A Simple Examination for Abdominal Pains
Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. Welcome back to another installment of GI Common Concerns -- Computer Consult .
Today I want to talk to you about unexplained abdominal pain.
Gastroenterologists and other clinicians often see abdominal pain complaints referred to us for sundry reasons. A lot of times we don't find the explanation that necessarily gives the diagnosis, and we kind of push the can down the road and refer it to somebody else, or the patient is left in the lurch without an explanation.
I want to leave you with a pearl of a physical technique that's all about back to basics, beginning with taking a good history and then confirming that with a physical finding.
Case Presentation: A Painful Vacation
Let me begin with a case scenario.
I recently saw a 34-year-old woman who had been in the emergency room (ER) twice in the course of the past month. She noted an onset of right upper quadrant pain that was fairly stabbing in nature, which had occurred during a trip to Europe. She was backpacking with her husband and child and was frequently struck by this pain. It was stabbing, somewhat positional, ameliorated with recumbency, never aggravated by meals, and became persistent and programmatically worsened over the course of the several days of the trip.
When she got back to the United States, she had such severe pain one night that she went to the ER. While there, she probably didn't get a physical exam, but she got a CT scan that showed nothing. They then referred her to a surgeon for possible biliary colic. The surgeon ordered an ultrasound and a CCK/HIDA scan, which was normal. The patient was told that it's not a surgical problem and that she could go back to her primary care doctor, which she did. There was really nothing else to be said in that intervention.
She then had another episode of abdominal pain, so she went back to the ER. Guess what she received yet again? Yes, another CT scan. The ER physician also suggested that she see a gastroenterologist, which is how we ended up seeing this young lady.
We took the history, during which she recalled that she had had this episode when she was backpacking, swinging the backpack, and also carrying her child on her right hip. Therefore, she really had a lot of unusual positional requirements over the course of that week when the onset of the pain started.
With that in mind, I started to think about what could potentially be causing a nongastrointestinal type of pain. When I examined her, I found that she was point tender in the right upper quadrant. Through a positional change and flexing her neck forward, the pain became exquisitely tender. I told her that this is all musculoskeletal pain.
The Carnett Sign: A 90-Year-Old Tool
Why was I able to tell her that?
It goes back to something called the Carnett sign, which was first described by Dr John Carnett in 1926.
It basically involves a physical finding where, on an abdominal exam, you find the point of maximum tenderness. The way that Dr Carnett initially described it was that he would place his hands on that point of maximum tenderness and have his patients cross their arms and then do a sit-up. If that pain got worse, that was much more compatible with a musculoskeletal rather than an intra-abdominal source.
With the increasing habitus of the patients that we see these days, it's a little hard for me to get them to do sit-ups. What I do instead is locate the point of maximum tenderness, have them flex their neck up, and then try and lift their shoulders off the table. Basically, that does the same thing, which is stretching the rectus sheath and the lateral obliques so that the abdominal muscles are tensed up. If it's more tender, it tells me that that is much more likely compatible with a musculoskeletal source, which, again, is what Dr Carnett's sign had inferred back in 1926.
How does this work?
The way I explain it to my patients is that if you're pushing down in the abdomen and they experience an intra-abdominal pain, you have to push through to those muscles to get to the intra-abdominal cavity. When they tighten up like that, they're more or less "putting a roof on the house," as I say. You elevate the abdominal muscles up and pull the examining hand away from the peritoneal cavity into the muscle. If the muscle is already tender and stretched, it becomes even more tender.
It's a great physical finding and something that you can do very easily. Compared with a CT scan, it's something that doesn't cost $1000 and has no radiation exposure, which was twice incurred by my patient. CT scans don't always beat history and physical examination.
Locating a Proper Diagnosis
When I make that diagnosis, though, I naturally have to then explain to the patient why they have this pain.
In our patient's history, it was pretty clear that she had done several things over the course of the week during her trip that had naturally torqued her abdominal musculature.
However, what I see in a lot of patients is a compression with age where they lose vertical height. As the vertical height goes down, their abdominal muscles get a little bit out of sort. Often what I'll do during an examination is have them turn around and look at their pelvis. This allows me to inspect their pelvic balance, the pelvic brim. Sometimes what you'll see is a slight tilt, a leg-length discrepancy that occurs for whatever reason. They may have mild scoliosis or kyphosis, and this alteration of height or pelvic tilt will have changed their abdominal muscle bearing.
They may need a referral to a physiatrist for leg-length discrepancy or heel lift, for exercises to allow for relaxing, stretching, and core strengthening.
What you can't do is simply turn these patients away and say it's not gastrointestinal pain, which is what the surgeon who referred the patient to me had done. We can't leave these patients in the lurch. In these patients, we need to remember to use the Carnett sign, which is a great physical finding.
When you find musculoskeletal pain, look for the possible etiology so that you can suggest potential next steps to the patient.
A lot of these patients respond to some local heat. If you can understand the causality, you can then refer them to a personal trainer or a physiatrist.
There may also be injections that can be offered. There are some data indicating that local steroid injection or the topical application of capsaicin or lidocaine may be of some help. But again, this starts with a relatively simple physical finding.
Take a good history and do a good physical exam, which doesn't necessarily need to include a CT scan. It's about a back-to-basics approach that we were taught a long time ago in our initial training: Examine the patient, talk to them, and listen to them. Remember the Carnett sign the next time you have a patient with abdominal pain, which I hope will be very helpful to you. I guarantee you that it will be one of those things that you'll put in your quiver and keep there for a long time when you're evaluating abdominal pain complaints.
I am Dr David Johnson. Thanks again for listening, and see you next time.
Carnett JB. Intercostal neuralgia as a cause of abdominal pain and tenderness. Surg Gynecol Obstet. 1926;42:625-632.
Greenbaum DS, Joseph JG. Abdominal wall tenderness test. Lancet. 1991;337:1606-1607.
Johnson DA. Value of the lost art of a good history and physical exam. Clin Traslat Gastro. 2016;7:e136.
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Cite this: Abdominal Pains: A Simple Exam Can Save Unnecessary Costs to Patients and Payers Alike - Medscape - Jul 20, 2016.