Gastrointestinal Emergencies

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What elements of history are helpful to elicit from a patient with abdominal pain?

Establish the location, severity, duration, and a description of the pain. Any associated symptoms, such as fevers, vomiting, diarrhea, dysuria, hematuria, or passing out, should be noted. Identify factors that improve or worsen the pain, such as movement or eating. Ask about any recent trauma. Women of childbearing age should be asked about pregnancy status. Obtain a complete past medical and surgical history, with special attention to any previous abdominal surgeries. A history of multiple abdominal surgeries increases the risk of bowel obstruction, and absence of the gallbladder, appendix, or ovary can help rapidly eliminate possibilities. Alcohol use should be assessed. Ask if the patient has experienced similar symptoms in the past and, if so, what diagnosis they received at that time.

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Describe the key elements of the abdominal examination.

Patients with abdominal pain should have a full set of vital signs including temperature. Assess the patient’s general appearance and level of distress. The abdominal examination begins with inspection for distention, bruising, rash (such as shingles), previous surgical scars, or obvious hernia. Palpate all four quadrants of the abdomen, starting away from the area of greatest pain. Note any masses, enlargement of the liver, or focal tenderness. A pulsatile abdominal mass is a sign of abdominal aortic aneurysm. Guarding occurs when the patient tenses his or her muscles to protect against pain with palpation. It is called “voluntary guarding” when the patient can intentionally relax the muscles or stops guarding with distraction. “Involuntary guarding” occurs when the patient is unable to relax the abdomen and is worrisome. To assess for rebound tenderness, slowly push in on the abdomen, then release the pressure. Increased pain with removal of your hand is positive rebound tenderness and can be a sign of peritonitis from infection or organ perforation. Patients with peritonitis are often exquisitely sensitive to any movement of their stretcher or the ambulance.

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What non-gastrointestinal (GI) conditions can present with abdominal pain or vomiting?

Abdominal pain is not specific to the GI system. Abdominal aortic aneurysm or abdominal aortic dissection can present with abdominal pain. Diabetic ketoacidosis frequently causes vomiting and abdominal pain. Pneumonia in the lower lobes can also be felt as abdominal pain due to irritation of the diaphragm. A wide variety of toxic ingestions, including alcohol intoxication, can present with abdominal pain or vomiting. Myocardial infarction can present atypically with upper abdominal pain, nausea, or vomiting, especially in diabetic patients, women, and the elderly. Increased intracranial pressure from intracranial hemorrhage, stroke, a brain mass, or meningitis can cause vomiting. Genitourinary conditions such as testicular or ovarian torsion, renal stone, pyelonephritis, urinary retention, or pregnancy-related complications can also present with abdominal pain and vomiting. Have a low threshold to obtain a 12-lead electrocardiogram (EKG) or fingerstick glucose level in patients with abdominal pain or vomiting, especially if there is not a specific area of tenderness on palpation to suggest an intra-abdominal cause.

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