Key Feature 2: In a patient with diagnosed abdominal pain (ex: gastroesophageal reflux disease, peptic ulcer disease, ulcerative colitis, Crohn’s disease), manage specific pathology appropriately (ex: with. medication, lifestyle modifications).
Skill: Clinical Reasoning
Key Feature 8: Given a patient with a diagnosis of inflammatory bowel disease (IBD) recognize an extra intestinal manifestation.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis
Key Feature 1: In a patient with a diagnosed chronic disease who presents with acute symptoms, diagnose:
When I was on rotation on the Family Practice Teaching Service at St Paul's Hospital I was managing a 27 year old female inpatient admitted with abdominal pain NYD (not yet diagnosed). Her past medical history was significant for ulcerative colitis, intravenous drug use now on opioid agonist therapy, pelvic inflammatory disease, and a ruptured ovarian cyst. Prior to the onset of the pain that brought her into the emergency department, she had not been taking any medications for the ulcerative colitis (the disease had been in remission) and she was on opioid agonist therapy to help manage her opioid use disorder. When she presented to the ED with acute abdominal pain she did not have a clear etiology to blame, and she was certainly unwell, so she was admitted to our service so we could manage her pain and figure out what was going on to resolve the underlying issue. After a couple of days into her admission and many investigations later, the team surmised that her pain was likely secondary to a flare up of the ulcerative colitis compounded with the pain of acute opioid withdrawal - the opioid agonist therapy she was taking was in the form of ingested slow-release oral morphine, which was likely not getting absorbed in her gut given its disposition. She was started back up on her antiinflammatory medication, her pain was temporarily managed with hydromorphone, and soon she was feeling back to her baseline.
The list of possible aetiologies for abdominal pain is - as I've highlighted in previous blog posts - extensive. I will outline here the general management of selected aetiologies of abdominal pain that I must be familiar with as a family doctor.
My information was gathered from Bugs & Drugs and the following UpToDate articles:
Overview of the management of gastroesophageal reflux disease (GERD)
For uncomplicated GERD without alarm features*
Overview of the management of peptic ulcer disease (PUD)
The patient will have already been seen by a gastroenterologist, as endoscopy would've been done to detect the presence of ulceration. Although this means the gastroenterologist almost certainly will have developed a treatment plan for the patient to follow, it is important for family doctors to understand what needs to be done so they can ensure patient compliance.
Overview of the management of inflammatory bowel disease [IBD] (ulcerative colitis [UC] or Crohn's disease [CD])
As with patients diagnosed with PUD, patients diagnosed with IBD will be seen and likely will continue to be seen by a gastroenterologist. It is important for family doctors to understand the management of IBD because they will be actively involved in helping patients manage the disease as well as their overall health, which can be impacted in numerous ways by IBD.
*Interestingly, the patient I was managing who had ulcerative colitis had an outbreak of lesions on her arms and legs, which she said started only a few days before she went in to the ED with abdominal pain. The two common types of extraintestinal skin manifestations associated with IBD are erythema nodosum and pyoderma gangrenosum. According to the UpToDate article, Dermatologic and ocular manifestations of inflammatory bowel disease, "Erythema nodosum typically appears as raised, tender, red or violet subcutaneous nodules on the extensor surfaces of extremities. As erythema nodosum usually parallels intestinal disease activity, treatment is directed at the underlying IBD. If skin nodules precede any bowel symptoms or occur during quiescent phases of IBD, therapy with other medications, including prednisone, may be required." I looked up pictures of erythema nodosum, and the lesions the patient had certainly fit the look, along with the fact that they were nodular and tender to palpation, and were located on the extensor surfaces of her arms and legs. How interesting that they erupted at the same time or possibly right before the concomitant flare-up in her bowel disease!
In summary, this has been another long but not even very detailed post that provides an overview of important elements in the management of common and occasionally serious causes of abdominal pain.