Belly pain, the black box of medicine

Up to 8% of all emergency room visits are for abdominal pain. Up to 50% of those will leave without a clear diagnosis.

Said one ED attending to another, 'what if we just had a belly pain team? Then that team could see all the belly pain patients on one shift, and you could rotate through it'.

Came the reply, 'if you wanted to kill yourself, that'd be a great idea'.

Frustration. Risk. Hallmarks of a belly pain patient. I remember opening the abdomen during anatomy. It was a mess. A mess contributed to by a cadaver that had megacolon (you can guess what that caused, I suppose), but a mess in any case. There are pouches (of Douglas, of Morrison), ligaments (of Treitz), ascensions (of the colon), flexures, anastomoses (my favorite, the superior and inferior pancreaticoduodenal), gutters, and lumens. There are systemic arteries and veins, and then the portal venous system that returns to the liver for metabolism from the digestive tract. There are spots for hemorrhage and infection inside the peritoneum (the lining of the gut) and behind the peritoneum. There's an omentum that hangs over it all like a beaded curtain.

So one can understand why the abdomen can be frustrating. There are also extra-abdominal causes of 'abdominal' pain, some of them catastrophic. In an elderly diabetic lady with indigestion and belly pain, an EKG is a sensible order to rule out a heart attack. Pulmonary embolism and pneumonia can both present with belly pain of one sort or another.

Obscure causes such as an abdominal migraine (the gut has more serotonin receptors than the brain) usually seen in children and errors in hemoglobin metabolism can cause belly pain. And, of course, the appendix.

Ah, the appendix. Still the most commonly missed diagnosis in the ED. So the question for a new belly pain patient could be phrased, 'why isn't this appendicitis?' It can flip up, as high as right below the rib cage, especially in pregnant women. It can migrate down and hide behind the bladder.

So here's to the 8% of my future life spent looking for the appendix.

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