Location, History Matters When Dealing with Abdominal Pain

Thomas Kintanar, MD, FAAFP

Thomas Kintanar, MD, FAAFP

When it comes to diagnosing abdominal pain, a history and physical trumps all, according to the presenter of Thursday morning's "Abdominal Pain and Acute Abdomen Emergent and Urgent Care: A Case and Evidence-based Tour of the Scenery Around the Neighborhood."

Thomas Kintanar, MD, FAAFP, clinical associate professor of medicine, Indiana University School of Medicine, and a physician with Associated Family Medical Consultants Lutheran Medical Group in Fort Wayne, walked attendees through several diagnoses by visiting four "neighborhoods:" right upper, left upper, right lower, and left lower quadrants.

Acute abdominal pain is common in all age groups, with peak incidence in those 18-24 years old with a slight female predominance. Since people react to pain differently, he warned, textbook descriptions of abdominal pain have limitations.

Kintanar said that acute, severe abdominal pain almost always was a symptom of intraabdominal disease. Patient presentation can significantly narrow the differential diagnosis, he said, so consider age and sex along with the type of pain. Laboratory tests should be performed based on suspected diagnosis and pain location.

Pain location should determine the type of imaging used. Kintanar said that a review of current literature found that ultrasound was most useful in the right upper quadrant (as well as the suprapubic area), CT scan was best in the left upper quadrant, while CT scan with IV contrast is tops for the right lower quadrant and CT with oral and IV contrast were best for the lower left quadrant.

"I understand that a lot of colleagues will share with me that when you're doing a CT scan, the radiologist will call and ask if you really want to do the contrast," Kintanar said. "Actually, when you're doing a scan of the belly, the CT without contrast is the proper clinical direction, but when we're looking specifically at these different areas, contrast is best."

About 1.5 percent of office visits are for abdominal pain. In the emergency department, abdominal pain is responsible for 5 percent of visits, with 10 percent of those patients presenting with severe or lifethreatening issues that may require surgery.

Several case studies illustrated Kintanar's key clinical points.

Kintanar said a "Golden Pearl of Vomiting" can help determine the severity of abdominal pain: Patients who vomit before having pain generally have a medical condition that doesn't require surgery. But someone experiencing pain before vomiting should be considered a possible surgical candidate because of reflex pylorospasm.

Kintanar also emphasized that patients present with acute abdominal pain and metabolic acidosis, physicians should think ischemia, even going to the point of getting an angiogram of the area to rule it out completely. It's useful to think of it as angina of the intestines, he said.

In the right upper quadrant, liver chemistries and urinalysis tests are important, and testing for STDs and pregnancy should also be considered. Kintanar strongly supported simultaneous amylase and lipase measurements because an elevated lipase level with a normal amylase level is not likely to be caused by pancreatitis.

"One of the things that is very frustrating to me is when I get a call at 2 in the morning and an emergency room doctor says the lipase is elevated and he thinks he's got pancreatitis," Kintanar said. "I ask what the amylase is, and he says they didn't order that."