bowel mesentery

patients with abdominal pain can have literallyhundreds of things wrong with them, involving many different organs and systems. your jobis to figure out what’s wrong and start the right treatments – an intimidating task! there are a number of life-threatening diagnosesthat cannot be missed. i would like to introduce you to the hipoi framework: could my patienthave an hemorrhage, infection or inflammation, perforation, obstruction, or ischemia? h is for hemorrhage. you need to rule outan aortic aneurysm if your patient presents with sudden onset of pain that radiates tothe back, and you should rule out a ruptured ectopic pregnancy in a woman of childbearingage. these hemorrhagic disorders manifest

with a sudden onset of pain and often havesymptoms of volume loss that include weakness and dizziness, or syncope. i is for infection or inflammation. you needto rule these out in a patient who has a localized area of pain and tenderness, along with infectioussymptoms like fever, chills, and myalgias. in right lower quadrant think of appendicitis,in the right or left lower quadrant – diverticulitis, in the right upper quadrant – cholecystitis,and in either flank – pyelonephritis. pancreatitis is more of an inflammatory condition, andcauses upper abdominal pain, which is usually epigastric. p is for perforation. non-traumatic bowelperforations generally present with a sudden

onset of generalized severe pain and an “acuteabdomen” with generalized guarding, rebound, and shake tenderness. shoulder tip pain mayindicate sub-diaphragmatic air. o is obstruction. patients with bowel obstructionstypically present with colicky generalized abdominal pain, bilious vomiting, and significantabdominal distension. they will report constipation and absence of flatus. remember to check forhernias in any patient who has a bowel obstruction. i is for ischemia. patients with mesentericartery thromboembolism (or “ischemic gut”) have a sudden onset of generalized severeabdominal pain but an absence of impressive peritoneal findings on exam. patients withatrial fibrillation (who are not anti-coagulated) and with patients known vascular disease atare higher risk of this illness.

finally, remember that patients who are sufferingfrom a myocardial infarction can present with epigastric or abdominal pain, so rememberto rule this out. using the hipoi, framework in a patient presentingwith acute abdominal pain ensures that you will not miss an important cause of your patientspain.