Specific Problems: Abdominal Pain PDF Print E-mail
Health Care Providers - Problem Oriented Clinical Guidelines

Sickle pain episodes may present with pain in the abdomen and intra-abdominal pathology can precipitate pain crisis. This population has the usual problems which can present with abdominal pain, however, the incidence of gall stones with cholecystitis, peptic ulcer disease, and pyelonephritis is increased. Complications such as splenic or hepatic sequestration are almost unique problems in patients with these diseases. This protocol will address some of the more common problems and is not meant to be encyclopedic. When in doubt, the advice of a surgical consult is invaluable and admission for observation almost mandatory.

Edited by James Eckman, M.D. and Allan Platt, PA-C

As in many clinical settings, the evaluation of abdominal pain in the hemoglobinopathy patient is fraught with difficulty. Sickle pain episodes may present with pain in the abdomen and intra-abdominal pathology can precipitate pain crisis. This population may also have the usual problems that can present with abdominal pain, however, the incidence of gall stones with cholecystitis, peptic ulcer disease, and pyelonephritis is increased. Complications such as splenic or hepatic sequestration are almost unique problems in patients with these diseases. This protocol will address some of the more common problems and is not meant to be encyclopedic. When in doubt, the advice of a surgical or gynecological consult is invaluable and admission for observation almost mandatory.

Clinical Findings

Subjective Data

Present Illness. Define the onset, whether continuous, intermittent, new or recurrent, location, radiation, character (diffuse, localized, crampy, sharp, dull aching), duration, aggravating/ alleviating factors, nausea, vomiting, diarrhea, constipation, change in urine/stool color, melena, hematemesis, increased jaundice, anorexia, distension, last menstrual period (date, duration, normality), illness in contacts.

Past Medical History. Document hemoglobin phenotype, general health, past surgery (appendectomy, cholecystectomy, tubal ligation, hysterectomy) dates, recent hospitalizations, pregnancies, present medications, drug allergies.

Review of Symptoms. Do a general ROS. Define fever, weight change, urinary frequency, urgency, dysuria, sexual history, vaginal discharge, past menstrual problems.

Objective Data

Physical Examination

- Vital Signs. Temperature, pulse, blood pressure, respiratory rate.

- HEENT. Scleral icterus.

- Neck. Lymph nodes, thyroid.

- Chest. Change in basilar breath sounds, dullness, or rales to suggest lower lobe pneumonia or effusions.

- Heart. Cardiomegaly, murmur, gallop.

- Abdomen. Inspect for organomegaly, peristaltic waves, distension, flank bulging, surgical scars. Bowel sounds present, increased, decreased, rushes, high pitched, bruits. Tenderness, rebound, guarding, increased liver/spleen size and tenderness or masses.

- Rectal/Pelvic. Cervical discharge, tenderness, adnexal tenderness/masses, rectal masses, stool guaiac.

-Back/Extremities. CVA tenderness, pulses intact, edema.

Laboratory

- Minimum Lab. CBC with differential, platelet and reticulocyte counts, urinalysis and culture, SMA 18 for pain not characteristic of pain episodes, change in jaundice, vomiting or diarrhea.

-Additional Lab. Chest x-ray, ECG, and supine and upright abdomen if patient meets admission criteria. Consider amylase, pregnancy test, GC smear/culture, ultrasound, HIDA scan, or IVP.

Differential Diagnosis

- Pain Episode (Crisis). Pain is usually diffuse, steady, involves back and extremities, and is characteristic for patient. Bowel sounds are normal-active. Diffuse tenderness without guarding or rebound is present. Liver and spleen size is unchanged. Fever less than 101oF and WBC less than 20,000 without left shift. One of the best questions of patient is, "Is the pain typical for your pain crisis?"

- Cholecystitis. Pain is usually in right upper quadrant, may radiate to right shoulder, chest or epigastrium. Usually severe and steady, may occur after meals, often associated with nausea and vomiting. Urine may become darker, stool lighter, and jaundice may increase. Physical findings include fever, RUQ tenderness, a positive Murphy’s sign, and decreased bowel sounds. Lab findings include leukocytosis with left shift, increased direct and indirect bilirubin, elevated alkaline phosphatase, and bile in urine. Ultrasound or HIDA scan may show stones.

- Peptic Ulcer Disease. Pain is usually mid-epigastric occasionally with radiation through to back. Often characterized as burning, episodic, gnawing, relieved by antacids, may increase or decrease after food. Exam reveals normal bowel sounds, epigastric tenderness, and guaiac positive stools with bleeding. Laboratory tests are unchanged. UGI or endoscopy may be diagnostic. Significant complications include bleeding, outlet obstruction and perforation. Bleeding patients may present with hypotension, hematemesis, melena, and positive guaiac. Outlet obstruction will often cause vomiting and pain after eating. Perforation causes severe abdominal pain, hypotension, guarding, rebound, free air and ileus on x-ray of abdomen.

- Appendicitis. Pain usually starts periumbilical, settles in right lower quadrant, and is slowly increasing. Appetite is usually gone and nausea and vomiting may occur. Low grade fever, decreased bowel sounds, RLQ tenderness with rebound and referred rebound, rectal tenderness are characteristic. There is guarding and diffuse rebound with perforation. Leukocytosis with left shift is present. Plain films of the abdomen may show ileus, right psoas shadow gone, and free air late.

- Gastroenteritis. A prodrome of low grade fever, myalgias, or URI is followed by nausea, vomiting and diarrhea. There may be a history of similar symptoms in family or contacts. Pain is often crampy. Bowel sounds are increased. Tenderness is diffuse, without rebound or guarding. White count is usually normal or low without left shift.

- Pancreatitis. Severe pain in epigastrium with radiation to back relieved by bending forward associated with nausea and vomiting is characteristic. May have history of alcohol intake or cholecystitis. On physical exam findings often include epigastric tenderness, guarding, hypoactive bowel sounds, fever, and hypotension. Laboratory results show leukocytosis with left shift. SGOT, LDH, Alk P’tase, and bilirubin may be elevated over baseline. Increased serum and/or urine amylase. Serum calcium may be low.

- Hepatitis. Prodrome of anorexia, arthralgias, rash, and fever may be present . Acute illness often includes symptoms of RUQ pain, increasing jaundice, nausea, vomiting, dark urine, and lighter stools. An enlarging tender liver is often the main physical finding. Lab shows mild increase or decrease in WBC, reactive lymphs, increased SGOT, LDH, indirect bilirubin, HBsAg (+), Anti-HBs (-) [Hepatitis B]; or HAVAB IgM (+) [Hepatitis A]. See Hepatitis

- Hepatic Sequestration. This complication is usually, but not invariably, associated with pain crisis. History may be signs or symptoms of precipitating infection, nausea and vomiting. Physical exam shows rapidly enlarging tender liver with increasing jaundice.Patient may be hypotensive. Bowel sounds are often present. Lab shows a rapid decrease in hemoglobin level over baseline. WBC, platelets and reticulocyte count are high. LDH, SGOT, direct and indirect bilirubin, alkaline phosphatase are markedly increased. BUN, Cr, and CPK may also be elevated.

- Splenic Sequestration. LUQ pain, early satiety, nausea, vomiting, dizziness, orthostatic hypotension may be present. In children, listlessness, increased pallor, and increasing spleen size may be the only findings. Seen in children with Hb SS, SC, or SThal and adults with Hb SC or SThal. Exam reveals increased jaundice and splenomegaly. Lab findings are often the same as with hepatic sequestration, however, increasing anemia with a high reticulocyte count may be the only findings. (see Sequestration)

- Pyelonephritis. Presents with abdominal pain and often a history of dysuria, frequency, fever, chills, suprapubic or back pain. Exam shows fever, CVA and suprapubic tenderness. Lab reveals leukocytosis with left shift on CBC and WBCs, casts, bacteria on urinalysis in classic presentations.

- Nephrolithiasis, Papillary Necrosis. Hemoglobinopathy patients may have increased incidence of kidney stones from increased excretion of uric acid. Acute papillary necrosis does occur with increased frequency in all of the sickle syndromes. Both can have very similar presentations with severe pain in back, flank, abdomen with radiation to groin and testicle. Exam shows hypoactive bowel sounds, guarding, CVA tenderness usually without fever. Lab reveals some increase in white count without left shift. UA positive for RBCs. Intravenous or retrograde pyelograms will establish the diagnosis.

- Bowel Infarction. Diffuse or periumbilical, crampy pain which increases in severity. Exam shows decreased or absent bowel sounds, distension, fever, hypotension, guarding and rebound may be present. Lab shows leukocytosis with left shift, high anion gap acidosis, and increased amylase. X-ray shows ileus.

- Bowel Obstruction. More common etiologies include intussusception, volvulus, or adhesions from prior surgery. Crampy pain in waves then continuous, nausea, vomiting, constipation. Exam shows high pitched bowel sounds with rushes then decreased bowel sounds, Diffuse tenderness worse over obstruction, guarding and rebound late. Lab leukocytosis with left shift late. X-ray shows ileus with air fluid levels.

- Pelvic Pain. Ectopic pregnancy, endometriosis, corpus luteum cyst rupture, torsion of ovary, ovulation, dysmenorrhea, pelvic inflammatory disease, cystitis all can present with primarily complaints of abdominal pain. Pregnancy test and careful pelvic examinations are important procedures in the evaluation of any female with abdominal pain.

- Pneumonia. Lower lobe pneumonias may present with upper abdominal pain and tenderness. Exam may show rales, evidence of consolidation, or rubs. X-rays frequently diagnostic but may be negative initially if the patient is dehydrated.

Treatment

- Pain Crisis. Criteria for admission are the same as outlined in that chapter, however, admission for observation may be indicated if true etiology of the abdominal pain is unclear in this patient population.

- Cholecystitis. Patients with acute cholecystitis with fever, leukocytosis, or pain crisis require surgical consult and admission. Chronic should be documented with ultrasound or HIDA scan and referred to a surgeon for elective cholecystectomy. Many recommend cholecystectomy for all with gall stones, all advocate surgery for symptomatic stones.

- Peptic Ulcer Disease. For pain suggestive of peptic ulcer disease without other complications, start antacids, cimetidine (20-40 mg/kg/day up to 300mg P.O. q.i.d.) or sucralfate 1 gm P.O. Q.I.D.), ranitidine 150 mg orally every 12 hours, and famotidine 40 mg orally (if renal function is normal) or Omeprazole 20-40 mg per day are the treatments of choice. One may consider eradicating H. pylori. A c triple-drug regimen includes 2 weeks of bismuth subsalicylate (Pepto-Bismol) tablets, 2 tablets (525 mg) qid, plus metronidazole, 250-500 mg tid, plus either tetracycline, 500 mg qid, or amoxicillin, 500 mg qid. Concomitant use of an H(sub 2)- blocker (e.g., ranitidine) or omeprazole (for duodenal ulcers) usually is advised . Omeprazole (Prilosec), 20 mg bid, and amoxicillin, 500 mg qid, both for 2 weeks, has also been an effective regimen. Schedule the patient for upper GI, and appoint to GI clinic. Safety of cimetidine and sucralfate have not been established in children under 12. Bleeding, signs of perforation, or obstruction require emergent admission and surgery consult.

- Appendicitis. Surgery consult for urgent removal. Exchange transfusions may be indicated if time permits.

- Gastroenteritis. If pain crisis is also present, admit the patient for I.V. hydration and observation. If patient is dehydrated or has severe vomiting or diarrhea, admit for intravenous fluid therapy to prevent pain episodes or other complications. Outpatient management includes administration of clear liquids, Coca Cola, ginger ale, bismuth subgallate 400 mg PO t.i.d. PC, and vistaril or phenergan for nausea.

- Pancreatitis. Admit for intravenous therapy, support and observation.

- Hepatitis. Admit if anorexia and vomiting prevents hydration and caloric intake. Enteric isolation is indicated and prevention for recommendation for contacts. See weekly in follow-up if not admitted.

- Hepatic Sequestration. Admit immediately and monitor carefully. Patient will need aggressive transfusion, close monitoring, and treatment of complications.

- Splenic Sequestration. Admit to I.C.U. for aggressive transfusion and close monitoring

- Pyelonephritis. Admit for intravenous antibiotics.

- Nephrolithiasis or Acute papillary Necrosis. Admit for IV hydration with hypotonic solutions, alkalinization of the urine, and pain control. Strain urine for tissue and stones and proceed with urologic evaluation.

- Bowel Infarction. Surgery consult for emergency surgery.

- Bowel Obstruction. Surgery consult for emergent evaluation and surgery.

- Pelvic Pain. If pelvic exam indicates a possible pelvic source of abdominal pain, obtain a beta -HCG and a gynecology consult immediately.

- Pneumonia. Admit for I.V. antibiotics based on sputum smear.

Prevention

Splenic size should be noted on each visit and patients and parents of patients with large spleens should be taught to examine for changes in spleen size. Similar considerations are present in adults with significant hepatomegaly

The use of a tongue blade as a spleen stick (See Splenic Sequestration, ) provides an accurate way of assessing and recording spleen size at home and in the clinic.

.Many suggest that screening for gall stones should be initiated in older children and that cholecystectomy is indicated if stones are documented. Others advocate non-intervention and only evaluate patients that have symptoms suggestive of cholecystitis. Similarly these individuals only recommend cholecystectomy for symptomatic stones.

Close contacts of patients with hepatitis A should be treated with I.M. immune globulin. Patients exposed to blood products should receive hepatitis B vaccine. Sexual contacts or those exposed to blood should receive hepatitis B immune globulin and vaccine.

Patient and Parent Education

The most important consideration in abdominal pain is that splenic sequestration be diagnosed early as above. Patients should also be taught to present for evaluation if they develop unusual abdominal pain, urinary, gynecologic symptoms. Patients with known gall stones need to be evaluated for changes in pain or jaundice. Safe sex using barrier methods needs to be taught in the early teens.

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References

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