Lower Abdominal Complaints

Lower Abdominal Complaints

Differential Diagnosis: Acute Pain

  1. Appendicitis

    • Typically presents as periumbilical pain that later radiates to the right lower quadrant (RLQ).

  2. Diverticular Disease

    • Symptoms may include cramping, bloating, flatulence, and irregular defecation. Often presents with a several-day history of left lower quadrant (LLQ) pain.

  3. Kidney Stones

    • Symptoms arise when the stone passes from the renal pelvis into the ureter, causing paroxysms of severe pain lasting 20-60 minutes. The CT scan is the gold standard for diagnosis.

  4. Pelvic Pain

    • In women, often associated with disorders of reproductive organs.

Differential Diagnosis: Chronic Pain

  1. Irritable Bowel Syndrome (IBS)

    • A functional gastrointestinal disorder characterized by chronic abdominal pain and altered bowel habits.

  2. Inflammatory Bowel Disease (IBD)

    • Includes conditions like Crohn's disease and ulcerative colitis, which cause chronic inflammation of the gastrointestinal tract.

  3. Celiac Disease

    • An autoimmune disorder triggered by gluten, leading to intestinal damage and malabsorption.

Causes of Abdominal Pain by Location

  • Right Upper Quadrant

    • Hepatitis, Cholecystitis, Cholangitis, Pancreatitis, Budd-Chiari syndrome, Pneumonia/empyema pleurisy, Subdiaphragmatic abscess.

  • Right Lower Quadrant

    • Appendicitis, Salpingitis, Ectopic pregnancy, Inguinal hernia, Nephrolithiasis, Inflammatory bowel disease, Mesenteric adenitis (Yersinia).

  • Epigastric

    • Peptic ulcer disease, Gastroesophageal reflux disease, Gastritis, Pancreatitis, Myocardial infarction, Pericarditis, Ruptured aortic aneurysm.

  • Periumbilical

    • Early appendicitis, Gastroenteritis, Bowel obstruction, Ruptured aortic aneurysm.

  • Left Upper Quadrant

    • Splenic abscess, Splenic infarct, Gastritis, Gastric ulcer, Pancreatitis.

  • Left Lower Quadrant

    • Diverticulitis, Salpingitis, Ectopic pregnancy, Inguinal hernia, Nephrolithiasis, IBS, Inflammatory bowel disease.

  • Diffuse

    • Gastroenteritis, Mesenteric ischemia, Metabolic conditions (e.g., Diabetic Ketoacidosis (DKA), porphyria), Malaria, Familial Mediterranean fever, Bowel obstruction, Peritonitis, IBS.

History Taking for Abdominal Pain

  • Important Factors to Note

    • Location of pain

    • Radiation of pain

    • Factors that exacerbate or alleviate symptoms

    • Associated Symptoms: fever, chills, weight changes, nausea, vomiting, diarrhea, constipation, hematochezia, jaundice, and changes in urine or stool color.

    • Past Medical or Surgical History

    • Family History of bowel disorders

    • Alcohol Intake

    • Current Medications: prescription, over-the-counter (OTC), and herbal remedies

    • Menstrual and Contraceptive History for women.

Physical Examination

  • Vitals: Check for indicators of systemic illness.

  • Examine Eyes and Skin: Look for jaundice.

  • Auscultation: Listen to the chest and abdomen for bowel sounds.

  • Palpation: Assess abdomen for masses, tenderness, and peritoneal signs.

  • Rectal Exam: Check for occult blood.

  • Pelvic Exam: Especially necessary in women to assess reproductive organs.

Initial Testing

  • Complete Blood Count (CBC): To check for infections or anemia.

  • Electrolytes, BUN, Creatinine, Glucose: Evaluate kidney function.

  • Liver Function Tests (LFTs): Including bilirubin level tests.

  • Lipase and Amylase: To assess for pancreatitis.

  • Urinalysis (UA): Check kidney and bladder function.

  • Human Chorionic Gonadotropin (HCG): In women of childbearing age to rule out pregnancy.

  • Imaging:

    • Flat plate of the abdomen may provide useful information.

    • CT of the abdomen/pelvis or Ultrasound of the RUQ can be diagnostic.

Appendicitis

  • Commonly starts with RLQ pain that migrates from periumbilical pain.

  • Symptoms: Nausea, vomiting, anorexia may be present.

  • Sign Checking: Check for rebound tenderness, guarding, and the + psoas sign indicates irritation of the iliopsoas muscle due to appendicitis.

  • Clinical evidence shows that the presence of both an elevated WBC and C-reactive protein (CRP) significantly raises suspicion for appendicitis. If both are normal, appendicitis is less likely, and further imaging is not necessary.

  • Referral to a tertiary center may be warranted based on clinical judgement.

Diarrhea

  • Definitions:

    • Acute: Lasting less than 14 days

    • Persistent: Lasting between 14 days to 30 days

    • Chronic: Lasting more than 30 days

  • Defined as the passage of 3 or more unformed stools per day.

  • Most cases of diarrhea are infectious (due to viruses/bacteria) and tend to be self-limiting; noninfectious causes become more prevalent in chronic diarrhea cases.

Diagnostic Approach to Diarrhea

  • Careful history is essential to determine:

    • Duration of symptoms

    • Frequency and characteristics of stool.

  • Assess for evidence of volume depletion: indicators include decreased skin turgor and orthostatic hypotension.

  • Investigate the presence of fever or peritoneal signs.

  • Inquire about occupational exposure, recent travel, pets, hobbies, and food history including consumption of unpasteurized dairy or undercooked meat.

Evaluation and Recommendations

  • Evaluation should be considered for:

    • Profuse watery diarrhea with signs of hypovolemia

    • Passage of small volume stools containing blood or mucus

    • Bloody diarrhea with a temperature > 101.3 °F

    • Passage of > 6 unformed stools in 24 hours or illness lasting > 48 hours

    • Severe abdominal pain

    • Recent antibiotic use or hospitalization

    • Elderly patients (age > 70 years) or immunocompromised individuals

    • Systemic illness, especially in pregnant women.

  • Recommendations for Stool Cultures:

    • Immunocompromised patients, those with comorbidities, and individuals with severe inflammatory diarrhea including bloody diarrhea should be tested.

    • Employees as food handlers requiring negative cultures to return to work.

Differential Diagnosis for Diarrhea

  1. Infectious Causes

    • Bacterial: Salmonella, Campylobacter, Shigella, Cryptosporidium, E. coli, Listeria, Vibrio, Clostridium difficile.

    • Viral: Norovirus.

    • Parasites: Giardia.

  2. Noninfectious Causes

    • Consider IBD, celiac disease, or IBS-D.

Treatment for Diarrhea

  • Key interventions include maintaining hydration and dietary alterations.

  • Antibiotic therapy is typically not required, but considerations should be made when:

    • Moderate to severe travelers’ diarrhea (defined as >4 stools a day) with fever or blood.

    • Passage of >8 stools per day, volume depletion, or symptoms persisting beyond 1 week requiring potential hospitalization.

    • Confirmed specific pathogens can warrant antibiotic use.

  • Medications such as Imodium may be considered when fever is absent and stools are not bloody.

  • Bismuth has antimicrobial and antisecretory properties.

Constipation

  • Definition: Infrequent defecation (less than 3 bowel movements per week), often associated with hard stools.

  • It includes dysfunctional emptying, excessive straining, sensation of incomplete evacuation, and the need for digital/manual evacuation.

  • It is considered a symptom, not a disease.

Interventions for Constipation

  • Dietary Changes: Increase fruits, vegetables, and fiber intake as the first line of treatment.

  • Fluid Intake: Encourage increased fluid consumption.

  • Physical Activity: Enhances digestive transit time.

  • Behavioral Changes: Do not ignore the sensation to defecate, evaluate current medications that may cause constipation.

  • Consider stool softeners and rare laxatives; probiotics may improve stool frequency, gut transit time, and stool consistency.

Chronic Idiopathic Constipation

  • Characterized by sensations of incomplete evacuation, straining with defecation, and fewer than 3 bowel movements per week with hard stools. Alarm symptoms include the presence of blood in stools, unintended weight loss, and family history of colon cancer.

Approaches to Treatment for Constipation

  • First Line: Include dietary and lifestyle interventions.

  • Second Line: Utilize pharmacologic agents.

  • Third Line: Consider nonpharmacologic approaches or prescription medications.

    • Examples are probiotics, increased exercise, water intake, and fiber supplements.

    • Pharmacologic treatments can range from OTC osmotic agents (such as Milk of Magnesia, Miralax, Lactulose) to prescription secretagogues (Plecanatide, Linaclotide, Lubiprostone).

Diverticular Disease

  • Prevalence increases with age; 70% remain asymptomatic, while 15-25% develop diverticulitis, and 5-15% may present with rectal bleeding.

  • Uncomplicated diverticular disease may lead to symptoms like mild cramping, bloating, flatulence, and irregular defecation.

  • Diverticulitis signifies the perforation of diverticula, which can lead to inflammation and complications such as abscess or obstruction.

  • Common complaint includes LLQ pain with low-grade fever and mild leukocytosis, though in Asian populations, RLQ pain is prevalent in 75% of cases.

Diagnosis of Diverticular Disease

  • The hallmark of diverticular bleeding is painless rectal bleeding, often with unremarkable physical examination findings.

  • Diagnosis typically relies on history and physical alone, although an abdominal flat plate can help rule out other causes.

  • A CT scan of the abdomen with contrast is the preferred test for diagnosis.

  • A high-fiber diet is generally recommended for management.

Treatment for Diverticulitis

  • Outpatient management criteria include:

    • Reliability to return for reevaluation if conditions worsen

    • Tolerance for oral intake

    • Abdominal pain not severe, with no higher than low-grade fever.

    • Compliance with outpatient treatment plans and having an available support system.

  • Hospitalization is warranted for elderly patients, immunocompromised individuals, significant comorbidities, or those with high fever (>102.5°F/39°C) or severe leukocytosis.

Antibiotic Treatment for Diverticulitis

  • Recommended Regimen:

    • Ciprofloxacin 500 mg orally twice daily plus Metronidazole 500 mg orally three times a day for 10-14 days.

    • Amoxicillin-clavulanate (875/125 mg twice daily) is an alternative.

    • If Metronidazole is not tolerated, Clindamycin can be considered.

Irritable Bowel Syndrome (IBS)

  • Characterized by chronic abdominal pain with altered bowel habits without any organic cause.

  • Described as crampy pain with variable intensity, often with periodic exacerbations.

  • Commonly associated with symptoms of diarrhea, constipation, or alternating between both.

  • Stools often occur during waking hours, mostly after meals or in the morning, frequently preceded by cramps and urgency. Approximately half of patients also report mucus in their stools.

Symptoms and Associations of IBS

  • Upper gastrointestinal symptoms include reflux and nausea, while extraintestinal symptoms may involve dysmenorrhea, urinary urgency, and more.

  • Patients may have a higher incidence of hypertension, asthma, and fibromyalgia.

Differential Diagnosis for IBS

  • Considering lactose or fructose intolerance, small intestine bacterial overgrowth, colitis, and other functional diarrhea conditions.

  • Additional considerations include celiac disease and inflammatory bowel disease.

Rome IV Criteria for IBS Diagnosis

  • Recurrent abdominal pain occurring at least once a week on average over the past three months, associated with:

    • Changes related to defecation.

    • Changes in stool frequency.

    • Changes in stool form.

Subtypes of IBS

  1. Constipation-Predominant IBS: Includes hard and lumpy stools in 25% of bowel movements, and patients may feel incomplete evacuation.

  2. Diarrhea-Predominant IBS: Characterized by frequent loose stools occurring on 25% of days, not accompanied by abdominal discomfort.

  3. Mixed IBS: Normal stools for 50% of the time with variances in stool consistency.

  4. Unsubtyped IBS: Lacks sufficient abnormality in stool consistency for classification.

  • Notably, 75% of IBS patients may change subtypes within a year post-diagnosis.

Alarm Symptoms

  • Symptoms requiring urgent evaluation include:

    • Weight loss, severe and unrelenting abdominal pain, rectal bleeding, abdominal mass, anemia, changes in chronic symptoms, acute onset post age 50 without prior cancer screening, and family history of colon cancer or IBD.

Diagnostic Studies for IBS

  • For those meeting the Rome criteria without alarm symptoms, limited diagnostics can help rule out organic disease. Recommended tests include:

    • CBC to rule out anemia.

    • C-reactive protein for suspicions of IBD.

    • Serum testing for celiac disease.

    • Colonoscopy for patients over age 50.

Treatment for IBS

  1. Dietary Modifications: Exclude lactose and gas-producing foods, and consider food allergy testing.

  2. Medication Options: Antispasmodic agents and antidepressants for managing neuropathic pain.

    • Antidiarrheal medications like loperamide for diarrhea-prone IBS, or specific IL-11 inhibitors and bile acid sequestrants for those with associated issues.

Agents for IBS-D

  • Initial Therapy: Loperamide (Lomotil).

  • Eluxadoline (Viberzi): Acts on mu and delta opioid receptors.

  • Bile Acid Sequestrants: Such as colesevelam, beneficial for bile malabsorption.

  • Alosetron (Lotronex): For those not responding to other treatments.

  • Rifaximin (Xifaxan): Antimicrobial reserved for treatment failure scenarios.

Hemorrhoids

  • Normal vascular structures present in the anal canal, with cardinal features including bleeding, pruritus, prolapse, and pain due to thrombosis.

  • Differential Diagnosis: Anal fissures, condyloma, rectal prolapse, anal cancer, Crohn's disease.

  • Treatment Options: Increasing dietary fiber, laxatives, sitz baths, topical medications. Severe cases may require banding procedures.

Acute Lower GI Bleeding

  • Nearly one in three patients may have diverticulosis, and one in five may present with colon cancer.

  • Colonoscopy is necessary for diagnosis in these cases.

Celiac Disease

  • Defined by:

    • Villous atrophy and malabsorption symptoms (e.g. steatorrhea, weight loss).

    • Resolution of symptoms upon removal of gluten from the diet.

    • Patients typically show antibodies against gliadin or transglutaminase.

Diagnosis of Celiac Disease

  • Atypical Presentation: Patients might only experience minor gastrointestinal complaints, alongside signs like anemia and nutritional deficiencies.

  • Severe mucosal damage is usually present despite mild features.

Classic Symptoms of Celiac Disease

  • Diarrhea characterized by bulky, foul-smelling, floating stools (steatorrhea).

  • Symptoms of malabsorption include weight loss, growth failure in children, severe anemia, and osteopenia due to deficiency in vitamins D and calcium.

  • A notable portion may present atypically or remain asymptomatic.

Recommended Testing for Celiac Disease

  • Testing is advised for those with gastrointestinal symptoms like chronic diarrhea and malabsorption or for individuals without clear causes for other nutritional deficiencies.

  • High-risk populations include individuals with autoimmune disorders and first-degree relatives of diagnosed patients.

Gluten-Free Diet

  • Avoid foods containing wheat, rye, and barley while consuming safe alternatives like rice, corn, and potatoes.

  • Caution is advised in choosing prepared foods for hidden gluten ingredients.

  • Initial lactose avoidance is recommended due to potential secondary intolerance.

Nutritional Management for Celiac Disease

  • Check for specific deficiencies (e.g. iron, folic acid, calcium) and correct them.

  • Manage dietary fiber intake to alleviate constipation from a gluten-free diet.

Bone Health and Celiac Disease

  • Regular screening for bone loss using DEXA scans is crucial, especially for patients diagnosed with celiac disease. The repeated DEXA scan is beneficial one year following initial diagnosis, particularly for individuals with osteopenia.

  • Pneumococcal Vaccine: Recommended due to elevated risk from hyposplenism associated with celiac disease.