II. Precautions

  1. See Acute Abdominal Pain for precautions and red flags

III. Symptoms: Abdominal Pain

  1. Abdominal Pain timing
    1. Sudden, severe onset
      1. Mesenteric Ischemia with arterial Occlusion
      2. Ruptured Abdominal Aortic Aneurysm
      3. Perforated viscus
      4. Ovarian Torsion
    2. Insidious onset
      1. Appendicitis
      2. Nonocclusive Mesenteric Ischemia
    3. Paroxysmal, episodic (often progressing to constant)
      1. Cholecystitis
    4. Night pain
      1. Duodenal peptic ulcer
  2. Abdominal Pain palliative factors
  3. Abdominal Pain provocative factors
    1. Fatty foods
      1. Cholecystitis
    2. Eating food of any type
      1. Mesenteric Infarction
      2. Gastric peptic ulcer (Epigastric Pain with eating)
      3. Duodenal peptic ulcer (Epigastric Pain 1 hour after eating or at night)
    3. Movement, cough or sneezing (Rebound Abdominal Pain)
      1. Peritonitis
      2. Perforated viscus
      3. Appendicitis
  4. Abdominal Pain characteristics
    1. Colicky or cramping Abdominal Pain
      1. Small Bowel Obstruction or large Bowel Obstruction (generalized pain)
      2. Cholecystitis
      3. Nephrolithiasis
    2. Sharp pain
      1. Ovarian Torsion
  5. Abdominal Pain localization and radiation
    1. See Generalized Abdominal Pain
    2. See Left Upper Quadrant Abdominal Pain
    3. See Right Upper Quadrant Abdominal Pain
    4. See Left Lower Quadrant Abdominal Pain
    5. See Right Lower Quadrant Abdominal Pain
    6. See Extraperitoneal Abdominal Pain Causes
    7. See Abdominal Wall Pain Causes
    8. See Epigastric Pain
    9. See Suprapubic Pain
  6. Abdominal Pain radiation to extra-abdominal site (or primary symptom as referred pain)
    1. Back or Flank Pain
      1. Retrocecal appendix
      2. Cholecystitis
      3. Abdominal Aortic Aneurysm
      4. Nephrolithiasis or Ureterolithiasis
      5. Pancreatitis
    2. Shoulder Pain
      1. Cholecystitis (right Shoulder or Scapula)
  7. Associated Symptoms
    1. Nausea or Vomiting
      1. Feculent Vomiting
        1. Distal ileal Small Bowel Obstruction
        2. Large Bowel Obstruction
      2. Bilious Vomiting
        1. Small Bowel Obstruction distal to pylorus
    2. Fever
      1. Appendicitis
      2. Cholecystitis
      3. Diverticulitis
    3. Anorexia
      1. Appendicitis
      2. Cholecystitis
    4. Diarrhea
      1. Diverticulitis
      2. Gastroenteritis
    5. Constipation
      1. Small Bowel Obstruction or large Bowel Obstruction (generalized pain)
    6. Bloody stool
      1. Diverticulitis
      2. Mesenteric Ischemia
    7. Black Stool or Melana (or maroon in rapid blood loss)
      1. Peptic Ulcer Disease
    8. Dysuria
      1. Urinary Tract Infection
      2. Urethritis (STD, especially Chlamydia)
    9. Hematuria
      1. Nephrolithiasis
    10. Vaginal Discharge
      1. Pelvic Inflammatory Disease
    11. Vaginal Bleeding
      1. Ectopic Pregnancy
      2. Dysmenorrhea

IV. History

  1. Past Medical History
    1. Abdominal surgery, procedures or Trauma
      1. Consider Small Bowel Obstruction
    2. Cholelithiasis
      1. Cholecystitis
      2. Pancreatitis
    3. Diverticulitis
      1. Recurrence in 9-30% of patients
    4. Cardiovascular disease
      1. Consider Mesenteric Ischemia
      2. Consider Abdomnal Aortic Aneurysm
      3. Consider referred cardiac ischemia pain
    5. Atrial Fibrillation
      1. Mesenteric Ischemia
    6. Diabates Mellitus
      1. Diabetic Ketoacidosis
    7. Peptic Ulcer Disease or
    8. Human Immunodeficiency Virus (HIV)
    9. Sickle Cell Anemia
    10. Inflammatory Bowel Disease
    11. Immunocompromised status
      1. May present without fever despite significant intraabdominal infection
  2. Social History
    1. Tobacco Abuse
      1. Mesenteric Ischemia
      2. Abdominal Aortic Aneurysm
    2. Alcohol Abuse
      1. Pancreatitis
      2. Gall Bladder disease
    3. Sexually Transmitted Disease
      1. Pelvic Inflammatory Disease
  3. Medications
    1. NSAIDs
      1. Peptic Ulcer Disease
    2. Corticosteroids
      1. Peptic Ulcer Disease
      2. Immunosuppression
    3. Intrauterine Device (IUD)
      1. Ectopic Pregnancy
  4. Recent Travel
    1. Parasitic Infection
  5. Review of Symptoms
    1. Pharyngitis (may mimic surgical Abdomen)
      1. Mononucleosis
      2. Streptococcal Pharyngitis
    2. Genitourinary
      1. Menstrual History
      2. Obstetrical history
      3. Urinary Symptoms (Dysuria, Hematuria, frequency)

V. Exam: Abdominal Exam

  1. Observation
    1. Distention, Asymmetry or Peristalsis
      1. Small Bowel Obstruction or large Bowel Obstruction
      2. Mesenteric Ischemia (late finding)
    2. Scars from prior abdominal surgeries, Trauma
      1. Small Bowel Obstruction
    3. Hernia (and signs of incarceration)
      1. Small Bowel Obstruction
    4. Reduced chest excursion (due to guarding)
      1. Peritonitis
      2. Cholecystitis
      3. Peptic Ulcer Disease
    5. Pain out of proportion to exam
      1. Mesenteric Ischemia
  2. Auscultation
    1. Borborygmi
      1. Small Bowel Obstruction
    2. Hypoactive bowel sounds
      1. Small Bowel Obstruction
    3. Silent
      1. Consider surgical Abdomen
  3. Palpation
    1. Maximal tenderness (see specific signs below)
    2. Pulsatile masses
      1. Abdominal Aortic Aneurysm
    3. Abnormal fullness (mass)
      1. Closed loop Small Bowel Obstruction
    4. Muscle tone
  4. Specific signs
    1. Murphy Sign (RUQ tenderness on deep inspiration)
      1. Cholecystitis
    2. Right lower quadrant tenderness
      1. Appendicitis (LR+8)
    3. Psoas Sign (RLQ Pain on right hip passive extension)
      1. Appendicitis
    4. Rovsing Sign (RLQ Pain on palpation of LLQ)
      1. Appendicitis
    5. Obturator Sign (RLQ Pain on internal rotation of flexed right hip)
      1. Appendicitis
    6. Left lower quadrant pain
      1. Sigmoid Diverticulitis (85% of cases)
    7. Right upper quadrant and epigastric tenderness
      1. Cholecystitis
      2. Pancreatitis
      3. Peptic Ulcer Disease
  5. Rebound Abdominal Tenderness
    1. Do not test Rebound Tenderness by rapid release
      1. See Rebound Tenderness for other methods (e.g. cough, inspiration, expiration)
    2. Perforated viscus
    3. Peritonitis

VI. Exam: Genitourinary

  1. Examine for Femoral Hernia
  2. Consider rectal exam in all patients with Abdominal Pain
    1. Pain on palpation
    2. Occult or frankly bloody stool
  3. Pelvic exam in all women
    1. Cervical motion tenderness
      1. Pelvic Inflammatory Disease
      2. Ectopic Pregnancy

VII. Exam: General

  1. General appearance
    1. Acutely or chronically ill appearing patient
    2. Malnourished patient
    3. Positioning
      1. Retroperitoneal irritation: Thighs flexed
      2. Peritonitis: Lie very still
      3. Bowel Obstruction or Nephrolithiasis: Restless
    4. Jaundice
      1. Biliary tract (especially Ascending Cholangitis or Common Bile Duct Stone)
  2. Vital Signs: Red flags for significant causes (surgical Abdomen, Hemorrhage)
    1. Hypotension
    2. Tachycardia
  3. Back Exam
    1. Flank Ecchymosis
    2. Costovertebral Angle Tenderness (flank tenderness)
  4. Cardiopulmonary examination
    1. Assess for Myocardial Infarction
    2. Assess for Cardiac Arrhythmia
    3. Arterial Pulses
      1. Femoral pulse
      2. Pedal pulses (dorsalis pedis and posterior tibial)

VIII. Labs

  1. First-Line
    1. Urinalysis
    2. Urine Pregnancy Test (all women of child-bearing age)
    3. Complete Blood Count (CBC)
      1. Leukocytosis False Negatives
        1. Absence of Leukocytosis does not exclude serious cause (e.g. Appendicitis)
          1. Especially true when clinical findings (e.g. peritoneal signs) are present
        2. Leukocytosis lags other findings in elderly (even with acute surgical Abdomen)
      2. Leukocytosis False Positives
        1. Corticosteroids raise White Blood Cell Count
          1. Neutrophil Count >80% suggests infection
    4. Comprehensive metabolic panel including Liver Function Tests
    5. Lipase Indications
      1. Pancreatitis (Test Sensitivity approaches 100%)
      2. Bowel Obstruction
      3. Duodenal Ulcer
  2. Second-Line studies as indicated
    1. Electrocardiogram
    2. Pulse Oximetry
    3. Blood Cultures
    4. Lactic Acid
      1. Peritonitis or other serious intraabdominal infection
      2. Mesenteric Ischemia
        1. Normal Lactic Acid does not exclude Mesenteric Ischemia
    5. Serum Phosphate
      1. Mesenteric Ischemia (increased phosphate)
    6. Arterial Blood Gas or Venous Blood Gas
      1. Metabolic Acidosis
      2. Diabetic Ketoacidosis
    7. Coagulation studies (INR/PT, PTT)
      1. Consider in liver disease, active bleeding or Anticoagulant use
      2. Routine coagulation studies are not indicated even if going to surgery unless specific indication
    8. Amylase (Lipase usually preferred)
      1. Pancreatitis (Lipase preferred)
      2. Bowel Obstruction
      3. Bowel perforation or peptic ulcer perforation
      4. Mesenteric Ischemia

IX. Imaging: Available studies

  1. Approach
    1. Directed imaging where specific cause is suggested
    2. Abdominal CT is most broadly useful study
      1. "Workhorse" of Acute Abdomen evaluation
      2. Sucher (2002) Semin Laparosc Surg 9(1):3-9 [PubMed]
    3. Right upper quadrant Ultrasound
      1. First-line study if biliary tract disease suspected
    4. Upper Endoscopy
      1. Indicated if Peptic Ulcer Disease suspected
  2. Chest XRay Indications
    1. Congestive Heart Failure
    2. Pneumonia
    3. Abdominal free air
      1. Test Sensitivity: 60-80% for perforated viscus (free air under diaphragm)
      2. However, chest/abdominal xray adds little if undergoing Abdominal CT without delay
      3. Increased sensitivity
        1. Left lateral decubitus XRay
        2. XRay after 500 ml air given via Nasogastric Tube
  3. Abdominal XRay (KUB) Indications (Abdominal CT is usually preferred)
    1. Radiopaque Foreign Body
    2. Small Bowel Obstruction or Large Bowel Obstruction
      1. Test Sensitivity: 71-77%
    3. Incarcerated Hernia
    4. Volvulus
    5. Bowel perforation (free air, see Chest XRay above)
    6. Nephrolithiasis
      1. Consider obtaining after stone localization on CT for monitoring
  4. Ultrasound Indications
    1. Cholecystitis
      1. Test Sensitivity: 91-94% and Test Specificity: 78%
    2. Abdominal Aortic Aneurysm (hemodynamically unstable, bedside emergency Ultrasound)
      1. Test Sensitivity: 100% for enlarged aorta (skilled clinician in Bedside Ultrasound)
    3. Appendicitis
      1. Test Sensitivity: 40-50% and Test Specificity: 90%
      2. Lower efficacy than CT, but without radiation (considered first-line in children, pregnancy)
    4. Ectopic Pregnancy
      1. Test Sensitivity: 84% and Test Specificity: 99%
    5. Ovarian Torsion (with color doppler flow)
      1. Test Sensitivity: 93%
    6. Acute Pancreatitis
    7. Tuboovarian Abscess
    8. Nephrolithiasis (Hydronephrosis)
    9. Abdominal Trauma (FAST Exam)
  5. Abdominal CT Indications (with IV contrast and oral water unless otherwise noted)
    1. Use IV contrast with Oral Contrast for Abdominal Pain in a low BMI adult (BMI<20 kg/m2)
    2. Appendicitis
      1. Test Sensitivity: 97% and Test Specificity: 100%
    3. Diverticulitis
      1. Test Sensitivity: 93-100% and Test Specificity: 100%
    4. Small Bowel Obstruction or Large Bowel Obstruction
      1. Test Sensitivity: 93-100%
    5. Acute Pancreatitis
      1. Test Sensitivity: 78% and Test Specificity: 86%
      2. Not generally indicated in first 72 hours unless diagnosis unclear
        1. CT primarily used to evaluate for later complications (pseudocyst, abscess)
    6. Nephrolithiasis or Ureterolithiasis (no oral or IV contrast, "Stone Run CT")
      1. Test Sensitivity: 100%
    7. Abdominal Aortic Aneurysm (IV contrast only)
      1. Test Sensitivity: 100%
    8. Mesenteric Ischemia (CT angiography)
      1. Test Sensitivity: 94-100% and Test Specificity: 96-100%
    9. Crohn's Disease (CT enterography)
    10. Abdominal Trauma (IV contrast only)
    11. Intraabdominal abscess (with Oral Contrast in addition to IV contrast)
  6. Abdominal MRI
    1. Mesenteric Ischemia (MR Angiography Indications)
    2. Common Bile Duct Stone (MRCP)
    3. Appendicitis (e.g. pregnancy, children)
  7. Hepatobiliary Scan (HIDA Scan)
    1. Cholecystitis or Common Bile Duct Stone
      1. Test Sensitivity: 97% and Test Specificity: 99%

X. References

  1. Natesan (2015) Crit Dec Emerg Med 29(12): 2-11
  2. Cartwright (2015) Am Fam Physician 91(7): 452-9 [PubMed]

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Related Studies

Ontology: Abdominal Pain (C0000737)

Definition (MSHCZE) Pocit nevolnosti, obtíží nebo bolesti v břišní oblasti; obvykle při funkčních poruchách, tkáňových poraněních nebo nemocech.
Definition (MEDLINEPLUS)

Your abdomen extends from below your chest to your groin. Some people call it the stomach, but your abdomen contains many other important organs. Pain in the abdomen can come from any one of them. The pain may start somewhere else, such as your chest. Severe pain doesn't always mean a serious problem. Nor does mild pain mean a problem is not serious.

Call your healthcare provider if mild pain lasts a week or more or if you have pain with other symptoms. Get medical help immediately if

  • You have abdominal pain that is sudden and sharp
  • You also have pain in your chest, neck or shoulder
  • You're vomiting blood or have blood in your stool
  • Your abdomen is stiff, hard and tender to touch
  • You can't move your bowels, especially if you're also vomiting
Definition (NCI_CTCAE) A disorder characterized by a sensation of marked discomfort in the abdominal region.
Definition (NCI) Painful sensation in the abdominal region.
Definition (MSH) Sensation of discomfort, distress, or agony in the abdominal region; generally associated with functional disorders, tissue injuries, or diseases.
Concepts Sign or Symptom (T184)
MSH D015746 , D003085
ICD9 789.00, 789.0
ICD10 R10.9
SnomedCT 207205003, 207230000, 158498003, 158512003, 139313005, 21522001
LNC MTHU013636, LA15468-4
English Abdominal Pains, Pains, Abdominal, Abdominal pain NOS, Abdominal Pain, [D]Abdominal pain (context-dependent category), [D]Abdominal pain NOS (context-dependent category), Abdo pain, Pain abdo, Abd. pain, [D]Abdominal pain, [D]Abdominal pain NOS, abdominal pain (symptom), abdominal pain, Pain abdominal, Gut pain, Abdmnal pain unspcf site, Unspecified abdominal pain, Abdominal Pain [Disease/Finding], Pain;abdominal, gut pain, abdomen pain, abdominal pains, Bellyache, Pain, Abdominal, Abdomen pain, [D]Abdominal pain (situation), [D]Abdominal pain NOS (situation), ABDOMINAL PAIN, PAIN, ABDOMINAL, Abdominal pain, AP - Abdominal pain, Abdominal pain (finding), abdominal; pain, abdominalgia, pain; abdominal, Abdominal pain, unspecified site
French DOULEUR ABDOMINALE, Douleur abdominale SAI, Douleur intestinale, Douleur abdo, Douleur abdo., Douleur abd., Colique, Douleur abdominale, Douleur de l'abdomen
Portuguese DOR ABDOMINAL, Dor abdominal NE, Dor intestinal, Câimbras Abdominais, Cólicas, Câimbra Abdominal, Cãibra Abdominal, Dor abdominal, Cólica, Dor Abdominal
Dutch darmpijn, buikpijn NAO, pijn abdominaal, abdominaal; pijn, pijn; abdominaal, abdominale pijn, Buikpijn, Pijn, buik-
German Schmerz abdominal, Bauchschmerz, abd. Schmerz, Abdominalschmerzen NNB, Schmerz abdo, abdo. Schmerz, ABDOMEN SCHMERZHAFT, Abdominalschmerz, Abdominalschmerzen, Bauchschmerzen, Kolik
Italian Dolore intestinale, Dolore addominale NAS, Dolore colico, Colica, Dolore addominale
Spanish Dolor de barriga, Dolor abdominal NEOM, [D]dolor abdominal, SAI (categoría dependiente del contexto), [D]dolor abdominal (categoría dependiente del contexto), ABDOMEN, DOLOR, [D]dolor abdominal (situación), [D]dolor abdominal, SAI (situación), [D]dolor abdominal, [D]dolor abdominal, SAI, dolor abdominal (hallazgo), dolor abdominal, Dolor abdominal, Dolor Abdominal
Japanese 腸管痛, 腹痛NOS, 腹痛, フクツウ, チョウカンツウ, フクツウNOS, 疝痛, 腹部痙攣, 仙痛, 腹部けいれん
Swedish Buksmärta
Czech kolika, Břišní bolest NOS, Střevní bolest, Bolest břicha, bolesti břicha, břicho - bolest
Finnish Koliikki, Vatsakipu
Polish Ból brzucha
Hungarian Hasi fájdalom, Abdominalis fájdalom k.m.n., Bél fájdalom, Abdominalis fájdalom, Hasfájdalom
Norwegian Kolikksmerter, Magesmerter, Kolikk, Abdominalsmerter, Magesmerte