Abdominal Pain

sites.google.com/view/fmres/gi/abdominal-pain

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

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Pulmonary:
Pneumonia, embolus
Biliary:
Cholecystitis, cholelithiasis, cholangitis
Gastric:
Esophagitis, gastritis, peptic ulcer, small-bowel mass or obstruction
Colonic:
Appendicitis, colitis, diverticulitis, IBD, bowel obstruction, peritonitis, celiac
disease
Hepatic:
Hepatitis, abscess, mass
Pancreatic:
Pancreatitis, mass
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:
IBS

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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

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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) ifRUQ/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

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 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

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 >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:

Pediatric Health Med Ther. 2017.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5774593/
AAFP 2016. Acute Abdominal Pain in Children.
https://www.aafp.org/afp/2016/0515/p830.html
AAFP 2015. Diagnostic Imaging of Acute Abdominal Pain in Adults.
https://www.aafp.org/afp/2015/0401/p452.html
AAFP 2008. Evaluation of Acute Abdominal Pain in Adults.
http://www.aafp.org/afp/2008/0401/p971.html

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