Abdominal pain in women

[wareagle726]

Alright, 6 months out and this one keeps getting me extended LOS and honestly when I get 2 or 3 at a time it seems like my cognitive load capacity is just depleted. Had two tonight. Young women, present in agonizing pain. Maybe a little tacky, maybe not. Tender belly. Improve with morphine. CT neg. Labs pretty much normal, maybe a mildly bumped WBC or some other nonspecific finding. Normal UA, preg neg. US comes back neg. Still tearful in bed saying they are dying. Seems like I just can't come to a disco on these patients in a reasonable time and it throws me off my game. I feel like I'm looking for a reason to admit these patients because I don't know what to do. Is it PID? bowel spasm? constipation? Some random autoimmune issue? Who's the hell knows?!? All the while I see other docs getting the disposition in less than 2 hours. Any advice from the more seasoned docs? Thanks.

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[JacobMcCandles]

Once you understand that you'll never get a diagnosis more often than not in abdominal pain you'll come to terms with your workup and that they need to follow up as outpatient. Also, if you continue to CT then US all of these you'll never improve your disposition times.

 

[cyanide12345678]

Alright, 6 months out and this one keeps getting me extended LOS and honestly when I get 2 or 3 at a time it seems like my cognitive load capacity is just depleted. Had two tonight. Young women, present in agonizing pain. Maybe a little tacky, maybe not. Tender belly. Improve with morphine. CT neg. Labs pretty much normal, maybe a mildly bumped WBC or some other nonspecific finding. Normal UA, preg neg. US comes back neg. Still tearful in bed saying they are dying. Seems like I just can't come to a disco on these patients in a reasonable time and it throws me off my game. I feel like I'm looking for a reason to admit these patients because I don't know what to do. Is it PID? bowel spasm? constipation? Some random autoimmune issue? Who's the hell knows?!? All the while I see other docs getting the disposition in less than 2 hours. Any advice from the more seasoned docs? Thanks.

No acute emergent issue. Discharge. Pcp follow up. Your job often is to rule out, which you have, then you move on.

 

[johhnybgood]

Why do a pelvic u/s with negative ct?
Just as sensitive/specific for torsion as u/s. Pid and toa should be picked up with hpi and symptoms. Doing ct then us is going to be 3+ hr work up every time.

 

[cyanide12345678]

Why do a pelvic u/s with negative ct?
Just as sensitive/specific for torsion as u/s. Pid and toa should be picked up with hpi and symptoms. Doing ct then us is going to be 3+ hr work up every time.

Which literature states that the sensitivity is the same? I doubt it is. Seen a couple of CTs read as "ovarian cysts" that were torsion on ultrasound. In my mind, if negative CT, unlikely to be torsion since you usually have a fairly large ovary, but if CT shows large ovary, then CT can't tell if it's a cyst or torsion.

But yes, usually you don't necessarily need to do both ultrasound and CT, but if it's a young woman, screaming in pain, with lower abdomen/pelvic pain, I'm sure as hell ordering both. But if comfortable looking, then i probably won't do both.

 

[johhnybgood]

Redirect Notice

 

[GeneralVeers]

I order CT and US at the same time in all these patients with lower abdominal pain. It really improves throughput. If you order one, it will likely be negative then you are stuck ordering the other.

I tell these people at the outset that 30% of women don't get a diagnosis when we see them for abdominal pain, but that we are going to help their pain and rule out an emergency.

It's really not a diagnostic puzzle. Get at minimum CT, US, Preg, UA and you will have no problem ruling out the majority of crap.

 

[The Knife & Gun Club]

My wife, an OB, is a big fan of “pelvic congestion syndrome” diagnosis for these women when all else fails. You give them a Depo-Provera shot, say it takes 3-4 weeks to work, and dispo with NSAIDS.

It’s the fibromyalgia of the pelvis. Placebo disease, placebo treatment.

 

[AMEHigh]

My wife, an OB, is a big fan of “pelvic congestion syndrome” diagnosis for these women when all else fails. You give them a Depo-Provera shot, say it takes 3-4 weeks to work, and dispo with NSAIDS.

It’s the fibromyalgia of the pelvis. Placebo disease, placebo treatment.

Why do you give depo?
What if they want to or are trying to get pregnant?

 

[Angry Birds]

I have a practiced speech that I give at the beginning of care:
"OK well I have good news and bad news. The bad news is that belly pain is often very hard to diagnose, especially in the ER and it can sometimes take months to figure it out. You might need to follow up with a GI specialist who might even need to do a colonoscopy. It can be a long and drawn out process. But the good news is that today we will be able to rule out some big bad things and also help you with the pain."

This sets the expectations from the get go.

 

[Fox800]

I have seen literature saying that a normal CT abdomen/pelvis with contrast, with normal-sized ovaries, with *no free fluid* around the ovaries, is sufficiently sensitive to rule out torsion if your suspicion is low.

"CT with IV contrast will often display findings suggestive of torsion.5,16,33,39–42 Findings on CT with high specificity for ovarian torsion include a twisted vascular pedicle (see Figure 2), a thickened fallopian tube with target/beak-like appearance, absent or reduced ovarian enhancement with contrast, and an enlarged ovary with a follicular ovarian stroma and peripherally displaced follicles.16,33,39–42 Features that are commonly found but not specific include an enlarged ovary, an adnexal mass, adnexal mass mural thickening, free pelvic fluid, fat stranding surrounding the ovary, uterine deviation toward the torsed ovary, and ovarian displacement toward the uterus.16,33,39–42 CT with contrast demonstrates a high sensitivity for these secondary findings, approaching 100 percent.16,33,39–42 If one of these secondary findings is present, TVUS and OB/GYN consultation should be expedited. If these findings are not present and the ovary is normal in size, TVUS may not be needed, depending on the any changes in the clinical course."

Dispelling 5 Ovarian Torsion Myths - Page 3 of 5 - ACEP Now

ACEP Now offers real-time clinical news, news from the American College of Emergency Physicians, and news on practice trends and health care reform for the emergency medicine physician. ACEP Now is an official publication of the American College of Emergency Physicians.

www.acepnow.com

This assumes your suspicion for torsion is low.

Kind of like people that are inappropriately using the PERC rule when your gestalt for PE is not low.

 

[Hercules]

Agree with everything above. This is all about expectation setting at the outset. I use similar messaging about not getting a diagnosis the majority of the time in an ED but that our testing will rule out dangerous emergencies that would require surgery or hospitalization. That also lets them know that when all this is normal (as it almost always is) they are going home. I find that haldol works great for dramatic abdominal pain as well.

 

[alpinism]

There have been a few recent studies that actually show CT having better sensitivity than US for torsion.

Regardless if you have a high suspicion I'd recommend immediately calling OB/GYN for possible laparoscopy.

 

[Dr Mantis Toboggan]

There have been a few recent studies that actually show CT having better sensitivity than US for torsion.

Regardless if you have a high suspicion I'd recommend immediately calling OB/GYN for possible laparoscopy.

Like the idea, but do people actually work with ob/gyn’s who will take patients straight to the OR?

 

[s/p epilepticus]

Like the idea, but do people actually work with ob/gyn’s who will take patients straight to the OR?

I had a pediatric patient a few days ago during a shift at the local Children's hospital that was taken to the OR for diagnostic laparoscopy based on US findings. Op note was in before my shift ended. Cyanotic ovary, one twist of the mesovarium.

 

[Mushdoc]

I think he means high suspicion either before imaging or with negative imaging. Which is technically the board answer for both that and testicular torsion.

 

[Dr Mantis Toboggan]

I had a pediatric patient a few days ago during a shift at the local Children's hospital that was taken to the OR for diagnostic laparoscopy based on US findings. Op note was in before my shift ended. Cyanotic ovary, one twist of the mesovarium.

Sure but with no U/S at all that would be a tough sell at my hospital. Ditto for torsion, mush. Which is the board answer I know but not the reality I deal with.

 

[The Knife & Gun Club]

Why do you give depo?
What if they want to or are trying to get pregnant?

The thinking is the depo has so vasoactive effects on the vasculature and will decrease venous congestion and permeability. With the added benefit that if it’s some other hormonally mediated cause like endometriosis or adenomyosis that we just can’t see on US/CT, it will treat that too.

Ive yet to run into someone who’s both having this issue AND actively trying to get pregnant in the next 3 months. But if they are...NSAIDs? Idk.

 

[JacobMcCandles]

Regardless if you have a high suspicion I'd recommend immediately calling OB/GYN for possible laparoscopy.

That's the test answer but it isn't the real life answer.

 

[GeneralVeers]

That's the test answer but it isn't the real life answer.

I've never had this happen in the real non test world.

 

[thegenius]

Once you understand that you'll never get a diagnosis more often than not in abdominal pain you'll come to terms with your workup and that they need to follow up as outpatient. Also, if you continue to CT then US all of these you'll never improve your disposition times.

I agree with this general sentiment. Young people with abdominal pain 99.9% will have emergency pathology found on labs or CT. That is...if they have normal labs and a negative CT, it is highly highly doubtful you are missing an emergency.

Give them 3-5 mg IV of the beautiful medicine haldol.

I’ll work a little harder if they don’t abuse the ER, but if they come in every month crying and whining about their pain and it’s visit #18, i just tell them straight up that the ER will NEVER EVER FIGURE OUT why they have pain.

sometimes they don’t come back.

 

[thegenius]

Like the idea, but do people actually work with ob/gyn’s who will take patients straight to the OR?

no! They all want US

 

[southerndoc]

Haldol? We got droperidol in our ER recently and let's just say it's the miracle drug.

 

[DrDrummer]

What everyone else said. I think there's decent literature to support that US/CT have similar sensitivity and specificity (keeping in mind that neither is perfect for ruling out or ruling in).

I'll just throw out there that almost certainly at least one of these women will have PID. Without re-hashing the debate about pelvic exams in the ED, for any learners in the thread, consider the diagnosis and at least do shared decision making with these women regarding a spec exam or a self-swab.

I have seen several young women bounce back to ERs I work in who have underwent this diagnostic pathway at least twice without diagnoses, no pelvic or documentation of conversations around it, and who have gnarly infections on exam.

As others have mentioned, I have started talking to people about the diagnoses that aren't seen on CT scans or physical exam (inflammatory bowel conditions, endometriosis, pelvic congestion whatever, interstitial cystidities, etc. x infinity) and that's why PCP/GYN follow up and specialist evaluation is so important.

 

[AlmostAnMD]

I've only seen one torsion in the last year

did not present "classically", minimal suspicion for THAT more for other belly stuff

CT w/ IV contrast read as ovarian torsion, also recommended "ultrasound correlation"

Ended up being a 17 cm cyst that went full twisty

She really didn't look that bad, although maybe that's because it was all dead ovary

 

[Groove]

I have the same pattern as @GeneralVeers. I order hcg,belly labs, ua, CT and US on just about all of these pt's. On the US, I always remark "comment on ovarian flow" so they will specifically state that there is no evidence of torsion. If everything is negative, you're done. If there is anything remotely in the history to suggest PID, I have a low threshold to empirically treat it. I try to avoid pelvics for the majority of these. For the really melodramatic ones, I will give 5mg haldol IM for "nausea" that chills them out very nicely and t's you up for an improved re-examination after all the negative studies are back.

On rare occasions, I've had the pt with a cascading pattern of severe pain where I have been suspicious of intermittent torsion and will call OB even with the US negative to get them on board with the disposition but that's pretty rare.

 

[thegenius]

As others have mentioned, I have started talking to people about the diagnoses that aren't seen on CT scans or physical exam (inflammatory bowel conditions, endometriosis, pelvic congestion whatever, interstitial cystidities, etc. x infinity) and that's why PCP/GYN follow up and specialist evaluation is so important.

Oh we tell them. We tell them all the time to see other doctors. We implore them to go. All they have to do is put in a modicum of effort and they can go.

But they don't go!

The other problem is I find outpatient internal medicine kind of useless with this particular set of symptoms. If we can't figure it out after labs, UA and imaging, then there isn't much more an internal medicine doc can do. If it's PID they are not going to do a pelvic exam, if it's irritable bowel (inflammatory bowel usually has inflamed bowel and usually (but not always) can be picked up on CT) they get referred to GI which takes 1 month, if it's interstitial cystitis because their his an abnormal UA, they refer to Urology, or whatever else they just refer.

Then patients get frustrated because they are still in pain and they come back to the ER. And the cycle repeats itself.

 

[RoyBasch]

I order CT and US at the same time in all these patients with lower abdominal pain. It really improves throughput. If you order one, it will likely be negative then you are stuck ordering the other.

I tell these people at the outset that 30% of women don't get a diagnosis when we see them for abdominal pain, but that we are going to help their pain and rule out an emergency.

It's really not a diagnostic puzzle. Get at minimum CT, US, Preg, UA and you will have no problem ruling out the majority of crap.

This is the money approach for these patients.

If they really wanna keep screaming after a few doses of morphine, just admit them.

I think Veers touches on a useful approach, telling these patients at the outset if you think the workup is likely to be negative. (Assuming you think that based on the H&P mind you). I think it helps coach expectations and facilitate dc dispositions.

I find this approach is also helpful with young low risk non specific probably anxiety-related chest pains.

 

[RoyBasch]

There have been a few recent studies that actually show CT having better sensitivity than US for torsion.

Regardless if you have a high suspicion I'd recommend immediately calling OB/GYN for possible laparoscopy.

I get that this is the "right" answer at ABEM general or for oral boards; however, I have worked at 6 different hospitals, and I have NEVER encountered an OB/GYN who would take a patient like this immediately to the OR for diagnostic laparoscopy without imaging already done. Perhaps in some academic centers where the residents need procedures numbers and staff is readily available (business hours, etc.) "Diagnostic surgeries" of any kind without imaging are going to be very unusual in a community hospital and you better be ready to trade your own kidney to get it done.

 

[RoyBasch]

Oh we tell them. We tell them all the time to see other doctors. We implore them to go. All they have to do is put in a modicum of effort and they can go.

But they don't go!

The other problem is I find outpatient internal medicine kind of useless with this particular set of symptoms. If we can't figure it out after labs, UA and imaging, then there isn't much more an internal medicine doc can do. If it's PID they are not going to do a pelvic exam, if it's irritable bowel (inflammatory bowel usually has inflamed bowel and usually (but not always) can be picked up on CT) they get referred to GI which takes 1 month, if it's interstitial cystitis because their his an abnormal UA, they refer to Urology, or whatever else they just refer.

Then patients get frustrated because they are still in pain and they come back to the ER. And the cycle repeats itself.

I usually figure after my workup I have already done the PCP workup and then some, so they are kind of at the end of their diagnostic pathway and I give them outpatient follow up with either GI or gyn (depending on whether it seems like there is associated GI or gyn symptoms).

 

[alpinism]

If the patient's got a textbook presentation I'll call to let them know that we might have a torsion.

That being said I agree they'll usually want it confirmed on imaging before doing a laparoscopy.

 

[thegenius]

I usually figure after my workup I have already done the PCP workup and then some, so they are kind of at the end of their diagnostic pathway and I give them outpatient follow up with either GI or gyn (depending on whether it seems like there is associated GI or gyn symptoms).

I hear ya, and this further progresses the general shift away from PCP's working up sick patients. Its as if they only deal with chronic and preventative medicine.

 

[GeneralVeers]

I hear ya, and this further progresses the general shift away from PCP's working up sick patients. Its as if they only deal with chronic and preventative medicine.

The problem is that most people have HMOs or Medicaid and have to go through their PCP before any specialist referral.

 

[turkeyjerky]

I hear ya, and this further progresses the general shift away from PCP's working up sick patients. Its as if they only deal with chronic and preventative medicine.

The problem is that most people have HMOs or Medicaid and have to go through their PCP before any specialist referral.

Yeah, the combination of these two factors contributes to the truly awful job our healthcare 'system' does with most subacute, but serious, conditions. These patients bounce around, waiting for a referral or insurance approval, until they decompensate to the point of needing admission.

 

[thegenius]

Yeah, the combination of these two factors contributes to the truly awful job our healthcare 'system' does with most subacute, but serious, conditions. These patients bounce around, waiting for a referral or insurance approval, until they decompensate to the point of needing admission.

100% agree well said. We have a terrible health care system. Even those with insurance....it’s just not a good system.

 

[GeneralVeers]

100% agree well said. We have a terrible health care system. Even those with insurance....it’s just not a good system.

It's the worst system, except for all the others.

 

[wareagle726]

I have the same pattern as @GeneralVeers. I order hcg,belly labs, ua, CT and US on just about all of these pt's. On the US, I always remark "comment on ovarian flow" so they will specifically state that there is no evidence of torsion. If everything is negative, you're done. If there is anything remotely in the history to suggest PID, I have a low threshold to empirically treat it. I try to avoid pelvics for the majority of these. For the really melodramatic ones, I will give 5mg haldol IM for "nausea" that chills them out very nicely and t's you up for an improved re-examination after all the negative studies are back.

I greatly appreciate all the feedback. I think this one sums it up best. It's the "really melodramatic ones" that I do give haldol and then I DO go back for a re-exam and they are still like "OMG everything hurts and I'm dying." No way to admit that to a hospitalist with normal vitals and labs. I guess at some point I have to trust my exam/workup/statistics over what the muggle says. It's just frustrating. I know I have to raise my acceptable miss rate and that's likely the whole problem. FYI this patient could easily be young person with chest pain...insert standard workup. Just an example.

As an aside, yeah I know there's very little reason to get a pelvic US on general abd pain in women. I'm specifically referring to the ones with lower and pain/ttp with the suspicion for TOA/torsion.

 

[wareagle726]

Also, I feel like I end up just putting them on 14 days of doxy. Probably CYA and bad medicine but seems worth it for my license.

 

[Rekt]

Lots of good advice here.

My two cents is actually do a decent physical exam. I see way too many of these patients. Lay them completely flat. Flex at the hips and relax the abdominal wall muscles. You'll be able to delineate if it's adnexal vs peritoneal like 90% of the time. While you're doing it have the discussion of ultrasound vs CT. Usually can discharge after a neg ultrasound (which is significantly faster at my shop) and a repeat abdominal exam and clear documentation.

Also very surprised, I would never get obgyn to touch a negative ultrasound or a hospitalist to admit intractable abdominal pain. Must work in fairytale land.

 

[Apollyon]

It's the worst system, except for all the others.

Props for the Churchill reference!

 

[thegenius]

I greatly appreciate all the feedback. I think this one sums it up best. It's the "really melodramatic ones" that I do give haldol and then I DO go back for a re-exam and they are still like "OMG everything hurts and I'm dying." No way to admit that to a hospitalist with normal vitals and labs. I guess at some point I have to trust my exam/workup/statistics over what the muggle says. It's just frustrating. I know I have to raise my acceptable miss rate and that's likely the whole problem. FYI this patient could easily be young person with chest pain...insert standard workup. Just an example.

As an aside, yeah I know there's very little reason to get a pelvic US on general abd pain in women. I'm specifically referring to the ones with lower and pain/ttp with the suspicion for TOA/torsion.

I'm fine with missing PID on the pts who come in 2/month complaining of the same thing every single time, like clockwork. The fact is they don't have PID. they do dumb stuff like smoke weed or eat Popeyes every day, and either refuse to admit it or refuse to change their lifestyle. They have lifestyle pathology.

 

[GeneralVeers]

Props for the Churchill reference!

Thanks. He's a personal hero of mine. His portrayal by John Lithgow on The Crown is a must see.

 

[thegenius]

The most recent one played by Gary Oldman "Darkest Hour" is better than the John Lithgow one

 

[RuralEDDoc]

Also very surprised, I would never get obgyn to touch a negative ultrasound or a hospitalist to admit intractable abdominal pain. Must work in fairytale land.

Agree, and that’s probably for the best. Admissions for pain management without associated pathology is (mostly) bad for the patient and the healthcare system. IV dilaudid fixes nothing, just dulls pain from one of a variety of sources - nociceptive, neuropathic, psychiatric, etc. Its only good for the first, for the other two, it’s counterproductive.

 

[RoyBasch]

Also very surprised, I would never get obgyn to touch a negative ultrasound or a hospitalist to admit intractable abdominal pain. Must work in fairytale land.

I would be careful about being this dogmatic. For context, I work primarily in the community with very hard nosed specialists who generally do not enjoy or appreciate talking/consulting with the ER.

If you talk to any of the people on this board who have been doing this a long time I am sure they can regale you with many cases of imaging-negative, emergent pathology-positive situations. Torsions, ectopics, appys, choles, etc. Understanding the limitations of your tests is essential. None of our advanced imaging has 99% sensitivity.

It's all Baseyian statistics, the tests lower your post test probability, but if the pre test probability is very high (i.e. highly suspect history or physical exam), you may still not get to a sufficiently low level to "rule out" a serious problem. No we cannot rule out everything, yes there are atypical cases that will always be missed. But sometimes you get a classic story or gestalt seems right and the imaging is negative or equivocal, you have to pursue the next step.

In the community I would not call a specialist or surgeon until the imaging is done, but negative imaging is not 100% slam dunk, you're done. Diseases, particularly intraabdominal diseases are not simply positive or negative, they emerge on a continuum and early in their course they can be difficult to detect and the test characteristics are going to be poorer. It is not always completely unreasonable to admit patients for observation and tincture of time.

Not every patient with severe pain is "faking it." Malingering is a diagnosis of exclusion, and you cannot necessarily exclude every serious cause in the ER with the tests and time we have available. Severe intractable pain should be considered a red flag that raises clinical suspicion for serious pathology. If you have a patient with a low-normal number of ER visits in the last few years for normal things, my first thought is not "this person is a bull**** artist."

Obviously different patient with "10/10 pain" who looks completely comfortable on exam, with 12 ER visits in the last 6 months and 10 negative advanced imaging studies, allergies to all analgesics besides dilaudid, and who "somehow never can see the gynecologist," That's a different story.

Of course there are going to be questions of degree between those two hypothetical patients, but I think its probably prudent to assume the worse when it is unclear rather than immediately thinking the person is FOS.

 

[GeneralVeers]

The more noise they are making, the more likely it is malingering. Filling a vomit bag full of air and noise is almost always marijuana hyperemesis, cyclic vomiting, and/or malingering. My pre-test probability for badness is inversely proportional to the amount of noise/drama.

I'm so glad we have droperidol back. 2.5 mg IV usually silences any noise.

 

[VA Hopeful Dr]

I hear ya, and this further progresses the general shift away from PCP's working up sick patients. Its as if they only deal with chronic and preventative medicine.

Because people don't come to us first for stuff like this anymore. I'd love to spare patients a trip to the ED, I think I can do a pretty good and/pelvic pain work up but it takes time. I can't always get a same day CT and pretty much never for US. Labs outside of a CBC take a day.

That's unacceptable in many people's minds and so here we are.

 

[turkeyjerky]

Because people don't come to us first for stuff like this anymore. I'd love to spare patients a trip to the ED, I think I can do a pretty good and/pelvic pain work up but it takes time. I can't always get a same day CT and pretty much never for US. Labs outside of a CBC take a day.

That's unacceptable in many people's minds and so here we are.

Yeah but meanwhile two days ago I saw a patient sent in from her primary care “provider” (you know what I mean) for a CT scan after coming to clinic for 3 weeks of post-prandial ruq pain. She’d scheduled the appt a week ago, no acute symptoms.

 

[VA Hopeful Dr]

Yeah but meanwhile two days ago I saw a patient sent in from her primary care “provider” (you know what I mean) for a CT scan after coming to clinic for 3 weeks of post-prandial ruq pain. She’d scheduled the appt a week ago, no acute symptoms.

No question, our NPs refer stupid stuff all the time. ED usage isn't that much different from our physicians but there's an informal rule that anyone you want to send has to be run by one of us first.

 

[Angry Birds]

Also, I feel like I end up just putting them on 14 days of doxy. Probably CYA and bad medicine but seems worth it for my license.

Man Doxy is harsh on the stomach, so I wouldn't do that personally.