Vanderbilt University School of Medicine
VC3 – Vanderbilt Core Clinical Curriculum

Abdominal Pain

 

A variety of important acute and chronic diseases cause abdominal pain. Many of these diseases pose serious threats to patients. Mastery of the approach to patients with abdominal pain is important to third-year medical students.

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Prerequisites

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Describe and discuss:

  • anatomy of the abdomen and pelvis

  • basic physiology

  • basic pharmacology

  • epidemiology of abdominal pain

Demonstrate:

  • ability to take a medical history

  • ability to conduct a basic physical examination of the abdomen

  • basic communication skills

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Apply Medical Knowledge in the Clinical Encounter

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1.     Describe and discuss principal types of pathophysiologic mechanisms of abdominal pain (i.e., obstruction, peritoneal irritation, vascular insufficiency, abnormal motility, mucosal irritation, metabolic aberrations, nerve injury, referred pain, psychopathology).

2.     Describe and discuss the relative likelihood of common causes of abdominal pain according to the quadrant in which the pain is located and describe the elements of the history important in distinguishing among those causes.

3.     Describe and discuss symptoms and signs indicative of an acute abdomen.

4.     Describe and discuss the indications and the limitations of principal diagnostic studies necessary to differentiate among common causes of abdominal pain.

 

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Diagnose

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1.     Obtain, document, and present an age-appropriate medical history that differentiates among etiologies of disease, including:

  • characterization of a patient’s abdominal pain: location, severity, character, pattern,   radiation

  • temporal sequence: onset, frequency, duration, progression

  • associated symptoms: nausea, vomiting, fever, chills, anorexia, weight change, cough, dysphagia, dysuria, altered bowel function (diarrhea, constipation, obstipation, hematochezia, melena)

  • exacerbating and remitting factors: position, food, activity, medications

  • pertinent medical history: prior surgery, other illness (attn. to diabetes, cardiovascular disease, immunosuppression), menstrual cycle

  • medications: prescription and supplements (attn. to anticoagulation, steroids)

  • family history

2.     Perform a physical exam to establish the diagnosis and severity of disease including:

  • correct order and technique for examining the abdomen

  • adequate rectal and pelvic exam (under supervision)

  • identification of relevant scars, abnormal bowel sounds, and signs of peritoneal inflammation

3.     Demonstrate various maneuvers utilized in evaluating acute abdominal pain. Examples: iliopsoas sign, Rovsing’s sign, obturator sign, Murphy’s sign, cough tenderness, heel tap, cervical motion tenderness.

4.     Describe the keys to successful examination of special populations, including infants and children, pregnant women, patients with altered neurologic status, and post-operative patients.

5.     Generate a list of the most important and likely causes of a patient’s abdominal pain, recognizing specific history and physical exam findings that distinguish between potential causes.

6.     Recommend when to order the following diagnostic and laboratory tests necessary to determine the cause of a patient’s abdominal pain. Be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of costs and test performance characteristics as well as patient preferences.

  • CBC

  • BMP

  • liver enzymes

  • amylase and lipase

  • lactate

  • hepatitis serology

  • fecal leukocytes

  • stool culture

  • stool guaiac

  • stool fat

  • CT scan

  • abdominal/pelvic ultrasound

  • FAST u/s

  • radionuclide scan of hepatobiliary system

  • MRCP

  • ERCP

  • upper endoscopy

  • sigmoidoscopy

  • colonoscopy

  • barium studies

  • angiography

  • paracentesis

 7.     Know the indications for and demonstrate the ability to perform the following procedures in the evaluation of a patient with abdominal pain:  

  • nasogastric tube

  • peripheral intravenous catheter

  • venipuncture

  • insertion of Foley catheter

8.     Compose appropriate admission orders as part of the initial assessment and care of patients with acute abdominal pain.

9.     Explain the results of the evaluation to the patient, taking into consideration the patient’s knowledge about his/her condition.

10.  Record, present, research, critique, and manage clinical information.

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Develop a Management Plan

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1.     Discuss the relative urgency of treating various causes of abdominal pain.

2.     Describe the surgical management of abdominal pain including:

  • the indications for operative intervention

  • the key elements of informed consent

  • the maintenance of other organ systems during the physiologic stress of the peri-operative period, including measures for prophylaxis against complications

  • the resuscitation of patients with acute abdominal process

3.     Describe the medical management of various diagnosis presenting with abdominal pain. Know the indications and side effects of various treatment modalities, including antibiotic therapy.

4.     Communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring and compassionate manner, reflecting an understanding of the emotional impact of disease and its potential effect on lifestyle (work performance, sexual functioning, etc.).

5.     Provide education for the patient about his or her treatment plan, including counseling related to preventive measures.

6.     Refer for psychological support if indicated, including the management of chronic abdominal pain.

7.     Plan for follow-up.

*************************************************************************************Differential Diagnosis

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Gastroduodenal

  • GERD

  • Gastritis

  • Peptic ulcer disease

  • Gastroparesis

  • Pyloric stenosis (peds)  

Biliary

  • Gallstone ds

    • biliary colic

    • cholecystitis

    • cholangitis

  • Acalculous cholecystitis

  • Hepatitis

  • Hepatic abscess

  • Pancreatitis  

Small Bowel

  • Small bowel obstruction

    • complete vs partial

    • adhesions

    • hernia

    • tumor

    • malrotation (peds)

  • Irritable bowel syndrome

  • Gastroenteritis

  • Enterocolitis

    • opportunistic infections

  • Ileus

  • Inflammatory bowel disease

  • Meckel’s diverticulitis

  • Intussusception

  • Necrotizing enterocolitis (peds)

Large Bowel

  • Appendicitis

  • Constipation

  • Hirschsprung’s (peds)

  • Diverticulitis

  • Pseudomembranous colitis

  • Typhlitis

  • Large bowel obstruction

    • adhesions

    • hernia

    • tumor

    • volvulus 

Spleen

  • Rupture

  • Infarct

Vascular

  • AAA rupture

  • Other aneurysmal ds (splenic a)

  • Mesenteric ischemia

    • acute vs chronic

Urinary Tract

  • Urolithiasis

  • Pyelonephritis 

Pelvic

  • PID

  • Tubo-ovarian abscess

  • Ovarian cyst

  • Ovarian torsion

  • Endometriosis

  • Ectopic pregnancy

  • Intrauterine pregnancy

Genital

  • Testicular torsion

  • epididymitis

Abdominal wall

  • hernia

Extra-Abdominal

  • MI

  • Pneumonia

  • DKA

  • Sickle cell crisis

  • Herpes Zoster

Trauma

  • (see Trauma objectives)