Abdominal Pain on the CCFP exam

Approach

• Pin down the timing first. Hours to days is acute. Weeks to months, or attacks that keep coming back, is chronic or recurrent.
• Map the pain to a region, then list causes by region (table below). Add causes outside the belly: heart attack, lower lung pneumonia, diabetic ketoacidosis.
• Check vital signs and feel the belly before you order anything. A soft belly and normal vital signs leave time for history and blood work.
• Acute upper pain with heart risks: get an electrocardiogram (ECG) and troponin (a heart-damage blood test). Add lipase for the pancreas and a blood count for bleeding.
• Upper middle pain for a month or more, under 60, with no alarm features: test for Helicobacter pylori without a scope. Treat it if positive. Alarm features: weight loss, anemia, worsening trouble swallowing.
• If that test is negative, or pain persists after treatment, try a proton pump inhibitor (PPI). At 60 or older, an endoscopy (camera test of the stomach) is suggested.
• Do not use the guaiac stool test for hidden blood to work up symptoms. In Canada, the fecal immunochemical test is for screening people without symptoms.

Approach

• Stop the NSAID (non-steroidal anti-inflammatory drug) and heal the ulcer with a PPI.
• Keep ASA taken to prevent another heart event. A Canadian guideline suggests not holding it, even during an acute gut bleed.
• Treat Helicobacter pylori for 14 days, whatever the regimen. Shorter courses cure fewer patients (table below).
• Reflux or dyspepsia on a long-term PPI: use the lowest dose that works and try stopping once a year. Not for Barrett's esophagus, severe esophagitis or a past gut bleed.
• Mild to moderate ulcerative colitis: oral plus rectal 5-aminosalicylate (5-ASA) first. Add a steroid if that fails. The goal is remission without steroids.
• Crohn's disease: do not use oral steroids to keep remission. In either disease, do not use opioids long-term for pain.

Approach

• Test for pregnancy in every patient who could be pregnant, whatever the history says. A missed ectopic pregnancy can kill.
• Think of the pelvis: ectopic pregnancy, ovarian torsion, a bleeding or burst cyst, pelvic inflammatory disease, endometriosis.
• Examine the pelvis when infection or a mass is possible, the patient has been sexually active, and consents. In a child, image instead.
• Torsion: sudden one-sided pain that comes in waves, often with vomiting. Normal flow on Doppler does not rule it out.
• Suspected torsion goes to a gynecologist or pediatric surgeon the same day. Do not wait for more imaging.
• Pelvic inflammatory disease is sexually acquired. It is very unlikely in someone who has never had sex.

Approach

• Signs of peritonitis (an inflamed belly lining): guarding, a rigid belly, and pain on coughing, moving or a gentle tap.
• Pain that moves and settles in one place points to a surgical cause.
• Vomiting with a swollen belly and no stool or gas suggests obstruction. Pain far worse than the exam findings points to gut ischemia.
• Read the vital signs. A fast pulse, low blood pressure, or fever with local pain points to a surgical source.
• Gastroenteritis and nonspecific pain come last, once surgical causes are out.
• Call the surgeon on the exam findings. Do not wait for imaging to make the call.

Approach

• Child with suspected appendicitis: ultrasound first, because it avoids radiation. CT may follow if the ultrasound is unclear.
• In a child or teen with lower pain and vomiting, think of torsion of the testis or ovary. It cannot wait.
• In pregnancy, do not let worry about the fetus delay imaging or a surgeon.
• An older adult with a first kidney stone attack needs an aortic aneurysm ruled out.

Approach

• Look for shock: fast pulse, low blood pressure, cool skin, confusion or fainting.
• Ruptured aortic aneurysm: an older patient with belly or back pain and collapse. A bedside ultrasound shows the aorta. Call vascular surgery at once.
• Ruptured ectopic pregnancy: a positive pregnancy test, pain, and shock or free fluid on bedside ultrasound. Call gynecology for surgery at once.
• For bleeding: two large intravenous (IV) lines, a cross-match (matching donor blood), and blood. Do not send an unstable patient to the CT scanner.
• Septic shock from a perforation: a fast bolus of isotonic fluid such as normal saline, then reassess. Give antibiotics early, and operate once the circulation responds.
• A bleeding rupture goes to surgery while you resuscitate. Do not wait for the blood pressure to recover.

Approach

• IBS: belly pain at least 1 day a week for 3 months, linked to bowel movements or a change in stool.
• Do a celiac blood test. Do not routinely test C-reactive protein (CRP, a blood test for inflammation), fecal calprotectin (a stool test for gut inflammation) or food allergies.
• Diet: try a low FODMAP diet (fewer fermentable sugars). Psyllium may help; wheat bran and a gluten-free diet are not advised.
• Other options: peppermint oil, antispasmodics, some antidepressants, cognitive behavioural therapy or hypnotherapy. Choose drugs by the main stool pattern. Loperamide is not advised for overall symptoms.
• Under 50 with IBS and no alarm features: no routine colonoscopy. Rectal bleeding, weight loss or anemia need investigation.
• New IBS-type symptoms at 50 or older: a colonoscopy is recommended to rule out other causes.
• Book follow-up. A change in the pattern or a new alarm feature restarts the work-up.

Approach

• Joints: arthritis of large joints, and of the spine (ankylosing spondylitis).
• Eyes: episcleritis (redness of the eye's white) and uveitis (inflammation inside the eye). Eye pain, light sensitivity or blurred vision needs urgent eye care.
• Skin: erythema nodosum (tender red lumps on the shins) and pyoderma gangrenosum (a deep, fast-growing ulcer). Mouth sores too.
• Liver: primary sclerosing cholangitis, a scarring of the bile ducts. Suspect it when liver tests show a blocked-bile pattern, with a high alkaline phosphatase (a liver enzyme).
• Blood clots: IBD triples the risk of a vein clot, and flares raise it further. Give clot prevention to inpatients with a flare unless bleeding is severe.
• Also look for anemia and bone loss.