Here is a case that happened to me a few years ago. A nine-year-old boy came into the ED by ambulance with right upper quadrant abdominal pain that occurred while he was having a bowel movement. He was a little different than the usual kids I have taken care of in the past. I felt he just didn’t really respond like I thought a nine-year-old boy should have but didn’t think too much of it. His exam was benign; his vital signs were benign. His pain was focal in the right upper quadrant, so I did a workup to include some labs and I did a KUB. I felt I didn’t need a CT scan because his belly was too soft. He had no risk factors and was on no medications. Other than a lot of stool on the radiograph by the hepatic flexure, his work-up was negative. So, I put him on Dulcolax suppositories, but I know something about medical malpractice and here’s the deal.
Don’t be last!! Don’t be the last person to see the patient before they have a bad outcome. I understand that and bellies can be sneaky, right? So, I called his doctor and said, “Hey, I got this kid here, it looks like constipation. Can you see him tomorrow?” The doc said, “Sure.” All is well and good and he was discharged home. However, he comes back the next day with worsening belly pain. He was seen by my colleague who did a rectal exam on him which was negative. He went to the next step and sent the kid for a CT scan. All appropriate, should be done. Well, the CT scan came back read as a distended bladder above the umbilicus. My colleague responded, “We got to put a Foley in the kid.”
Well, when they tried to do that, the nurse was like said, “You better get in here.” They found a constricting rubber band on the shaft of the penis of this patient. Initially, it looked like the pons was necrotic. This was my second lawsuit in the 21 years I’ve been in clinical practice. I was initially served and then eventually relinquished of responsibility from the case. There was a small payout by the hospital and thankfully there was no long-term sequela for the patient. So, this month’s discussion is going to be on abdominal pain.
Now I know this sounds very basic, but I want to talk about the three physical exam findings of abdominal pain and what they mean to me. The first is guarding. Guarding is like a positive myoglobin. It means something’s going on, but I don’t know what. It’s a voluntary response to me pushing on someone’s belly. It could mean that there’s pain and they’re trying to block me from it or shield themselves. A great phrase to say to a surgeon is, “Hey, there’s focal guarding in the right lower quadrant. There’s focal guarding in the right upper quadrant.”
Next is rigidity. Rigidity is where the belly is super firm and taunt, very painful and they can’t relax. Now you have to understand, you have your peritoneum, which is a hotbed of nerves. Then clearly the intestines are below. When I have a patient with rigidity, that implies to me that there’s some caustic substance in the belly touching the peritoneum and causing it to be super inflamed. So, a rigid belly to me says fluid that shouldn’t be there is inflaming the belly. Now that could be blood, which would imply a surgical fix. It could be pus, which also implies a surgical fix. Could also be an ovarian cystic fluid in a female two weeks into her cycle and the cyst ruptures.
The last physical exam finding I want to mention is rebound. Now, this is important. Rebound means when you have an inflamed area, that area in and of itself hurts, such as a hot appendix. That hurts because the appendage is inflamed and distended. Now when you push down on the belly, it takes the peritoneum and pushes on the inflamed appendix. That even stimulates two different pain receptors, that of the appendix and that of the peritoneum, and that, as expected, hurts a lot. Then when you let go and the peritoneum slaps on the inflamed organ, it’s the peritoneum that actually hurts more than the appendix.
My tip for you when doing an abdominal exam is: push hard. When you do an exam, don’t be a wimp about it. Inspect the belly, listen to the belly and then do a really good physical exam. Push hard. Don’t be afraid to hurt your patients. If you find rigidity and rebound, this implies surgical consultation. That’s a good general rule for an emergency medicine PA.
Now, after that short review, I want to talk about how not to get burned when seeing patients with abdominal pain. First and foremost, you have to get a very, very good history and understand common pathology within the belly, and I’d like to review those with you now.
In the right upper quadrant, you have the liver. However, that’s not a real common cause of inflammation in an acute presenting patient. But the gallbladder typically is. Sometimes I’m concerned about gastritis or peptic ulcer disease and at times pancreatitis when a patient has RUQ pain. We also have Charcot’s triad: jaundice, right upper quadrant pain and fever.
When dealing with the most common right upper quadrant pain, please remember the four phases of biliary disease:
- Phase one: Biliary colic
- Phase two: Cholecystitis. They have a positive Murphy’s sign and the gallbladder is really inflamed.
- Phase three: Choledocholithiasis is where the stone gets stuck in the common bile duct.
- Phase four: Cholangitis
With left upper quadrant, my experience is there are very few sinister things there. Clearly, the spleen is there and they can rupture but that’s not common unless there was some kind of trauma. When you have right lower quadrant, clearly the appendix is there and typically thought of first. But with left lower quadrant, you have to think diverticulitis.
Now, a general rule about abdominal pain is you really cannot clinically evaluate a patient without labs. If you’re a senior clinician, you know what I am saying. However, it is the new provider that needs to hear this. Abdominal pain with a white count of 10,000 is very different than an abdominal pain with a white count of 20,000. The only way you’re going to know is by doing labs. So, my advice and my guidance are to always do labs, especially if you are going to obtain IV access to give IV fluids or antiemetics medicine. Just draw blood; just send them. That’s what I do.
Always, always, always, always do a urinalysis, okay? There are so many things you can find in the urine. That should be a gold standard for anybody with belly pain. Clearly, a pregnancy test in anybody of childbearing age is extremely important.
Two big points that I need to make to you and feel you can get you absolutely burned if you do not know this. As you know, rebound, guarding and rigidity are your pertinent physical exam findings and help you in your medical decision making when you examine a patient. However, there are two different people that may not have those physical exam findings on examination. It’ll be completely void. Those are patients who are on steroids and patients who are diabetics. What I mean is they could have a perf bowel but a completely soft belly. You have to be mindful of that, so you have to scan more bellies of patients that are diabetics or that have steroids on board.
Now my other big point is that there’s a sneaky, sneaky, sneaky, sneaky, sneaky form of abdominal pain that I don’t want you to be missing and that’s mesenteric ischemia. Understand that when you have a vascular compromised patient, someone who has really bad blood vessels (typically it’s your diabetics or smokers), they usually also have A. Fib. Remember that the mantra of acute mesenteric ischemia is “pain out of proportion to exam.” They’re writhing in pain, they look like a kidney stone, but with a really soft belly. When you have somebody who looks like they have a kidney stone, and they’re a diabetic and a smoker, you have to think about their vascular status and the possibility of acute mesenteric ischemia.
The chronic form of mesenteric ischemia is where people get very severe pain after they eat and that can often be confused with biliary colic. They take out the gallbladder and they’re still having this agonizing pain, plus the CT scan’s negative. That’s when you need to dig deeper and do an angiogram to look at the color flow doppler to see if the bowel’s getting blood. This form of abdominal pain is often missed. If you have blinders on, that can go on for a long time in your patient. Remember that abdominal pain can be sneaky and you must know what you’re doing.
Continuing with working up abdominal pain, I want to talk about CT scans. You need to be appropriate about when to order. Dr. Greg Henry is a tremendous speaker and I have tremendous respect for him. He was the president of the American College of Emergency Physicians, and he’s guided me a number of times through emails and phone calls, which I really appreciate. I’m going to quote him, and he said something that affected my practice. “When you walk outside, you get solar radiation, no big deal. A chest x-ray is only a couple of days of solar radiation. But an abdominal CT scan is about three and a half years or about a thousand days of solar radiation.” Dr. Henry said, “The way we use CT scans today is going to be the mesothelioma of tomorrow.” That was pretty powerful to me. So, I’m saying don’t indiscriminately scan people. As often as you can, don’t use a CT scan, but when you have to, you have to.
I think we’re in a new era of opiate use. Clearly, we’re not lightly writing prescriptions for opiates. The same goes for antibiotics and resistance. My hope is that anybody who is getting this content is selective with antibiotics. We’re not whipping them out easily and I hope that we’re the same way with CT scans. But that can be a tough thing to do. It’s tough for me as an educator. I get to teach all over the country, and as a new graduate PA, I don’t want them to miss an appendix because they’ll get sued. No one’s getting sued for the ovarian cancer a patient gets in 10 years. But it is important in medicine that we are a steward of the resources and the risk that the patients may not even know about.
Thanks for reading. If you like these newsletters or like my podcast, we have a number of live conferences coming in 2019. We’re going to Key West, Alaska and Yellowstone National Park. We have three different curriculums.
Our Vital Emergency Medicine Program is for anybody who takes care of ER patients with chest pain, abdominal pain and shortness of breath. It is the essence of what I’ve been teaching the last 25 years. It is the best course I’ve ever developed. It will change your practice.
Our Urgent Care Summit is for anybody who works in urgent care and takes care of patients who don’t get admitted. It’s wound care, orthopedics, mild head injuries, otitis media, sinusitis, STDs, etc. It’s the kind of content that if you work urgent care medicine, we’re going to make you very efficient, very clean, and we’re going make sure you learn the best information on the up-to-date antibiotic selections for many common problems seen.
The last course we’re going to have is the Advanced Emergency Medicine Curriculum for Critical Access PAs. People work by themselves and want advantages in tools to help them practice; they want increased confidence and competence. It will be an all-encompassing course to teach you to think right about airway, about how to run codes and how to prevent codes from happening in the first place.
If you’re interested in joining us, visit Emergency-Medicine-Institute.com. I look forward to seeing you in 2019. We have most of these programs on video too. So, if you like how I teach, come and see us. I understand that you invest your time in me so I don’t want to waste your time. I want to make your time extraordinarily useful.