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
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 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
"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
abdominal pain is
responsible for 5 percent
of visits, with 10 percent of
those patients presenting
with severe or lifethreatening
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
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Location, History Matters When Dealing with Abdominal Pain