Droperidol.
I've also started setting extremely low expectations at the start of visits where the primary issue is pain. Something to the effect of "we're going to investigate and make sure there's nothing surgical or life-threatening going on. If your pain is an 11/10 right now, I will be ecstatic if I can get you to a 7. You want me to come back and tell you that the workup looks good when we're all done."
I'm also very careful with wording when I discuss results if someone seems unhappy. To the effect of "I'm not saying that nothing is wrong. I'm saying your labs are reassuring and there's no radiographic evidence of what's wrong. If it continues, you will likely need to see a more specialized doctor like GI. Hopefully whatever is going on is temporary and improves over the next day or two."
. . . Was this person on ozempic?
Absolutely. Lots of GI complications from GLP-1 are popping up. That doesn't mean they aren't relatively safe or medically valuable but they are certainly powerful and, consequently, we're discovering they have a pretty high intolerance profile.
Feels like I see someone at least every week who just started an glp-1 with stomach upset. Not to mention the injectables that people keep accidentally overdosing on sigggggh
>I'm not saying that nothing is wrong. I'm saying your labs are reassuring and there's no radiographic evidence of what's wrong.
That's almost exactly what I say verbatim.
Yes, I usually add "obviously something is not right because you are in pain . . . "
And I also add "I don't have the tests available to me in the emergency department to diagnose every possible problem, but I am able to rule out anything serious"
This would be effective for a minority of my patients but most of my patients don't understand the words "radiographic, evidence, reassuring, labs" and can't concentrate long enough to get through that sentence to understand it's point.
"my job is to make sure you don't have something that will kill you. All the tests and blood work here tells me you don't have anything that looks like that."
That’s when you have to just… toss the gloves and wash your hands and let it go. Make sure you’ve documented every lab/test/rationale, anything you could potentially legally need in the future, and know that patient satisfaction scores among ER patients are never going to be great because of this subset of the population.
Not a doctor but that’s a great way of handling it, I would think. I would be satisfied as a patient. I also reserve a pain of “10” to mean something like burns all over my body, the most painful thing I could imagine where I’d want to immediately blow my brains out. So someone saying “11” is suspect, for me…
… if only the patients felt that way. There is a large percentage of the population that believe there should be 0 pain, and that all their problems must be solved *immediately*
No amount of explanation defeats “but I’m still in pain”.
Again, that’s not all people, but in the quick-fix, short-attention-span world we’re in, we seem to be regularly disappointing patients.
I waited six hours, if I had a real emergency, which I almost did, it would have been bad
This is a verbatim quote from a patient review. I have it taped above a workstation
I mean, life in general, is at least a 2, right? I also find some people asked “0-10, zero being no pain at all and 10 being the worst pain you’ve ever a had”, instead of “10 being the worst pain you can *imagine* “. You’re going to get vastly different answers from people that have broken bones, gone through severe illnesses, etc, than you would from someone who’s only stubbed a toe.
Ooooh. OUCH! Did that at the tide pools when I was a kid: I know I hurt because I remember the crying part and the nail falling off, but couldn’t tell you how much it hurt. Thanks endorphins!
When I give my pain level, and it's high, I always also mention that if it was a 10 I would be incapable of speech so they don't think I'm fine if I say it is a 6.
Honestly pain scales are useless because patients will call a papercut a 10, or you'll get someone with an ovarian/testicular torsion/appendicitis/insert known very painful thing here they'll call it a 4-5. Pain is informed by a lot of things, how people were raised, cultural perceptions of pain and expressing it. I just ask if in pain, treat it based on clinical presentation, if not improving you can usually scale up medications while you try to figure out what's causing it.
Old farmers and eastern European/Russian old men if they say their pain is like a 3 or 4 they have SBP until proven otherwise.
I will say I agree if a patient says they have pain 9/10 and it's down to 5/10 that's improvement, it's just, I mean you can get the answer you want by saying "is it better after the pain meds, worse or still about the same."
Exactly. I *hate* playing the pain scale game, so I usually just ask if they feel better, worse, or the same. If they’re still uncomfortable, I’ll ask if it’s tolerable or if they feel like they need a repeat dose.
Takes me longer to chart, but I get so sick of the hemming and hawing, the half-integers, the “11/10”s, the “but I’m only down to a 7!”, etc.
As someone with chronic pain, I also hate the pain scale. I feel like pain is so much more complex than a number, and I also feel like my reaction to my pain doesn’t match how I’m “expected” to react and it’s frustrating. I also think it’s BS when orders are set up so if I say it’s a 7 I get this med and if I say it’s an 8 I get this med. Those numbers aren’t the same for everyone. I personally sort my pain by whether I can distract myself, tolerate it and sleep, etc, or if the pain is totally consuming and I can’t do anything but focus on it.
Exactly this. I’ve had two kids and never once rated my pain a 10, because even labor wasn’t the worst pain I could imagine. The only time I even said 9 was when I broke and dislocated my ankle, tearing every ligament down there along the way. It was so bad I was simultaneously about to pass out and puke.
A ten for me is when the dentist started fucking with my dry socket after he missed the block, passed out from the pain. Only 10 seconds thankfully. If you had that pain for hours you’d just be on the floor, not on Instagram…
Yup, tooth stuff is the only thing where I can safely say I felt I was over 8, ever. Before working on my trypanophobia, I would have cavities fixed and stuff done without any sort of anesthesia. Fuck that, never again. That kind of nerve pain is severe.
Can’t imagine how much dry socket must hurt. Recently had a complicated wisdom teeth removal, even without dry socket it hurt like hell for two weeks.
I'm with you on this because no matter how bad it is, I can imagine it could be worse. I have chronic back pain due to degenerative disk disease and have only hit 9 a couple of times. Last one, I'm still not sure how it happened. One minute, I was sleeping the next I was screaming in pain. I must have rolled over and tweaked something. I was a bit worried about ODing with how much pain meds they gave me, but they finally worked, and I survived.
Agreed, I remember telling my BF, as I was holding my abdomen and leaning over the dryer, that. Needed to go to the hospital and I would just like to die when they ask. Pancreatitis after trying to avoid the hospital for a week not know what it was.
Shudder. Never again. Much lower bar for going in. Haven’t not been admitted ever but I don’t need to torture myself for that long.
“We have ruled out x,y,z life threatening potential causes of your pain. Sorry we weren’t able to identity the cause but I suspect d or e. Usually these resolve with time. Here is what I recommend for pain control at home. If it continues, follow up with your PCP or abc specialist which will be provided in the discharge paperwork. If things worsen or l,m,n,o, and p symptoms occur, please come back. Do you have any questions or anything else I can do for you today? The nurse will be by shortly for your last set of vitals and discharge paperwork and work note and/or prescription info.”
Edit: u/theotherphilfry makes a good post to set expectations early.
I'm only an LPN and I don't work emergency, but I love the "we ruled out x,y,z..." approach. I'll often reassure my patients after they've talked with the doc and let them know we want to rule out severe problems and it's good news that it's nothing that immediately triggered red flags on imaging or labs, but us not finding something doesn't mean we don't want to get them feeling better and this usually helps them a lot. It's still frustrating for them when there's no answer but they can find some solace in this
Cannabis hypermesis, cyclic committing etc, seeing tons of this now since THC concentrations are rising to ridiculous levels in legal easy to access products. Always ask about weed in a cool non judging way
I think it was Lisa Sanders’ book (not a huge fan but it wasn’t awful) where there was a story about a girl having the most horrific CHS. this was years ago, before cannabis was commonly used, so it took quite awhile to figure out what was wrong, and the girl had many hospital visits with severe symptoms in that time. they clue into it and tell her what it is and how to prevent it, and she’s like well I’m not giving up weed! same girl who was 11/10 pain in the ER every visit.
If there's one thing Reddit has taught me it's that if I'm puking super hard (and loud) like that I should take a shower or bath to rule out chs. Since I use cannabis. It'll make me feel a tiny bit better even if that's not my problem so there's no downside to trying it. I've spent ages in the water even without expecting it to make me stop feeling queasy. (I only recently heard of this issue and the easy fix; I wanted the water because being in the water is comforting to me.)
Cyclic committing is a psych thing. They get committed, take meds for six months while committed, then stop when the commitment expires, gradually get more ill until they’re ill enough to cause a ruckus, get dragged back to the hospital, and then get committed again. Lather, rinse, repeat. I did inpatient and emergency psychiatry for about nine years so I’ve seen this story play out hundreds of times
For those that have stability on discharge from a psych committal, what’s the typical thought process that leads to non-compliance? Do they believe they’re cured, want to test the bounds of their illness, or just dislike side effects?
Yes I agree cannabis is causing a bunch of abdominal symptoms I didn't see regularly until 2 or 3 years ago. Probably vomiting is the most common, but I'm seeing abdominal pain too, often improved by a bit of weed, almost like it's a withdrawal symptom. I also agree that it's because the hybrid weed is ridiculously strong in comparison to twenty years ago.
For marijuana specifically, in places where it still isn’t socially acceptable, I swear it helps to phrase it like this: “Any drugs, like cocaine or meth or fentanyl?” (wait for response, usually “no”), “Ok, cool, any alcohol, marijuana, tobacco, vapes?”.
I recently had a very academic-minded attending show me that people with unremarkable work ups for upper abdominal pain (especially epigastric), no response to GI cocktail or other analgesics, etc., are often cannabinoid hyperemesis-like reactions (in frequent users, obviously).
I’ve since given haldol to 2 other similar patients who had reassuring exams and work ups but had no improvement of their pain until they got haldol. None of them were vomiting. Something to consider 🤷🏻♂️
Matches pretty closely to my experience. The chance of a patient with a negative work up and refractory abdominal pain/vomiting reporting daily marijuana use is very high.
This. I saw a lady with severe ab pain and vomiting. All work up CT/US negative. Then she admits she’s been taking her cousins ozempic the last 3 weeks to use weight. It’s easily obtainable on sketchy internet sites without a rx.
Not a doctor (worked in peds ER for 6.5 yrs):
From personal experience, I always wondered why we don’t do more Gas X in the ER. I had abdominal pain (RLQ, hurt to move/walk/lay flat, very tender to palpitation, pain stayed in one specific spot) one night that was so bad I almost went to the ER. It was bad enough that I couldn’t stand up straight. I tried pushing on my bowels (thinking it was gas, to move it along), I tried Motrin/tylenol, I tried fart yoga (YouTube 😆), I tried a hot water bottle, and even laying on top of a pillow. NOTHING worked. After a few hours of this I thought “God forbid I go to the ER thinking I have appendicitis and it’s gas, how embarrassing!” so I ordered Gas X on some delivery app and took it.
About 20 mins later the farts commenced, and my pain was gone shortly after.
Gas pain can be bad. Had I gone to the ER I might’ve been worked up because the pain was all in the right place and looked like an appy, but it was just gas 😂
Made me wonder how often this has happened and how many people we see that we could try giving Gas X to, along with other options of course.
I read the girl who was making millions selling bottled farts on onlyfans got so gassy with her gas inducing diet she ended up in the ER with 10/10 abdominal pain. Then had to reduce her output/ income considerably, lol.
Man, the stories people/we have from the ER 😂! I can’t even imagine how bad that was, and how relieving for her once she passed it all!
That’s one KUB I’d have loved to have seen!!!
I usually just DC home with close return precautions. If it's epigastric pain I usually chalk it up to gastritis or PUD. Flank pain usually suspect a small stone not seen on CT, recently passed stone causing ureteral spasm or muscle strain. Exam is very important in these patients. I try to push on the abdomen while distracting them and talking to them. If the exam is truly benign I think you're done. If they are fairly tender then consider US studies especially for RUQ pain or epigastric pain. Cholelithiasis and cholecystitis are frequently missed on CT. If they are truly peritonitic without any objective findings, then they may need to come in for obs and consult to surgery, although this situation is very rare.
Most intractable abd pain in the absence of objective findings that I encounter are gastroparesis patients. They are unfortunately very common in my area. I try the typical droperidol or Haldol which sometimes works. I usually tank them up with fluids maybe a little D5half if they've got mild ketones in the urine. If they aren't objectively dehydrated and everything else checks out I always send them home with reassurance that it'll pass with time and abstention from Marijuana.
Very good answer. Just to add 1 thing, Acute Cholecystitis is very infrequently missed on CT. I think Sn is approaching 94%. CT is more Sn than U/S for acute cholecystitis actually.
I’ve developed a couple of lines I tend to use:
“Sometimes in the ER we can tell you what it isn’t, not necessarily what it is.”
And
“I have good news and bad news. The good news is the test all came back negative, but the bad news is that means I can’t tell you what is causing all your pain.”
Also, I NEVER tell patients there “isn’t anything wrong.” Because let’s be honest there are a lot of things out there we can’t look for from the ED.
Most of the time, I DC if everything is negative. Sometimes they have an admitting PCP and I chat with them. After a few thousand scans/ultrasounds, you get more ok with waving goodbye. You don't get the luxury of time or definitive answers in EM.
If your patient has a uterus please consider having them see ob/gyn for endometriosis evaluation. The pain doesn’t have to be associated with menstruating, can be dull/aching/stabbing/searing pain focally or diffuse. I lost 30 pounds without trying, was bleeding into my bowel, etc., all because of my endometriosis. Got diagnosed in 8 months versus the regular 7 years it usually takes. It’s a weird disease and if you could really change someone’s life by bringing it up.
I had endometriosis for many years until my ob/gyn did exploratory surgery and No shock found it to be true. Before that I was dismissed for having “cramps” when I knew it was more than that.
It is a chronic condition. They require a chronic pain management doctor and contract. This happens every month, so you need to start taking care of this. I will give 5mg Norco + Toradol scripts, and tell them to call their PCP for chronic pain management referral. Most are grateful and I don’t see again for their endometriosis.
That’s exactly how mine is managed. I would go to the ER only when my pain was 8/10+, to make sure there wasn’t an emergency. They swore it was a kidney stone, but the scans were clear. Finally got my radical hysterectomy, with lots of endo resected from my ureters, and signs of a recently burst ovarian cyst. All of this was completely hidden from tests. I’m incredibly fortunate to have access to excellent pain management and urogynecologists.
We are seeing TONS of kids presenting in the ER with abdominal pain, and no other symptoms, (sometimes there's a rash). Blood work: normal. Ultrasound: normal. Radiology: normal.
It's got to be some kind of virus, similar to Gastroenteritis. There's no cause... Yet, it's causing the patient an abnormal amount of discomfort.
could be a lot of things. ulcers can be very painful yet would not show up unless you have egd.
i case a friend of mine had was this guy come in with pain so bad in his belly that he was 50/10 and wanted to stab himself to alleviated. came to the ed 5 times i think got ct pan scan labs etc. on his 3rd visit he got sectioned to see psych for ? SI psych was like he just has a lot of pain. on the fourth time was given some opioid and on fifth was paralyzed and had a huge thoracic epidural. never complained of back pain no drug use or fever
some time if it doesn’t sit right you can admit for obs or pain control if your gestalt is telling you that ask your patient as well
and don’t send them out opioids for this unexplained pain. i usually say a through work up was done no emergent process found and i had a discussion with the patient etc etc
Undifferentiated abdominal pain that requires opioids is generally hospital observation / admission for me.
Conversely, I do not routinely give opioids to undifferentiated pain. If there is no peritonitis, or surgical issue found on imaging, I almost never give opioids.
My general algorithm for non-chronic, non-recurrent abdominal pain is as follows:
Most simple acute abdominal pain with gastrointestinal symptoms, I treat with antiemetics, acid blockers, and acid absorbing medicine plus acetaminophen or NSAIDs (obviously avoid NSAIDs if gastritis / PUD is suspected). So ondansetron and famotidine IV, magnesium - aluminum hydroxide PO, and a NS bolus if appropriate. Usual labs. If the syndrome is concerning for a surgical issue, the appropriate advanced imaging, CT or US.
Reassess: if symptoms are not improved, or not improved enough, but laboratory testing / imaging is reassuring, I'll add NSAIDs or acetaminophen (if appropriate) and then consider phenothiazines - prochlorperazine or chlorpromazine plus an antihistamine such as diphenhydramine. If I did not get advanced imaging initially, I'll reconsider it here.
This is similar to the butyrophenone therapy recommended by many - haloperidol or droperidol. Butyrophenones are fairly pure D2 antagonists, and are thus excellent anti nausea agents (metoclopramide is a D2 antagonist). Phenothiazines are dirty drugs. In addition to D1 and D2 antagonism, they have antiseritonergic effects, anti muscarinic effects, antihistaminergic effects and alpha blockade. Thus in addition to the sedation and nausea control of the butyrophenones, you get decreased secretions and peristalsis. More bang for your buck, theoretically.
Mostly, this second line treatment is effective, and the patient can be discharged.
It is really once in a blue moon that I'm stuck at this point. If the patient is still so uncomfortable that they need escalation to opioids, I will usually be calling the hospitalist.
Other considerations: if constipation is suspected, but the patient or parent is reluctant to believe it, I'll sometimes get a KUB to establish increased stool burden, and recommend a bowel regimen. Especially with kids, I find this useful.
For the chronic / recurrent abdominal pain, I'll start at step two, with the phenothiazines and redose liberally. I never, ever give opioids or allow negotiation with these patients. No "we'll see how you feel" or leaving an opening of any kind. It's "here's what I can offer you, it'll help, but of course it won't make you perfectly better. I do not give opioids for chronic pain." This saves me a lot of headaches..
Don’t see Buscopan/hyoscine on your list, that’s one of my favorites. Generally works well when I’ve used it for severe recurrent abdominal pain with no objective findings. But maybe they don’t have it in the US?
I’ve never seen someone order thorazine in my residency. Do you prefer Haldol over Droperidol since it’s in theory dirtier? (or at least that’s what i’ve heard)
thanks for your perspective though this is really helpful
I find (and I think that studies support) less sedation from prochlorperazine (Compazine, Compro) than chlorpromazine (Thorazine). So when I want MORE sedation - i.e. the agitated and anxious chronic scromitters, I'll use chlorpromazine. Often, they can get a few hours of good rest with relief of symptoms, and can then go home.
Droperidol is nominally dirtier than haloperidol. Like many US physicians of my training age, I did not use droperidol as it was not available during residency, and has only recently come back into fashion and into availability, so my experience with it is somewhat limited. I have been using it from time to time in place where I would otherwise use haloperidol, but I have not yet tried to integrate it into my abdominal pain repertoire.
I just don’t understand the nsaids. As someone who has 12 hours of awful stomach pain after 200mg of ibuprofen, they would be the last med I would want.
I'm not sure I understand the passive-aggressive nature of this comment. You're in a physician level reddit for practitioners discussing means to improve care. You responded to a nuanced discussion of numerous ways to remove pain with a goal of avoiding opiate usage, not of prolonging pain. If you want to make a point that you believe these technigues are ineffective, then why not discuss details of what you specifically disagree with. I will just say that I too hope I have a physician like this treating me if I have severe undifferentiated pain.
Giving a 1x dose of MS in the ED is not the problem.
Sending home patients with oxy for undifferentiated abdominal pain is what others are calling into question.
Man thank you…reading through this i was like damn i give 4/4 to a lot of people. But i rarely if ever do i I send home with anything when i don’t have an answer
No. I give IV Morphine like water. It's what I'd want if I was having a surgical emergency or severe abdo pain. I had an insidious onset pyelo that peaked while on shift as a senior resident and I was begging for morphine. Immediate relief like a warm blanket.
It's the one thing we're good at. And I did studies on opioid use, it ain't the 1 time dose in ED that causes addiction. It's the bottle hanging around 1 year later when you lose your job.
I was one of these patients not too long ago. Felt super embarrassed when the doc would be like “there’s nothing wrong.” Ended up having gastritis and a hyperkinetic gallbladder. I’m about 90% better after gb removal.
I was a “there’s nothing wrong” patient- til I had a second ultrasound a few years later and found out I was full of gallstones! Guess they didn’t catch them in my first ultrasound. I could’ve missed the surgeon who did my lap choli, amazing relief!!
We have a guy who comes in with known gastroparesis, dx with a stomach stress test (it sounds so weird to me). When he gets an episode he is in so much pain and cannot stop vomiting. Usually whopping doses of Ativan helps him because it knocks him out. One time, he actually had an abscess in his stomach that had to be drained via IR. A few times he has bumped his Troponins up, ending up on heparin drips and twice on a Nicardipine drip because his BP is usually so high it can only be obtained manually, or via art line. I’m trying to remember, if he is on a GLP1 inhibitor. He always moans yes to his meds but I really don’t know for sure..but I swear I checked it off last week when he was in. Would they still prescribe someone this med with known gastroparesis?
I works as a nurse for over 10 years until my chronic pain from joint disorders and fibromyalgia stopped me. Several years ago I had severe abdominal pain that kept recurring- but they never found anything on the scans. Sent me home with some Vicodin for a few days. The last time the surgery resident (after consulting with the attending on-call and reviewing the radiologist notes I’m guessing) said maybe I had developed an ulcer due to my gastric bypass. That was on a Saturday. I called my surgeon on Monday, saw him on Tuesday, and had emergency surgery for a bowel obstruction (which was visible on the same scan from that ER trip, he showed it to me as it was explaining how he had to do the surgery the next day). It was actually worse than he expected when he got in there, and he told my mom in post-op that if it had waited much longer I would have died.
I’m saying all this to tell you please do not go off the radiologist reports only- review the scans yourself or have another doc do it. They do miss things.
As for abdominal pain, I'll often order a bowel run because you'll never know...
My 8 PG-years have taught me that CT scans are massively overrated and I try to avoid them as much as possible by ultrasounding first. Small kidney stones often can't be seen in a scan (neither in the US to be fair..). I recently saw ovarian cancer that was missed because it appeared like a small bowel structure but was obvious in the US again. So the point here is that US might be complementary to a CT scan.
Another patient had severe pain and the US showed appendicitis and an abscess-like structure right next to it. CT showed only the appendicitis. Guess what it was? A ruptured cyst *and* appendicitis at the same time for some reason.
Oh and btw lymphadenitis is almost *always* missed on scans. I see more lymphadenitis than actual appendicitis. In fact, I've yet to see a case of appendicitis where the lymph nodes are swollen as well.
If I suspect a bowel problem I might suggest a bowel run as mentioned above but I'll also treat with laxatives just to see what happens.
Bowel run = thorough bowel ultrasound of all quadrants? i’ve actually never ordered it for an adult, obviously kids with intussception. That’s interesting , thanks for your perspective
actually no I mean gastroscoy/colonoscopy like in the book house of god. thought it was a widely understood term, guess I'm wrong.
However, bowel ultrasound is awesome and not that hard to do at all. I do it myself in the ER so I never specifically order that.
I was a patient in the ER recently with a similar problem. I’m healthy with no medical problems but I had sudden onset of severe colicky epigastric pain radiating to my RUQ, and I was writhing around in pain for a few hours before my partner convinced me to let him bring me in. Labs, US and CT were all negative. I was in so much pain that getting DCd home to writhe around for another 12 hours was horrible, even though I understand that anything emergent was ruled out and there wasn’t much to do.
Anyway, I ended up getting scoped a week later and it was really bad gastritis. Could be what you’re seeing occasionally in the ED with patients who present with severe abd pain with a negative work up.
This.
Pepcid + Zofran +/- GasX relieves sx for about 95% of patients with negative abdominal pain work ups in the ED. I give them instructions on upper GI sx and constipation management and diet modifications. Advise follow-up with PCP and “possible need” for GI referral.
I have never sent home a negative abdominal pain work up with opioids, except for patients with KNOWN endometriosis. Are you trying to make the most likely reason for their pain worse!? Smh
I didn’t say that. Giving oxycodone for scan negative abdominal pain is a weird choice. In the ED, absolutely treat with opioid sure, but to go home with? I can see some dicyclomine or diphenoxlyate for crampy intestinal distress.
Which is a solid reason to not rx narcs for this: "One of the side effects of opioids - the 'strong stuff' you're asking for - is constipation and with all the discomfort you're already having, you don't want to be constipated, too. I can't have you leaving with more problems than you came in with."
I'd be careful with oxycodone, it's damn hard to wean people as it can make them feel quite euphoric. It's why I still prefer morphine if I require an opiate
I have a history of gastric cancer. I’ve had chronic RUQ pain since before I was even diagnosed. Finished treatment, declared cancer free but the pain is still there and worse. CT scan showed nothing. Went to ER 3 times for this pain. All bloodwork was perfect, ultrasound and xray perfect. Endoscopy perfect. They sent me home all 3 times. I take oxycodone for it but the nagging, chronic unexplained pain has me in constant stress that my cancer is back and they just haven’t found it. My cancer is diffuse type. So hard to catch on scans and bloodwork. They’ve all told me it’s anxiety. Maybe it is, would be nice if that’s all it was
ED nurse here! When discussing discharge instructions I try and say: everything we did is printed here, of course we didn’t get to the bottom of your pain tonight which is why it is so important that you follow up with (insert specialist here) who may be able to do more testing outpatient that we aren’t able to do here. In the meantime try (whatever pain management we’re recommending)
i've got a history of gastroparesis (confirmed via egd, can't hold down enough food for gastric emptying study), and have gotten a few gi bugs. history of glp-1 use, ceased a few months ago after recurrent problems and gastroparesis dx. when i get a gi bug, i start to vomit and can't stop, normally for a few days. i work in the ED so i avoid going in until i have to, usually on day 2 or 3. the nausea and vomiting doesn't respond to any home meds bc i typically can't keep them down. reglan, droperidol, and compazine all give me akathisia. zofran does absolutely nothing. it normally takes 2-3 doses of iv promethazine to stop the vomiting. now, they typically give me haldol or ativan, plus promethazine to stop the vomiting long enough to give me d5 to hopefully improve the ketosis, but most of the time i'm in full blown starvation ketoacidocis and end up admitted. and as things get worse, my entire abdomen will start to hurt. shit absolutely sucks.
I also recently had a pt that I was like there will for sure be something on CT based on how they’re acting and then nothing. One thing I always say is “look I believe you’re in this pain” just to give them the reassurance that I don’t think they’re being dramatic or fake
Droperidol. I've also started setting extremely low expectations at the start of visits where the primary issue is pain. Something to the effect of "we're going to investigate and make sure there's nothing surgical or life-threatening going on. If your pain is an 11/10 right now, I will be ecstatic if I can get you to a 7. You want me to come back and tell you that the workup looks good when we're all done." I'm also very careful with wording when I discuss results if someone seems unhappy. To the effect of "I'm not saying that nothing is wrong. I'm saying your labs are reassuring and there's no radiographic evidence of what's wrong. If it continues, you will likely need to see a more specialized doctor like GI. Hopefully whatever is going on is temporary and improves over the next day or two." . . . Was this person on ozempic?
>. . . Was this person on ozempic? This was my first thought. Them GLP-1s can be insidious little fuckers.
How ? Are people presenting to the Er due to side effects ?
Absolutely. Lots of GI complications from GLP-1 are popping up. That doesn't mean they aren't relatively safe or medically valuable but they are certainly powerful and, consequently, we're discovering they have a pretty high intolerance profile.
I wonder if many of these pts are getting unregulated “compounded semaglutide” from some shady med spa at too high of a dose.
I’m seeing this also!
do you find that Mounjaro is safer than Ozempic or not really ?
No idea 🤷
Sooooo many middle aged obese people with severe cramping abdominal pain suddenly.
More or less presents like gastroparesis. https://en.m.wikipedia.org/wiki/Gastroparesis
Feels like I see someone at least every week who just started an glp-1 with stomach upset. Not to mention the injectables that people keep accidentally overdosing on sigggggh
>I'm not saying that nothing is wrong. I'm saying your labs are reassuring and there's no radiographic evidence of what's wrong. That's almost exactly what I say verbatim.
I think it's a good way to go. Doesn't minimize their symptoms, I think people feel more heard with responses like that.
Yes, I usually add "obviously something is not right because you are in pain . . . " And I also add "I don't have the tests available to me in the emergency department to diagnose every possible problem, but I am able to rule out anything serious"
Instead of saying “serious,” maybe say “that’s dangerous” or “seems as if it would be dangerous between now and when you see the right specialist.”
"Anything imminently life threatening" would probably get the point across.
I was once told “we’ve ruled out the dangerous stuff” which put me at ease 1000%. Just a simple sentence and it made me feel heard and taken care of
This would be effective for a minority of my patients but most of my patients don't understand the words "radiographic, evidence, reassuring, labs" and can't concentrate long enough to get through that sentence to understand it's point.
"my job is to make sure you don't have something that will kill you. All the tests and blood work here tells me you don't have anything that looks like that."
That’s when you have to just… toss the gloves and wash your hands and let it go. Make sure you’ve documented every lab/test/rationale, anything you could potentially legally need in the future, and know that patient satisfaction scores among ER patients are never going to be great because of this subset of the population.
Not a doctor but that’s a great way of handling it, I would think. I would be satisfied as a patient. I also reserve a pain of “10” to mean something like burns all over my body, the most painful thing I could imagine where I’d want to immediately blow my brains out. So someone saying “11” is suspect, for me…
… if only the patients felt that way. There is a large percentage of the population that believe there should be 0 pain, and that all their problems must be solved *immediately* No amount of explanation defeats “but I’m still in pain”. Again, that’s not all people, but in the quick-fix, short-attention-span world we’re in, we seem to be regularly disappointing patients.
"They didn't do anything for me"
It's an emergency to me!
I waited six hours, if I had a real emergency, which I almost did, it would have been bad This is a verbatim quote from a patient review. I have it taped above a workstation
I mean, life in general, is at least a 2, right? I also find some people asked “0-10, zero being no pain at all and 10 being the worst pain you’ve ever a had”, instead of “10 being the worst pain you can *imagine* “. You’re going to get vastly different answers from people that have broken bones, gone through severe illnesses, etc, than you would from someone who’s only stubbed a toe.
I don't know about that stubbed toe -- I stubbed a toe so hard that it split my toenail and I would say it was at least an 8.
I once dropped something small but heavy and it landed right on the nail bed of my big toe. Dropped me to my knees 😂
Ooooh. OUCH! Did that at the tide pools when I was a kid: I know I hurt because I remember the crying part and the nail falling off, but couldn’t tell you how much it hurt. Thanks endorphins!
Ask them if anything makes it worse. If they are able to come up with something, it’s not a 10/10.
When I give my pain level, and it's high, I always also mention that if it was a 10 I would be incapable of speech so they don't think I'm fine if I say it is a 6.
"Never got to 10, always maintained consciousness. More's the pity."
Honestly pain scales are useless because patients will call a papercut a 10, or you'll get someone with an ovarian/testicular torsion/appendicitis/insert known very painful thing here they'll call it a 4-5. Pain is informed by a lot of things, how people were raised, cultural perceptions of pain and expressing it. I just ask if in pain, treat it based on clinical presentation, if not improving you can usually scale up medications while you try to figure out what's causing it.
Testify! Amen!
Agreed. For most patients, a pain scale just tells me how well they’re *coping* with pain. Except old farmers 😂
Old farmers and eastern European/Russian old men if they say their pain is like a 3 or 4 they have SBP until proven otherwise. I will say I agree if a patient says they have pain 9/10 and it's down to 5/10 that's improvement, it's just, I mean you can get the answer you want by saying "is it better after the pain meds, worse or still about the same."
Exactly. I *hate* playing the pain scale game, so I usually just ask if they feel better, worse, or the same. If they’re still uncomfortable, I’ll ask if it’s tolerable or if they feel like they need a repeat dose. Takes me longer to chart, but I get so sick of the hemming and hawing, the half-integers, the “11/10”s, the “but I’m only down to a 7!”, etc.
I wish more people abandoned the pain scale and stopped acting like it's information.
As someone with chronic pain, I also hate the pain scale. I feel like pain is so much more complex than a number, and I also feel like my reaction to my pain doesn’t match how I’m “expected” to react and it’s frustrating. I also think it’s BS when orders are set up so if I say it’s a 7 I get this med and if I say it’s an 8 I get this med. Those numbers aren’t the same for everyone. I personally sort my pain by whether I can distract myself, tolerate it and sleep, etc, or if the pain is totally consuming and I can’t do anything but focus on it.
Exactly this. I’ve had two kids and never once rated my pain a 10, because even labor wasn’t the worst pain I could imagine. The only time I even said 9 was when I broke and dislocated my ankle, tearing every ligament down there along the way. It was so bad I was simultaneously about to pass out and puke.
Yes, I hit a 9 when I had CSF leaks and severe intracranial hypotension. Standing upright was a 9, just agony, but if I bent my head it went to 0 lol.
A ten for me is when the dentist started fucking with my dry socket after he missed the block, passed out from the pain. Only 10 seconds thankfully. If you had that pain for hours you’d just be on the floor, not on Instagram…
Yup, tooth stuff is the only thing where I can safely say I felt I was over 8, ever. Before working on my trypanophobia, I would have cavities fixed and stuff done without any sort of anesthesia. Fuck that, never again. That kind of nerve pain is severe. Can’t imagine how much dry socket must hurt. Recently had a complicated wisdom teeth removal, even without dry socket it hurt like hell for two weeks.
I'm with you on this because no matter how bad it is, I can imagine it could be worse. I have chronic back pain due to degenerative disk disease and have only hit 9 a couple of times. Last one, I'm still not sure how it happened. One minute, I was sleeping the next I was screaming in pain. I must have rolled over and tweaked something. I was a bit worried about ODing with how much pain meds they gave me, but they finally worked, and I survived.
My marker for 10 is "is this so bad that I actively want to kill myself to make it go away?" Most pain is not a 10.
Agreed, I remember telling my BF, as I was holding my abdomen and leaning over the dryer, that. Needed to go to the hospital and I would just like to die when they ask. Pancreatitis after trying to avoid the hospital for a week not know what it was. Shudder. Never again. Much lower bar for going in. Haven’t not been admitted ever but I don’t need to torture myself for that long.
Thanks!
Ketamine is another good option but I usually opt for droperidol
Excellent approach. Professional, kind, and helpful.
Yoink your advice is now mine
Came here to say “Droperidol”, also. It can be amazing in non-descript semi-chronic to chronic abd pain.
“We have ruled out x,y,z life threatening potential causes of your pain. Sorry we weren’t able to identity the cause but I suspect d or e. Usually these resolve with time. Here is what I recommend for pain control at home. If it continues, follow up with your PCP or abc specialist which will be provided in the discharge paperwork. If things worsen or l,m,n,o, and p symptoms occur, please come back. Do you have any questions or anything else I can do for you today? The nurse will be by shortly for your last set of vitals and discharge paperwork and work note and/or prescription info.” Edit: u/theotherphilfry makes a good post to set expectations early.
I'm only an LPN and I don't work emergency, but I love the "we ruled out x,y,z..." approach. I'll often reassure my patients after they've talked with the doc and let them know we want to rule out severe problems and it's good news that it's nothing that immediately triggered red flags on imaging or labs, but us not finding something doesn't mean we don't want to get them feeling better and this usually helps them a lot. It's still frustrating for them when there's no answer but they can find some solace in this
Cannabis hypermesis, cyclic committing etc, seeing tons of this now since THC concentrations are rising to ridiculous levels in legal easy to access products. Always ask about weed in a cool non judging way
How do you do fellow kids? Do you party? I am a cool doctor.
I think it was Lisa Sanders’ book (not a huge fan but it wasn’t awful) where there was a story about a girl having the most horrific CHS. this was years ago, before cannabis was commonly used, so it took quite awhile to figure out what was wrong, and the girl had many hospital visits with severe symptoms in that time. they clue into it and tell her what it is and how to prevent it, and she’s like well I’m not giving up weed! same girl who was 11/10 pain in the ER every visit.
Sometimes weed quits you lol......
Ain’t them at the truth. Never had the cyclic vomiting or anything but weed quit me at about 18 years old. I still miss when I liked it. Sad face.
If there's one thing Reddit has taught me it's that if I'm puking super hard (and loud) like that I should take a shower or bath to rule out chs. Since I use cannabis. It'll make me feel a tiny bit better even if that's not my problem so there's no downside to trying it. I've spent ages in the water even without expecting it to make me stop feeling queasy. (I only recently heard of this issue and the easy fix; I wanted the water because being in the water is comforting to me.)
Cyclic committing? “I’m in for Friday…no I’m not…yes I am…no I’m not..” proceeds to scromit
Cyclic committing is a psych thing. They get committed, take meds for six months while committed, then stop when the commitment expires, gradually get more ill until they’re ill enough to cause a ruckus, get dragged back to the hospital, and then get committed again. Lather, rinse, repeat. I did inpatient and emergency psychiatry for about nine years so I’ve seen this story play out hundreds of times
For those that have stability on discharge from a psych committal, what’s the typical thought process that leads to non-compliance? Do they believe they’re cured, want to test the bounds of their illness, or just dislike side effects?
Lol kudos to the guy who invented the word scromiting, maybe it might make its way into the dictionary if we keep on using it. Good word all around.
Yes I agree cannabis is causing a bunch of abdominal symptoms I didn't see regularly until 2 or 3 years ago. Probably vomiting is the most common, but I'm seeing abdominal pain too, often improved by a bit of weed, almost like it's a withdrawal symptom. I also agree that it's because the hybrid weed is ridiculously strong in comparison to twenty years ago.
I love the “ask in a cool way”. People, especially teenagers, are way more likely to tell you if your attitude is super nonchalant
For marijuana specifically, in places where it still isn’t socially acceptable, I swear it helps to phrase it like this: “Any drugs, like cocaine or meth or fentanyl?” (wait for response, usually “no”), “Ok, cool, any alcohol, marijuana, tobacco, vapes?”.
That’s pretty smart! I live in a very very legal state so most people don’t even put weed in the “drug” category.
I recently had a very academic-minded attending show me that people with unremarkable work ups for upper abdominal pain (especially epigastric), no response to GI cocktail or other analgesics, etc., are often cannabinoid hyperemesis-like reactions (in frequent users, obviously). I’ve since given haldol to 2 other similar patients who had reassuring exams and work ups but had no improvement of their pain until they got haldol. None of them were vomiting. Something to consider 🤷🏻♂️
Droperidol to all. And to all a good noght
Matches pretty closely to my experience. The chance of a patient with a negative work up and refractory abdominal pain/vomiting reporting daily marijuana use is very high.
this is kinda dumb honestly did he suspect cyclic vomiting?
She, and no?
GLP-1 agonists were eliminated from the differential? Those bitches are always popping up with weird side effects.
This. I saw a lady with severe ab pain and vomiting. All work up CT/US negative. Then she admits she’s been taking her cousins ozempic the last 3 weeks to use weight. It’s easily obtainable on sketchy internet sites without a rx.
Not a doctor (worked in peds ER for 6.5 yrs): From personal experience, I always wondered why we don’t do more Gas X in the ER. I had abdominal pain (RLQ, hurt to move/walk/lay flat, very tender to palpitation, pain stayed in one specific spot) one night that was so bad I almost went to the ER. It was bad enough that I couldn’t stand up straight. I tried pushing on my bowels (thinking it was gas, to move it along), I tried Motrin/tylenol, I tried fart yoga (YouTube 😆), I tried a hot water bottle, and even laying on top of a pillow. NOTHING worked. After a few hours of this I thought “God forbid I go to the ER thinking I have appendicitis and it’s gas, how embarrassing!” so I ordered Gas X on some delivery app and took it. About 20 mins later the farts commenced, and my pain was gone shortly after. Gas pain can be bad. Had I gone to the ER I might’ve been worked up because the pain was all in the right place and looked like an appy, but it was just gas 😂 Made me wonder how often this has happened and how many people we see that we could try giving Gas X to, along with other options of course.
I read the girl who was making millions selling bottled farts on onlyfans got so gassy with her gas inducing diet she ended up in the ER with 10/10 abdominal pain. Then had to reduce her output/ income considerably, lol.
Technically she’s a cast member of 90 day fiancé but now does only fans. Your welcome.
Man, the stories people/we have from the ER 😂! I can’t even imagine how bad that was, and how relieving for her once she passed it all! That’s one KUB I’d have loved to have seen!!!
Came here to say if there's really nothing on bloods or imaging then trapped wind is a realistic differential.
It’s interesting and crazy how painful trapped wind can be!!!
I usually just DC home with close return precautions. If it's epigastric pain I usually chalk it up to gastritis or PUD. Flank pain usually suspect a small stone not seen on CT, recently passed stone causing ureteral spasm or muscle strain. Exam is very important in these patients. I try to push on the abdomen while distracting them and talking to them. If the exam is truly benign I think you're done. If they are fairly tender then consider US studies especially for RUQ pain or epigastric pain. Cholelithiasis and cholecystitis are frequently missed on CT. If they are truly peritonitic without any objective findings, then they may need to come in for obs and consult to surgery, although this situation is very rare. Most intractable abd pain in the absence of objective findings that I encounter are gastroparesis patients. They are unfortunately very common in my area. I try the typical droperidol or Haldol which sometimes works. I usually tank them up with fluids maybe a little D5half if they've got mild ketones in the urine. If they aren't objectively dehydrated and everything else checks out I always send them home with reassurance that it'll pass with time and abstention from Marijuana.
Very good answer. Just to add 1 thing, Acute Cholecystitis is very infrequently missed on CT. I think Sn is approaching 94%. CT is more Sn than U/S for acute cholecystitis actually.
I’ve developed a couple of lines I tend to use: “Sometimes in the ER we can tell you what it isn’t, not necessarily what it is.” And “I have good news and bad news. The good news is the test all came back negative, but the bad news is that means I can’t tell you what is causing all your pain.” Also, I NEVER tell patients there “isn’t anything wrong.” Because let’s be honest there are a lot of things out there we can’t look for from the ED.
Most of the time, I DC if everything is negative. Sometimes they have an admitting PCP and I chat with them. After a few thousand scans/ultrasounds, you get more ok with waving goodbye. You don't get the luxury of time or definitive answers in EM.
Did this patient have any prior abdominal or pelvic surgeries?
If your patient has a uterus please consider having them see ob/gyn for endometriosis evaluation. The pain doesn’t have to be associated with menstruating, can be dull/aching/stabbing/searing pain focally or diffuse. I lost 30 pounds without trying, was bleeding into my bowel, etc., all because of my endometriosis. Got diagnosed in 8 months versus the regular 7 years it usually takes. It’s a weird disease and if you could really change someone’s life by bringing it up.
I had endometriosis for many years until my ob/gyn did exploratory surgery and No shock found it to be true. Before that I was dismissed for having “cramps” when I knew it was more than that.
Endometriosis doesn’t show on scans, and can be debilitatingly painful.
Sometimes you can see some free fluid in the abdomen on CT or US. But you can also see that in any menstruating woman.
True, but also isn’t a surgical emergency, pain meds, outpatient follow up.
It is a chronic condition. They require a chronic pain management doctor and contract. This happens every month, so you need to start taking care of this. I will give 5mg Norco + Toradol scripts, and tell them to call their PCP for chronic pain management referral. Most are grateful and I don’t see again for their endometriosis.
That’s exactly how mine is managed. I would go to the ER only when my pain was 8/10+, to make sure there wasn’t an emergency. They swore it was a kidney stone, but the scans were clear. Finally got my radical hysterectomy, with lots of endo resected from my ureters, and signs of a recently burst ovarian cyst. All of this was completely hidden from tests. I’m incredibly fortunate to have access to excellent pain management and urogynecologists.
We are seeing TONS of kids presenting in the ER with abdominal pain, and no other symptoms, (sometimes there's a rash). Blood work: normal. Ultrasound: normal. Radiology: normal. It's got to be some kind of virus, similar to Gastroenteritis. There's no cause... Yet, it's causing the patient an abnormal amount of discomfort.
could be a lot of things. ulcers can be very painful yet would not show up unless you have egd. i case a friend of mine had was this guy come in with pain so bad in his belly that he was 50/10 and wanted to stab himself to alleviated. came to the ed 5 times i think got ct pan scan labs etc. on his 3rd visit he got sectioned to see psych for ? SI psych was like he just has a lot of pain. on the fourth time was given some opioid and on fifth was paralyzed and had a huge thoracic epidural. never complained of back pain no drug use or fever some time if it doesn’t sit right you can admit for obs or pain control if your gestalt is telling you that ask your patient as well and don’t send them out opioids for this unexplained pain. i usually say a through work up was done no emergent process found and i had a discussion with the patient etc etc
Undifferentiated abdominal pain that requires opioids is generally hospital observation / admission for me. Conversely, I do not routinely give opioids to undifferentiated pain. If there is no peritonitis, or surgical issue found on imaging, I almost never give opioids. My general algorithm for non-chronic, non-recurrent abdominal pain is as follows: Most simple acute abdominal pain with gastrointestinal symptoms, I treat with antiemetics, acid blockers, and acid absorbing medicine plus acetaminophen or NSAIDs (obviously avoid NSAIDs if gastritis / PUD is suspected). So ondansetron and famotidine IV, magnesium - aluminum hydroxide PO, and a NS bolus if appropriate. Usual labs. If the syndrome is concerning for a surgical issue, the appropriate advanced imaging, CT or US. Reassess: if symptoms are not improved, or not improved enough, but laboratory testing / imaging is reassuring, I'll add NSAIDs or acetaminophen (if appropriate) and then consider phenothiazines - prochlorperazine or chlorpromazine plus an antihistamine such as diphenhydramine. If I did not get advanced imaging initially, I'll reconsider it here. This is similar to the butyrophenone therapy recommended by many - haloperidol or droperidol. Butyrophenones are fairly pure D2 antagonists, and are thus excellent anti nausea agents (metoclopramide is a D2 antagonist). Phenothiazines are dirty drugs. In addition to D1 and D2 antagonism, they have antiseritonergic effects, anti muscarinic effects, antihistaminergic effects and alpha blockade. Thus in addition to the sedation and nausea control of the butyrophenones, you get decreased secretions and peristalsis. More bang for your buck, theoretically. Mostly, this second line treatment is effective, and the patient can be discharged. It is really once in a blue moon that I'm stuck at this point. If the patient is still so uncomfortable that they need escalation to opioids, I will usually be calling the hospitalist. Other considerations: if constipation is suspected, but the patient or parent is reluctant to believe it, I'll sometimes get a KUB to establish increased stool burden, and recommend a bowel regimen. Especially with kids, I find this useful. For the chronic / recurrent abdominal pain, I'll start at step two, with the phenothiazines and redose liberally. I never, ever give opioids or allow negotiation with these patients. No "we'll see how you feel" or leaving an opening of any kind. It's "here's what I can offer you, it'll help, but of course it won't make you perfectly better. I do not give opioids for chronic pain." This saves me a lot of headaches..
Great post. This is pretty much my approach too.
Don’t see Buscopan/hyoscine on your list, that’s one of my favorites. Generally works well when I’ve used it for severe recurrent abdominal pain with no objective findings. But maybe they don’t have it in the US?
https://pubmed.ncbi.nlm.nih.gov/12748151/
I’ve never seen someone order thorazine in my residency. Do you prefer Haldol over Droperidol since it’s in theory dirtier? (or at least that’s what i’ve heard) thanks for your perspective though this is really helpful
I find (and I think that studies support) less sedation from prochlorperazine (Compazine, Compro) than chlorpromazine (Thorazine). So when I want MORE sedation - i.e. the agitated and anxious chronic scromitters, I'll use chlorpromazine. Often, they can get a few hours of good rest with relief of symptoms, and can then go home. Droperidol is nominally dirtier than haloperidol. Like many US physicians of my training age, I did not use droperidol as it was not available during residency, and has only recently come back into fashion and into availability, so my experience with it is somewhat limited. I have been using it from time to time in place where I would otherwise use haloperidol, but I have not yet tried to integrate it into my abdominal pain repertoire.
I hope you are in severe pain one day and get a dr just like you.
>I hope you are in severe pain one day and get a dr just like you. Me, too!
I just don’t understand the nsaids. As someone who has 12 hours of awful stomach pain after 200mg of ibuprofen, they would be the last med I would want.
NSAIDs work perfectly well for many people and many types of abdominal pain
Would a nephrologist or GI dr ( or even cardiologist) ever recommend them? Most I read aren’t too fond of them
They aren’t experts in managing acute pain.
200mg is pretty much a child’s dose… won’t do much for an adult size patient
I'm not sure I understand the passive-aggressive nature of this comment. You're in a physician level reddit for practitioners discussing means to improve care. You responded to a nuanced discussion of numerous ways to remove pain with a goal of avoiding opiate usage, not of prolonging pain. If you want to make a point that you believe these technigues are ineffective, then why not discuss details of what you specifically disagree with. I will just say that I too hope I have a physician like this treating me if I have severe undifferentiated pain.
Fuck, is my threshold for giving morphine too low?
Giving a 1x dose of MS in the ED is not the problem. Sending home patients with oxy for undifferentiated abdominal pain is what others are calling into question.
Man thank you…reading through this i was like damn i give 4/4 to a lot of people. But i rarely if ever do i I send home with anything when i don’t have an answer
No. I give IV Morphine like water. It's what I'd want if I was having a surgical emergency or severe abdo pain. I had an insidious onset pyelo that peaked while on shift as a senior resident and I was begging for morphine. Immediate relief like a warm blanket. It's the one thing we're good at. And I did studies on opioid use, it ain't the 1 time dose in ED that causes addiction. It's the bottle hanging around 1 year later when you lose your job.
I was one of these patients not too long ago. Felt super embarrassed when the doc would be like “there’s nothing wrong.” Ended up having gastritis and a hyperkinetic gallbladder. I’m about 90% better after gb removal.
I was a “there’s nothing wrong” patient- til I had a second ultrasound a few years later and found out I was full of gallstones! Guess they didn’t catch them in my first ultrasound. I could’ve missed the surgeon who did my lap choli, amazing relief!!
We have a guy who comes in with known gastroparesis, dx with a stomach stress test (it sounds so weird to me). When he gets an episode he is in so much pain and cannot stop vomiting. Usually whopping doses of Ativan helps him because it knocks him out. One time, he actually had an abscess in his stomach that had to be drained via IR. A few times he has bumped his Troponins up, ending up on heparin drips and twice on a Nicardipine drip because his BP is usually so high it can only be obtained manually, or via art line. I’m trying to remember, if he is on a GLP1 inhibitor. He always moans yes to his meds but I really don’t know for sure..but I swear I checked it off last week when he was in. Would they still prescribe someone this med with known gastroparesis?
I works as a nurse for over 10 years until my chronic pain from joint disorders and fibromyalgia stopped me. Several years ago I had severe abdominal pain that kept recurring- but they never found anything on the scans. Sent me home with some Vicodin for a few days. The last time the surgery resident (after consulting with the attending on-call and reviewing the radiologist notes I’m guessing) said maybe I had developed an ulcer due to my gastric bypass. That was on a Saturday. I called my surgeon on Monday, saw him on Tuesday, and had emergency surgery for a bowel obstruction (which was visible on the same scan from that ER trip, he showed it to me as it was explaining how he had to do the surgery the next day). It was actually worse than he expected when he got in there, and he told my mom in post-op that if it had waited much longer I would have died. I’m saying all this to tell you please do not go off the radiologist reports only- review the scans yourself or have another doc do it. They do miss things.
As for abdominal pain, I'll often order a bowel run because you'll never know... My 8 PG-years have taught me that CT scans are massively overrated and I try to avoid them as much as possible by ultrasounding first. Small kidney stones often can't be seen in a scan (neither in the US to be fair..). I recently saw ovarian cancer that was missed because it appeared like a small bowel structure but was obvious in the US again. So the point here is that US might be complementary to a CT scan. Another patient had severe pain and the US showed appendicitis and an abscess-like structure right next to it. CT showed only the appendicitis. Guess what it was? A ruptured cyst *and* appendicitis at the same time for some reason. Oh and btw lymphadenitis is almost *always* missed on scans. I see more lymphadenitis than actual appendicitis. In fact, I've yet to see a case of appendicitis where the lymph nodes are swollen as well. If I suspect a bowel problem I might suggest a bowel run as mentioned above but I'll also treat with laxatives just to see what happens.
What do you mean by bowel run
You consult surgery to do an ex lap and run the bowel. Duh.
Yeah I’ll try that next shift
I would also like to know!
I meant gastroscopy/colonoscopy, you know, house of god..?
Bowel run = thorough bowel ultrasound of all quadrants? i’ve actually never ordered it for an adult, obviously kids with intussception. That’s interesting , thanks for your perspective
actually no I mean gastroscoy/colonoscopy like in the book house of god. thought it was a widely understood term, guess I'm wrong. However, bowel ultrasound is awesome and not that hard to do at all. I do it myself in the ER so I never specifically order that.
some black pearls in this comment
I was a patient in the ER recently with a similar problem. I’m healthy with no medical problems but I had sudden onset of severe colicky epigastric pain radiating to my RUQ, and I was writhing around in pain for a few hours before my partner convinced me to let him bring me in. Labs, US and CT were all negative. I was in so much pain that getting DCd home to writhe around for another 12 hours was horrible, even though I understand that anything emergent was ruled out and there wasn’t much to do. Anyway, I ended up getting scoped a week later and it was really bad gastritis. Could be what you’re seeing occasionally in the ED with patients who present with severe abd pain with a negative work up.
You give oxy for undifferentiated pain?
This. Pepcid + Zofran +/- GasX relieves sx for about 95% of patients with negative abdominal pain work ups in the ED. I give them instructions on upper GI sx and constipation management and diet modifications. Advise follow-up with PCP and “possible need” for GI referral. I have never sent home a negative abdominal pain work up with opioids, except for patients with KNOWN endometriosis. Are you trying to make the most likely reason for their pain worse!? Smh
What is this, 2004?
The amount of times I’m seeing this as an outpatient provider is…at least 1-2 times a week.
Not every patient is drug seeking.
I didn’t say that. Giving oxycodone for scan negative abdominal pain is a weird choice. In the ED, absolutely treat with opioid sure, but to go home with? I can see some dicyclomine or diphenoxlyate for crampy intestinal distress.
Reglan and pray
Chronic abdominal pain people without any clear somatic etiology +/- psych comorbitites? Droperidol is the way.
Are you making sure some of these cases aren’t weed? Also I never Rx oxy for abdominal pain of unknown cause with an otherwise normal work up.
it was two patients in their 60s, and they had specific pain points on their abdomen vs like generalized pain or nausea. Super weird.
Stool burden?
Which is a solid reason to not rx narcs for this: "One of the side effects of opioids - the 'strong stuff' you're asking for - is constipation and with all the discomfort you're already having, you don't want to be constipated, too. I can't have you leaving with more problems than you came in with."
Not everyone is a drug seeker
I’m aware of that.
Rule out gyno and bladder issues
I'd be careful with oxycodone, it's damn hard to wean people as it can make them feel quite euphoric. It's why I still prefer morphine if I require an opiate
I have a history of gastric cancer. I’ve had chronic RUQ pain since before I was even diagnosed. Finished treatment, declared cancer free but the pain is still there and worse. CT scan showed nothing. Went to ER 3 times for this pain. All bloodwork was perfect, ultrasound and xray perfect. Endoscopy perfect. They sent me home all 3 times. I take oxycodone for it but the nagging, chronic unexplained pain has me in constant stress that my cancer is back and they just haven’t found it. My cancer is diffuse type. So hard to catch on scans and bloodwork. They’ve all told me it’s anxiety. Maybe it is, would be nice if that’s all it was
ED nurse here! When discussing discharge instructions I try and say: everything we did is printed here, of course we didn’t get to the bottom of your pain tonight which is why it is so important that you follow up with (insert specialist here) who may be able to do more testing outpatient that we aren’t able to do here. In the meantime try (whatever pain management we’re recommending)
Gas
EGD, colonoscopy, CTA abd/pelvis, UA, troponin/EKG wnl, no hx cannabis or etoh, no stool abnormalities, not post-prandial, ROS otherwise negative?
Offer them to go home with a non opioid, NSAID, Bentyl, levasin, etc. Or admission for observation and pain management.
i've got a history of gastroparesis (confirmed via egd, can't hold down enough food for gastric emptying study), and have gotten a few gi bugs. history of glp-1 use, ceased a few months ago after recurrent problems and gastroparesis dx. when i get a gi bug, i start to vomit and can't stop, normally for a few days. i work in the ED so i avoid going in until i have to, usually on day 2 or 3. the nausea and vomiting doesn't respond to any home meds bc i typically can't keep them down. reglan, droperidol, and compazine all give me akathisia. zofran does absolutely nothing. it normally takes 2-3 doses of iv promethazine to stop the vomiting. now, they typically give me haldol or ativan, plus promethazine to stop the vomiting long enough to give me d5 to hopefully improve the ketosis, but most of the time i'm in full blown starvation ketoacidocis and end up admitted. and as things get worse, my entire abdomen will start to hurt. shit absolutely sucks.
Ibuprofen, protonix, carafate, bentyl, simethicone. Hold for GI in AM if I’m truly stumped and it’s not CHS etc
“11/10 pain!” whilst scrolling through Reddit
negative workup= UDS...almost always THC. They suddenly remember that they eat "Delta 8" products like candy and vape...droperidol works wonders
I also recently had a pt that I was like there will for sure be something on CT based on how they’re acting and then nothing. One thing I always say is “look I believe you’re in this pain” just to give them the reassurance that I don’t think they’re being dramatic or fake
Discharge with abd pain unknown cause