Hypogastric pain resident survival guide
|Hypogastric Pain Resident Survival Guide Microchapters|
The hypogastrium (alternative names including hypogastric region, pubic region and suprapubic region) is an area of the human abdomen located below the navel. The pubis bone constitutes its lower limit.
- Bladder stone
- Bladder cancer (transitional cell carcinoma)
- Ovarian cancer
- Ovarian cyst
- Ovarian torsion
- Pelvic inflammatory disease
Shown below is an algorithm depicting the diagnostic approach of acute abdominal pain in the hypogastric region.
|Peritoneal signs, shock or toxic appearing|
|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)
❑ Surgical consultation
❑ Bedside ultrasound
❑ Abdominal CT
|History, examination and risk factors suggest mesentric ischemia (pain out of proportion to exam)|
❑ Surgical consultation
❑ Abdominal CT
|History and examination suggest bowel obstruction (diffuse tenderness with distention and persistent vomiting) or perforation (rigidity with absent bowel sounds|
|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|
|Hypogastric pain/Suprapubic pain||Left upper quadrant tenderness|
|No urinary symptom||Presence of dysuria and voiding dysfunction||Dysuria and voiding dysfunction||No urinary symptoms|
|Consider bowel or vascular disease||Urine culture, suprapubic USS and catheterization||Urine culture, pelvic ultrasound and catheterization||Pain at the cervix or vaginal fornices||Vaginal examination|
|Refer to general surgery||Consider prostatitis, cystitis or urine retention||Consider cystitis or extrinsic bladder compression causing urine retention||Consider gynecological referral||If examination was unremarkable, refer to general surgery|
|Refer to urology||Refer to urology|
- 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.
- Suspect acute mesenteric ischemia or acute pancreatitis in patients presenting with poorly localized pain out of proportion to physical findings.
- Recommend initial imaging studies based on the location of abdominal pain:
- Ultrasonography is recommended when a patient presents with right upper quadrant pain.
- Computed tomography (CT) with intravenous contrast media is recommended for evaluating adults with acute right lower quadrant pain.
- CT with oral and intravenous contrast media is recommended for patients with left lower quadrant pain.
- 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.
- Perform diagnostic paracentesis (cell count, differential count, gram stain, culture, bilirubin and albumin) in patients with ascites and abdominal pain to rule out spontaneous bacterial peritonitis.
- 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.
- "Diagnosis and management of 528 abdom... [Br Med J (Clin Res Ed). 1981] - PubMed - NCBI".
- "http://www.acr.org/". External link in
- "http://www.ebmedicine.net/content.php?action=showPage&pid=94&cat_id=16". External link in