Acute abdominal pain resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amr Marawan, M.D. [2]

Acute Abdominal Pain Resident Survival Guide Microchapters
Overview
Causes
Management
Do's
Don'ts

Overview

Abdominal pain (or stomach ache) is a common symptom associated with transient disorders or serious disease. Diagnosing the cause of abdominal pain can be difficult, because many diseases can cause this symptom. Most frequently the cause is benign and/or self-limiting, but more serious causes may require urgent intervention. Acute abdominal pain is a severe, persistent abdominal pain of sudden onset that is likely to require surgical intervention to treat its cause. The pain may frequently be associated with nausea and vomiting, abdominal distention, fever and signs of shock.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

Diagnostic Approach

Shown below is an algorithm depicting the diagnostic approach of acute abdominal pain.
Abbreviations: ACS: Acute coronary syndrome; AAA: Abdominal aortic aneurysm; RUQ: Right upper quadrant; RLQ: Right lower quadrant; LUQ: Left upper quadrant; LLQ: Left lower quadrant

 
 
 
 
 
 
 
 
 
 
 
 
 
Characterize the pain:
❑ Onset (eg, sudden, gradual)
❑ Provocative and palliating factors (eg, Is the pain related to your meals?)
❑ Quality (eg, dull, sharp, colicky, waxing and waning)
❑ Radiation (eg, to the shoulder, back, flank, groin, or chest)
❑ Site (eg, a particular quadrant or diffuse)
❑ Pain location may change over time, reflecting progression of disease
❑ Intensity
❑ Time course (eg, hours versus weeks, constant or intermittent)

Other symptoms

Nausea & vomiting
Diaphoresis
Anorexia
Fever
Bloody stool
Vaginal discharge
Penile discharge
Painful urination
Shortness of breath
Altered mental status
Jaundice
Mal-digestion
Flatulence
Fatigue
Scrotal pain/swelling
❑ Recent trauma
❑ Mass in any of the quadrants
❑ Symptoms suggestive of sepsis
❑ Symptoms suggestive of common hepatic duct obstruction
❑ RUQ pain with fever & jaundice
❑ Symptoms suggestive of gallstone ileus
❑ Transient abdominal pain with nausea & vomiting
Hematemesis

Detailed history:

❑ Age (Patients above 50 years old are more likely to have sever diseases ,as ruptured abdominal aortic aneurysm or colon cancer, and atypical symptoms ,as in myocardial infarction)
❑ Past medical history (to exclude risk factors for cardiovascular diseases or peripheral vascular disease)
❑ Past surgical history (for previous abdominal surgeries)
❑ Menstrual and contraceptive history (pregnancy should be excluded in all women of childbearing age with abdominal pain)
❑ Social history (alcohol abuse predispose to pancreatitis and hepatitis, smoking also predisposes to different types of cancers, eg. cancer bladder, which may cause abdominal pain)
❑ Occupational history (exposure to chemicals or toxins)
❑ Travel history (might be a case of travelers' diarrhea)
❑ Medications (for over the counter drugs as, acetaminophen, aspirin, and NSAIDs)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

❑ Vital signs

Temperature
Heart rate (tachycardia)
Blood pressure (hypotension)
Respiratory rate (tachypnea)

❑ Skin

Diaphoresis
Pallor
Jaundice
Dehydration

❑ Inspection

❑ If the patient is curled up/agitated, this is suggestive of renal colic
❑ If the patient is lying still in bed with knees bent, this is suggestive of peritonitis
❑ Signs of previous surgery
❑ Abdominal pulsations
❑ Signs of systemic disease eg,
Pallor, suggestive of bleeding
Spider angiomata, suggestive of cirrhosis

❑ Auscultation

❑ Abdominal crepitations
❑ Reduced bowel sounds
❑ Increased bowel sounds
❑ Bruit, suggestive of abdominal aortic aneurysm

❑ Palpation

❑ Rigidity
Guarding
❑ Abdominal tenderness
Distension
❑ Detection of masses on palpating the abdomen
McBurney's point tenderness
Rovsing's sign
Carnett's sign

Psoas sign (suggestive of retrocecal appendix)
Obturator sign
Cullen's sign
Grey-Turner's sign
Digital rectal exam (tenderness may be present in retrocecal appendicitis)
Pelvic exam in females
Testicular examination in males
❑ Cardiovascular system
❑ Respiratory system
❑ Anorectal (bleeding)
Signs of sepsis: tachycardia, decreased urination, and hyperglycemia, confusion, metabolic acidosis with compensatory respiratory alkalosis, low blood pressure, decreased systemic vascular resistance, higher cardiac output, and dysfunctions of blood coagulation

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess hemodynamic stability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If the patient is unstable,
Stabilize the patient:
❑ Establish two large-bore intravenous peripheral lines
❑ NPO until the patient is stable
❑ Supportive care (fluids and electrolyes as required)
❑ Place nasogastric tube if there is bleeding, obstruction, significant nausea or vomiting
❑ Place foley catheter to monitor volume status
❑ Cardiac monitoring
❑ Supplemental oxygen as needed
❑ Administer early antibiotics if indicated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If the patient is stable,
Order laboratory tests:
Pregnancy test (required in women of child-bearing age)
CBC
Hematocrit
Urinalysis
Serum electrolytes
ESR
ABG
D dimer
Serum lactate
BUN
Creatinine
Amylase
Lipase
Triglyceride
❑ Total bilirubin
❑ Direct bilirubin
Albumin
AST
ALT
Alkaline phosphatase
GGT
❑ Stool for ova and parasites
❑ C. difficile culture and toxin assay

Order imaging studies:
❑ Order urgent trans abdominal ultrasound (TAUSG)
Abdominal CT
ECG
MRCP
Abdominal x-ray
Angiography
❑ Diagnostic paracentesis


*Order the tests to rule in a suspected diagnosis
or to assess a case of unclear etiology

*In case of elderly patients, immunocompromised
or those unable to provide a comprehensive
history, order broader range of tests
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signs of peritonitis or shock
Fever
❑ Abdominal tenderness
❑ Abdominal gaurding
❑ Rebound tenderness (blumberg sign)
❑ Diffuse abdominal rigidity
Confusion
❑ Weakness
❑ Low blood pressure
❑ Decreased urine output
❑ Tachycardia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signs and symptoms suggestive of acute coronary syndrome ❑ Risk factors: >40 years, smoking, diabetes mellitus, hypertension, obesity and high cholesterol
Chest tightness radiating to the left arm and the left angel of the jaw
Diaphoresis
❑ Shortness of breath
❑ Sense of impending death
Nausea and vomiting
For more details about management of ACS, click here
 
 
 
 
Signs and symptoms suggestive of abdominal aortic aneurysm
❑ Risk factors: smoking, alcohol, hypertension, high familial prevelance (genetic influences)
❑ Pulsating sensation of the abdomen
❑ Palpable abdominal mass
❑ If ruptured: hypovolemic shock, hypotension, tachycardia, cyanosis, and altered mental status
 
 
 
 
❑ Initiate resuscitation
❑ Obtain immediate surgical consultation
❑ Perform bedside ultrasound (evaluate aorta, hemoperitoneum, pericardium and inferior vena cava)
❑ Obtain indicated tests and studies (e.g. x-ray, ECG, lactate, lipase and LFTs)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Surgical consultation
❑ Bedside ultrasound
❑ Abdominal CT
For more details about management of AAA, click here
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signs and symptoms syggestive of mesenteric ischemia
Abdominal pain out of proportion to examination
❑ Bloody stools
Shock
Metabolic acidosis with dehydration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signs and symptoms suggestive of bowel obstruction or Intestinal perforation
❑ Diffuse tenderness with distention
❑ Persistent vomiting
Rigidity with absent bowel sounds
❑ Fecal vomiting
Dehydration and electrolyte abnormalities
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abdominal x-ray series
Presence of free air: Consult surgery
Presence of obstruction: Order abdominal CT
Absent free air and absent obstruction: Order abdominal CT
 
 
 
 
 
 
 
 
 
Where is pain localized
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
RUQ pain
 
RLQ pain
 
LUQ pain
 
Epigastric pain
 
Hypogastric pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



Approach to a female of child-bearing age

 
 
 
 
 
 
 
 
Signs of peritonitis or shock
Fever
❑ Abdominal tenderness
❑ Abdominal gaurding
❑ Rebound tenderness (blumberg sign)
❑ Diffuse abdominal rigidity
Confusion
❑ Weakness
❑ Low blood pressure
❑ Decreased urine output
❑ Tachycardia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnant: Perform a pregnancy test
 
 
 
 
 
 
 
 
 
 
❑ Initiate resuscitation
❑ Obtain immediate surgical consultation
❑ Perform bedside ultrasound (evaluate aorta, hemoperitoneum, pericardium and inferior vena cava)
❑ Obtain indicated tests and studies (e.g. x-ray, ECG, lactate, lipase and LFTs)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unilateral adnexal tenderness
 
Yes
 
 
 
❑ Perform ultrasound examination (consider ectopic pregnancy, appendicitis)
❑ Perform sterile pelvic examination (not in third trimester vaginal bleeding)
❑ Obtain quantitative HCG and other needed lab tests
❑ Obtain OB/Gyn and surgery consultation if indicated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
Rule out ovarian torsion or ovarian cyst by ultrasonography.
Signs and symptoms suggestive of ovarian torsion or cyst:
❑ Unilateral lower abdominal pain
Nausea and vomiting
❑ Uterine bleeding
❑ Irregular periods
❑ Constitutional symptoms as fatigue or headaches
 
Intrauterine pregnancy
 
Ectopic pregnancy:
❑ Risk factors: PID, infertility, usage of intrauterine device, tubal surgery, intrauterine surgery (eg, dilation and curettage)
Vaginal bleeding
Nausea, vomiting and diarrhea
❑ Abdominal distension
Hemorrhagic shock
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical pelvic inflammatory disease:
Fever
❑ Cervical motion tenderness
❑ Lower abdominal pain
Vaginal discharge
❑ Painful intercourse
❑ Irregular mesntrual bleeding
 
 
 
 
 
 
❑ Assess appendix with US
❑ Obtain OB/Gyn and surgery consultation as indicated
 
Obtain OB/Gyn consultation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Predominant RLQ pain
 
 
 
 
Toxic appearing or persistent vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adminster antibiotics as an outpatient
 
Admit, start IV antibiotics and consult gynaecology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Right upper quadrant.PNG Epigastric quadrant pain.PNG Left upper quadrant.PNG
Right flank quadrant.PNG Umbilical pain.PNG Left flank quadrant.PNG
Right lower quadrant.PNG Hypogastric.PNG Left lower quadrant.PNG

Differentiating Common Causes of Abdominal Pain

Shown below is a table summarizing some clues that help to distinguish the presentation of different diseases.

Causes Clues
Appendicitis Gradual achy pain that starts as diffuse periumbilical pain, then becomes localized in the right lower quadrant.
Cholecystitis Acute constricting pain that starts localized in the right upper quadrant and sometimes radiates to the scapula.
Pancreatitis Acute boring pain that starts in the epigastrium and radiates to midback.
Diverticulitis Gradual achy pain, localized in the left lower quadrant (called left sided appendicitis).
Perforated peptic ulcer Sudden burning pain, presents as a diffuse pain in the periumbilical region.
Small bowel obstruction Gradual crampy pain, presents as a diffuse pain in the periumbilical region.
Mesenteric ischemia or infarction Sudden agonizing pain, presents as a diffuse pain in the periumbilical region.
Ruptured abdominal aortic aneurysm Sudden tearing pain, presents as a diffuse pain in the abdomen, back and flanks.
Gastroenteritis Gradual spasmodic pain, presents as a diffuse pain in the periumbilical region.
Pelvic inflammatory disease Gradual achy pain, presents in either lower quadrants or pelvis and sometimes radiates to the upper thigh.
Ruptured ectopic pregnancy Sudden sharp pain, presents in either lower quadrants or pelvis.

Do's

  • Start the approach to acute abdominal pain by rapid assessment of the patient using the pneumonic "ABC:" airway, breathing and circulation, to identify unstable patients.
  • Consider abdominal aortic aneurysm, mesenteric ischemia and malignancy in patients above 50 years as it is much less likely for younger patients.
  • Perform pelvic and testicular examination in patients with low abdominal pain.
  • Re-examine patients at high risk who were initially diagnosed with pain of unclear etiology.
  • Taking careful history, characterizing the pain precisely and thorough physical examination is crucial for creating narrow differential diagnosis.
  • Correlate the CD4 count in HIV positive patients with the most commonly occurring pathology.
  • Order a pregnancy test before proceeding with a CT scan in females in the child bearing age.
  • Order an ultrasound or magnetic resonance among pregnant females to avoid exposure to radiation. In case the previous tests were inconclusive and appendicitis is suspected, the next step in the management includes proceeding with either laparoscopy or limited CT scan.
  • Consider peritonitis with cervical motion tenderness as it isn't specific for pelvic inflammatory disease.
  • Suspect abdominal aortic aneurysm in old patients presenting with abdominal pain with history of tobacco use.[1]
  • Suspect acute mesenteric ischemia or acute pancreatitis in patients presenting with poorly localized pain out of proportion to physical findings.[1]
  • Recommend initial imaging studies based on the location of abdominal pain:

Don'ts

  • Fail to evaluate elder patients in the presence of overt clinical signs.
  • Over rely on laboratory tests, they are only used as adjuncts.
  • Do not delay the initial intervention.
  • Do not order blood cultures routinely in all patients
  • Don’t delay resuscitation or surgical consultation for ill patient while waiting for imaging.
  • Don’t restrict the differential diagnosis of abdominal pain based on the location; for example, right-sided structures may refer pain to the left abdomen.[1]

References

  1. 1.0 1.1 1.2 "Diagnosis and management of 528 abdom... [Br Med J (Clin Res Ed). 1981] - PubMed - NCBI".
  2. 2.0 2.1 2.2 "http://www.acr.org/". External link in |title= (help)
  3. "http://www.ebmedicine.net/content.php?action=showPage&pid=94&cat_id=16". External link in |title= (help)



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