Abdominal Pain, Nausea, Vomiting, and Constipation

• Abdominal pain is a common factor in both clinical and emergency settings and has many potential mechanisms, descriptions, locations, and diagnoses, requiring discussion of onset (acute or chronic) and defining the quality as sharp, dull, constant, or intermittent.

Nausea and Vomiting

• GI or non-GI factors like medications, pain, cardiac issues, pregnancy, kidney problems, or chemotherapy can cause nausea and vomiting.
• It is important to get a thorough physical exam of most body systems when treating the cause of emesis.
• For managing nausea and vomiting, consider nonpharmacologic treatments like gut rest, ginger, BRAT diet, small meals, and vitamin B6, alongside labs.
• Indications for consultation, referral, or hospital admission include no resolution within 24 hours, nausea/vomiting with pain, neurological changes, dehydration, hematemesis, or electrolyte imbalances.
• Contact the Health Department for food poisoning.

Constipation

• Defined as fewer than three bowel movements per week.
• Acute constipation requires immediate attention.

Pathophysiology

• Fecal matter remains in the large intestine for extended periods, leading to increased water absorption and resulting in hard stools.

Causes

• Include medications, diet, fluid intake, sedentary lifestyle, anxiety, psychogenic factors, hypothyroidism, and IBS.
• The use of opioids, dehydration, lack of exercise, beta blockers, antidepressants, lack of fiber, cheese in diet, and older age are also possible causes.

Risk Factors

• Include being female, a child, older adult, obese, non-white, and having a low socioeconomic status or low fiber diet; the use of certain medications also contributes.

Differential Diagnosis

• Includes intra-abdominal infection, ileus, toxic megacolon, and obstruction.

Subjective

• Information includes passing hard stools, decreased frequency, straining, incomplete defecation, less than three stools per week, bloating, blocked feeling, fullness, the feeling of incomplete defecation, and needing assistance.

Objective

• Findings depend on the cause, assessing bowel sounds, dullness, masses, rebound tenderness, hemorrhoids, fissures, and palpating the thyroid.

Diagnostics

• ROME 4 criteria, CBC with differential, urinalysis, stool for occult blood, TSH, CMP, X-ray, CT, and colonoscopy.

Management

• Treatment addresses the underlying cause, increasing fluid and fiber intake, increasing exercise, and medications, with referral/hospitalization for acute cases.
• Probiotics, stimulants, bulk-forming agents(Metamucil), and osmotic laxatives may be used.
• Fiber intake of 25-30g/day is recommended.

Diarrhea

• Defined as more than three bowel movements per day.

Pathophysiology

• Disruption in epithelial transport, barrier permeability, and inflammatory mechanisms.
• The absorption phase is disrupted, with secretory phases influencing elimination.

Causes

• Trauma, medications like antibiotics, antacids, immunosuppressants, NSAIDs, and Metformin can cause diarrhea.
• Toxins, transient ischemia, diverticulitis, IBS, IBD, smoking, caffeine, weight loss products, laxative abuse, stress, anxiety, and depression can also cause diarrhea.

Differential Diagnosis

• It is important to consider medication or toxin exposure, IBS-D, Celiac disease, colitis, and Crohn's disease as differentials.

Subjective

• Complaints of abdominal pain, rectal pain, incomplete evacuation, and fecal incontinence. The presence of bloody, greasy, or mucousy stools.

Objective

• The presence of weight loss, dry mucous membranes, decreased skin turgor, abdominal distension, tenderness, rigidity, rebound tenderness, and guarding.

Diagnostics

• CBC with differential, CMP, TSH, stool analysis, and imaging are helpful.

Management

• Gut rest, hydration, clear liquids for 24 hours, and the use of antisecretory and antispasmodic-anticholinergic antimotility agents are considered.
• Consulting if there is no resolution in 48 hours, IV fluids if necessary; food poisoning warrants contacting the Health Department.

Traveler's Diarrhea

Pathophysiology

• Commonly caused by bacterial E. coli, Campylobacter jejuni, Shigella, Salmonella, and protozoal-Giardia, Cryptosporidium; can also be viral-Noro virus.
• The duration is 3-7 days, incubation is 6-72 hours for the viral source and 1-2 weeks for protozoal; can occur in a few hours for bacterial sources.

Risk Factors

• Traveling to Asia (excluding Japan and South Korea), the Middle East, Africa, Mexico, and Central and South America, and consuming unbottled water, raw foods, viral exposure, and some herbal teas.

Differential Diagnosis

• Colitis and food poisoning.

Subjective

• Cramping, urgent loose stools, severe abdominal pain, bloody stools, nausea, and/or vomiting.

Objective

• Presence of fever a bloody stool sample.

Diagnostics

• A stool sample may be obtained, alongside travel history.

Management

• Medications like Cipro, Rifaximin, Azithromycin, or bismuth subsalicylate (Pepto-Bismol, avoid if pregnant or allergic to aspirin).
• Antimotility medications are used only in non-inflammatory conditions and avoided if there is blood in stools, with hydration and clear liquids indicated; Fluoroquinolones are an appropriate preventative option.

Gastroenteritis

• Inflammation of the stomach and intestines, transmitted through food, water, or person-to-person contact; common pathogens include Norovirus, Salmonella, and Botulism.

Risk Factors

• Mostly viral, travel, antibiotic use, hospital stays, outbreaks, exposure to animals/pets, contaminated food, daycares, and contaminated drinking water.

Subjective

• Symptoms include an abrupt onset of nausea/vomiting, cramps, diarrhea, explosive flatulence, headache, weakness, fever, myalgia, dizziness, large volume stools, and mucous or blood in the stools.

Objective

• Fever, possibly low-grade with a viral cause, higher with bacterial infection, and diffuse abdominal tenderness/hyperactive bowel sounds are noted.
• Absent/hypoactive bowel sounds (botulism) and neurological deficits (dizziness, difficulty swallowing) also occur.

Diagnostics

• Not always required; CBC.

Management

• Hydration, Pepto-Bismol, and antispasmodic-anticholinergics such as atropine sulfate or scopolamine, anti-motility agents such as loperamide, and antibiotics.

Irritable Bowel Syndrome (IBS)

• Multifactorial with altered intestinal motility, sensitivity, sensory processing changes, and a gut-brain disorder; more common in women.

Differential Diagnosis

• Colon cancer, IBD, cholecystitis, pancreatic insufficiency, celiac disease, gastroenteritis, and thyroid disorder.

Subjective

• Chronic abdominal pain, bloating, distention, flatulence, mucous, bowel changes (diarrhea, constipation, or both), abdominal discomfort with bowel movements, mucous in the stool, absence of blood, diarrhea or constipation.

Objective

• Findings are not helpful.

Diagnostics

• According to the ROME IV criteria, symptoms must be present for at least three months with an onset six months before diagnosis. Includes fewer than three bowel movements per week with the passage of hard or lumpy stools, a sensation of straining with more than 25% of defecations, a feeling of incomplete evacuation or anorectal obstruction in more than 25% of defecations, or the use of manual maneuvers; soft, easily passed stools without laxatives and insufficient criteria for IBS exist.

CBC,

• CRP, ESR, CMP, TSH, stool analysis, imaging, colonoscopy, or flexible sigmoidoscopy may be performed.

Management

• Nonpharmacologic approaches are dietary (eliminate aggravating foods, avoid large meals, increase fiber), supportive, behavioral therapy, education, reassurance, and addressing depression or anxiety.
• Pharmacologic options include fiber, antispasmodics, antidiarrheals, anti-constipation agents, and psychotropic medications; referral is recommended for more than mild IBS.
• Tricyclic antidepressants manage diarrhea if not constipation (Metamucil, Imodium, Pepto - avoid stimulant laxatives).

Appendicitis

Pathophysiology

• Inflammatory condition involving blockage of the appendiceal lumen.
• Simple cases may progress to gangrenous or perforated within 36 hours; rupture results in peritoneal cavity infection.

Risk Factors

• Young age is a risk factor.

Differential Diagnosis

• Ectopic pregnancy, gastroenteritis, diverticulitis, perforated peptic ulcer, cholecystitis, and intestinal obstruction.

Subjective

• Periumbilical or epigastric pain shifting to RLQ pain, along with abdominal rigidity, nausea/vomiting, anorexia, aggravation with walking or coughing, spasms, and constipation.

Objective

• Still or fetal position, rebound tenderness, guarding, McBurney point tenderness, and positive Psoas, Obturator, and Rovsing signs.

Diagnostics

• CBC with differential, CMP, Beta-hCG, amylase and lipase, CRP, urinalysis, and CT scan.

Management

• Surgical consult referral.

Cholecystitis

Pathophysiology

• Obstruction of bile flow into the small intestine, usually by gallstones, leading to inflammation of the gallbladder, undigested fat, and jaundice. In most cases, bacterial infections contribute.

Risk Factors

• Being female, pregnancy, family history, obesity, rapid weight loss, and ethnicity.

Differential Diagnosis

• Bowel obstruction, diverticulitis, hepatitis, gastritis, and cardiac issues.

Subjective

• RUQ pain, nausea/vomiting, pain occurs after eating fatty meals, and possible chest pain.
• Right upper quadrant abdominal pain that radiates to the right posterior shoulder within an hour of eating any type of large meal, specifically one high in fat content.

Objective

• RUQ tenderness, hypoactive bowel sounds, Murphy's sign with inspiratory arrest, jaundice, possible palpable mass.

Diagnostics

• CBC, CMP, LFTs, Beta-hCG, BUN, Creatinine, and ultrasound are conducted.

Management

• Transfer to the emergency department or referral to a GI/surgeon.

Hemorrhoids

Pathophysiology

• Multifactorial, involving weakening of the structures supporting hemorrhoidal cushions.

Risk Factors

• Age, pregnancy, lifting, prolonged standing or straining with bowel movements, low fiber diets, prolonged periods on the toilet, and genetics.

Differential Diagnosis

• Anal cancer, colorectal cancer, and rectal prolapse.

Subjective

• Pruritus, irritation, a lump, and bleeding.

Diagnostics

• Physical exam, anoscopy

Objective

• If thrombosed the area is purple/dark blue and enlarged.

Management

• Symptomatic relief through high fiber diet, increased fluids, bulking agents, avoiding prolonged periods of time on the toilet and straining, exercise, stool softeners, laxatives, topical analgesics, and referral if necessary.

Peptic Ulcer Disease

Pathophysiology

• Damage to the protective mucosa, with H. pylori being a major cause; approximately 5% of cases are malignant.

Risk Factors

• NSAIDs, family history, smoking, COPD, caffeine, alcohol, and stress.

Differential Diagnosis

• Cholecystitis, GERD, IBD, and non-ulcer dyspepsia.

Subjective

• Duodenal ulcers manifest with intermittent epigastric pain, gnawing, burning, nagging sensations; pain awakens the person at night and is relieved by food or antacids, with possible weight gain.
• Gastric ulcers worsen with food intake, leading to weight loss, dyspepsia, bloating, nausea, anorexia, and excessive flatulence.

Objective

• May have epigastric tenderness.

Diagnostics

• H. pylori - stool sample, EGD a gold standard, CBC.

Management

• H2RAs, PPIs (omeprazole is most potent), and prostaglandin therapy are used as interventions; NSAID use should be discontinued.

Patient Education

• Stop NSAIDs, stop smoking, decrease psychological stressors.

Gastroesophageal Reflux Disease (GERD)

Pathophysiology

• Multifactorial in etiology, relaxation, defects, and poor acid clearance contribute.

Risk Factors

• Smoking, alcohol, obesity, certain medications, and some foods.

Differential Diagnosis

• Esophageal cancer, cardiac ischemia, aspiration pneumonia, and peptic ulcer disease.

Subjective

• The patient describes heartburn, sour taste in the mouth, cough, sore throat, and meal-related aching or burning sensations.

Objective

• Not helpful, although dental erosions, halitosis, and epigastric tenderness may be present.

Diagnostics

• EGD, H. pylori, CBC

Management

• PPIs are the primary treatment.

Patient Education

• Decrease meal size, raise HOB, reduce alcohol consumption, reduce carbonated drinks, decrease certain foods and caffeine, quit smoking, weight loss.

Diverticulitis

Pathophysiology

• Stagnation of fecal matter in the diverticulum leads to pressure necrosis and inflammation.

Risk Factors

• Older age, family, or personal history of colorectal cancer.

Differential Diagnosis

• Appendicitis, gastroenteritis, cystitis, colitis, ectopic pregnancy, and testicular torsion.

Subjective

• LLQ pain over several days, constant or intermittent, constipation, and increased pain with defecation.

Objective

• Low-grade fever, guarding, rebound tenderness, LLQ rigidity, and possible abscesses; diffuse pain may indicate perforation and requires immediate ER transfer.

Diagnostics

• CBC, CRP, urinalysis, BUN, Creatinine, and CT scan.

Management

• Nonpharmacologic and pharmacologic interventions with referral.
• No known correlation connects eating nuts and seeds.
• Consume 15 g or less of fiber/day to decrease fecal matter volume to reduce pressure and irritation.

Hepatitis

• Diagnostic LFTs and CBC, alongside viral testing for all suspected Hepatitis patients.

HAV- Hepatitis A

Characteristics

• RNA virus
• Low socioeconomic status, poor sanitation, poor access to clean drinking water
• Transmitted fecal-oral, blood, person-to-person, ingestion of contaminated food or water
• Incubation period 2-6 weeks, survives for months in fresh and saltwater
• Symptoms appear approximately 4 weeks after exposure
• The virus can be found in liver cells, bile, stool, and blood
• Vaccination available-good for 20 years

HBV- Hepatitis B

Characteristics

• Worldwide endemic
• Most common in adolescents and young adults
• Transmitted by sexual contact and blood contact
• Symptoms range from asymptomatic to fulminant and fatal liver failure
• The virus can be found in blood, tears, CSF, breast milk, saliva, vaginal secretions, seminal fluid
• Can be spread vertically from mother to infant
• Vaccine is available
• Screening and patient education is crucial

HCV- Hepatitis C

Characteristics

• Epidemic proportions in the U.S.
• Significant cause of cirrhosis, hepatocellular carcinoma and liver transplant
• Blood born infection - IV drug use, manicures, pedicures, body piercings, tattoos
• Single-stranded RNA genome = high rate of mutation and replication
• Can affect skin, kidneys and nerves
• Vertical transmission from mother to infant/child is around 2.5% in the U.S.
• No vaccine available
• Screening and patient education is crucial

Pancreatitis

• Patients presenting with pancreatitis are not treated and are given a referral.

Pathophysiology

• Autodigestion of the pancreas, although the exact mechanisms are not well understood.

Risk Factors

• Gallstones, alcoholism, idiopathic causes, and post-ERCP complications.

Differential Diagnosis

• Cholecystitis, MI, and bowel obstruction.

Subjective

• Abdominal pain that radiates to the back, N/V, and pain that worsens over time, particularly in the supine position.

Objective

• Atelectasis, tachycardia, orthostatic hypotension, direct rebound tenderness, and jaundice.

Diagnostics

• CBC, amylase/lipase, Chem-12, and Beta-hCG if the patient is of childbearing age.

Management

• Transfer ASAP

Take Away

• Consult or refer a patient with GI disorders who presents with
• Blood in the stool
• Weight loss
• Anemia
• Dysphagia
• Certain red flags
• Acute abdomen
• Anytime you aren't sure of the diagnosis