What is the best course of action to diagnose and manage abdominal pain and arthritic pain in a patient with a history of abdominal wall injury?

From the Guidelines

The patient should undergo a step-up approach for diagnosis, starting with clinical and laboratory examination, and then progressing to imaging examinations, such as an ultrasound of the left lower abdomen, not the right, to rule out any complications from the abdominal wall injury. The patient's history of a ripping sensation in the left lower abdomen after sneezing hard suggests a possible abdominal wall injury, and the persistent discomfort warrants further investigation 1.

Given the patient's symptoms and history, a thorough physical examination should be performed to assess for tenderness, guarding, or signs of inflammation. Laboratory tests, including complete blood count, liver and kidney function tests, and inflammatory markers (ESR, CRP), should also be ordered to help diagnose any potential underlying conditions.

For the patient's arthritic pain, a multimodal approach is recommended, including acetaminophen (500-1000mg every 6 hours, not exceeding 4g daily) and NSAIDs like ibuprofen (400-800mg three times daily with food) or naproxen (250-500mg twice daily), with caution due to gastrointestinal risks. Topical NSAIDs like diclofenac gel applied to arthritic joints can provide localized relief with fewer systemic effects.

It is essential to note that the patient's request for a renewal of Tylenol and ibuprofen should be evaluated in the context of their abdominal wall injury and arthritic pain, and the medications should only be renewed if they are deemed necessary and safe for the patient's current condition. The patient's medication regimen should be regularly reviewed and adjusted as needed to ensure optimal pain management while minimizing potential risks.

In terms of imaging studies, an ultrasound of the left lower abdomen is a reasonable initial choice, given its lower radiation exposure compared to CT scans, and it can help evaluate the abdominal wall injury and rule out other causes of pain 1. However, if the ultrasound is inconclusive, a CT scan may be necessary to further investigate the patient's symptoms.

Ultimately, a comprehensive and individualized approach is necessary to diagnose and manage the patient's abdominal pain and arthritic pain, taking into account their unique medical history, symptoms, and potential risks and benefits of different treatment options 1.

From the FDA Drug Label

NSAIDs, including ibuprofen tablets can cause serious gastrointestinal (GI) adverse events including inflammation, bleeding, ulceration, and perforation of the stomach, small intestine, or large intestine, which can be fatal Patients with a prior history of peptic ulcer disease and/or gastrointestinal bleeding who use NSAIDs have a greater than 10-fold increased risk for developing a GI bleed compared to patients treated with neither of these risk factors To minimize the potential risk for an adverse GI event in patients treated with a NSAID, the lowest effective dose should be used for the shortest possible duration

The best course of action to diagnose and manage abdominal pain and arthritic pain in a patient with a history of abdominal wall injury is to:

• Monitor the patient closely for signs and symptoms of GI ulcerations and bleeding during NSAID therapy
• Use the lowest effective dose of ibuprofen for the shortest possible duration to minimize the risk of adverse GI events
• Consider alternative therapies that do not involve NSAIDs for high-risk patients
• Evaluate the patient immediately if signs or symptoms of hypersensitivity, such as fever or lymphadenopathy, are present 2, 2, 2

From the Research

Diagnostic Approach for Abdominal Pain

• The patient's complaint of abdominal pain following a sneezing incident and a ripping sensation in the left lower abdomen suggests a possible abdominal wall injury 3, 4.
• Diagnostic ultrasound is a suitable imaging technique for patients with acute abdominal pain, as it can help reduce the number of possible differential diagnoses and provide an early appropriate therapeutic approach 5, 6.
• However, in this case, the patient's symptoms have persisted for over a month, indicating a possible chronic condition. Ultrasound-guided trigger point injection may be considered for abdominal wall pain, as it has been shown to provide significant symptom relief in some patients 3.

Management of Abdominal and Arthritic Pain

• The patient's request for a renewal of Tylenol and ibuprofen for arthritic pain should be considered, as these medications can help manage chronic pain.
• However, it is essential to monitor the patient's response to these medications and adjust the treatment plan as needed.
• For the abdominal pain, an ultrasound of the abdomen may be performed to rule out any underlying conditions, such as a rupture of the abdominal wall 5, 6.
• If the ultrasound results are inconclusive, a computed tomography (CT) scan may be considered, as it can provide a more accurate diagnosis in urgent conditions 7.

Considerations for Imaging Techniques

• Ultrasound is a suitable initial imaging technique for patients with acute abdominal pain, especially when costs and ionizing radiation exposure are concerns 7.
• CT scans are more accurate and informative in cases of bowel obstruction or perforation, but may not be necessary for all patients with abdominal pain 7.
• Magnetic resonance imaging (MRI) is a promising alternative to CT scans, but more data is needed to support its use in acute abdominal pain evaluation 7.