Abdominal (GI)


Abdominal Pain

Rapid Review

  • Differentials
    • Gastrointestinal
      • Pancreatitis
      • Hepatitis
      • Gastritis
      • Peptic Ulcer Disease
      • Cholecystitis
      • Chiledocholithiasis
      • Cholangitis
      • Diverticulitis
      • Crohn’s disease
      • Ulcerative colitis
      • Bowel obstruction
      • Hernia
      • Constipation
    • Vascular
      • Mesenteric ischemia
      • Ischemic colitis
    • Renal/Urinary
      • Pyelonephritis
      • Urinary tract infection
    • Urologic
      • Testicular torsion
      • Epididymitis
    • Gynecologic
      • Pelvic inflammatory disease
      • Ovarian torsion
      • Ovarian cyst rupture
      • Endometriosis
      • Uterine fibroid
    • Referred pain
      • ACS
      • Pulmonary embolism
      • Pneumonia
  • History
    • Which region does the pain hurt most
      • Differentials vary based on location
    • Fever/chills
      • Suggests infectious process
    • Urinary symptoms
      • Suggests pyelonephritis, cystitis, nephrolithiasis
    • Melena/hematochezia
      • Consider GI bleed
    • Alcohol use
      • Consider hepatitis or pancreatitis
    • Exacerbated or relieved with foods
      • Consider gastric or duodenal ulcers
    • Hx of unprotected sex or recent STI
      • Consider PID
  • Physical Exam
    • Murphy’s sign
      • Suggests biliary process
    • Rigid abdomen
      • Suggests peritonitis
    • Rebound Tenderness/Rovsing’s/Obturator/Psoas Signs
      • Suggests appendicitis
    • CVA tenderness
      • Suggests pyelonephritis or nephrolithiasis
  • Work-Up
    • Labs
      • CBC, CMP, Lipase
      • Lactate (if suspect mesenteric ischemia, sepsis, strangulated hernia)
    • Imaging
      • Abdominal X-ray
      • RUQ ultrasound 
      • CT abdomen/pelvis

Pearls

  • Surgery begets surgery. Be careful with patients who have had prior abdominal surgeries, as this can cause additional complications (ex. small bowel obstructions)
  • Maintain a low threshold to get imaging on elderly patients. Even the most benign appearing presentations may be from life-threatening pathologies.
Video Credit: Strong Medicine


Constipation

Rapid Review

  • Differentials
    • Mechanical obstruction
      • Stricture (colon, rectum, anus)
      • Volvulus
      • Hernia
      • Neoplasm
    • Functional/Idiopathic
      • Irritable bowel syndrome
      • Diverticular disease
      • Megacolon
      • Pelvic intussusception
    • Metabolic/Endocrine
      • Hypothyroidism
      • Hypokalemia
      • Hypomagnesemia
      • Hypercalcemia
      • Pregnancy
      • Diabetes 
    • Medications
      • Opiates
      • Iron
      • Calcium 
      • Anticholinergics
      • Antipsychotics
  • History
    • Time since last bowel movement
      • Gauge severity of constipation
    • Fever
      • Consider infectious pathology
    • Bloody stools
      • Consider trauma, diverticular disease, or rectal foreign body
    • Unintentional weight loss
      • Consider colon cancer
  • Physical Exam
    • Pale skin, cachexia
      • Signs of anemia
    • Guarding/rigidity
      • May indicate peritonitis secondary to bowel perforation or obstruction
    • Abnormal vitals (hypotension, tachycardia, fever)
      • Concerning for serious pathology
    • Absent bowel sounds/high-pitched
      • Suggests complete or near-complete mechanical obstruction
    • Blood on rectal exam
      • Indicates active GI bleeding
  • Work-up
    • Labs
      • CBC, BMP, Magnesium, TSH, Pregnancy test
    • Imaging
      • Abdominal X-Ray
        • If uncomplicated
      • Abdominal/Pelvic CT
        • More sensitive for high risk pathologies

Pearls

  • Always keep in mind life-threatening mimics of constipation (eg. intra-abdominal abscesses, volvulus, bowel obstruction)
  • Maintain a low threshold to perform CT imaging on elderly patients. 
Video Credit: JJ Medicine


Diarrhea

Rapid Review

  • Differentials
    • Bacterial
      • C. difficile
      • Campylobacter
      • Shigella
      • Salmonella
      • E. coli
    • Viral
      • HIV
      • Enteroviruses
    • Parasitic
      • Entamoeba histolytica
      • Giardia lamblia
    • Other
      • Inflammatory bowel disease
      • Ulcerative colitis
      • Diverticulitis
      • Medications
      • Alcoholism
  • History
    • Frequency and volume of stools
      • Watery, large volume stools likely viral
    • Recent antibiotics
      • Consider C. difficile
    • Exposure to poultry, livestock, turtles
      • Consider salmonella
    • Travel to developing countries
      • Consider bacterial/parasitic infections
    • Consumption of raw, undercooked meats
      • Consider bacterial organisms
  • Physical Exam
    • Dry mucous membranes
      • Suspect dehydration
    • Abdominal tenderness
      • Suspect inflammatory process (pancreatitis, cholecystitis, appendicitis) 
    • Bloody stools
      • Suggest bacterial/parasitic
  • Work-Up
    • Labs
      • CBC, BMP, hepatic panel
      • C. diff PCR
      • Hepatic panel
      • Stool culture
      • Stool ova/parasites
    • Imaging
      • CT Abdomen pelvis (if concern for acute abdomen)

Pearls

  • Always consider C. difficile in all patients presenting with diarrhea, especially if they are coming from a nursing home. 
  • Stool cultures are generall not needed unless patients are systemically unwell, have recent travel history, work in public/food facilities, or have prolonged cases of diarrhea.

Deep Dive

Video Credit: JJ Medicine


GI Bleeding

Rapid Review

  • Differentials
    • Upper GI bleeding
      • Esophageal varices
      • Boerhaave syndrome
      • Aortoenteric fistula
      • Mallory Weiss tear
      • Gastritis
      • Gastric cancer
      • Peptic ulcer disease
    • Lower GI bleeding
      • Diverticular disease
      • Malignancy
      • Mesenteric ischemia
      • Ulcerative Colitis
      • Hemorrhoids
      • Colitis
      • Anorectal fissure
  • History
    • Blood thinners (antiplatelets or anticoagulants)
      • High-risk for life-threatening bleed
    • Chronic NSAID use
      • Risk factor for peptic ulcer disease
    • Recent iron or bismuth use
      • May turn stools black
    • Chronic alcohol use or liver disease
      • Consider varices
    • Family Hx of colon cancer
      • Consider malignancy
  • Physical Exam
    • Jaundice
      • Consider varices secondary to liver disease
    • Abdominal Exam
      • Look for signs of peritonitis
    • Rectal Exam
      • Evaluate for source of bleeding (anal fissures/hemorrhoids)
    • Abnormal vitals (tachycardia, hypotension)
      • Signs of hemorrhagic shock
  • Work-Up
    • Labs
      • CBC, BMP, coagulation studies, LFTs, Type and screen
    • Procedures
      • Anoscopy (if suspect internal hemorrhoids or fissures)
    • Imaging
      • Upright CXR/Abdominal films
        • If concern for aspiration or to evaluate for free air
      • Abdominal CT
        • If concerned for perforation

Pearls

  • Bright red blood in stool (hematochezia) is usually caused by lower GI bleeding, but can also be due to severe/massive upper GI bleeding. 
  • Unless there is concern for intestinal/gastric perforation, imaging is rarely useful in these patients.
Video Credit: Strong Medicine

Brandon Simpson, PA-C
Latest posts by Brandon Simpson, PA-C (see all)
  • Blog - 25 Feb 2021