Abdominal Pain
Richard W. Emerine
Abdominal pain of varying causes, ranging from the functional to the organic, is one of the top ten outpatient complaints; it is the chief complaint for 5% to 10% of patients presenting to emergency departments (1).
Approach
Rapid assessment is aimed at determining whether the abdominal pain is emergent or nonemergent. This assessment should be tempered with the understanding that in certain populations (the elderly, the young, the immune compromised) signs and symptoms of ominous disease can be blunted or absent.
A. Emergent abdominal pain. Did the patient experience sudden or severe pain or demonstrate hemodynamic changes—hypotension or tachycardia? Is the patient pregnant? (Up to 13% of women with a positive pregnancy test and abdominal pain have an ectopic pregnancy.) Emergent intervention is required for abdominal aortic aneurysm (AAA), bowel obstruction, ruptured spleen, and ruptured ectopic pregnancy.
B. Nonemergent abdominal pain. When emergent causes are reasonably excluded, nonemergent causes can be considered. Common nonurgent conditions include functional bowel syndrome, urinary tract infections (UTI), constipation, renal stones, cholelithiasis, gastroenteritis, and dysmenorrhea.
History
A. History of present illness. Medication use, alcohol and tobacco history, and menstrual history in women are vital. When did the pain begin and what are the characteristics of the pain? Use the “OPQRST” approach outlined below to question the patient about pain characteristics.
1. O: Onset of pain. Pain of sudden onset or that awakens a patient from sleep can represent appendicitis, leaking abdominal aortic aneurysm, ectopic pregnancy, pancreatitis, or perforating ulcer. Gradual onset of pain can represent cholecystitis, diverticulitis, inflammatory bowel disorders, or pancreatitis. Longstanding pain without debility that is worsened by emotional stress is suggestive of irritable bowel syndrome.
2. P: Palliative or Provocative factors (diet, exercise, sleep, bowel movement, and so on).
3. Q: Quality of pain—pain descriptors are often associated with specific causes:
a. “Burning” pain—ulcer
b. “Agony”—pancreatitis
c. “Shearing” or “tearing”—abdominal aortic aneurysm
d. “Colicky” or “cramping”—cholecystitis, bowel obstruction, urolithiasis, irritable bowel syndrome
e. “Constant ache”—appendicitis, peritonitis, herpes zoster
4. R: Radiation or Referred—pain from appendicitis, simple colic, and bowel obstruction from strangulation or volvulus is often first felt in the epigastrium. Abdominal causes may result in referred or radiating pain to extraabdominal sites:
a. Abdominal aortic aneurysm—to the midback
b. Biliary colic—to the right scapula
c. Renal colic—to the costovertebral angles, testicle, or thigh
d. Hernias—to the genitalia
5. Extraabdominal pathology can cause referred pain to the abdomen.
a. Cardiac ischemia—to the epigastrium
b. Scrotal pathology—to the abdomen
6. S: Severity—level of intensity (some use a 1–10 scale)
7. T: Time or Temporal relationships—with meals, after bowel movement, menses, and so on
B. Past medical history. Is there a history of previous abdominal or pelvic surgery? Prior abdominal surgery increases the risk for bowel incarceration, obstruction, and strangulation. Fallopian tube surgery and prior pelvic inflammatory disease (PID) increase a woman’s risk for ectopic pregnancy (Chapter 11.3).
C. Review of systems. Are there associated symptoms that point to a specific etiology? Chills and fever suggest infectious causes (UTI, PID, prostatitis, and pneumonia). Emesis occurring before the onset of pain is associated with appendicitis; with the onset of pain, cholecystitis or urolithiasis; after onset of pain, gastroenteritis. Late onset or feculent emesis suggests bowel obstruction; bilious emesis occurs in cholecystitis. Postprandial right upper quadrant pain is common in cholecystitis. Diarrhea with a recent travel history suggests dysentery or parasitic infections. Genitourinary complaints (dysuria, frequency, hematuria, vaginal discharge, and dypareunia) should prompt evaluation for UTI, sexually transmitted disease, and PID.
Physical examination
A thorough, targeted physical examination, directed by a complete history, leads to a correct diagnosis in most cases (2).
Complete vital signs are essential. Tachycardia or hypotension can indicate hypovolemia and the need for urgent intervention (Chapter 7.12). Rapid, shallow breaths occur with peritoneal irritation. Inspect the abdomen for distention (obstruction), pulsations (AAA), or scars from past surgery. High-pitched hyperactive bowel sounds occur with bowel obstruction. Palpation and percussion help localize tenderness, organomegaly, and masses. Pain with movement, rebound tenderness, or rigidity are indicative of peritonitis and should prompt surgical consultation.
Cardiovascular, pulmonary, and digital rectal and genitourinary examinations should be included in all evaluations of significant abdominal pain. The pelvic examination must be done to exclude ectopic pregnancy and PID. Among patients in whom pregnancy is a possibility, the presence of peritoneal signs, cervical motion tenderness, or lateral (or bilateral) abdominal or pelvic tenderness should raise concern about possible ectopic pregnancy (3).
Testing
A. Clinical laboratory tests. Human chorionic gonadotrophin should be obtained if the patient has any potential for pregnancy. If appendicitis is suspected, sensitivity approaches 96% when both the total white blood cell count and neutrophil counts are elevated. Overall, however, hemograms do not by themselves often result in a change of disposition. Serum electrolytes are generally of little diagnostic value, except for the anesthesia provider if surgery is contemplated.
Urinalysis may identify urinary infection or calculi. Liver function tests in patients with right upper quadrant pain may help differentiate hepatitis and hepatobiliary disease (Chapter 9.8). Serum amylase is not a specific test for pancreatitis; it can be elevated in many other conditions that cause abdominal pain. Serum lipase has a higher sensitivity and specificity for pancreatitis than total amylase (4).
B. Diagnostic imaging
1. Plain films. Plain radiographs have utility primarily when attempting to identify specific abdominal pathology such as renal stones, perforated viscus, or bowel obstruction. They can detect as little as 5 ml of free air. Up to five air-fluid levels of less than 2.5 cm in length may be normal; however, dilation of the small bowel beyond 2.5 cm suggests obstruction.
2. Ultrasonography. Abdominal and pelvic sonograms are rapid, inexpensive, and noninvasive. They are especially accurate in detecting hepatobiliary, pancreatic, aortic, pelvic, and renal pathology.
3. Computed tomography (CT). Consider for patients with challenging presentations. CT is valuable in identifying abscesses, hematomas, and pancreatitis, and in evaluating solid organs and the abdominal vascular system; it is remarkably useful in evaluating patients with trauma. Magnetic resonance imaging has not proved particularly beneficial in the evaluation of acute abdominal pain.
Diagnostic assessment
The critical key is to identify the patient with an acute surgical abdomen. Physical examination coupled with a careful history narrows the differential diagnosis so that confirmation can be made by appropriately selected laboratory and imaging studies. In most cases, a good clinical history augmented by a focused physical examination leads to a correct diagnosis with limited need for further testing. Extremes of age, an impaired immune system, use of pain medications, and obesity can complicate the evaluation. Surgical consultation should be obtained immediately for patients with abdominal pain accompanied by peritoneal signs or shock.
References
1. Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. Am J Emerg Med 1995;13:301–303.
2. Silen W, ed. Cope’s early diagnosis of the acute abdomen, 19th ed. New York: Oxford University Press, 1996.
3. Dart RG. Predictive value of history and physical examination in patients with suspected ectopic pregnancy. Ann Emerg Med 1999;33;283–290.
4. Gwozdz GP, Steinberg WM, Werner M, Henry JP, Pauley C. Comparative evaluation of the diagnosis of acute pancreatitis based on serum and urine enzyme assays. Clin Chim Acta 1990;187:243–254.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
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