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Abdominal Pain

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  1. Given a patient with abdominal pain, paying particular attention to its location and chronicity:

    1. Distinguish between acute and chronic pain.

    2. Generate a complete differential diagnosis (ddx).

    3. Investigate in an appropriate and timely fashion.

  2. In a patient with diagnosed abdominal pain (e.g., gastroesophageal reflux disease, peptic ulcer disease, ulcerative colitis, Crohn’s disease), manage specific pathology appropriately (e.g., with medication, lifestyle modifications).

  3. In a woman with abdominal pain:

    1. Always rule out pregnancy if she is of reproductive age.

    2. Suspect gynecologic etiology for abdominal pain.

    3. Do a pelvic examination, if appropriate.

  4. In a patient with acute abdominal pain, differentiate between a surgical and a non-surgical abdomen.

  5. In specific patient groups (e.g., children, pregnant women, the elderly), include group-specific surgical causes of acute abdominal pain in the ddx.

  6. Given a patient with a life-threatening cause of acute abdominal pain (e.g., a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy):

    1. Recognize the life-threatening situation.

    2. Make the diagnosis.

    3. Stabilize the patient.

    4. Promptly refer the patient for definitive treatment.

  7. In a patient with chronic or recurrent abdominal pain:

    1. Ensure adequate follow-up to monitor new or changing symptoms or signs.

    2. Manage symptomatically with medication and lifestyle modification (e.g., for irritable bowel syndrome).

    3. Always consider cancer in a patient at risk.

  8. Given a patient with a diagnosis of inflammatory bowel disease (IBD) recognize an extra intestinal manifestation.

DDx Abdominal Pain

  • Cardiovascular:

    • ACS, pericarditis

    • Aortic dissection, mesenteric ischemia, sickle cell crisis

  • Pulmonary:

  • Biliary:

    • Cholecystitis, cholelithiasis, cholangitis

  • Gastric:

    • Esophagitis, gastritis, peptic ulcer, small-bowel mass or obstruction

  • Colonic:

  • Hepatic:

  • Pancreatic:

  • Renal:

    • Cystitis, nephrolithiasis, pyelonephritis

  • Splenic:

    • Abscess

  • Gynecologic:

    • Ectopic pregnancy, ovarian mass, ovarian torsion, PID, fibroids, endometriosis, ovulatory pain, ruptured ovarian cyst

  • Abdominal wall:

    • Herpes zoster, muscle strain, hernia

  • Metabolic:

    • Uremia, DKA, porphyria, adrenal insufficiency, narcotic withdrawal, heavy metal poisoning

  • Psych:

 

History

  • Acute vs. Chronic

  • Fever, stools (diarrhea, bloody), vomiting (bilious, bloody)

  • Malignancy (early satiety, weight loss, night sweats, changes in stools)

  • Alcohol, smoking, drugs

  • NSAIDs

  • Past surgeries (obstruction)

  • Females (pregnancy)

    • Vaginal bleeding/discharge, LMP

Physical Exam

  • Vitals

  • Chest/Lung

  • Abdo

  • Pelvic/Genital exam

  • Rectal exam

Investigations

  • Labs (eg. CBC, ALT/AST, amylase/lipase, lytes (glucose, creat), UA, bhCG)

  • Ultrasound

  • X-ray (CXR, AXR)

  • Endoscopy/Colonoscopy

  • ERCP

  • Urea breath test

Choice of imaging

  • Ultrasound (gallbladder, gyne) if RUQ/suprapubic

  • Otherwise, CT

    • Consider IV contrast for RLQ, non-localized (r/o appendicitis)

    • Consider Oral + IV contrast LLQ (r/o sigmoid diverticulitis)

  • X-ray limited use

    • Free air (if upright)

      • Perforation

    • Calcifications

      • 10% of gallstones, 90% of kidney stones, and 5% appendicoliths

    • Multiple dilated loops of the bowel and air-fluid levels

      • Bowel obstruction or paralytic ileus

Women

Do NOT Miss Dx in Acute Pelvic Pain in Women

  • Life-threatening

    • Ectopic pregnancy

    • Appendicitis

    • Ruptured ovarian cyst

  • Fertility-threatening

    • PID

    • Ovarian Torsion

Children

Red Flags

  • Fever (after onset of vomiting or pain)

  • Bilious vomiting

  • Bloody diarrhea

  • Absent bowel sounds

  • Voluntary guarding

  • Rigidity

  • Rebound tenderness

  • ** Do not forget testis **

Differential diagnosis based on age group

  • <1yo

    • Common: Colic, constipation, GERD, food protein allergy

    • Urgent: Acute gastroenteritis, malrotation without volvulus, pyloric stenosis

    • Emergent: Trauma (abuse), midgut volvulus, NEC, omphalitis, incarcerated hernia, intussusception

  • 1-5yo

    • Common: UTI, constipation

    • Urgent: Acute gastroenteritis, HSP, pneumonia, Meckel diverticulum

    • Emergent: Trauma, appendicitis, asthma

  • 5-12yo

    • Common: UTI, constipation, functional

    • Urgent: Acute gastroenteritis, IBD, HSP, pneumonia

    • Emergent: Trauma, appendicitis, gonadal torsion, DKA, asthma

  • >12yo

    • Urgent: Gastroenteritis, IBD, pneumonia, hepatitis, pancreatitis, nephrolithiasis, PID

    • Emergent: Trauma, appendicitis, gonadal torsion, ectopic pregnancy, DKA, asthma

Investigation in children with abdominal pain

  • Consider urinalysis, CBC, pregnancy test, ESR/CRP

  • Consider ultrasound prior to proceeding with abdominal CT

Elderly

  • More likely complicated by coexistent disease, medications

  • May present later in course of illness and nonspecific symptoms

    • Physical examination can be misleadingly benign

  • Increase risk of cholecystitis, pancreatitis, diverticulitis, obstructions (adhesions, malignancy)

  • Do not miss AAA, mesenteric ischemia

 

 

References:

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