Abdominal (GI)

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.

Deep Dive

• Abdominal Pain Mimics: Pearls and Pitfalls (emDocs)

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. 

Deep Dive

• Management of Patients Presenting with Constipation (JUCM)

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

• Diarrhea (emDocs)

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.

Deep Dive

• 3am GI Bleed (emDocs)