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Abdominal Pain Evaluation
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Abdominal Pain Evaluation
See Also
Acute Abdominal Pain
Acute Abdominal Pain Causes
Abdominal Pain in Older Adults
Precautions
See
Acute Abdominal Pain
for precautions and red flags
Symptoms
Abdominal Pain
Abdominal Pain
timing
Sudden, severe onset
Mesenteric Ischemia
with arterial
Occlusion
Ruptured
Abdominal Aortic Aneurysm
Perforated viscus
Ovarian Torsion
Insidious onset
Appendicitis
Nonocclusive Mesenteric Ischemia
Paroxysmal, episodic (often progressing to constant)
Cholecystitis
Night pain
Duodenal peptic ulcer
Abdominal Pain
palliative factors
Abdominal Pain
provocative factors
Fatty foods
Cholecystitis
Eating food of any type
Mesenteric Infarction
Gastric peptic ulcer (
Epigastric Pain
with eating)
Duodenal peptic ulcer (
Epigastric Pain
1 hour after eating or at night)
Movement, cough or sneezing (
Rebound Abdominal Pain
)
Peritonitis
Perforated viscus
Appendicitis
Abdominal Pain
characteristics
Colic
ky or cramping
Abdominal Pain
Small Bowel Obstruction
or large
Bowel Obstruction
(generalized pain)
Cholecystitis
Nephrolithiasis
Sharp pain
Ovarian Torsion
Abdominal Pain
localization and radiation
See
Generalized Abdominal Pain
See
Left Upper Quadrant Abdominal Pain
See
Right Upper Quadrant Abdominal Pain
See
Left Lower Quadrant Abdominal Pain
See
Right Lower Quadrant Abdominal Pain
See
Extraperitoneal Abdominal Pain Causes
See
Abdominal Wall Pain Causes
See
Epigastric Pain
See
Suprapubic Pain
Abdominal Pain
radiation to extra-abdominal site (or primary symptom as referred pain)
Back or
Flank Pain
Retrocecal appendix
Cholecystitis
Abdominal Aortic Aneurysm
Nephrolithiasis
or
Ureterolithiasis
Pancreatitis
Shoulder Pain
Cholecystitis
(right
Shoulder
or
Scapula
)
Associated Symptoms
Nausea
or
Vomiting
Feculent Vomiting
Distal ileal
Small Bowel Obstruction
Large
Bowel Obstruction
Bilious Vomiting
Small Bowel Obstruction
distal to pylorus
Fever
Appendicitis
Cholecystitis
Diverticulitis
Anorexia
Appendicitis
Cholecystitis
Diarrhea
Diverticulitis
Gastroenteritis
Constipation
Small Bowel Obstruction
or large
Bowel Obstruction
(generalized pain)
Bloody stool
Diverticulitis
Mesenteric Ischemia
Black
Stool
or Melana (or maroon in rapid blood loss)
Peptic Ulcer Disease
Dysuria
Urinary Tract Infection
Urethritis
(STD, especially
Chlamydia
)
Hematuria
Nephrolithiasis
Vaginal Discharge
Pelvic Inflammatory Disease
Vaginal Bleeding
Ectopic Pregnancy
Dysmenorrhea
History
Past Medical History
Abdominal surgery, procedures or
Trauma
Consider
Small Bowel Obstruction
Cholelithiasis
Cholecystitis
Pancreatitis
Diverticulitis
Recurrence in 9-30% of patients
Cardiovascular disease
Consider
Mesenteric Ischemia
Consider Abdomnal Aortic Aneurysm
Consider referred cardiac ischemia pain
Atrial Fibrillation
Mesenteric Ischemia
Diabates Mellitus
Diabetic Ketoacidosis
Peptic Ulcer Disease
or
Human Immunodeficiency Virus
(HIV)
Sickle Cell Anemia
Inflammatory Bowel Disease
Immunocompromised
status
May present without fever despite significant intraabdominal infection
Social History
Tobacco Abuse
Mesenteric Ischemia
Abdominal Aortic Aneurysm
Alcohol Abuse
Pancreatitis
Gall Bladder
disease
Sexually Transmitted Disease
Pelvic Inflammatory Disease
Medications
NSAID
s
Peptic Ulcer Disease
Corticosteroid
s
Peptic Ulcer Disease
Immunosuppression
Intrauterine Device
(IUD)
Ectopic Pregnancy
Recent Travel
Parasitic Infection
Review of Symptoms
Pharyngitis
(may mimic surgical
Abdomen
)
Mononucleosis
Streptococcal Pharyngitis
Genitourinary
Menstrual History
Obstetrical history
Urinary Symptoms (
Dysuria
,
Hematuria
, frequency)
Exam
Abdominal Exam
Observation
Distention, Asymmetry or Peristalsis
Small Bowel Obstruction
or large
Bowel Obstruction
Mesenteric Ischemia
(late finding)
Scars from prior abdominal surgeries,
Trauma
Small Bowel Obstruction
Hernia
(and signs of incarceration)
Small Bowel Obstruction
Reduced chest excursion (due to guarding)
Peritonitis
Cholecystitis
Peptic Ulcer Disease
Pain out of proportion to exam
Mesenteric Ischemia
Auscultation
Borborygmi
Small Bowel Obstruction
Hypoactive bowel sounds
Small Bowel Obstruction
Silent
Consider surgical
Abdomen
Palpation
Maximal tenderness (see specific signs below)
Pulsatile masses
Abdominal Aortic Aneurysm
Abnormal fullness (mass)
Closed loop
Small Bowel Obstruction
Muscle
tone
Specific signs
Murphy Sign
(RUQ tenderness on deep inspiration)
Cholecystitis
Right lower quadrant tenderness
Appendicitis
(LR+8)
Psoas Sign
(
RLQ Pain
on right hip passive extension)
Appendicitis
Rovsing Sign (
RLQ Pain
on palpation of LLQ)
Appendicitis
Obturator Sign
(
RLQ Pain
on internal rotation of flexed right hip)
Appendicitis
Left lower quadrant pain
Sigmoid
Diverticulitis
(85% of cases)
Right upper quadrant and epigastric tenderness
Cholecystitis
Pancreatitis
Peptic Ulcer Disease
Rebound Abdominal Tenderness
Do not test
Rebound Tenderness
by rapid release
See
Rebound Tenderness
for other methods (e.g. cough, inspiration, expiration)
Perforated viscus
Peritonitis
Exam
Genitourinary
Examine for
Femoral Hernia
Consider rectal exam in all patients with
Abdominal Pain
Pain on palpation
Occult or frankly bloody stool
Pelvic exam in all women
Cervical motion tenderness
Pelvic Inflammatory Disease
Ectopic Pregnancy
Exam
Gene
ral
Gene
ral appearance
Acutely or chronically ill appearing patient
Malnourished patient
Positioning
Retroperitoneal irritation:
Thigh
s flexed
Peritonitis: Lie very still
Bowel Obstruction
or
Nephrolithiasis
: Restless
Jaundice
Biliary tract (especially
Ascending Cholangitis
or
Common Bile Duct Stone
)
Vital Sign
s: Red flags for significant causes (surgical
Abdomen
,
Hemorrhage
)
Hypotension
Tachycardia
Back Exam
Flank
Ecchymosis
Costovertebral Angle Tenderness
(flank tenderness)
Cardiopulmonary examination
Assess for
Myocardial Infarction
Assess for
Cardiac Arrhythmia
Arterial Pulse
s
Femoral pulse
Pedal pulses (dorsalis pedis and posterior tibial)
Labs
First-Line
Urinalysis
Urine Pregnancy Test
(all women of child-bearing age)
Complete Blood Count
(CBC)
Leukocytosis
False Negative
s
Absence of
Leukocytosis
does not exclude serious cause (e.g.
Appendicitis
)
Especially true when clinical findings (e.g. peritoneal signs) are present
Leukocytosis
lags other findings in elderly (even with acute surgical
Abdomen
)
Leukocytosis
False Positive
s
Corticosteroid
s raise
White Blood Cell Count
Neutrophil Count
>80% suggests infection
Comprehensive metabolic panel including
Liver Function Test
s
Lipase
Indications
Pancreatitis
(
Test Sensitivity
approaches 100%)
Bowel Obstruction
Duodenal Ulcer
Second-Line studies as indicated
Electrocardiogram
Pulse Oximetry
Blood Culture
s
Lactic Acid
Peritonitis or other serious intraabdominal infection
Mesenteric Ischemia
Normal
Lactic Acid
does not exclude
Mesenteric Ischemia
Serum Phosphate
Mesenteric Ischemia
(increased phosphate)
Arterial Blood Gas
or
Venous Blood Gas
Metabolic Acidosis
Diabetic Ketoacidosis
Coagulation studies (INR/PT, PTT)
Consider in liver disease, active bleeding or
Anticoagulant
use
Routine coagulation studies are not indicated even if going to surgery unless specific indication
Amylase (
Lipase
usually preferred)
Pancreatitis
(
Lipase
preferred)
Bowel Obstruction
Bowel
perforation or peptic ulcer perforation
Mesenteric Ischemia
Imaging
Available studies
Approach
Directed imaging where specific cause is suggested
Abdominal CT
is most broadly useful study
"Workhorse" of
Acute Abdomen
evaluation
Sucher (2002) Semin Laparosc Surg 9(1):3-9 [PubMed]
Right upper quadrant
Ultrasound
First-line study if biliary tract disease suspected
Upper Endoscopy
Indicated if
Peptic Ulcer Disease
suspected
Chest XRay
Indications
Congestive Heart Failure
Pneumonia
Abdominal free air
Test Sensitivity
: 60-80% for perforated viscus (free air under diaphragm)
However, chest/abdominal xray adds little if undergoing
Abdominal CT
without delay
Increased sensitivity
Left lateral decubitus XRay
XRay after 500 ml air given via
Nasogastric Tube
Abdominal XRay (KUB) Indications (
Abdominal CT
is usually preferred)
Radiopaque Foreign Body
Small Bowel Obstruction
or Large
Bowel Obstruction
Test Sensitivity
: 71-77%
Incarcerated Hernia
Volvulus
Bowel
perforation (free air, see
Chest XRay
above)
Nephrolithiasis
Consider obtaining after stone localization on CT for monitoring
Ultrasound
Indications
Cholecystitis
Test Sensitivity
: 91-94% and
Test Specificity
: 78%
Abdominal Aortic Aneurysm
(hemodynamically unstable, bedside emergency
Ultrasound
)
Test Sensitivity
: 100% for enlarged aorta (skilled clinician in
Bedside Ultrasound
)
Appendicitis
Test Sensitivity
: 40-50% and
Test Specificity
: 90%
Lower efficacy than CT, but without radiation (considered first-line in children, pregnancy)
Ectopic Pregnancy
Test Sensitivity
: 84% and
Test Specificity
: 99%
Ovarian Torsion
(with color doppler flow)
Test Sensitivity
: 93%
Acute Pancreatitis
Tuboovarian Abscess
Nephrolithiasis
(
Hydronephrosis
)
Abdominal Trauma
(
FAST Exam
)
Abdominal CT
Indications (with IV contrast and oral water unless otherwise noted)
Use IV contrast with
Oral Contrast
for
Abdominal Pain
in a low BMI adult (BMI<20 kg/m2)
Appendicitis
Test Sensitivity
: 97% and
Test Specificity
: 100%
Diverticulitis
Test Sensitivity
: 93-100% and
Test Specificity
: 100%
Small Bowel Obstruction
or Large
Bowel Obstruction
Test Sensitivity
: 93-100%
Acute Pancreatitis
Test Sensitivity
: 78% and
Test Specificity
: 86%
Not generally indicated in first 72 hours unless diagnosis unclear
CT primarily used to evaluate for later complications (pseudocyst, abscess)
Nephrolithiasis
or
Ureterolithiasis
(no oral or IV contrast, "Stone Run CT")
Test Sensitivity
: 100%
Abdominal Aortic Aneurysm
(IV contrast only)
Test Sensitivity
: 100%
Mesenteric Ischemia
(CT angiography)
Test Sensitivity
: 94-100% and
Test Specificity
: 96-100%
Crohn's Disease
(CT enterography)
Abdominal Trauma
(IV contrast only)
Intraabdominal abscess (with
Oral Contrast
in addition to IV contrast)
Abdominal MRI
Mesenteric Ischemia
(MR Angiography Indications)
Common Bile Duct Stone
(
MRCP
)
Appendicitis
(e.g. pregnancy, children)
Hepatobiliary Scan (
HIDA Scan
)
Cholecystitis
or
Common Bile Duct Stone
Test Sensitivity
: 97% and
Test Specificity
: 99%
References
Natesan (2015) Crit Dec Emerg Med 29(12): 2-11
Cartwright (2015) Am Fam Physician 91(7): 452-9 [PubMed]
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