Abdominal Pain Evaluation

Aka: Abdominal Pain Evaluation, Abdominal Pain History, Abdominal Pain Exam, Abdominal Pain Imaging

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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. Aortic Dissection
      4. Perforated viscus
      5. Ovarian Torsion
      6. Ureterolithiasis
      7. Intra-abdominal Hemorrhage
    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. 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
      1. Small Bowel Obstruction
    11. Malignancy
      1. Small Bowel Obstruction
    12. 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 Use Disorder
      1. Pancreatitis
      2. Gall Bladder disease
      3. Gastroesophageal Reflux
      4. Gastritis or Peptic Ulcer Disease
      5. Esophageal Varices
      6. Ascites
      7. Retching (Mallory-Weiss Syndrome, Boerhaave Syndrome)
    3. Opioid Use Disorder
      1. Opioid Induced Constipation (or Adynamic Ileus, pseudo-obstruction)
      2. NarcoticBowel Syndrome (chronic abdominal colic due to hyperalgesia)
    4. Cannabinoids
      1. Cannabinoid Hyperemesis Syndrome
    5. Stimulant Abuse (Cocaine, Amphetamines)
      1. Mesenteric Ischemia (due to Vasoconstriction)
      2. Hepatic ischemia (due to Vasoconstriction)
      3. Pancreatitis (Cocaine)
    6. Sexually Transmitted Disease
      1. Pelvic Inflammatory Disease
    7. References
      1. Cates (2021) Emerg Med Clin North Am 39(4): 821-37 [PubMed]
  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. Findings: Signs and Symptoms Suggestive of Surgical Abdomen

  1. See Acute Abdominal Pain Evaluation
  2. Anorexia
  3. Duration of pain at presentation
    1. Severe, sudden onset pain (pain out of proportion) under 1 hour
      1. High risk for intra-abdominal catastrophe
      2. Causes (especially in elderly)
        1. Ruptured Abdominal Aortic Aneurysm
        2. Mesenteric Ischemia
        3. Myocardial Infarction
        4. Perforated viscus
        5. Nephrolithiasis
    2. Pain duration under 48 hours: 18% need surgery
    3. Pain duration over 48 hours: 11% need surgery
    4. Delayed presentation in young and old
  4. Pain precedes Vomiting
    1. Appendicitis
    2. Cholecystitis
    3. Small Bowel Obstruction
  5. Fever >38 C (only when accompanied by another sign)
    1. Fever lags symptoms in elderly
  6. Tachycardia (Heart Rate exceeds 110 bpm)
  7. Leukocytosis with Neutrophils >75%
  8. Peritoneal signs
  9. Age over 65 years

IX. Labs

  1. First-Line
    1. Urinalysis
    2. Urine Pregnancy Test or Serum HCG (in 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. Serum Lipase
      1. Acute Pancreatitis
        1. Serum Lipase levels >3 times upper limit of normal are consistent with Pancreatitis
        2. Test Sensitivity approaches 100%
        3. May also be elevated in Small Bowel Obstruction or 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. Inflammatory markers (e.g. C-Reactive Protein)
      1. Elevated levels may be associated with inflammation or infection (but are non-specific)
    6. Serum Phosphate
      1. Mesenteric Ischemia may be associated with increased phosphate
    7. Arterial Blood Gas or Venous Blood Gas
      1. Metabolic Acidosis
      2. Diabetic Ketoacidosis
    8. 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
    9. Amylase (Lipase usually preferred)
      1. Pancreatitis (Lipase preferred)
      2. Bowel Obstruction
      3. Bowel perforation or Peptic Ulcer perforation
      4. Mesenteric Ischemia

X. 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. See RUQ Ultrasound
      2. Test Sensitivity: 91-94% and Test Specificity: 78%
    2. Abdominal Aortic Aneurysm (hemodynamically unstable, bedside emergency Ultrasound)
      1. See Ultrasound in Abdominal Aortic Aneurysm
      2. Test Sensitivity: 100% for enlarged aorta (skilled clinician in Bedside Ultrasound)
    3. Appendicitis
      1. See Appendix Ultrasound
      2. Test Sensitivity: 40-50% and Test Specificity: 90%
      3. 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)
      1. See Limited Ultrasound for Acute Renal Colic
    9. Abdominal Trauma
      1. See FAST Exam (identifies intraabdominal Hemorrhage)
  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%

XI. References

  1. Natesan (2015) Crit Dec Emerg Med 29(12): 2-11
  2. Cartwright (2015) Am Fam Physician 91(7): 452-9 [PubMed]
  3. Yew (2023) Am Fam Physician 107(6): 585-96 [PubMed]

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