Health Questions and Answers » Abdominal Pain

Question: A patient with severe abdominal pain is found to be in diabetic ketoacidosis (DKA). How do I decide whether the abdominal pain is a manifestation of the DKA or whether a surgical condition has precipitated DKA?

rtrafaelmd — Wed, 05 Sep 2007 12:16:51 +0000

Answer: Patients with established DKA often present to the Emergency Room with severe abdominal pain. Physical examination reveals a dehydrated, hyperpneic patient with generalized abdominal tenderness and guarding, which may progress to boardlike rigidity. Bowel sounds usually are reduced or absent, and rebound tenderness may be noted. Although the precise mechanism of abdominal pain and ileus in patients with DKA is not well understood, hypovolemia, hypotension, and a total body potassium deficit probably contribute. An acute surgical lesion may initiate DKA; nevertheless, most patients have no such pathology. Symptoms characteristically resolve as medical treatment restores the patient to biochemical homeostasis. Treatment of the DKA must precede any surgical intervention because of the extremely high intraoperative mortality among patients not so stabilized. Similarly, among patients with alcoholic ketoacidosis, the most common complaints are gastrointestinal, including abdominal pain. Objective signs are typically absent, however, and when found reliably point to concomitant problems, such as pancreatitis, hepatitis, gastritis, or pneumonia.

Question: Are air-fluid levels within the intestine always abnormal?

rtrafaelmd — Tue, 04 Sep 2007 00:00:20 +0000

Answer: It is commonly taught that air-fluid levels when seen on an upright abdominal film are pathognomonic for small bowel obstruction. A study of 300 normal patients by Gammill and Nice showed, however, that the average number of air-fiuid levels was 4 per patient, with some films showing 20. Although typically less than 2.5 cm in length, some were 10 cm. Most of the air-fluid levels were found in the large bowel; only 14 of 300 normal patients studied showed air- fluid levels in the small bowel. The authors suggested that before air-fluid levels are used as the sole criterion for the diagnosis of paralytic ileus or mechanical obstruction, one should see more than two air-fluid levels within the dilated loops of the small bowel.

QUESTION: Which plain films are most useful?

rtrafaelmd — Mon, 03 Sep 2007 23:56:32 +0000

ANSWER: Traditional teaching holds that plain abdominal films should include a supine view plus either an upright view or a left lateral decubitns view (if unable to stand) or all three. The supine view of the abdomen is the most informative and worthwhile abdominal film. The upright film is superior for visualizing air-fluid levels associated with ileus and obstruction and biliary air. If the patient is unable to stand, the left lateral decubitus (left side down) view may be substituted when looking for either obstruction or free air. The erect chest radiograph is most sensitive for detection of free intraperitoneal air and may show basal pneumonia, ruptured esophagus, elevated hemidiaphragm, air-fluid levels associated with subdiaphragmatic or hepatic abscess, pleural effusion, and pneumothorax. In the evaluation of patients with abdominal pain, the upright chest film, taken alone, has been shown to be more useful than films of the abdomen itself.

QUESTION: Are radiographs always indicated?

rtrafaelmd — Mon, 03 Sep 2007 01:17:19 +0000

ANSWER: No. Plain films of the abdomen have the highest yield when used in the evaluation of patients with suspected bowel obstruction, intussusception, ileus, free air, intraabdominal mass, renal calculi, gallbladder disease, aortic aneurysm, past history of abdominal surgery or tumor, or severe generalized abdominal pain and tenderness. Conversely, among patients with uncomplicated peptic ulcer disease or massive hematemesis, pain present for more than 1 week, strangulated abdominal wall hernias, or other obvious clinical indications-for laparotomy, plain radiographs probably add little.

Question: Which are the most useful preliminary laboratory tests to order?

rtrafaelmd — Sun, 02 Sep 2007 03:01:54 +0000

Answer: A complete blood count with differential WBC count and urinalysis generally are recommended. The initial hematocrit helps to define antecedent anemia, and serial measurements may reveal ongoing hemorrhage. An elevated WBC count suggests significant pathology but is nonspecific. Elevated urinary specific gravity reflects dehydration, and an increased urinary bilirubin in the absence of urobilinogen points toward total obstruction of the common bile duct. Pyuria, hematuria, and a positive dipstick for glucose and ketones may reveal nonsurgical causes for abdominal pain. For patients with epigastric or right upper quadrant pain, lipase and liver function studies are advised. Amylase may be added but is nonspecific. In addition to indicating pancreatitis, amylase may be elevated with biliary obstruction, cholecystitis, posterior perforation of a peptic ulcer, bowel obstruction or inflammation, and salpingitis. Any woman with childbearing capability should receive a pregnancy test. Serum electrolytes, glucose, blood urea nitrogen, and creatinine are indicated if there is clinical hypovolemia resulting from copious vomiting or diarrhea, tense abdominal distention, or delay of several days after onset of symptoms and especially if the patient is likely to require emergency general anesthesia.

An ECG should be obtained if the patient is older than age 40.

QUESTION: Is there a place for narcotic analgesics in the management of acute abdominal pain of uncertain cause?

rtrafaelmd — Sat, 01 Sep 2007 00:11:17 +0000

ANSWER:

For fear of masking vital symptoms or physical findings, conventional surgical wisdom proscribes the use of narcotic analgesics until a firm diagnosis is established. More recently, some experts have suggested that pain medication may be given to selected patients with stable vital signs because the analgesic effect may be reversed readily at any time after the administration of naloxone.

Pace and Burke, in a prospective, double-blind study of 71 patients with acute abdominal pain, found that pain control with morphine (versus normal saline) had no deleterious effect on preoperative diagnostic accuracy. Although inconclusive, a growing body of data suggests that evaluation of acute abdominal disease may be facilitated when severe pain has been controlled and the patient can cooperate more fully. Surgical consultation should be obtained and all appropriate consent forms for anticipated treatment completed in patients needing surgery before the administration of large doses of narcotics. Patients who have received narcotics for pain control should be discouraged from leaving the Emergency Room (ER) against medical advice.

QUESTION: What other factors should be sought in the history that may alter significantly the presentation of patients with abdominal pain?

rtrafaelmd — Fri, 31 Aug 2007 23:59:43 +0000

ANSWER:
Symptoms and physical findings in patients with schizophrenia and diabetes may be muted significantly. The use of narcotics, steroids, or antibiotics may alter signs and laboratory results substantially.