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LEARNING OBJECTIVES

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  1. Accurately identify the most likely etiology when patients present with heartburn or abdominal pain, thorough history, diagnostic tests, and ppropriate patient findings on examination, to enable the appropriate recommendation of effective treatment or referral to an appropriate provider.

  2. Use the knowledge of the pathophysiology, etiology, and common presentation of abdominal complaints as a primary symptom to review prescription orders for appropriateness and to accurately educate patients about their disease and its treatment.

  3. Use the knowledge of the pathophysiology, etiology, and common presentation of diseases with heartburn or abdominal pain as a primary symptom to accurately interpret the diagnostic process to advise regarding the most appropriate prescription therapy.

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ETIOLOGY

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Heartburn and abdominal pain plus associated symptoms are common presentations in ambulatory and urgent care. Gastroenteritis, appendicitis, and peptic ulcer disease are common causes of abdominal pain. Each accounts for 11% to 13% of patients seen with abdominal pain in the emergency room. Similarly, gynecological and urinary tract problems account for 9% and 7%, respectively. The most common cause (20%) is nonspecific. Patients who present with symptoms usually associated with the gastrointestinal tract (heartburn, indigestion, nausea, vomiting, diarrhea, bloating, or abdominal distention) may actually have diseases in the genitourinary tract, central nervous system, cardiovascular system, or endocrine system, or they may be due to medications or metabolic abnormalities. Therefore, the assessment of abdominal symptoms must include considerations of problems associated with multiple other organ systems or exogenous issues. Most of these disorders require referral to definitive care, so it is important for pharmacists to recognize common features when patients request help with self-care with nonprescription products.

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DIAGNOSIS

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The diagnosis of the exact etiology of abdominal pain and heartburn can be difficult as evidenced by the high percentage of cases in which no specific cause can be found on the first encounter in the emergency room. Part of the problem is the lack of specific innervation of the visceral organs. Pain in one organ may be felt in any of several places. The literature is full of descriptions of “classical presentations” of diseases of the abdomen. However, atypical presentations are common especially in the elderly. For example, the classic pain of gallbladder disease is described as sharp, colicky right upper quadrant pain. Unfortunately, 25% of patients with biliary disease do not present with the “classical” symptoms. Figure 10.1 shows the location of “classical” pain by external anatomical location of the abdominal surface.

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FIGURE 10.1

Abdominal architecture. RUQ = Right upper quadrant, RLQ = Right lower quadrant, LUQ = Left upper quadrant, LLQ = Left lower quadrant.

Graphic Jump Location
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Diagnostic accuracy is dependent on a careful history and physical examination, since there are few laboratory tests that can specifically diagnose diseases that produce abdominal symptoms (Table 10.1). Location of the pain, the type ...

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