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Critical Diagnoses of Upper Abdominal Pain

General

• Work-up for upper abdominal pain begins with resuscitation and exclusion of critical diagnoses
• Then, through a detailed history and physical, consider all the causes of upper abdominal pain (see below)
• The differential may then come down to Gallstone etiology vs Gastritis/PUD → will need further imaging based on suspicion (US abdomen)

Resuscitate

• IV/O2/Monitor, IV Fluids, Labs as needed, pregnancy test

Rule Our Critical diagnoses of Upper Abdominal Pain:

• AAA, Mesenteric Ischemia, Perforation, SBO, ectopic pregnancy

Emergent Gastrointestinal ( GI ) Causes of Upper Abdominal Pain

1. Billiary Tract Disease

General:

• The goal is to find the location of the stone and its associated complications → Is it still in the gallbladder (symptomatic cholelithiasis), in the cystic duct (cholecystitis), or in the CBD (choledocholithiasis, gallstone pancreatitis, ascending cholangitis)

Cholelithiasis

• Prevalence of 10% in US, usually asymptomatic (symptoms develop in 2%/yr)

BILIARY COLIC

• Symptomatic cholelithiasis → obstruction of cystic duct by gallstones
• Clinical: Episodic pain in Right Upper Quadrant (RUQ), minutes to hours, resolves spontaneously
  • Precipitated by meals/fatty foods
• Treatment: Recurrent biliary colic → pain control, elective outpatient cholecystectomy

CHOLECYSTITIS

• Clinical (vs biliary colic, may be difficult to distinguish)
  • Pain longer in duration (>6 hours), localizes to RUQ, ↑ N/V/F (more nausea, vomitus)
  • Murphy’s sign:
    • Localized peritonitis over gallbladder → arrest of inspiration on gallbladder palpation with pain
    • Highest LR+ of PE/lab values
    • Diminished in elderly

• Course
  • 1/3 will worsen→ complications (cholangitis, perforation)
  • 1/2 will improve spontaneously (7-10days)

• Laboratory: ↑ WBC, mild ↑ LFTs
• Radiology
  • RUQ U/S (sensitivity 84-97%, specificity up to 100%)
  • Findings: Gallstones, pericholecystic fluid, gallbladder wall thickening (>3mm), sonographic Murphy’s
  • HIDA scan: non-visualization of contrast in gallbladder (cholecystitis) or intestine (choledocholithiasis)

• Treatmentof Cholecystitis
  • NPO/IVF/Abx (antibiotics) (broad spectrum)
  • Semi-urgent Cholecystectomy, laparoscopic (at 24-48h) with CBD exploration or ERCP if CBD stone of concern

• Complications of Cholecystitis: gallbladder perforation, emphysematous cholecystitis, gangrenous cholecystitis, cholangitis, gallstone ileus

CHOLEDOCHOLITHIASIS

• Define: Gallstone lodged in common bile duct
• Clinical: similar presentation to cholecystitis except elevated LFTs (↑Alk Phos, ↑T. Bili)
• Radiology: RUQ U/S
  • Dilated CBD (>6mm)
  • Common bile duct stone?
• ERCP
  • Diagnose and treat common duct stones (with sphincterectomy)
  • R/O other causes of obstruction (tumors…)

GALLSTONE PANCREATITIS

• Elevated amylase, lipase
• ERCP to decompress biliary tree

ASCENDING CHOLANGITIS

• CBD obstruction causing infection proximal to obstruction → sepsis (↑ mortality)
• Charcot’s triad (RUQ pain, fever, jaundice)
• Reynold’s pentad (Charcot + hypotension + AMS)
• Treatment
  • Conservative (NPO, IVF, broad-spectrum Abx → elective ERCP at resolution)
  • If failure of conservative tx (15%)→ emergent surgery (Percutaneous vs ERCP)

2. Acute Pancreatitis

Etiology of Acute Pancreatitis:

• Gallstones (35%), Alcohol (30%)
• Idiopathic (10%),ERCP complications (4%), Tumors, Drugs (furosemide, sulfa, thiazides, valproate, tetracyclines…), infection (viral, mycoplasma), blunt trauma (1.5%), scorpion, hypercalcemia, elevated triglycerides ( hypertriglyceridemia )

Symptoms and Signs of Acute Pancreatitis

• Epigastric pain radiating to back
• Nausea/ Vomitus /fever, +/- jaundice
• Abdominal tenderness / guarding, Cullen’s (peri-umbilical ecchymosis), Gray Turner’s (flank bruising)

Diagnosis of Acute Pancreatitis:

• Lipase
  • Levels peak (12-36h), duration (2 weeks)
  • Test of choice, better sensitivity and specificity over amylase → lipase level 3x normal, more specific
  • If high suspicion for pancreatitis and lipase negative → CT scan
  • Level of lipase not predictive of severity of pancreatitis
• Amylase
  • Less specific, duration (1 week)
  • Not used: many false positives and false negatives
  • Many sources: bowel, uterus, pancreas
  • Amylase: level 3x normal, not specific
• CT A/P
  • Unsure of diagnosis (high index of suspicion and lipase low)
    • Will see acute and chronic changes on CT
  • Rule out surgical issues
  • Staging system (Balthazar) → help stage and predict which patients will develop severe complication: necrotizing pancreatitis (Radiology 1994;193(2):297)
• RUQ U/S → diagnose gallstone pancreatitis

Treatment of Acute Pancreatitis

• Resuscitation
  • NPO / bowel rest / IVF/ NG suction
  • Fluid resuscitation (up to 10L/day → maintain adequate UOP)
• Antibiotics
  • Meta-analysis→ prophylactic antibiotics for necrotizing pancreatitis decreased sepsis
  • and mortality
  • Save for sickest pts → Imipenem/meropenem (Ann Surg. 2006;243(2):154)
• Necrotizing Pancreatitis
  • Antibiotics (Imipenem), CT A/P, Urgent surgical consultation, ICU
  • Fluid collections→ CT or U/S guided drainage
  • Infected pancreatic collections →benefit from early surgery
• Gallstone Pancreatitis
  • RUQ US to diagnose
  • MRCP if not sure of obstructive etiology
  • Treatment: ERCP (but may cause pancreatitis)

Complications of Acute Pancreatitis

• NECROTIZING PANCREATITIS
  • Pancreatitis → necrosis/liquefaction of tissue → local/systemic complications
  • Greatest life-threatening complication of pancreatitis (mortality up to 50%)
  • Predisposes to sepsis, multi-organ failure and death
  • Predictive factors:
    • Hemorrhage? (Gray-Turner, Cullen’s→ delayed 48h),
    • Pancreatic enzymes (low levels more consistent with necrosis),
    • ↑ Severity of pancreatitis (↑ Ranson’s)
      • i. Hemoconcentration: Hct >47% at 48h has high sensitivity and may need CT early in course (Am J Gastroenterol 1998;93:2130-4)
  • Treatment
    • ✓ Antibiotics (Imipenem), CT A/P, Urgent surgical consultation, ICU
    • ✓ Fluid collections→ CT or U/S guided drainage
    • ✓ Infected pancreatic collections → benefit from early surgery
• SEPSIS
  • Responsible for most mortality associated with AP
  • See Sepsis algorithm
• PSEUDOCYST
  • Drainage → >6cm after 6 wks observation, or causing sx (abd pain, gastric outlet obstruction, biliary obstruction)
• Other
  • ↓ Ca, ↑ glucose, ↑ TG, GI hemorrhage, ascites, pleural effusion, ARDS, renal failure

3. Gastritis , GERD , Peptic Ulcer Disease

General:

• If patient stable→ often considered default diagnosis when work-up negative and excluded lifethreats (MI, perforation…)
• Empiric therapy given with abdomen re-check

Clinical

• GERD: Heartburn, atypical angina, water brash, cough
• Gastritis: Asymptomatic vs epigastric pain, N/V, anorexia
• PUD: Epigastric pain relieved (duodenal) or worsened (gastric) by food; back pain & ↑ lipase (post perforation)

Treatment

• Lifestyle change (↑ Head of bed), stop precipitants (NSAIDS / alcohol)
• H. Pylori treatment, antacid / H2 blocker / PPI

Complications:

• Peptic Ulcer Disease:
  • Hemorrhage, Perforation, Intractable pain, Obstruction
  • Posterior perforation → may present like pancreatitis (back pain, ↑ enzymes, vomiting…)

Other Causes of Upper Abdominal Pain

• Consider other causes above and below the area of tenderness
  • Acute hepatitis, liver abscess, appendicitis, splenic infarct/aneurysm (L sided pain), MI, lower lobe pneumonia