II. Definitions

  1. Acute Abdominal Pain
    1. Abdiominal pain onset within 7 days

III. Epidemiology

  1. Abdominal Pain represents 5-10% of ER visits
  2. Only 10% of these evaluations require surgery
  3. Accounts for 10% of Malpractice claims

IV. Pearls

  1. Cohorts with atypical presentations of serious Abdominal Pain causes
    1. Elderly and Immunocompromised
      1. Use low threshold for admiting elderly (and Immunocompromised) for observation
      2. See Abdominal Pain in Older Adults
    2. Pregancy
      1. Appendix migrates upward into peri-renal and even RUQ in third trimester
  2. Most commonly missed surgical diagnoses
    1. Appendicitis
    2. Small Bowel Obstruction
  3. Specific Warning signs
    1. Low Back Pain in elderly
      1. Abdominal Aortic Aneurysm
    2. Atrial Fibrillation and Abdominal Pain
      1. Mesenteric Ischemia
  4. Common serious causes mimicking more benign causes
    1. Retrocecal appendix
      1. May present with back pain or upper quadrant Abdominal Pain
    2. Abdominal aoortic aneurysm
      1. May present with Renal Colic symptoms (Flank Pain, LLQ Pain and even Hematuria)
  5. Exercise caution when diagnosing Acute Gastroenteritis and non-specific Abdominal Pain
    1. Although combined these account for 20% of Acute Abdominal Pain, they are also common misdiagnoses
    2. Atypical Gastroenteritis (e.g. prominent pain, Vomiting without Diarrhea) may represent a more serious cause

VI. Findings

  1. See Abdominal Pain Evaluation for history and symptoms, exam and signs

VII. Evaluation

VIII. Labs and Diagnostic Studies

IX. Imaging

X. Management: Surgery Consultation Indications

  1. Severe Abdominal Pain or progressive Abdominal Pain (regardless of non-diagnostic imaging)
  2. Vomit feculent or bile-stained
  3. Abdominal guarding or rigidity
  4. Abdominal Rebound Tenderness
  5. Abdominal Distention and hypertympanic to percussion
  6. Significant Traumatic Injury to Abdomen
  7. Abdominal Pain of unclear etiology
  8. Intra-abdominal fluid accumulation

XI. Management: General

  1. Antiemetics
    1. Ondansetron (Zofran)
    2. Prochlorperazine (Compazine)
      1. More effective Antiemetic in Abdominal Pain than Phenergan, Reglan
      2. Ernst (2000) Ann Emerg Med 36(2): 89-94 +PMID:10918098 [PubMed]
  2. Parenteral Analgesics
    1. Opioid Dosing
      1. Dilaudid 0.3 to 0.5 mg every 15 minutes prn
      2. Morphine Sulfate 2-4 mg every 15 minutes prn
    2. ParenteralNSAIDs
      1. Toradol 15-30 mg IV (or 30-60 mg IM) every 6 hours as needed
    3. Do not delay adequate analgesia
      1. Does not interfere with exam
      2. Pace (1996) Acad Emerg Med 3:1086-92 [PubMed]
      3. Thomas (2003) J Am Coll Surg 196:18-31 [PubMed]

XII. Management: Disposition

  1. Re-evaluate in 6-12 hours persistent Abdominal Pain with non-diagnostic evaluation and unclear cause
  2. Appendicitis rupture is unlikely in first 36 hours (<2%)
    1. Bickell (2006) J Am Coll Surg 202(3):401-6 [PubMed]

Images: Related links to external sites (from Bing)

Related Studies