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Revision as of 21:19, 6 March 2014 by Amr Marawan (talk | contribs)
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Detailed history:
❑ Age
❑ Sex
❑ Past medical history
❑ Past surgical history
❑ Occupational history travel history
❑ Travel history
❑ Medications

Characterize the symptoms:
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
Maldigestion
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
Signs of sepsis
❑ Cardiovascular system
❑ Respiratory system
❑ Anorectal (bleeding)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess hemodynamic stability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stable
 
 
 
 
 
Unstable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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

Order imaging studies:
❑ Order urgent trans abdominal ultrasound (TAUSG)
Abdominal CT
Chest x-ray
Angiography


*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
 
 
 
 
 
Stabilize the patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Peritoneal signs, shock or toxic appearing
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
No
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symptoms, signs, risk factors or ECG suggestive of acute coronary syndrome
 
 
 
 
Symptoms, signs or risk factors suggestive of abdominal aortic aneurysm
 
 
 
 
❑ Initiate resuscitation
❑ Obtain immediate surgical consultation
❑ Perform bedside ultrasound (evaluate aorta, hemoperitoneum, pericardium and inverior vena cava)
❑ Obtain indicated tests and studies (e.g. x-ray, ECG, lactate, lipase and LFTs)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Appropriate management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Surgical consultation
❑ Bedside ultrasound
❑ Abdominal CT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History, examination and risk factors suggest mesentric ischemia (pain out of proportion to exam)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Surgical consultation
❑ Abdominal CT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History and examination suggest bowel obstruction (diffuse tenderness with distention and persistent vomiting) or perforation (rigidity with absent bowel sounds
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abdominal x-ray series
 
 
 
 
 
 
 
 
 
Where is pain localized
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of free air
 
Presence of obstruction
 
 
Absent free air and absent obstruction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Epigastric or upper right quadrant tenderness
 
Right lower quadrant tenderness
 
Left lower quadrant tenderness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgical consult
 
Abdominal CT
 
 
Abdominal CT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Left upper quadrant tenderness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pulmonary symptoms
 
 
Urinary symptoms
 
 
 
Colic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider pulmonary embolus or pneumonia
 
 
Consider urinary tract infection or nephrolithiasis
 
 
 
Consider a hepatobiliary cause or nephrolithiasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tachypnea, hypoxia or pulmonary findings
 
 
Costovertebral or suprapubic tenderness
 
 
 
Perform ultrasonography of abdomen, if non diagnostic, consider nephrolithiasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest x-ray, if nondiagnostic, helical CT and D dimer assay to evaluate for pulmonary embolism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform a urinalysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pyuria
 
Hematuria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider urinary tract infection or pyelonephritis
 
Consider nephrolithiasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



Approach to a female of child-bearing age

 
 
 
 
 
 
 
 
Peritoneal signs or shock
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnant
 
 
 
 
 
 
 
 
 
 
❑ Stabilize airway, breathing and circulation
❑ Obtain emergent surgical consultation
❑ Obtain pregnancy test
❑ Perform bedside ultrasound
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 as indicated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
US to rule out ovarian torsion or ovarian cyst
 
Intrauterine pregnancy
 
Ectopic pregnancy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical pelvic inflammatory disease
 
 
 
 
 
 
❑ Assess appendix with US
❑ Obtain OB/Gyn and surgery consultation as indicated
 
Obtain OB/Gyn consultation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Predominant right lower quadrant tenderness
 
 
 
 
Toxic appearing or persistent vomiting
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adminster antibiotics as an outpatient
 
Admit, start IV antibiotics and consult Gyn
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

  • 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.
  • Suspect abdominal aortic aneurysm in old patients presenting with abdominal pain with history of tobacco use. [1]
  • Suspect acute mesenteric ischemia and 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:
  • Ultrasonography is recommended when a patient presents with right upper quadrant pain. [2]
  • Computed tomography (CT) with intravenous contrast media is recommended for evaluating adults with acute right lower quadrant pain. [2]
  • CT with oral and intravenous contrast media is recommended for patients with left lower quadrant pain. [2]
  • Order ECG for old patients with upper abdominal pain with high cardiac risk factors.
  • Administer narcotic analgesia for patients who present to the ED with moderate or severe abdominal pain. [3]

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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