Epigastric pain resident survival guide: Difference between revisions

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==Do's==
==Do's==
*Start the approach to acute abdominal pain by rapid assessment of the patient using the pneumonic "ABC" to identify unstable patients. NB. ABC: '''A'''irway, '''b'''reathing and '''c'''irculation.
*Start the approach to [[acute abdominal pain]] by rapid assessment of the patient using the pneumonic "ABC:" '''a'''irway, '''b'''reathing and '''c'''irculation, to identify unstable patients.
*Consider abdominal aortic aneurysm, mesenteric ischemia and malignancy in patients above 50 years as it is much less likely for younger patients.
*Consider [[abdominal aortic aneurysm]], [[mesenteric ischemia]] and malignancy in patients above 50 years as it is much less likely for younger patients.
*Perform pelvic and testicular examination in patients with low abdominal pain.
*Perform pelvic and [[testicular examination]] in patients with low [[abdominal pain]].
*Re-examine patients at high risk who were initially diagnosed with pain of unclear etiology.
*Re-examine patients at high risk who were initially diagnosed with pain of unclear etiology.
*Taking careful history, characterizing the pain precisely and thorough physical examination is crucial for creating narrow differential diagnosis.  
*Taking careful history, characterizing the pain precisely and thorough physical examination is crucial for creating narrow differential diagnosis.  
*Correlate the CD4 count in HIV positive patients with the most commonly occurring pathology.
*Correlate the [[CD4 count]] in [[HIV]] positive patients with the most commonly occurring pathology.
*Order a pregnancy test before proceeding with a CT scan in females in the child bearing age.  
*Order a [[pregnancy test]] before proceeding with a CT scan in females in the child bearing age.  
*Order an ultrasound or magnetic resonance among pregnant females to avoid exposure to radiation. In case the previous tests were inconclusive and appendicitis is suspected, the next step in the management includes proceeding with either laparoscopy or limited CT scan.  
*Order an ultrasound or magnetic resonance among pregnant females to avoid exposure to radiation. In case the previous tests were inconclusive and [[appendicitis]] is suspected, the next step in the management includes proceeding with either laparoscopy or limited CT scan.  
*Consider peritonitis with cervical motion tenderness as it isn't specific for pelvic inflammatory disease.
*Consider [[peritonitis]] with [[cervical motion tenderness]] as it isn't specific for [[pelvic inflammatory disease]].
*Suspect abdominal aortic aneurysm in old patients presenting with abdominal pain with history of tobacco use.<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Diagnosis and management of 528 abdom... [Br Med J (Clin Res Ed). 1981] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/6788329 | publisher =  | date =  | accessdate =  }}</ref>
*Suspect [[abdominal aortic aneurysm]] in old patients presenting with [[abdominal pain]] with history of tobacco use.<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Diagnosis and management of 528 abdom... [Br Med J (Clin Res Ed). 1981] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/6788329 | publisher =  | date =  | accessdate =  }}</ref>
*Suspect acute mesenteric ischemia and acute pancreatitis in patients presenting with poorly localized pain out of proportion to physical findings.<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Mesenteric ischemia in the elderly. [Clin Geriatr Med. 1999] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/10393740 | publisher =  | date =  | accessdate = }}</ref>
*Suspect [[acute mesenteric ischemia]] or [[acute pancreatitis]] in patients presenting with poorly localized pain out of proportion to physical findings.<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Mesenteric ischemia in the elderly. [Clin Geriatr Med. 1999] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/10393740 | publisher =  | date =  | accessdate = }}</ref>
*Recommend initial imaging studies based on the location of abdominal pain:
*Recommend initial imaging studies based on the location of [[abdominal pain]]:
:*Ultrasonography is recommended when a patient presents with right upper quadrant pain.<ref name="www.acr.org">{{Cite web  | last =  | first =  | title = http://www.acr.org/ | url = http://www.acr.org/ | publisher =  | date =  | accessdate = }}</ref>
:*Ultrasonography is recommended when a patient presents with [[right upper quadrant pain]].<ref name="www.acr.org">{{Cite web  | last =  | first =  | title = http://www.acr.org/ | url = http://www.acr.org/ | publisher =  | date =  | accessdate = }}</ref>
:*Computed tomography (CT) with intravenous contrast media is recommended for evaluating adults with acute right lower quadrant pain.<ref name="www.acr.org">{{Cite web  | last =  | first =  | title = http://www.acr.org/ | url = http://www.acr.org/ | publisher =  | date =  | accessdate = }}</ref>
:*Computed tomography (CT) with intravenous contrast media is recommended for evaluating adults with acute [[right lower quadrant pain]].<ref name="www.acr.org">{{Cite web  | last =  | first =  | title = http://www.acr.org/ | url = http://www.acr.org/ | publisher =  | date =  | accessdate = }}</ref>
:*CT with oral and intravenous contrast media is recommended for patients with left lower quadrant pain.<ref name="www.acr.org">{{Cite web  | last =  | first =  | title = http://www.acr.org/ | url = http://www.acr.org/ | publisher =  | date =  | accessdate = }}</ref>
:*CT with oral and intravenous contrast media is recommended for patients with [[left lower quadrant pain]].<ref name="www.acr.org">{{Cite web  | last =  | first =  | title = http://www.acr.org/ | url = http://www.acr.org/ | publisher =  | date =  | accessdate = }}</ref>
*Order ECG for old patients with upper abdominal pain with high cardiac risk factors.
*Order [[ECG]] for old patients with upper abdominal pain with high cardiac risk factors.
*Administer narcotic analgesia for patients who present to the ED with moderate or severe abdominal pain.<ref name="www.ebmedicine.net">{{Cite web  | last =  | first =  | title = http://www.ebmedicine.net/content.php?action=showPage&pid=94&cat_id=16 | url = http://www.ebmedicine.net/content.php?action=showPage&pid=94&cat_id=16 | publisher =  | date =  | accessdate =  }}</ref>
*Administer narcotic analgesia for patients who present to the ED with moderate or severe [[abdominal pain]].<ref name="www.ebmedicine.net">{{Cite web  | last =  | first =  | title = http://www.ebmedicine.net/content.php?action=showPage&pid=94&cat_id=16 | url = http://www.ebmedicine.net/content.php?action=showPage&pid=94&cat_id=16 | publisher =  | date =  | accessdate =  }}</ref>
*Perform diagnostic [[paracentesis]] (cell count, differential count, gram stain, culture, [[bilirubin]] and [[albumin]]) in patients with [[ascites]] and abdominal pain to rule out [[spontaneous bacterial peritonitis]].
*Perform diagnostic [[paracentesis]] (cell count, differential count, gram stain, culture, [[bilirubin]] and [[albumin]]) in patients with [[ascites]] and abdominal pain to rule out [[spontaneous bacterial peritonitis]].


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*Do not order blood cultures routinely in all patients
*Do not order blood cultures routinely in all patients
*Don’t delay resuscitation or surgical consultation for ill patient while waiting for imaging.
*Don’t delay resuscitation or surgical consultation for ill patient while waiting for imaging.
*Don’t restrict the differential diagnosis of abdominal pain based on the location; for example, right-sided structures may refer pain to the left abdomen.<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Clinical policy: critical issues for the initi... [Ann Emerg Med. 2000] - PubMed - NCBI | url =http://www.ncbi.nlm.nih.gov/pubmed/?term=Annals+of+Emergency+Medicine.+2000%3B36%3A406-415 | publisher =  | date =  | accessdate = }}</ref>
*Don’t restrict the differential diagnosis of [[abdominal pain]] based on the location; for example, right-sided structures may refer pain to the left abdomen.<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Clinical policy: critical issues for the initi... [Ann Emerg Med. 2000] - PubMed - NCBI | url =http://www.ncbi.nlm.nih.gov/pubmed/?term=Annals+of+Emergency+Medicine.+2000%3B36%3A406-415 | publisher =  | date =  | accessdate = }}</ref>


==References==
==References==

Revision as of 15:50, 11 March 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2], Amr Marawan, M.D. [3]

Definition

The epigastrium (or epigastric region) is the upper central region of the abdomen. It is located between the costal margins and the subcostal plane.

Causes

Do's

  • Start the approach to acute abdominal pain by rapid assessment of the patient using the pneumonic "ABC:" airway, breathing and circulation, to identify unstable patients.
  • Consider abdominal aortic aneurysm, mesenteric ischemia and malignancy in patients above 50 years as it is much less likely for younger patients.
  • Perform pelvic and testicular examination in patients with low abdominal pain.
  • Re-examine patients at high risk who were initially diagnosed with pain of unclear etiology.
  • Taking careful history, characterizing the pain precisely and thorough physical examination is crucial for creating narrow differential diagnosis.
  • Correlate the CD4 count in HIV positive patients with the most commonly occurring pathology.
  • Order a pregnancy test before proceeding with a CT scan in females in the child bearing age.
  • Order an ultrasound or magnetic resonance among pregnant females to avoid exposure to radiation. In case the previous tests were inconclusive and appendicitis is suspected, the next step in the management includes proceeding with either laparoscopy or limited CT scan.
  • Consider peritonitis with cervical motion tenderness as it isn't specific for pelvic inflammatory disease.
  • Suspect abdominal aortic aneurysm in old patients presenting with abdominal pain with history of tobacco use.[1]
  • Suspect acute mesenteric ischemia or acute pancreatitis in patients presenting with poorly localized pain out of proportion to physical findings.[1]
  • Recommend initial imaging studies based on the location of abdominal pain:

Don'ts

  • Fail to evaluate elder patients in the presence of overt clinical signs.
  • Over rely on laboratory tests, they are only used as adjuncts.
  • Do not delay the initial intervention.
  • Do not order blood cultures routinely in all patients
  • Don’t delay resuscitation or surgical consultation for ill patient while waiting for imaging.
  • Don’t restrict the differential diagnosis of abdominal pain based on the location; for example, right-sided structures may refer pain to the left abdomen.[1]

References

  1. ↑ 1.0 1.1 1.2 "Diagnosis and management of 528 abdom... [Br Med J (Clin Res Ed). 1981] - PubMed - NCBI".
  2. ↑ 2.0 2.1 2.2 "http://www.acr.org/". External link in |title= (help)
  3. ↑ "http://www.ebmedicine.net/content.php?action=showPage&pid=94&cat_id=16". External link in |title= (help)

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