Case Study – Acute Abdominal Pain

Something that’s been nagging me I had to write about…

The Case

It’s 3 am, you can tell that because the alarm clock by your bunk bed in the unlit bedhall says so. The chill of the air bites your nose as you try and go back to sleep. You close your eyes and roll over, but the crackle of the station intercom wakes you… “companies stand by…” followed by a high pitched beeping tone and the turnout lights coming on. “Respond to a one alpha one, 35 year old female with abdominal pain…”

“Belly pain…” you grumble as you roll out of bed, pulling on your uniform pants and boots and walking out of the room. You grab the print out sheet from the watchman and head to your ambulance. You depress the button on the door opener as your ambulance roars to life and pulls out of the bay. This is a “low priority” call so you respond without lights or siren.

The drive takes forever it seems, which seems to be a function of the time of day and not necessarily distance, but you finally arrive at your given address. You grab your first in bag and pull on some gloves on the way up to the door. You find your patient, a 35 year old woman, in the back bedroom of the small three bedroom house, she appears in obvious severe pain.

She describes the onset of severe pain to be sudden, and woke her from sleep. She describes the pain as “sharp” and localized to the right upper quadrant (RUQ) that is unrelieved by positioning. She states she tried to drink something but only vomited it back up and the pain does not radiate as well as rating a 10 of 10 on a 0-10 scale. She is able to ambulate to the ambulance and you secure her to the cot. On palpation there is no rebound tenderness or masses noted, and the pain increases on palpation with muscle guarding. You initiate IV access and advise the patient to assume a position of comfort (she assumes a recumbent position on the right side). You place the monitor in a position to view it and dial your portable radio in the closest hospital…

Discussion

Acute non-traumatic abdominal pain is one the most common presentations to the ED, and similarly, emergency medical services calls for service, representing about 6% of ED visits (Jones et al, 2005). The causes are many, making an exact diagnosis of pain extremely difficult simply because of the wide array of organs in the abdominal cavity. It contains the organs necessary for blood filtering, blood sugar regulation, excess fluid elimination, and digestion of food and elimination of waste products.

Outside of trauma, problems in the abdomen could range from inflammatory responses due to infections like PID, hepatitis, or appendicitis. Chronic inflammatory diseases like Crohn’s or ulcerative colitis are also common, or the problem could be mechanical such as bowel obstruction or hernia. Rarely there will be a vascular problem such as ischemia which leads to infarcted bowel. Bowel obstructions and bowel infarctions are commonly problems in the elderly due to decreased gastric motility and will often go unrecognized if those patients are institutionalized. All of these problems will cause a pain response.

This a common problem faced by EMS and ED physicians alike: we don’t treat pain adequately. This stems from the teachings of physicians stemming back decades. Dr Zachary Cope, in his book Early Diagnosis of the Acute Abdomen, printed in 1921, states that “Though it may appear cruel, it is really kind to withhold morphine until one is certain or not that surgical interference is necessary, i.e. until a reasonable diagnosis has been made” (Jones et al 2005). Physicians not only used this as a base to deny abdominal pain patients analgesics for anywhere from 2 to 6 hours because they may “mask” symptoms, but also as a crutch in favor of obtaining informed patient consent.

Recent studies have proven these beliefs to be false. In Radiology, Vermeulen et al stated in Acute Appendicitis: influence of early pain relief on the accuracy on clinical and US findings in the decision to operate, that they designed a double blind, placebo controlled study to challenge the belief that analgesia affected the assessment findings necessary to diagnose appendicitis. They admitted 340 patients to the study with 175 patients receiving morphine and 165 patients receiving placebo. The appropriateness of surgery vs discharge was 100% in all groups: placebo vs morphine, and men vs women. Wolfe et al in Morphine and Appendicitis also found that there was no change is patient disposition between the morphine and placebo groups (Wolfe et al 2005, 283).

Thomas et al stated that there were no changes between the control group and morphine groups in their study in respect to assessment and diagnostic findings, and morphine patients were no more like than control groups to have a change in pain location or differences in diagnostic tests, and the correlation between the phsyician’ clinical course and final diagnosis showed no masking of symptoms caused by analgesia.

So what does this mean? Simply that we can safely manage abdominal pain with opioids and the physician’s fear that they will mask the symptoms needed for an assessment are unfounded based on the research. I never understood why they are still using a textbook from the 1920’s to be the definition of care 90 years later.

That being said, we have a few different medications that can be used for the relief of abdominal pain and related symptoms. Anti-emetics like promethazine (Phenergan) and ondansetron (Zofran) can be used for the relief of nausea and vomiting by blocking histamine uptake (Phenergan) or by blocking seratonin uptake in the brain and GI tract (Zofran). These drugs are effective in preventing or stopping nausea. In terms of analgesics, morphine sulfate is a common opioid found in EMS services, and many use fentanyl for it’s fast action and shorter half life.

Conclusion

The patient’s blood pressure is stable and the pain persists, so you hang a bag of saline and administer 2 mg or Zofran and an additional 4 mg of morphine, which reduces the patient’s nausea and pain from 10 to 6, which is manageable according to the patient. You deliever a patient that is no longer writhing in pain but is calm and able to describe the pain to the physician without additional problems. You find out later that the patient was admitted for surgical intervention to remove her gall bladder, which had become obstructed due to stones.

References

http://en.wikipedia.org/wiki/Abdominal_pain

http://en.wikipedia.org/wiki/Antiemetic

A. D. Jones & K. Ramakrishnan : Analgesics In The Initial Management Of Acute Abdominal Pain . The Internet Journal of Emergency Medicine. 2005 Volume 2 Number 2

Thomas SH, Silen W, Cheema F, Reisner A, Aman S, Goldstein JN, Kumar AM, Stair TO. Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial. J Am Coll Surg. 2003 Jan;196(1):18-31.