by fasting, alcohol, estrogens, sulfa drugs, and barbiturates. There are a million other possible triggers, but those are the big ones. Acute attacks are treated with standard analgesia and supportive care. In addition, IV glucose and IV hematin may help.
A 30 year old male presents with recurrent episodes of abdominal pain. He has associated nausea, vomiting, and diarrhea. He has had multiple negative workups in the emergency department and he is usually discharged after symptomatic improvement with IV opioids and anti-emetics. Vital signs are T 37, P 125, BP 141/92, RR 20, O2 100% on room air. Exam is significant for piloerection, mydriasis, and clammy skin. The abdomen is soft and nontender.
So this patient may actually be malingering somewhat. But he does have a medical diagnosis: opiate withdrawal. Piloerection is a big word and in item-writer jargon, this is fairly specific for opiate withdrawal.
Sudden onset of severe abdominal pain in a female of childbearing age
This is ruptured ectopic pregnancy until proven otherwise
Sudden onset of severe flank or back pain in an elderly patient
This is a ruptured AAA until proven otherwise
Obtain a bedside ultrasound
Upper abdominal pain in a patient over 50, with known CAD, or with multiple cardiac risk factors
This is a STEMI until proven otherwise
Pediatric testicular torsion
Presentation: sudden onset of severe lower abdominal pain
Management: If no cremasteric reflex, activate code testicle and speak to urology without the ultrasound. If there is cremasteric reflex, proceed to ultrasound.
Presentation: Pain is severe, sudden-onset, and unilateral in the lower abdomen. There will be a risk factor mentioned (pregnancy, ovarian cyst, recent pelvic surgery, etc.)
Management: US or CT are both viable options, but consult OB/Gyn first.
Good to know: Stop the workup if imaging is completely normal. The most common nonspecific abnormality on imaging is an enlarged ovary. At this point, nothing short of laparoscopy rules this out.
Acute adrenal insufficiency (AAI)
Presentation: Hypotension refractory to fluids.
Most common cause: Sepsis. Give antibiotics in addition to steroids.
Exam clue: hyperpigmented skin
Lab clues: hyponatremia, hyperkalemia, hypoglycemia
PID with perihepatitis (Fitz-Hugh-Curtis syndrome)
Presentation: RUQ pain and tenderness with a normal hepatic panel and normal gallbladder ultrasound
Do not discharge this patient without a pelvic exam. If there is cervicitis, cervical motion tenderness, or adnexal tenderness, treat for PID.
Cyclical vomiting syndrome
Treat with migraine medicines
Try to identify the trigger
Marijuana can cause cannabis hyperemesis syndrome
Acute intermittent porphyria (AIP)
The cause: genetic defect causing defective heme metabolism and build up of porphyrins and its precursor
Presentation: severe recurrent attacks of abdominal pain +/- autonomic, neurological, or psychiatric manifestations
The test: urine porphobilinogen
Specific treatments to try: IV dextrose and IV hematin infusions
On exam is synonymous with piloerection
