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Abdominal Pain

Surgery

Assumptions
Students understand: the anatomy and relationships of various abdominal viscera; the normal structure and function of various abdominal viscera and their associated organ systems; the physiology of pain perception and how to apply this to differentiating visceral, somatic and referred pain patterns involved in abdominal pathology. Students have a basic understanding of the pathophysiology of inflammation, neoplasia, ischemia and obstruction.

Knowledge Objectives
Through their reading and patient care experiences, at the end of the rotation students should be able to:

Relate the significance of the various components of patient history as they apply to common abdominal pathologic processes. Example:

characterization of pain (location, severity, character, pattern)
temporal sequence (onset, frequency, duration, progression)
alleviating/ exacerbating factors (position, food, activity, medications)
associated signs / symptoms (nausea vomiting, fever, chills, anorexia, wt. loss, cough, dysphagia,
dysuria/frequency altered bowel function (diarrhea, constipation, obstipation, hematochezia, melena, etc.)
pertinent medical history: prior surgery or illness, associated conditions (pregnancy, menstrual cycle, diabetes, atrial fibrillation or cardiovascular disease, immunosuppression). Medications: anticoagulation, steroids etc.

Relate the significance of the various component examinations: observation, auscultation, percussion, palpation as they apply to common abdominal pathologic processes. Examples:

distention,
visible peristalsis,
high pitched or absent bowel sounds,
tympany,
mass,
localized vs.generalized guarding and/or rebound tenderness.

Relate the significance of the various maneuvers utilized in evaluating acute abdominal pain. Examples:

iliopsoas sign,
Rovsing’s sign,
obturator sign,
Murphy’s sign,
cough tenderness,
heel tap,
cervical motion tenderness.

Describe the keys to successful examination of infants and children with abdominal pain. Characterize examination skills that may be utilized in pregnancy, or patients with altered neurologic status.

Develop a differential diagnosis for various patients presenting with acute abdominal pain. Differentiate based on:

location: RUQ, epigastric, LUQ, RLQ, LLQ
symptom complex: examples: periumbilical pain localizing to RLQ, acute onset left flank pain with radiation to the testicle etc.
age: pediatric, adult, geriatric
associated conditions: pregnancy, immunosuppression (AIDS, transplant, chemotherapy/radiation therapy)

Explain the rationale for utilizing various diagnostic modalities in the evaluation of abdominal pain.

Laboratory: CBC, amylase, electrolytes, BUN, creatinine, glucose, urinalysis, beta-HCG, liver profile.
Diagnostic imaging: flat and upright abdominal radiographs, upright chest X-ray, abdominal ultrasonography, CT scan of abdomen and pelvis, GI contrast radiography, angiography, IVP.
Special diagnostic / interventional techniques: upper endoscopy, procto-sigmoidoscopy, colonoscopy, laparoscopy.

Discuss the presentation, diagnostic strategy, and initial treatment of patients presenting with common or catastrophic abdominal conditions.

acute appendicitis
cholecystitis / biliary colic / choledocholithiasis / cholangitis
pancreatitis
peptic ulcer disease with & without perforation
gastroesophageal reflux
gastritis / duodenitis
diverticulitis
inflammatory bowel disease
enterocolitis
small bowel obstruction: incarcerated hernia, adhesions, tumor
colon obstruction: volvulus, tumor, stricture
splenomegaly / splenic rupture
mesenteric ischemia
leaking abdominal aortic aneurysm
gynecologic etiologies: ectopic pregnancy, ovarian cysts (torsion, hemorrhage, rupture) tuboovarian abscess, salpingitis, endometriosis
genito-urinary etiologies: UTI, pyelonephritis, ureterolithiasis, testicular torsion

Discuss the common non-surgical conditions that can present with abdominal pain. Examples:

MI,
pneumonia,
pleuritis,
hepatitis,
gastroenteritis,
mesenteric adenitis,
sickle cell crisis,
DKA,
herpes zoster,
nerve root compression.

Compare and contrast acute appendicitis in young adults, the very young, very old, and pregnant women.

Discuss issues relevant to presentation, diagnosis, treatment, complications etc. Example: perforation risk.

Discuss the diagnosis and treatment of abdominal problems with particular relevance to the pediatric population. Include: neonates, infants, children, adolescents. Be able to list the abdominal problems, characteristic of each group, and outline diagnostic and intervention strategies for:

Congenital: hernias, malrotation, midgut volvulus
Hirschsprung’s disease
Pyloric Stenosis
Intussuception
Meckel’s diverticulitis
Child abuse

Discuss unique causes of abdominal pain in patients who are immune-suppressed and the implication on treatment and outcomes. Examples:

neutropenic enterocolitis,
CMV enterocolitis,
bowel perforation,
acalculous cholecystitis,
acute graft rejection.

Discuss the approach to patients with common abdominal problems with emphasis on indications for surgical consultation, indications / contraindications to surgery, complications of disease and intervention, and expected outcomes. Examples:

laparoscopy vs. laparotomy;
complication rates of emergent vs. elective surgery,
perforated vs. non-perforated colon cancer;
complications:
intra-abdominal abscesses,
fistulae,
bleeding,
anastamotic disruption.

Describe the normal bacterial flora of the GI, GU and GYN systems and compare to pathologic infections.

Discuss appropriate antibiotic therapy where indicated in various conditions manifesting with abdominal pain.

Discuss the approach to patients with postoperative abdominal pain. Contrast findings in non-operated patients with regards to

presentation
examination
differential diagnosis
intervention strategies