All things considered, we need you to consider a three-advance methodology yet you need first with foundational signs and manifestations. So when you consider an individual with stomach torment you ought to ask are there other fundamental causes that might be driving this agony?
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 a familial Mediterranean fever, and do they need further testing for that.
Likewise, make sure to search for endocrine changes either in the skin or changes in their glucose because Addison's ailment and diabetic ketoacidosis can frequently give additionally stomach torment. Also, consider uremia in patients with a kidney infection as a reason for queasiness, heaving, stomach torment, particularly if their kidney work has disintegrated.
The point here is never to 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 need you to consider pneumonia a typical reason, particularly of upper quadrant torment and that, is because basilar pneumonia, those including the bases of the lungs, can regularly cause pleural irritation which can rub against either the liver case or the splenic container to allude to one side or left upper quadrant torment. So a febrile patient with hack and sputum creation who presents with right upper quadrant torment should make you contemplate expected aspiratory reasons for alluded torment.
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 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,
Ask yourself, is this patient potentially suffering from gastritis? Could they have peptic ulcer disease? Is the pain 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 quadrants 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 becomes suddenly hypotensive, never forget splenic rupture. It is a life-threatening condition and something that should always be on your mind especially in the setting of known spleen enlargement. Left or right lower quadrant pain can refer to several 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 the 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 its pain in that area. You also wanna try to elicit certain symptoms that may have the help you increase the likelihood of certain conditions in organ involvement.
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? 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 the stone disease from the gallbladder that may be causing obstructive cholangiopathy. Pain that gets better when someone stands up is almost always pancreatic so think about the pancreas. 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, which could be all related to some type of abdominal trauma or there may be an intro abdominal 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 is 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 good auscultation to look for bowel sounds but also tenderness and rebound and guarding. Get your usual labs, your CBC, your basic, and lactate if you are thinking about ischemia. Don't forget an ECG and a chest x-ray especially if you are thinking about referred pain. Remember that abdominal CT scan better than ultrasound for evaluating most intra-abdominal structures. And too much hesitation in ordering the CT scan and potentially missing diagnoses. 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 CT scan early and quickly. It will save you a lot of pain and trouble in managing that patient.
Stress plays a big role in gastrointestinal diseases, period. the organ in the body that has the most nerve endings in the GI tract and not the brain and spinal cord. If a patient has an inordinate amount of stress in their life, then they may need to address that with the primary care doctor or perhaps even the psychiatrist that they may be seeing. In addition to stress, and recognizing that as a contributing factor, that diet plays a huge role in the cause of the patient's symptoms as well as the management of the patient's symptoms. address it more with diet in terms of fruits, vegetables, high fiber cereals, high fiber types of foods, in terms of management of a patient in opposed to certain herbs or supplements or spices. And use medications when appropriate, but try to do things more naturally in terms of stress management or stress awareness, as well as dietary management.
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