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{{CMG}}; {{AE}} {{Rim}}, {{AM}}
{{CMG}}; {{AE}} {{AM}}


==Definitions==
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! Terms!! Definitions
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| '''Acute abdominal pain'''|| Severe, persistent abdominal pain of sudden onset that is likely to require surgical intervention to treat its cause. Duration of less than several days.
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Acute Abdominal Pain Resident Survival Guide Microchapters}}
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| '''Acute abdomen'''|| It is defined as a sudden, abrupt onset of severe localized or generalized abdominal pain with abdominal rigidity.<ref>{{Cite web  | last = | first =  | title = ICD-10 Version:2010 | url = http://apps.who.int/classifications/icd10/browse/2010/en#/R10.0 | publisher =  | date =  }}</ref> It is less than 24 hours in duration and requires urgent evaluation and diagnosis because it may indicate a need for immediate surgical intervention.(also known as '''surgical abdomen''')<ref name="isbn0-8036-2977-X">{{cite book | author = Venes, Donald | authorlink = | editor = | others = | title = Taber's Cyclopedic Medical Dictionary (Thumb-indexed Version) (Taber's Cyclopedic Medical Dictionary (Thumb Index Version)) | edition = | language = | publisher = F.A. Davis Company | location = Philadelphia, PA | year = 2013 | origyear = | pages = | quote = | isbn = 0-8036-2977-X | oclc = | doi = | url = | accessdate = }}</ref>
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute abdominal pain resident survival guide#Overview|Overview]]
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| '''Subacute abdominal pain'''|| It's a type of abdominal pain that has a duration of more than several days but less than six months.
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute abdominal pain resident survival guide#Causes|Causes]]
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| '''Chronic abdominal pain'''|| It has a duration of more than six months, either constantly or intermittently.<ref name="isbn1-4160-6189-4">{{cite book | author = Lawrence S. Cohen MD; Mark W. Green MD | authorlink = | editor = | others = | title = Sleisenger and Fordtran's Gastrointestinal and Liver Disease- 2 Volume Set: Pathophysiology, Diagnosis, Management, Expert Consult Premium Edition - Enhanced ... & Liver Disease (Sleisinger/Fordtran)) | edition = | language = | publisher = Saunders | location = Philadelphia | year = 2010 | origyear = | pages = | quote = | isbn = 1-4160-6189-4 | oclc = | doi = | url = | accessdate = }}</ref>
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute abdominal pain resident survival guide#Management|Management]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute abdominal pain resident survival guide#Do's|Do's]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Acute abdominal pain resident survival guide#Don'ts|Don'ts]]
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==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==
==Causes==
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*[[Splenic  infarction]]
*[[Splenic  infarction]]
*[[Ulcerative colitis]]
*[[Ulcerative colitis]]
===Common extraabdominal diseases===
*[[Alcoholic ketoacidosis]]
*[[Diabetic ketoacidosis]]
*[[Herpes zoster]]
*[[Pneumonia]] (involving the lower lobes)
*[[Pulmonary embolus]]
   
   
==Management==
==Management==
====Diagnostic Approach====
Shown below is an algorithm depicting the diagnostic approach of acute abdominal pain. <br>
<span style="font-size:85%"> '''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</span>
{{familytree/start |summary=Acute abdominal pain}}
{{familytree | | | | | | | | | | | | | | A01 | | | | | | | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Characterize the pain:'''<br>
:❑ 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)<br>
'''Other symptoms'''<br>
:❑ [[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 history and symptoms|sepsis]]
:❑ Symptoms suggestive of [[Mirizzi's syndrome|common hepatic duct obstruction]]
::❑ RUQ pain with fever & [[jaundice]]
:❑ Symptoms suggestive of [[gallstone ileus]]
::❑ Transient abdominal pain with nausea & vomiting
::❑ [[Hematemesis]]
'''Detailed history:'''<br>
:❑ 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]])</div>}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | A02 | | | | | | A02= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Examine the patient:''' <br>
❑ Vital signs<br>
:❑ [[Temperature]]<br>
:❑ [[Heart rate]] ([[tachycardia]]) <br>
:❑ [[Blood pressure]] ([[hypotension]])<br>
:❑ [[Respiratory rate]] ([[tachypnea]])<br>
❑ Skin <br>
:❑ [[Diaphoresis]]
:❑ [[Pallor]]
:❑ [[Jaundice]]
:❑ [[Dehydration]]
❑ Inspection <br>
:❑ If the patient is curled up/agitated, this is suggestive of [[renal colic]]<br>
:❑ If the patient is lying still in bed with knees bent, this is suggestive of [[peritonitis]]<br>
:❑ Signs of previous surgery<br>
:❑ Abdominal pulsations<br>
:❑ Signs of systemic disease eg,<br>
::❑ [[Pallor]], suggestive of bleeding<br>
::❑ [[Spider angiomata]], suggestive of [[cirrhosis]]<br>
❑ Auscultation <br>
:❑ Abdominal crepitations<br>
:❑ Reduced bowel sounds<br>
:❑ Increased bowel sounds<br>
:❑ Bruit, suggestive of [[abdominal aortic aneurysm]]<br>
❑ Palpation<br>
:❑ Rigidity
:❑ [[Guarding]]
:❑ Abdominal tenderness
:❑ [[Distension]]
:❑ Detection of masses on palpating the abdomen
:❑ [[McBurney's point]] [[tenderness]]<br>
:❑ [[Rovsing's sign]] <br>
:❑ [[Carnett's sign]]
❑ [[Psoas sign]] (suggestive of retrocecal appendix)<br>
❑ [[Obturator sign]]<br>
❑ [[Cullen's sign]]<br>
❑ [[Grey-Turner's sign]]<br>
❑ [[Digital rectal exam]] (tenderness may be present in retrocecal appendicitis)<br>
❑ [[Pelvic exam]] in females<br>
❑ [[Testicular examination]] in males<br>
❑ Cardiovascular system<br>
❑ Respiratory system<br>
❑ Anorectal (bleeding)<br>
❑ [[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<br>
</div>}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | | C01 | | | | | | | |C01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider extraabdominal differential diagnosis:'''<BR> ❑ [[Abdominal epilepsy]]<BR> ❑ [[Alcoholic ketoacidosis]]<BR> ❑ [[Diabetic ketoacidosis]]<BR> ❑ [[Esophageal spasm]] or rupture ([[boerhaav's syndrome]])<BR> ❑ [[Familial mediterranean fever]]<BR> ❑ [[Herpes zoster]]<BR> ❑ [[Lead poisoning]]<BR> ❑ [[Myocardial ischemia]] and infarction<BR> ❑ [[Myocarditis]]<BR> ❑ [[Pleurodynia]] ([[bornholm's disease]])<BR> ❑ [[Pneumonia]] (involving the lower lobes)<BR> ❑ [[Porphyria]]<BR> ❑ [[Pulmonary embolus]]<BR> ❑ [[Radiculopathy]]<BR> ❑ [[Sickle cell anemia]]<BR> ❑ [[Tabes dorsalis]]<BR> ❑ [[Uremia]]</div>}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | | E01 | | | | | | | | | |E01=❑ Assess hemodynamic stability }}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | Z02 | | | | | | | | |Z02=<div style="float: left; text-align: left; line-height: 150% ">'''If the patient is unstable,''' <br> '''Stabilize the patient:'''<br> ❑ Establish two large-bore intravenous peripheral lines<br> ❑ NPO until the patient is stable<br> ❑ Supportive care (fluids and electrolyes as required)<br> ❑ Place nasogastric tube if there is bleeding, obstruction, significant [[nausea]] or [[vomiting]]<br> ❑ Place [[foley catheter]] to monitor volume status<br> ❑ Cardiac monitoring<br> ❑ Supplemental oxygen as needed<br> ❑ Administer early antibiotics if indicated </div>}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | Z01 | | | | | | | | | | |Z01 =<div style="float: left; text-align: left; line-height: 150% ">'''If the patient is stable,'''<br> '''Order laboratory tests:'''<br> ❑ [[Pregnancy test]] (required in women of child-bearing age) <br>❑ [[CBC]]<br> ❑ [[Hematocrit]]<br> ❑ [[Urinalysis]]<br> ❑ [[Serum electrolytes]]<br>❑ [[ESR]]<br>❑ [[ABG]]<br> ❑ [[D dimer]]<br>❑ [[Serum lactate]]<br> ❑ [[BUN]] <br> ❑ [[Creatinine]] <br> ❑ [[Amylase]] <br> ❑ [[Lipase]] <br> ❑ [[Triglyceride]] <br>❑ Total [[bilirubin]]<br>❑ Direct [[bilirubin]]<br>❑ [[Albumin]]<br>❑ [[AST]]<br>❑ [[ALT]]<br>❑ [[Alkaline phosphatase]]<br>❑ [[GGT]]<br>❑ Stool for ova and parasites<br>❑ C. difficile culture and toxin assay 
----
'''Order imaging studies:''' <br> ❑ Order urgent trans abdominal ultrasound (TAUSG)<br> ❑ [[Abdominal CT]]<br> ❑ [[ECG]]<br> ❑ [[MRCP]] <br> ❑ [[Abdominal x-ray]] <br> ❑ [[Angiography]]<br> ❑ Diagnostic [[paracentesis]]<br>
----
'''''*Order the tests to rule in a suspected diagnosis<br> or to assess a case of unclear etiology'''''<br> '''''*In case of elderly patients, immunocompromised<br> or those unable to provide a comprehensive<br> history, order broader range of tests''''' </div>}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | A01 | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% "> '''Signs of [[peritonitis]] or [[shock]]'''<br> ❑ [[Fever]]<br> ❑ Abdominal tenderness<br>  ❑ Abdominal gaurding<br>  ❑ Rebound tenderness ([[blumberg sign]])<br> ❑ Diffuse abdominal rigidity<br> ❑ [[Confusion]]<br>  ❑ Weakness<br> ❑ Low blood pressure <br> ❑ Decreased urine output<br> ❑ Tachycardia<br> </div>}}
{{familytree | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| }}
{{familytree | | | | | | | C01 |-|-|-|-|-|.| | | | | | C03 | | | | | | | |C01=No|C02=No|C03=Yes}}
{{familytree | | | | | | | |!| | | | | | |!| | | | | | |!| }}
{{familytree | | | | | | | D01 | | | | | D02 | | | | | D03 |D01=<div style="float: left; text-align: left; width: 7em; padding:1em;"> '''Signs and symptoms suggestive of [[acute coronary syndrome]]''' ❑ Risk factors: >40 years, smoking, [[diabetes mellitus]], [[hypertension]], obesity and high [[cholesterol]]<br> ❑ [[Chest tightness]] radiating to the left arm and the left angel of the jaw<br> ❑ [[Diaphoresis]]<br> ❑ Shortness of breath<br> ❑ Sense of impending death<br> ❑ [[Nausea]] and [[vomiting]]<br> [[Acute coronary syndrome resident survival guide|For more details about management of ACS, click here]] </div>|D02=<div style="float: left; text-align: left; width: 7em; padding:1em;"> '''Signs and symptoms suggestive of [[abdominal aortic aneurysm]]'''<br> ❑ Risk factors: smoking, alcohol, [[hypertension]], high familial prevelance (genetic influences)<br> ❑ Pulsating sensation of the abdomen<br> ❑ Palpable abdominal mass<br> ❑ If ruptured: [[hypovolemic shock]], [[hypotension]], [[tachycardia]], [[cyanosis]], and [[altered mental status]]</div>|D03=<div style="float: left; text-align: left; width: 7em; padding:1em;">❑ Initiate resuscitation <br> ❑ Obtain immediate surgical consultation <br> ❑ Perform bedside ultrasound (evaluate aorta, hemoperitoneum, pericardium and inferior vena cava) <br> ❑ Obtain indicated tests and studies (e.g. x-ray, ECG, lactate, lipase and LFTs) </div>}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | | | | | | | G01 |^|-| G02 | | | | | | | | |G01=No|G02=Yes}}
{{familytree | | | | | | | | | | | | |!| | | | |!| | | | |}}
{{familytree | | | | | | | | | | | | |!| | | | F01 | | | | | | | | | | | |F01=<div style="float: left; text-align: left; line-height: 150% ">❑ Surgical consultation <br> ❑ Bedside ultrasound <br> ❑ Abdominal CT<br> [[Abdominal aortic aneurysm|For more details about management of AAA, click here]] </div>}}
{{familytree | | | | | | | | | | | | H01 | | | | | | | | | | | |H01=<div style="float: left; text-align: left; line-height: 150% "> '''Signs and symptoms syggestive of [[mesenteric ischemia]]''' <br> ❑ [[Abdominal pain]] out of proportion to examination<br> ❑ Bloody stools<br> ❑ [[Shock]]<br> ❑ [[Metabolic acidosis]] with [[dehydration]] </div>}}
{{familytree | | | | | | | | | | |,|-|^|-|-| I01 | | | | | |I01=Yes}}
{{familytree | | | | | | | | | | L01 | | | | |!| | | | | | |L01=No}}
{{familytree | | | | | | | | | | |!| | | | | J01 | | | | | |J01=<div style="float: left; text-align: left; line-height: 150% ">❑ Surgical consultation <br> ❑ Abdominal CT<br> [[Intestinal ischemia resident survival guide|For more details about management of mesenteric ischemia, click here]]  </div>}}
{{familytree | | | | | | | | | | K01 | | | | | | | | | | |K01=<div style="float: left; text-align: left; line-height: 150% "> '''Signs and symptoms suggestive of [[bowel obstruction]] or [[perforation|Intestinal perforation]]'''<br> ❑ Diffuse tenderness with distention<br> ❑ Persistent [[vomiting]]<br> ❑ [[Rigidity]] with absent bowel sounds<br> ❑ Fecal [[vomiting]]<br> ❑ [[Dehydration]] and [[electrolyte abnormalities]] </div> }}
{{familytree | | | | | | | | | |,|^|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | M01 | |M01=Yes}}
{{familytree | | | | | | | | | N01 | | | | | | | | | | | | | | |!| | |N01=No}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | M02 | |M02=<div style="float: left; text-align: left; line-height: 150% "> '''Abdominal x-ray series'''<br> ❑ ''Presence of free air:'' Consult surgery<br> ❑ ''Presence of obstruction:'' Order abdominal CT<br> ❑ ''Absent free air and absent obstruction:'' Order abdominal CT </div>}}
{{familytree | | | | | | | | | N02 | | | | | | | | | | | | | | | | | | | | | |N02=Where is pain localized}}
{{familytree | | | | |,|-|-|v|-|^|-|v|-|-|-|v|-|-|.| | | | | | | | | | | | | | | | | |}}
{{familytree | | | N03 | | N04 | | N05 | | N06 | | N07 | | | | | | | | | | | | | |N03=[[Right upper quadrant abdominal pain resident survival guide|RUQ pain]]|N04=[[Right lower quadrant abdominal pain resident survival guide|RLQ pain]]|N05=[[Left upper quadrant abdominal pain resident survival guide|LUQ pain]]|N06=[[Epigastric pain resident survival guide|Epigastric pain]]|N07=[[Hypogastric pain resident survival guide|Hypogastric pain]]}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree/end}}
<br>
<br>
==Approach to a female of child-bearing age==
{{familytree/start |summary=Sample 1}}
{{familytree | | | | | | | | | A01 | | | | | | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% "> '''Signs of [[peritonitis]] or [[shock]]'''<br> ❑ [[Fever]]<br> ❑ Abdominal tenderness<br>  ❑ Abdominal gaurding<br>  ❑ Rebound tenderness ([[blumberg sign]])<br> ❑ Diffuse abdominal rigidity<br> ❑ [[Confusion]]<br>  ❑ Weakness<br> ❑ Low blood pressure <br> ❑ Decreased urine output<br> ❑ Tachycardia<br> </div>}}
{{familytree | | | | | |,|-|-|-|^|-|-|-|-|-|-|-|-|.| | }}
{{familytree | | | | | B01 | | | | | | | | | | | B02 | | |B01=No|B02=Yes}}
{{familytree | | | | | |!| | | | | | | | | | | | |!| | | }}
{{familytree | | | | | C01 | | | | | | | | | | | C02 | | |C01='''Pregnant:''' Perform a pregnancy test|C02=<div style="float: left; text-align: left; line-height: 150% ">❑ Initiate resuscitation <br> ❑ Obtain immediate surgical consultation <br> ❑ Perform bedside ultrasound (evaluate aorta, hemoperitoneum, pericardium and inferior vena cava) <br> ❑ Obtain indicated tests and studies (e.g. x-ray, ECG, lactate, lipase and LFTs) </div>}}
{{familytree | | | | |,|^|-|-|-|-|-|-|-|.| | | | | | | }}
{{familytree | | | D01 | | | | | | | | E01 | | | | | |D01=No|E01=Yes}}
{{familytree | | | |!| | | | | | | | | |!| | | | | | | }}
{{familytree | | | I01 |-| J01 | | | | F01 | | | | | |I01=Unilateral adnexal tenderness|J01=Yes|F01=<div style="float: left; text-align: left; line-height: 150% ">❑ Perform ultrasound examination (consider [[ectopic pregnancy]], [[appendicitis]]) <br> ❑ Perform sterile pelvic examination (not in third trimester [[vaginal bleeding]]) <br> ❑ Obtain quantitative HCG and other needed lab tests <br> ❑ Obtain OB/Gyn and surgery consultation if indicated </div>}}
{{familytree | | |!| | | | |!| | | | |,|^|-|.| | | | | }}
{{familytree | | L01 | | | K01 | | G01 | | G02 | | | |L01=No|K01=<div style="float: left; text-align: left; line-height: 150% "> '''''Rule out [[ovarian torsion]] or [[ovarian cyst]] by ultrasonography.'''''<br> '''Signs and symptoms suggestive of [[ovarian torsion]] or cyst:'''<br> ❑ Unilateral lower abdominal pain <br> ❑ [[Nausea]] and [[vomiting]]<br> ❑ Uterine bleeding <br> ❑ Irregular periods <br> ❑ Constitutional symptoms as fatigue or headaches </div>|G01=Intrauterine pregnancy|G02=<div style="float: left; text-align: left; line-height: 150% "> '''Ectopic pregnancy:''' <br> ❑ Risk factors: [[PID]], [[infertility]], usage of intrauterine device, tubal surgery, intrauterine surgery (eg, dilation and curettage)<br> ❑ [[Vaginal bleeding]]<br> ❑ [[Nausea]], [[vomiting]] and [[diarrhea]]<br> ❑ Abdominal distension<br> ❑ [[Hemorrhagic shock]] </div>}}
{{familytree | | |!| | | | | | | | |!| | | |!| | | | | }}
{{familytree | | M01 | | | | | | | H01 | | H02 | | | |M01=<div style="float: left; text-align: left; line-height: 150% ">'''Clinical [[pelvic inflammatory disease]]:'''<br> ❑ [[Fever]] <br> ❑ Cervical motion tenderness <br> ❑ Lower abdominal pain <br> ❑ [[Vaginal discharge]] <br> ❑ Painful intercourse <br> ❑ Irregular mesntrual bleeding </div>|H01=<div style="float: left; text-align: left; line-height: 150% ">❑ Assess appendix with US <br> ❑ Obtain OB/Gyn and surgery consultation as indicated </div>|H02=Obtain OB/Gyn consultation}}
{{familytree | |,|^|-|-|-|-|-|.| | | | | | | | | | }}
{{familytree | N01 | | | | | N02 | | | | | | | | |N01=No|N02=Yes}}
{{familytree | |!| | | | | | |!| | | | | | | | | | }}
{{familytree | O01 | | | | | O02 | | | | | | | | |O01=Predominant [[Right lower quadrant abdominal pain resident survival guide|RLQ pain]]|O02=Toxic appearing or persistent vomiting}}
{{familytree | | | | | | | |,|^|.| | | | | | | | | }}
{{familytree | | | | | | P01 | | P02 | | | | | | |P01=No|P02=Yes}}
{{familytree | | | | | | |!| | | |!| | | | | | | | }}
{{familytree | | | | | | Q01 | | Q02 | | | | | | |Q01=Adminster antibiotics as an outpatient|Q02=Admit, start IV antibiotics and consult gynaecology}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree/end}}
<br>
{|
{|
|-
|-
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|-
|-
| [[Image:Right_lower_quadrant.PNG|link=Right lower quadrant abdominal pain resident survival guide]]||[[Image:Hypogastric.PNG|link=Hypogastric pain resident survival guide]]||[[Image:Left_lower_quadrant.PNG|link=Left lower quadrant abdominal pain resident survival guide]]
| [[Image:Right_lower_quadrant.PNG|link=Right lower quadrant abdominal pain resident survival guide]]||[[Image:Hypogastric.PNG|link=Hypogastric pain resident survival guide]]||[[Image:Left_lower_quadrant.PNG|link=Left lower quadrant abdominal pain resident survival guide]]
|}
===Differentiating Common Causes of Abdominal Pain===
Shown below is a table summarizing some clues that help to distinguish the presentation of different diseases.
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Causes'''||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Clues'''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''[[Appendicitis]]'''|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Gradual achy pain that starts as diffuse periumbilical pain, then becomes localized in the right lower quadrant.
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |  '''[[Cholecystitis]]'''||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Acute constricting pain that starts localized in the right upper quadrant and sometimes radiates to the scapula.
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''[[Pancreatitis]]'''||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Acute boring pain that starts in the epigastrium and radiates to midback.
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''[[Diverticulitis]]'''||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Gradual achy pain, localized in the left lower quadrant (called left sided appendicitis).
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''[[Perforated peptic ulcer]]'''||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left| Sudden burning pain, presents as a diffuse pain in the periumbilical region.
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''[[Small bowel obstruction]]'''||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Gradual crampy pain, presents as a diffuse pain in the periumbilical region.
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''[[Mesenteric ischemia]] or infarction'''||style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Sudden agonizing pain, presents as a diffuse pain in the periumbilical region.
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''Ruptured [[abdominal aortic aneurysm]]'''|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Sudden tearing pain, presents as a diffuse pain in the abdomen, back and flanks.
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''[[Gastroenteritis]]'''|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Gradual spasmodic pain, presents as a diffuse pain in the periumbilical region.
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''[[Pelvic inflammatory disease]]'''|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Gradual achy pain, presents in either lower quadrants or pelvis and sometimes radiates to the upper thigh.
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''[[Ruptured ectopic pregnancy]]'''|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | Sudden sharp pain, presents in either lower quadrants or pelvis.
|-
|}
|}


==Do's==
==Do's==
*Consider abdominal aortic aneurysm, mesenteric ischemia and malignancy in patients above 50 years as it is much less likely for younger patients.
*Start the approach to [[acute abdominal pain]] by rapid assessment of the patient using the pneumonic "ABC:" '''a'''irway, '''b'''reathing and '''c'''irculation, to identify unstable patients.
*Perform pelvic and testicular examination in patients with low abdominal pain.
*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.
*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.  
*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.
*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 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.  
*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. <ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Diagnosis and management of 528 abdom... [Br Med J (Clin Res Ed). 1981] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/6788329 | publisher =  | date =  | accessdate =  }}</ref>
*Consider [[peritonitis]] with [[cervical motion tenderness]] as it isn't specific for [[pelvic inflammatory disease]].
*Suspect acute mesenteric ischemia and acute pancreatitis in patients presenting with poorly localized pain out of proportion to physical findings. <ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Mesenteric ischemia in the elderly. [Clin Geriatr Med. 1999] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/10393740 | publisher =  | date =  | accessdate = }}</ref>
*Suspect [[abdominal aortic aneurysm]] in old patients presenting with [[abdominal pain]] with history of tobacco use.<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Diagnosis and management of 528 abdom... [Br Med J (Clin Res Ed). 1981] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/6788329 | publisher =  | date =  | accessdate =  }}</ref>
*Recommend initial imaging studies based on the location of abdominal pain:
*Suspect [[acute mesenteric ischemia]] or [[acute pancreatitis]] in patients presenting with poorly localized pain out of proportion to physical findings.<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Mesenteric ischemia in the elderly. [Clin Geriatr Med. 1999] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/10393740 | publisher =  | date =  | accessdate = }}</ref>
:*Ultrasonography is recommended when a patient presents with right upper quadrant pain. <ref name="www.acr.org">{{Cite web  | last =  | first =  | title = http://www.acr.org/ | url = http://www.acr.org/ | publisher =  | date =  | accessdate = }}</ref>
*Recommend initial imaging studies based on the location of [[abdominal pain]]:
:*Computed tomography (CT) with intravenous contrast media is recommended for evaluating adults with acute right lower quadrant pain. <ref name="www.acr.org">{{Cite web  | last =  | first =  | title = http://www.acr.org/ | url = http://www.acr.org/ | publisher =  | date =  | accessdate = }}</ref>
:*Ultrasonography is recommended when a patient presents with [[right upper quadrant pain]].<ref name="www.acr.org">{{Cite web  | last =  | first =  | title = http://www.acr.org/ | url = http://www.acr.org/ | publisher =  | date =  | accessdate = }}</ref>
:*CT with oral and intravenous contrast media is recommended for patients with left lower quadrant pain. <ref name="www.acr.org">{{Cite web  | last =  | first =  | title = http://www.acr.org/ | url = http://www.acr.org/ | publisher =  | date =  | accessdate = }}</ref>
:*Computed tomography (CT) with intravenous contrast media is recommended for evaluating adults with acute [[right lower quadrant pain]].<ref name="www.acr.org">{{Cite web  | last =  | first =  | title = http://www.acr.org/ | url = http://www.acr.org/ | publisher =  | date =  | accessdate = }}</ref>
*Order ECG for old patients with upper abdominal pain with high cardiac risk factors.
:*CT with oral and intravenous contrast media is recommended for patients with [[left lower quadrant pain]].<ref name="www.acr.org">{{Cite web  | last =  | first =  | title = http://www.acr.org/ | url = http://www.acr.org/ | publisher =  | date =  | accessdate = }}</ref>
*Administer narcotic analgesia for patients who present to the ED with moderate or severe abdominal pain. <ref name="www.ebmedicine.net">{{Cite web  | last =  | first =  | title = http://www.ebmedicine.net/content.php?action=showPage&pid=94&cat_id=16 | url = http://www.ebmedicine.net/content.php?action=showPage&pid=94&cat_id=16 | publisher =  | date =  | accessdate =  }}</ref>
*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]].<ref name="www.ebmedicine.net">{{Cite web  | last =  | first =  | title = http://www.ebmedicine.net/content.php?action=showPage&pid=94&cat_id=16 | url = http://www.ebmedicine.net/content.php?action=showPage&pid=94&cat_id=16 | publisher =  | date =  | accessdate =  }}</ref>
*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]].


==Don'ts==
==Don'ts==
Line 95: Line 291:
*Do not order blood cultures routinely in all patients
*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 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. <ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Clinical policy: critical issues for the initi... [Ann Emerg Med. 2000] - PubMed - NCBI | url =http://www.ncbi.nlm.nih.gov/pubmed/?term=Annals+of+Emergency+Medicine.+2000%3B36%3A406-415 | publisher =  | date =  | accessdate = }}</ref>
*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.<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = Clinical policy: critical issues for the initi... [Ann Emerg Med. 2000] - PubMed - NCBI | url =http://www.ncbi.nlm.nih.gov/pubmed/?term=Annals+of+Emergency+Medicine.+2000%3B36%3A406-415 | publisher =  | date =  | accessdate = }}</ref>


==References==
==References==
Line 108: Line 304:
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</div>

Latest revision as of 20:24, 20 March 2014

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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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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