2arsre024 Evaluation of the adult wth abdominal pain in the emergency department - UpToDate UpToDate eee ort ipeome nc andor ane ligne anes Sep Wolters Kluwer Evaluation of the adult with abdominal pain in the emergency department ‘Author: John | Kendal MO, FACE Mara € Moreira, MD Section Editor: Roper S Hockberger, MD, FACEP Deputy Eto: Jonathan Gray, MO, FaNEM ‘toples ar updated as new evidence becomes avalable and our pee review oroces is complete LUterature review curent through: feb 2021, | This topic at updated: Dec 22,2020, INTRODUCTION Abdominal pain continues to pose diagnostic challenges for emergency clinicians. In many cases, the differential diagnosis fs wide, ranging from benign to life-threatening conditions. Causes include medical, surgical, Intraabdominal, and extraabdominal alments. Associated symptoms often lack specificity and atypical presentations of common diseases are frequent, further complicating matters. Older adults, the immunocompromised, and women of childbearing age pose special diagnostic challenges. Older and diabetic patients often have vague, nonspecific complaints and atypical presentations af potentially life-threatening conditions leading ta time consuming workups [L.21. The immunocompromises patient may suffer from a wide range of ailments, including unusual and therapy-related conditions. Pregnancy leads to physiologic and anatomic changes affecting the presentation of common diseases. (See “Agoroach to acute abdominal pain in oregnant and postoartum women") This top review wil discuss how to assess the adult patient presenting tothe emergency department (ED) with abdominal pain, and provide a synopsis of important diagnoses to consider. Detailed discussions of specific diagnoses are found separately, EPIDEMIOLOGY [Abdominal pain comprises 5 to 10 percent of emergency department (ED) vist [3:6], Despite sophisticated diagnostic modalities, undifferentiated abdominal pain remains the diagnosis for approximately 25 percent of patients discharged from the ED and between 35 and 41 percent for those admitted to the hospital [4.1-8}. Approximately 80 percent of patients discharged with undifferentiated abdominal pain Improve or become pain-free within two weeks of presentation [3] Colder patients with abdominal pain have a six- to eightfold increase in mortality compared to younger patients [1,10], Older adults (ie, patients lover 65 years of age) account for 20 percent of ED vist, of which 3 to 4 percent are for abdominal pain (1.10.11). About one-half to two-thirds of these patients requires hospitalization, while one-third requires surgical intervention [2.5.12-14] Some studies suggest that mortalty rates ‘among older adults with abdominal pain increase whe ir iagnosis is not determined inthe ED (15) ‘The incidence of abdominal pain in the human immunodeficiency virus (HIV) patient population ranges from 12 to.45 percent (15.171, OF HIV positive patlents presenting with abdominal pain, 38 percent require admission (17). Eleven percent of HIV positve patlents requiring surgery hhad an acquired immune deficiency syndrome (AIDS) associated opportunistic infection, The remaining patients had pathology commonly seen inthe immunocompetent population. The most common diagnosis inthis group was undifferentiated abdominal pain. DIFFERENTIAL DIAGNOSIS Immediate life threatening conditions — Abdominal pain may be caused by the following life-threatening conditions, which are described below: * Abdominal aortic aneurysm + Mesenteric ischemia + Perforation of gastrointestinal tract (including peptic ulcer, bowel, esophagus, or appendix) + Acute bowel obstruction * Volvulus + Ectopic pregnancy + Placental abruption + Myocaraial infarction + Splenic rupture (eg, secondary to Epstein-Barr virus (EBV), leukemia, trauma) hitpshwowuplodate.com/contenslavalvation-ohe-adul-wih-abdominalpain-in-the-emergency-departmentprint?eearc 102arsre024 Evaluation of the adult wth abdominal pain in the emergency department - UpToDate + Abdominal aortic aneurysm (AAA) An aneurysm isa focal aortic dilation of at least 50 percent compared to normal, with any measurement greater than 3 cm considered abnormal. Most AAAS remain quiescent unt rupture, but some manifest as abdominal, back, or flank pain. ‘Aneurysm rupture typically causes exsanguinating hemorrhage and profound, unstable hypotension. (See "Clinical features and diagnosis of abdominal artic aneurysm") [Anumber of atypical presentations exist for ruptured AAA, contributing to a misdiagnosis rate of up to 30 percent [18], AAAS can rupture Into the retroperitoneum where they may tamponade, enabling the patient to remain normotensive initially. AAAS can present with back pain and hematuria leading to potential misdiagnosis as nephralithiass. [AAAs most common in men over 60 years, mith risk increasing dramatically as patients age beyond 60. Chronic obstructive pulmonary disease, peripheral vascular disease, hypertension, smoking, and a family history are associated with AAA, Mesenteric ischemia - Mesenteric ischemia can be differentia sno four enttes: arterial embolism (50 percent, arterial thrombosis (15 high percent), nonocclusive mesenteric ischemia (20 percent), and venous thrombosis (15 percent), Mesenteric ischemia is assoclated wit ‘mortality and prompt diagnosis crucial albeit often difficult (See "Overview of intestinal ischemia in adults") [Acute mesenteric ischemia Is classically said to present with rapid onset of severe periumbilical abdominal pain, often out of proportion £0 findings on physical examination, Nausea and vomiting are common, Sudden pain associated with few abdominal signs and forceful bowel ‘evacuation ina patient with risk factors should greatly heighten suspicion forthe diagnosis. The subset of patients with mesenteric venous thrombosis has @ more indolent course and lower reported mortality. Rsk factors include advanced age, atherosclerosis, low cardiac output states, cardiac arrhythmias (eg, atrial fibrillation), severe cardiac valvular disease, recent myocardial infarction, and intrsabdominal ‘malignancy Gastrointestinal perforation ~ Many causes of gastrointestinal perforation exst, but peptic ulcer disease (PUD) isthe mast common, Perforation can alsa complicate appendics, diverticulitis, ischemic bowel, and toxic megacolon. Ulcer perforation should be suspected in patients with a history of peptic ulcer symptoms who develop the sudden onset of severe, diffuse abdominal pain. A detaled assessment reveals a history of PUD or ulcer symptoms in the majority of cases, a notable exception being elder individuals with nonsteroidal antiinflammatory drug (NSAID).induced perforation. Perforation is more common and lethal among older adults, Delays in diagnosis greater ‘than 24 hours substantially increase mortality. Esophageal perforation (Boerhaave syndrome), which can occur with severe retching, can present with severe and progressive epigastric abdominal pain. (See “Overview of complications of neatlc ulcer disease", section on Perforation’) [Acute bowel obstruction ~The majority of bowel obstructions involve the small intestine. Mortality from bowel strangulation varies from 8 percent when surgery is performed within 36 hours to 25 percent when surgery is delayed beyond 36 hours, (See Etiologis, clinical ‘manifestations. and diagnosis of mechanical small bowel obstruction in adults" and "Management of small bowel abstruction in adults section on ‘Indications for immediate surgery’) ‘The most common symptoms of small Bowel abstruction (SBO) are abdominal distention, vomiting, crampy abdominal pain, and absence of flatus. In proximal obstruction, nausea and vomiting can be relatively severe compared with distal obstruction, but distention of the abdomen is somewhat les. The colon requires 12 to 24 hours to empty ater the onset of bowel obstruction so flatus and even passage of feces may continue after the onset of symptoms. Abdominal pain is frequently described as periumbilcal and crampy, with paroxysms of pain occurring every four or five minutes. Pain progresses from crampy to constant and more severe, and some clinicians fee that such progression isa sigh of impending strangulation. Focal abdominal pain inthe presence of other symptoms of obstruction may be an ‘ominous sign and should not be ignored, Previous upper or lower abdominal surgery increases the risk for obstruction. Causes of SBO include: adhesions (50 to 70 percent), Incarcerated hernias (15 percent), and neoplasms (15 percent) Gallstone ileus isthe cause in up to 20 percent of cases among older adult patlents. Patients with Crohn's disease frequently present with obstruction, Volvulus - The majarity of patients with cecal volvulus have a similar presentation to those with small Bowel obstruction, Symptoms include abdominal pain, nausea, vomiting, and obstipation. The pain is usually steady, with 3 superimposed colicky component, The abdomen is. often difusely distended. Fever, peritonitis, or hypotension may indicate the presence of intestinal gangrene. Risk factors for cecal volvulus Include adhesions, recent surgery, congenital bands, and prolonged constipation. Mortality for cecal volvulus ranges from 12 to 17 percent; ‘mortality among alder adults can be as high as 65 percent, (See "Cecal volvulus") Sigmoid volvulus accounts for the majority of volvulus cases. Most patients present with abdominal pain, nausea, abdominal distension, and Constipation; vomiting is less common. Younger patients may have a more insidious presentation with recurrent attacks of abdominal pain and intermittent resolution, presumably due to spontaneous detorsion. Compromise of the blood supply tothe sigmoid colon can lead to ‘gangrene with resulting peritonitis and sepsis, Pain is usually continuous and severe, with a superimposed colicky component. The abdomen 2402arsre024 Evaluation of the adult wth abdominal pain in the emergency department - UpToDate is usually distended and tympanic, Risk factors include excessive use of laxatives, tranquilizers, anticholinergic medications, ganglionic blocking agents, and medications for Parkinsonism, (See 'Sigmoid volvulus’) + Ectopic pregnancy - Clinicians must consider the diagnosis of ectopic pregnancy in any female of childbearing age with abdominal pain and should obtain a human chorionic gonadotropin (hCG test in all such patients. Rsk factors include a history of pelvic inflammatory disease, previous tubal pregnancy, previous tubal surgery, history of endometriosis, and an indwelling intrauterine device. Athough symptoms of ectopic pregnancy classically include the triad of amenorrhea, abdominal pain, and vaginal bleeding, up to 30 percent of patients do not hhave vaginal bleeding, the pelvic examination Is often nondiagnostc; transvaginal ultrasonography, or seal testing of hCG, is performed to make the diagnosis (See “Ectopic pregnancy: Clinical manifestations and diagnosis’ and "ukrasonagraghy of pregnancy of unknown location” and ‘Approach tothe aduk with vaginal bleeding in the emergency department) Placental abruption ~ An acute, clinical abruption classically presents with vaginal bleeding, abdominal or back pain, and uterine contractions. The uterus may be rigid and tender. The amount of vaginal bleeding correlates poorly with the degree of placental separation and in some cases may even be absent [15).n the presence of a severe abruption (250 percent placental separation), both fetus and mother may be at risk, and acute disseminated intravascular coagulation (DIC) can develop. (See "Placental abruption: Pathoohysiolegy. clinical features. diagnosis and conseauences* and "Placental abruption: Management and long-term prognosis" and ‘Approach to the adult with vaginal bleeding n the emergency department”) In approximately 10 to 20 percent of cases, a woman with placental abruption will present with preterm labar only and no vaginal bleeding. Therefore, even small amounts of vaginal bleeding inthe setting of abdominal pain and uterine contractions should prompt careful maternal and fetal evaluation, ‘Maternal hypertension isthe most common cause of abruption, occurring in 4@ percent of cases. Other risk factors include cocaine use, {alcohol consumption, cigarette smoking, trauma, and advanced maternal age, ‘Myocarcial infarction ~ Atypical presentations of myocardial infarction are most common in women older than 65 years of age. Abdominal pain s the presenting complaint for an acute myocardial infarction in approximately one-third of atypical cases. Patents with diabetes may also present atypically. (See "Clinical features and diagnosis of coronary heart disease in women’ and "Diagnosis of acute myocardial ‘infarction’ and “Initia evaluation and management of suspected acute coronary syndrome (myocardial infarction unstable angina) in the emergency department”) ‘Common conditions — Common and important gastrointestinal causes of abdominal pain are described brietly below, while the differential diagnosis s summarized in the following table( table 1) Gastrointestinal + Appendicitis -The early symptoms and signs of appendicitis are often subtle and nonspecific, and the examination unrevealing, Nausea and vomiting are generally not the frst symptoms. Classically, patients initially experience anorexia along with vague periumbilical discomfort that develops into marked right lower quadrant pain, This progression occurs with an inflamed anterior or pelvic appendix. However, 3 retracecal appendix may not cause focal signs of peritonitis. pelvic appendix can present with urinary symptoms or darthea. Scoring systems and advanced imaging as appropriate have improved dlagnostc accuracy. (See “Acute appendicitis in adults: Clinical manifestations and siferential diagnosis" and "Acute anpendicitis in adults: Diagnostic evaluation” Patients who have had an appendectomy may sil develop a stump appendicitis in which the appendix remnant becomes occluded, edematous, and infected. Presentation, dlagnoses, and treatment are similar to that of appendicitis. Clinicians often fail to diagnose appendicitis in older patients, in whom mortality can reach 70 percent. Older adults often present without the findings classically associated with appendicitis. Appendicitis is the most common extrauterine cause for abdominal surgery in pregnant Wornen. The right lower quadrant is the most common location of pain regardless of gestational age, despite traditional teaching that the appendix migrates into the right upper quadrant during pregnancy. (See “Acute appendicitis in preqnancy") Bilary disease - Patients with acute cholecystitis typically complain of abdominal pain, mast commonly in the right upper quadrant or epigastrium. The pain may radiate tothe right shoulder or back, Pains often steady and severe, Associated complaints may include nausea, vomiting, and anorexia. There is often a history of fatty food ingestion about one hour or more before the onset of pain. Patients are usually lil appearing, febrile, and tachycardic, with tenderness inthe right upper abdomen. Murphy's sign may be present, although the sensitivity of the test can be diminished in older adults, Progression ta septic shock can occur with ascending cholangitis. (See "Acute calculous cholecystitis: Clinica features and diagnosis" and “Treatment of acute calculous cholecystitis) Pancreatits - Acute pancreatitis almost always presents with acute upper abdominal pain, The pains steady and may be in the ‘midepigastrium, right upper quadrant, diffuse o, infrequently, confined to the lft side. Band-lke radiation tothe back is common. Pain often reaches maximum intensity within 10 to 20 minutes of onset, but can persist for days. Nausea and vomiting is common. In severe tps: www uptodate. com/contanslevaluaion-ohe-adul-wih-abdominalpain-in-the-emergency-departmentiprint7search=abdominal pain&sou 40221372024 Evaluation of the adult wth abdominal pain in the emergency department - UpToDate cases, patients can present in shock or coma, Physical findings vary with severity. In mild disease, the epigastrium may be minimally tender; In severe episodes, upper abdominal distention, tenderness, and guarding are common, (See "Clinical manifestations and diagnosis of acute pancreatitis” and ‘Management of acute pancreatitis) Predisposing factors include alcoholism, bilary tract disease, trauma, penetrating ulcer, infection, hypertriglyceridemia, drug reactions (eg, NSAIDs, furosemide, thiazides, sulfonamides, tetracycline, erythromycin, acetaminaghen,corticostercids, estrogens), hypercalcemia, carbon ‘monoxide exposure, and hypothermia, + Diverticular disease - The presentation of dverticultis depends upon the severity of inflammation and the presence of complications. Left ewer quadrant pain s the most common complaint. Pain is often present for several days prior to presentation. Many patients have had one ‘or mare similar past episodes. Nausea and vomiting and/or a change in bowel habits often accompany the pain, Examination usually reveals abdominal tenderness in the left lower quadrant. Older adult patients are at increased risk for developing diverticula and thelr complications, which can include diverticulti, perforation, obstruction, and hemorrhage. (See "Clinical manifestations and diagnosis af acute vertcults in adul cute colonic diverticulitis: Medical management") + Peptic ulcer disease ~ Epigastic pain, indigestion, and reflux symptoms are classically associated with peptic ulcer cisease (PUD), but none is sensitve or speci n the absence of complications, examination findings are unremarkable. Complications include bleeding and perforation. Marta from perforation is significantly higher inthe geriatric population, particularly when the diagnosis is delayed 24 hours fr longer. Older adults are often unaware they have PUD untila severe complication develops. (See immediate lfe-threatening conditions! above and “Peptic ulcer disease: Clincal manifestations and diagnosis") + Incarcerated hernia - Inguinal hernias are most common and often present with mild lower abdominal discomfort exacerbated by straining Inguinal and incisional hernias are more common in elder adult patients, Incarcerated hernias can cause severe pain and require immediate surgical consultation, (See “Classification, clinical features, and diagnosis of inguinal and femoral hern + Gastroenteritis and other infectious causes - Although common, gastroenteritis isa diagnosis of exclusion in the ED, where the clinician ‘must focus on life-threatening causes of abdominal pain. Infectious gastroenteritis, enteritis, and colitis have many etiologies (viral, bacterial, parasitic, antibiotic associated). Fever, diarrhea, andor vomiting may be more prominent symptoms than abdominal pain. (See ‘gastroenteritis in adults" and “Anproach to the adult with acute diarthea in resource-rich settings" and “Approach to the adult with acute slarthea In esource-limited countries") + Foodborne disease - Foodborne diseases typically manifest as a mixture of nausea, vomiting, fever, abdominal pain, and diarthea. Veriting or diarthes may be more prominent than abdominal pain. Depending upon the nature of the illness, symptoms can develop anywhere from ‘one hour to several days after the contaminated food is ingested. (See “Causes of acute infectious diarthea and other foodborne lnesses in resource-rich settings". section on ‘Clinial clues tothe microbial cause’) + Complications af bariatric (weightloss) surgery - Complications can occur within weeks or years after bariatric surgery, and many involve abdominal pain as part ofthe presentation In adltion to such standard complications as bleeding and bowel obstruction, other potential ‘complications (organized by procedure) include the following (20:22) + Roux-en-Y gastric bypass: Gastric remnant distension; stomal stenosis; marginal ulceration + Gastric banding: Stomal obstruction; port infection; band erosion; band movernent causing obstruction + Sleeve gastrectomy: Gastric outlet obstruction; gastric leaks (see ‘Late complications of bariatric suracal operations") + Inflammatory bowel disease - Acute complications from inflammatory bowel disease can include paln, bleeding, perforation, bowel obstruction fistula and abscess formation, and toxic megacolon. (See "Clinical manifestations, diagnosis, and prognosis of Crohn disease in adults" and "Clinical manifestations, diagnosis, and prognosis of ulcerative colts in adults") + Hepatitis ~ Hepatitis has a multitude of possible etiologies, including infections (bacterial, viral, parasitic, fungal), toxins, medications, and Immunologic disorders. (See ‘Approach to the patient with abnormal iver biochemical and function tests") + Spontaneous bacterial peritonitis (SBP) ~ SBP involves an acute bacterial infection f ascitic fluid in patients with lver disease, Usually there is no apparent source of infection, SBP occurs in up to a quarter of patients admitted with cirrhosis and ascites. Mortality is high in patients With clrhosts. See "Spontaneous bacterial peritonitis in adults: Clinical manifestations" and “Spontaneous bacterial peritonitis in adul Diagnosis" and “Spontaneous bacterial pe prophylaxis") its in adults: Treatment an + Trrtable bowel syndrome (165) Although common, 1BS's rarely diagnosed inthe ED, where the clinician must focus on life-threatening «causes of abdominal pain. Diagnosis of IBS requires persistent symptoms for three months over a one year period. Symptoms include ano2arsre024 Evaluation of the adult wth abdominal pain in the emergency department - UpToDate abdominal pain associated with a change in stool frequency or consistency. (See “Clinical manifestations and diagnosis of irritable bowel syndrome in adults") Genitourinary — Important genitourinary causes of abdominal pain are described briefly below. A number of tables summarizing the differential diagnosis of abdominal and pebic pain, including genitourinary causes, are provided( table 2and table) + Urinary tract infection (UTIVpyelonephritis - Lower urinary tract infections often present with suprapubic discomfort associated with urinary symptoms such as frequency, urgency, or dysuia. Fever (38°C), flank pain, costovertebral angle tenderness, and nausea or vomiting suggest upper tract infection and warrant more aggressive diagnostic and therapeutic measures. (See "Acute simple cysts in women’ and "acute complicated urinary rac infection (including pyelonephritis in aduks”) + Nephrolithiasis - Nephrolithiasis can present with severe abdominal pain, wich may mimic that of abdominal aortic aneurysm. Pain i often colicky and radiates tothe lank or groin. Hematuria is present in 70 to 90 percent of cases, (See ‘Diagnasis and acute management of suspected nephrolithiasis in adults") + Adnexal torsion ~The most common symptom of adnexal (or ovarian) torsion is sudden onset lower abdominal pain, often associated with waves of nausea and vomiting Patients with ovarian cysts or other masses are at higher risk. Ovarian tarsion isa gynecologic emergency. (See “Ovarian and fallooian tube torsion") + Ruptured ovarian cyst - Rupture of an avatian eyst may be asymptomatic or associated with the sudden onset of unilateral lower abdominal pain. Pain often begins during strenuous physical activity (eg, exercise or sexual intercourse) and may be accompanies by light vaginal bleeding, significant intraperitoneal bleeding can occur in the absence of vaginal bleeding, Unilateral lower abdominal tenderness s often present (See “Evaluation and management of cuptured ovarlan cyst" and “Anproach to the adult with vaginal bleeding in the emergency department”) + Preeclampsia ~ Preeclampsia usually occurs in the late stages of pregnancy and is defined by the triad of hypertension, proteinuria, and edema. Liver injury can occur producing right upper or epigastric abdominal pain. (See "Preeclampsia: Clinical features and diasnosis) + Pelvic inflammatory disease (PID) - PID refers to acute infection ofthe upper genital tract in women. Lower abdominal pain isthe cardinal symptom of PID. Pain that worsens during coitus ar with jarring movement may be the only symptom: the onset of pain during or shortly after menses is suggestive, Pain is usually bilateral but may be mild, Abnormal uterine bleeding, new vaginal discharge, urethritis, and fever ‘can be associated with PID but are neither sensitive nor specific See “Pelvic Inlammatory disease: Clinical manifestations and diagnosis") + Tube-ovarian abscess (TOA) - Infrequent, PID is complicated by TOA, Ultrasounds the preferred study for diagnosing TOA, which may require surgical drainage. (See "Epidemiology. clinical manifestations. and diagnosis of tubo-ovarian abscess") + Fit-Hugh Curtis syndrome ~ Approximately 10 percent of patients with PID go on o develop perihepatit’s(Ftz-Hugh Curtis Syndrome), Since these patients present with right upper quadrant pain and tenderness, the syndrome can mimic cholecystts, pneumonia, or pulmonary embolus. (See ‘Pelvic inflammatory disease: Clinical manifestations and diagnosis") + Endometriosis - Endometriosis is defined as endometrialike tissue located outside the uterine cavity that produces an inflammatory reaction. Common symptoms include pelvic pain (which may be chronic buts often more severe during menses or at ovulation) dysmenorthea, infertility, and deep dyspareunia. Examination Is often unremarkable. (See ~Endometvosis: Pathogenesis, clinical features, and.giagnosis") + Testicular torsion ~ Testicular torsion usually presents with the sudden onset of severe pain following vigorous activity or testicular trauma Examination often reveals an asymmetrically high-iding, transversely oriented testis on the affected side and loss of the cremasteric reflex. ‘Testicular salvage rates are over 20 percent if treatment is initiated within six hours of symptoms, but fall significantly thereafter. (See "Acute sctotal pain in adults") Trauma-related — injuries sustained during trauma may not manifest for days to weeks after the event, Splenic rupture is a common ‘example, but delayed presentations of perforated bowel, pancreatitis, and injuries to the lve, gallbladder, and genitourinary tact have all been reported, Diaphragmatic injury can even be delayed for months to even years ands often dificult to diagnose asthe diaphragm isnot well visualized by CT scan. Therefore, its important to ask patients presenting to the ED with abdominal pain about recent and past trauma, Bedside Ultrasonography may reveal intraperitoneal free fluid; CT imaging is often necessary in table patients to make a defnitve diagnosis. Immediate surgical consultation is needed for unstable patients in whom abdominal pain is suspected to be tauma-related, The intial evaluation and ‘management of trauma is discussed separately. (See "Initial management of trauma in adults") ‘Common extraabdominal diseases — A list of extraabdominal causes of abdominal pain is provided ( table 40221372024 Evaluation of the adult wth abdominal pain in the emergency department - UpToDate + Diabetic ketoacidosis (OKA) - DKA isthe intial presentation for approximately 3 percent of Type I diabetics, OKA can present with severe ‘abdominal pain and vomiting (See "Diabetic ketoacidosis and hyperosmolar hyperslycemic state in adults: Clinical features, evaluation, and sdiagnosis*) + Alcoholic ketoacidosis ~ Alcoholic ketoacidosis occurs in chronic alcohols after a recent binge. The binge is fellowed by veriting and decreased food intake. Up to 75 percent of patients present with nausea, vomiting, and abdominal pain, (See “Fasting ketosis and alcoholic ketoacidosis + Pneumonia - Symptoms of pneumonia may include nausea, vomiting, diarrhea, weight loss, anorexia, and abdominal pain. The abdominal pain stems from pleuriic irritation caused by a basilar infiltrate, The pain is generally sharp and aggravated by cough or deep inspiration, (See "Clinical evaluation and diagnostic testing for communityacquired pneumonia in adults") + Pulmonary embolus (PE) - PE can present with a range of nonspecific symptoms and signs, which may include upper abdominal pain and shoulder pain [23]. Two possible mechanisms for abdominal pain are pleural irritation ofthe diaphragm causing an ileus and hepa congestion from acute right ventricular failure. t seems unlikely that abdominal pain would be the sale manifestation of PE (See "Overview ‘of acute pulmonary embolism in adults") + Herpes zoster- Herpes zoster i a reactivation of alatent varicella-zoster viral infection ina dorsal root ganglion. Pain and a rash develop in a ddermatomal patern, which may involve the abdomen. Pain can precede the rash by days to weeks. (See "Euidemislogy. clinical ‘manifestations, and diagnosis of herpes zoster") Other conditions — Some of the diagnoses listed below will not be made in the emergency department (ED) but are included as a reference and {o enable clinicians o access more detalled Information easly + Toxin/érugerelated ~ Many toxins and drug ingestions can cause abdominal pain including the folowing: + Corrosives (eg, aspitin. iron, mercury, acids, and alkali) cause abdominal pain and mucosal injury that can result in esophageal or gastric perforation + Anticholinergcs and narcoties may cause abdominal pain secondary tiles or obstruction. + Charcoal ang drug bezoars can cause mechanical obstruction. + Amphetamines, ergotamines, and cocaine can cause absominal pain fram vasoconstriction producing bowel ischemia + Acetamlnanhen can cause hepatic injury, and dideoxyinosine (ddl) can cause pancreatts + Heavy metal (9, lead) intoxication i included inthe diferentil clagnosis of patients wth 2 combination of abdominal pain and anemia, + Mushroom polsoning can present with crampy abdominal pain, vomiting, and diarrhea. + Opioid withdrawal produces a numberof symptoms, af which abdominal pains typically prominent. + Heavy marijuana use can lead to cannabinoid hyperemesis syndrome, Patents present with a chief complaint of abdominal pain and associated vomiting, and they may describe relief of pain with hot showers or baths For discussions of specific toxins see the relevant toxicology topic review, including those listed here, (See “General approach to drug ppoisonine in adults" and “Caustic esonhageal Injury in adulis” and “Anticholineraic poisoning" and "Lead exposure and poisoning in adults" and ‘Clinical manifestations and evaluation of mushroom poisoning! and ‘Opioid withdrawal in the emergency setting”) [Neoplasm Abdominal pain may be the presenting symptom for neoplasms, Ovarian cancer can present with abdominal swelling, ‘dyspepsia, indigestion, abdominal distention, flatulence, anorexia, pelvic pressure, back pain, rectal fullness, or urinary urgency, or frequency. Colorectal cancer can present with abdominal pain associated with changes in bowel habits, weightloss, and rectal bleeding, Patients with leukemia can present with symptoms suggestive ofan acute abdomen from a functional obstruction, passibly due to autonomic dysfunction, localized vascular derangements, or peritoneal irritation, (See “Epithelial carcinoma of the ovary, fallopian tube. and petitonewm: Clinical features and diagnosis" and "Clinical aresentation, diagnosis. and siaging of colorectal cancet") ‘chemotherapy and radiation treatments for neoplasms can produce abdominal pain. As an example, vincristine can produce severe colicky abdominal pain for up to 10 days after administration. Patients undergoing chemotherapy for leukemia can present with typhltis ora necrotizing colitis involving the cecum or appendix. (See “Enterotoxiciy of chemotherageutic agents") Sickle cll disease ~ Acute painful episodes associated with sickle cell disease, formerly calle sickle cll crises, can result from ischemia or splenic or mesenteric infarction. Abdominal pain is often a sickle cell patient's typical pain. If the abdominal pain isnot typical, the clinician hitpsiwuuuplodate.com/contenslavalvation-ohe-adult-with-abdominal-pain -the-emergency-departmentiprin\?eearch=abdominal panBsource=.... 6402arsre024 Evaluation of the adult wth abdominal pain in the emergency department - UpToDate should investigate other causes. Sickle ell disease patients have a predilection for some common causes of abdominal pain (eg, gallstones) (See “Evaluation of acute pain in sickle cell disease’) + Toxic megacolon - Causes of toxic megacolon include Inflammatory bowel disease, infectious colts (eg, Clostridioides dificil, ischemic clits, and obstructive colon cancer. Signs and symptoms of acute colts, which are frequently resistant to therapy, are often present for at least one week prior to the onset af acute dilatation of the colon. Severe bloody diarrhea isthe most common presenting symptom: Improvement of diarthea ray herald the onset of megacolon (See "Toxic megacolon’) + Mesenteric lymphadenitis - Mesenteric adenitis is a common mimic of appendicts caused by vial or bacterial inflammation ofthe mesenteric mph nodes [2 Iti a diagnosis of exclusion inthe ED. (See "Clinical manifestations and diagnosis of Yersinia infections”, section on ‘Pseudoappendicitis') + Infectious mononucleosis - Among patients with infectious mononucleosis, approximately half will have splenic enlargement and a small percentage will develop a self-limited clinical hepatitis. Sudden left upper quadrant pain or generalized abdominal pain should raise concern for spontaneous splenic rupture, although this is rare. (See Infectious mononucleosis") + Toxic shock syndrome - This syndrome is characterized by fever, rash, hypotension, and multiorgan involvement. Abdominal complaints are ‘common and can include nausea, vomiting, diarrhea, and pain. (See "Staphylococcal toxic shock syndrome") + Rocky Mountain spotted fever (MSF) - The classic triad of fever, rash, and a history of ick exposure Is present in a small percentage of, patients during the first three days of illness. Abdominal pain is reported by 30 percent of patients. (ee “Clinical manifestations and sliagnosis of Rocky Mountain saotted fevec') + Porphyria - Porphyria is a rare condition caused by deficiency in one of the enzymes responsible for heme synthesis. Acute porphyrias can cause attacks of abdominal pain that may be associated with metabolic or neurologic findings (hyponatremia, agitation, hallucinations, pparess, seizures). While porphyria an unusual cause of abdominal pain, abdominal pain s the most common finding in acute porphyria attacks, Acute attacks can be (but are nat always) precipitated by drugs (eg, estrogens, barbiturates, phenytoin, ethanol, sulfonamides) or other triggers (eg, infection, stress, severe dietary restriction, menstrual changes). The abdominal examination is often unremarkable despite severe pain. The urine may be brown ar reddish, During an acute attack, acute porphyria can be readily rule in or out with a urine ‘est for porphobilinogen (PBG), as discussed separately. (See "Porphytias: An averview'. section on “Acute hepatic porphyrias (AHP: exemplified by AIP) + Familial Mediterranean fever - Familial Mediterranean fever is an autosomal recessive disorder characterized by recurring attacks of fever {and serosal inflammation of the peritoneum, pleura, or synovium. Attacks begin with fever and peak symptoms occur in the frst 12 hours ‘Abdominal pains present in over 95 percent of cases, (See “Clinical manifestations and diagnosis of familial Mediterranean fever") + angioedema ~ Both acquired angioedema in the setting of underlying malignancy and hereditary angioedema can cause recurrent abdominal pain and pseudo-cbstruction. (See "Hereditary angioedema: Epidemiology, clinical manifestations. exacerbating factors, and prognosis + Rectus sheath hematoma - Causes may include traura, anticoagulation therapy, physical exertion, paroxysmal cough, pregnancy, leukemia, and hypertension + Systemic lupus erythematosus (SLE) ~ SLE Involves the gastraintestinal trac, generally with nonspecific symptoms, in fewer than 50 percent of patients. However, several disorders that cause abdominal pain may be associated with SLE, including peritonitis, peptic ulcer disease, ‘mesenteric vascults with intestinal infarction, pancreatitis, and inflammatory bowel disease, (See "Gastrointestinal manifestations of systemic lugus erythematosus") + Immunoglobulin Avascults (lg; Henach-Schénlein purpura (SPD ~IgAV (HSPs a hypersensitivity vascultis most commonly occurring in children, although adults may be affected. tis characterized by palpable purpura, arthralgias, hematuria secondary to glomerulonephriis, calleky abdominal pain, nausea, vomiting, and dlarrhea (See “IgA. vascutis(Henoch-Schonleln purpura) Cal manifestations and diagnosis") + Polartertis nodosa - Polyarterts nodosa s a systemic disease that includes gastrointestinal symptoms in greater than 50 percent of cases. ‘These may include abdominal pain, nausea, vomiting, darthea, and bleeding. Up to a third of patients will develop surgical complications, such as bowel infarction, perferation, or hemorrhage, associated with high mortality. (See "Clinical manifestations and diagnosis of pobarteritis nodosa in adults") + Eosinophilic enterts - Eosinophilic entertsis a rare cause of recurrent right lower quadrant pain whose cause Is uncertain, (See 402arsre024 Evaluation of the adult wth abdominal pain in the emergency department - UpToDate + Hypercalcemia - Patients presenting with hypercalcemia can present with vague abdominal pain. The pain s associated with anorexia, nausea, vomiting and constipation, (See ‘Clinical manifestations of hypercalcemia") + Splder bite (Locradectus moctans) - Venom from this species stimulates release of acetylcholine peripherally and centrally, and symptoms usually begin within one to eight hours. Some patients may develop abdominal pain without physical findings while others present with bboard-lke rigidity, akhough bowel sounds are normal. See “Aparaach to the patient with a suspected spider bite: An overview") + Thoracic nerve root dysfunction - Thoracie nerve root dysfunction can present with severe constant abdominal pain that becomes worse at night. There may be associated loss of pinprick sensation over the abdominal wall + Glaucoma - Typical symptoms of acute glaucoma include ocular pain and decreased vision. However, abdominal discomfort, nausea, and headache can occur. (See “Oper-angle slaucama: Enidemiology, clinical presentation. and diagnosis + pheochromocytoma - Pheachromocytoma isa rare catecholamine secreting tumor with a classic presentation of headache and hypertension, Nausea is common and epigastric pain may occur (See “Clinical presentation and diagnosis of pheochromocytoma.) + Ovarian hyperstimulation syndrome - This gynecologic emergency occurs in women undergoing avulation induction. Multiple large ovarian cysts can precipitate acute fluid shifts with depletion of intravascular fluid and a shock-like syndrome, Consider the diagnosis in women taking fertility medications who present with abdominal pain. (See “Pathogenesis, clinical manifestations, and dagnosis of ovarian hyperstimulation syndrome’) HISTORY The combination ofa careful history and physical examination can often distinguish between organic and nenorganic causes of abdominal pain and s crucial for creating a focused and appropriate differential diagnosis. When trying to determine the etiology ofa patient's abdominal pain it is important to consider the patient's age, sex, past mecical and surgical history, and medications, and to characterize the pain as precisely as possible table 5). (See ‘Characterization of pain below) (older adults are far more likely to have severe disease and “atypical” symptoms (14.25.26) The risk for certain diseases, such as ruptured abdominal aortic aneurysm (AAA), mesenteric ischemia, atypical presentations of myocardial infarction, and colon cancer increases significantly in patients older than 50 years. The clinician must remember that older patients often present with different symptoms and signs than younger patients and take medications, such as prednisone, that mask classic symptoms and signs. As an example, older patients diagnosed surgically with cholecystitis preser ‘nor right upper quadrant pain [26], (See “Evaluation of the adult with abdominal pain’ section on History’ and Causes of abdominal pain in adults!) far more often with nausea or vomiting than pain, and among those over 65 years, 8 percent had neither epiga: In women of childbearing age, pregnancy status must be determined. Irthe patient Is pregnant, the differential dlagnosis includes complications of pregnancy such as an ectopic gestation and preeclampsia. However, pregnant patients are also at risk for common diseases such as appendicitis and cholecystitis See "Approach to acute abdominal pain in pregnant and postpartum women") Genitourinary causes of abdominal pain are numerous and should not be overlooked in nonpregnant women and men. Inquire about vaginal bleeding or slscharge, recent changes in menstruation, dysuria or hematuria, penile discharge, and scratal pain er sweling, and any recent Clisicians should consider both inra- and extra-abdominal causes of pain table 4). Upper abdominal symptoms may reflect thoracic disease, particularly in older adult patients, so its important to ask about such symptoms as dyspnea, cough, and palpitations Preexisting medical and surgical conditions and medications can increase a patient’ rsk for specific diseases. As an example, a history of cardiovascular or peripheral vascular disease corresponds with an increased risk for mesenteric ischemia and AAA. history of arial fibrillation or heart failure places patients at risk for mesenteric ischemia from emboli or low'flow respectively. A history of HIV predisposes to opportunistic infection or a medication-related complication (eg, pancreatitis or renal clic), Previous surgery increases the rsk for bowel obstruction. Ahistory of nonsteroidal antiinflammatory drug (NSAID) use predisposes to peptic ulceration and bleeding, Concurrent antibiotic or steroid use may mask Infections, while some antibiotics increase the risk for C efile colitis. See "Clostridioides (formerly Clostridium) dffice infection in adults: Ginical manifestations and diagnosis") ‘The socal history can be of great importance. Alcohol abuse places patients at ris for pancreatitis, hepatitis, cirrhosis, and spontaneous ‘bacterial peritonitis, Abdominal pain and nausea often figure prominently among the symptoms of patients withdrawing from opioids. Smokers have a greater risk of bladder and other cancers that may cause abdominal pain (27). (See "Opioid withdrawalin the emergency setting") ao2arsre024 Evaluation of the adult wth abdominal pain in the emergency department - UpToDate ‘An occupational and travel history may help to identify unusual causes. Occupational exposures to toxins or chemicals, recent travel, o similar symptoms among family or friends may be important clues indicative of a nonsurgical cause of pain, PAIN DESCRIPTION ‘Types of pain — Abdominal pain can be divided into three types: visceral, parietal (or somatic), and referred. The neurologic basis of abdominal pain is discussed in detail elsewhere, (See “Causes of abdominal pain in adults’, section on ‘Pathophysiology of abdominal pain:) Visceral pain bers originate in the walls of hollow organs and the capsules of solid organs and enter the spinal cord bilaterally at multiple levels. ‘Thus, stimulation of visceral nerves produces 2 dul, poorly localized pain fel in the micline. Pain 's perceived inthe abdominal region corresponding to the diseased organs embryonic origin, Visceral pain from structures that originated from the foregut (stomach, pancreas, Iver {and gallbladder, and proximal duodenum) manifests in the epigastrium; visceral pain from structures ofthe midgut (remainder of duodenum, small bowel, proximal large bowel) manifests in the periumbilical region; and visceral pain from structures ofthe hindgut (middle and distal large bowel, pelvic genitourinary organs) manifests inthe suprapuble region. Ischemia, inflammation or distention of hellow organs or capsular stretching of solid organs produces viscera type pain Parietal pain stimull are transmitted to specific dorsal roat ganglia on the same side and dermatomal level asthe origin ofthe pain. Therefore the pain is more distinct (usualy sharper) and localized. Ischemia, inflammation, or stretching ofthe parletal peritoneum produces parietal pain. Referred pain is felt ta site far from the diseased organ (eg, gallbladder disease experienced as pain in the right subscapular area, a perforated duodenal ulcer causing shoulder pain secondary to diaphragmatic iritation), Shared central pathways for afferent neurons from different locations cause this phenomenon. Characterization of pain — Accurate characterization of abdominal pain includes + Onset (eg, sudden, gradual) + Provocative and palliating factors (eg, does pain decrease after eating?) + Quality (eg, dll sharp, colicky, waxing and waning) + Radiation (eg, tothe shoulder, bac, flank, grain, or chest) + Site (eg, 8 particular quadrant or diffuse) + Symptoms associated with pain (eg, fever, vomiting diarrhea, bloody stool, vaginal discharge, painful urination, shortness of breath) + Time course (eg, hours versus weeks, constant oF intermittent) {table summarizing high-risk features of abdominal pains provided (sable) ‘cation may help to narrow the differential diagnosis ( table 1), Pain from abdominal viscera often localizes according tothe cembryologic origin, with foregut structures (mouth to proximal half of duodenum) presenting with upper abdominal pain, midgut s (distal half of duodenum to middle ofthe transverse colon) presenting with periumbilical pain, and hind gut structures (remainder of colon and rectum, pelvic genitourinary organs) presenting with lower abdominal pain, Right upper quadrant pain is often associated with the lver or gallbladder, akhough pain from bilary colic may be poorly localized and patients ‘may complain of lower chest, epigastric, or back discomfort (28). Other causes of right upper quadrant pain include myocardial infarction, right, lower labe pneumonia, and rightsided pulmonary embolus (PE) 29]. Left upper quadrant pain can be from pancreatit’s, gastric disease, of splenic enlargement. Other causes include left lower lobe pneumonia and myocardial infarction. Both appendicitis ans ectopic pregnancy may present with right lower quadrant pain. Diverticulit's usually presents with left lower quadrant pain. However, clinicians should not base the differential diagnosis solely upon the location of pain; diagnosis and pain location often do not correspond [30.31]. As an example, the diagnosis of appendicitis in patients presenting with right upper quadrant pain may be missed ifthe clinician falls to consider that retracecal appendicit’s can present inthis manner, One study looking at patterns of abdominal pain found that only 60 to 70 percent of patients would be correctly diagnosed based on “typical” exam findings alone, ylelding a misdiagnosis rate of 30 to 40 percent (2) Pain location may change overtime, reflecting progression of disease, As a classic example, the pain of appendicitis may begin as periumblical (eflecing its embryologic origin, but move to the right lower quadrant as the inflamed appendix irtates the peritoneum. Anather example ‘would be the changing location of pain associated with an extending aortic dissection. Radiation of pain may aid diagnosis ( figure 1). As ‘examples, pain from pancreatitis may radiate to the back while pain from gallbladder disease may radiate to the right shoulder or subscapular region, Pain aculty, duration, and intensity can provide cues to disease severity (3.22.23), Pain with maximum intensity at onset is concerning for abdominal or extraabdominal vascular emergencies (eg, aortic rupture or dissection, mesenteric ischemia, PE) [2]. The sudden onset of 0 tps: www uptodate. com/contanslevaluaion-ohe-adult-wih-abdominal-pain-in-the-emergency-departmentiprint7search=abdominal pain&sou2arsre024 Evaluation of the adult wth abdominal pain in the emergency department - UpToDate significant pain often reflects a serious underWying disorder, such as organ perforation or ischemia (eg, acute mesentery artery occlusion, ovarian torsion, or obstruction of small tubular structure (eg, biliary tractor ureter), A mare gradual onset of symptoms suggests an inflammatory or Infectious process eg, appendictis,diverticulits), or obstruction ofa large tubular structure (eg, bowel). Severe pain of sudden onset and constant or worsening pain lasting over six hours (but less than 48 hours) suggest a surgical cause. Nonsurgical causes tend to be less pail Aggravating and alleviating factors are important. The pain of peptic ulcer disease may improve after meals, whereas biliary colic worsens after ‘meals. Pancreatitis pain may improve when the patient sits upright and increase when the patient rectines, Patients with peritonitis le still ang coughing can worsen thelr pain, whereas the patlent with nephrolthiasis is restless and cannot finda comfortable postion. Ask the patient whether going over bumps duting the drive ta the hospital caused pain. A postive response suggests peritont’s and is roughly 80 percent sensitive, but only 52 percent specific, for appendicitis (0). The character ofthe abdominal pain is often linked to a specie diagnosis. Burning pain is associated with an ulcer, tearing pain with aortic dissection, and colicky or crampy pain with distention or stretching ofa hollow tube, such as with kidney stones inthe ureter. Sharp pain develops when inflammation or noxious stimuli (eg blood, stomach acid, bowel contents} contact parietal peritoneum. Associated symptoms can help narrow the diagnosis, especially with extraabdominal causes, Inquire about fever, cough, dyspnea, and chest paln, since pneumonia, pulmonary embollsm, and myocardial Infarction can all present with abdominal pain (23). Though vomiting and nausea are nonspecifi, the order ofthese symptoms may provide a clue to the dlagnosis. If vomiting occurs after the onset of pain, the pain is more Fkely to stem from a surgical process, such as bowel obstruction [. Vomiting from relatively benign causes is usually selt-imited, The type of vomiting may suggest a diagnosis. Bilous vomiting may be caused by an obstruction distal to the duodenum. Causes of coffee-ground or hhematemesis include peptic ulcer disease, varices, and, in patients with a history of aortic aneurysm repair, aortoenterc fistula, Diarchea is often ‘associated with an infectious cause or diverticulitis, ut can occur with mesenteric ischemia, in which case it may be bloody, or possibly bowel obstruction Associated genitourinary symptoms can be Important. In women, inquire about vaginal bleeding or discharge and recent changes in ‘menstruation; in men, inquire about penile discharge and scrotal pain or swelling. (See "Approach to the adult with vaginal bleeding in the emergency department”) keep in mind that the presentation and characteristics of abdominal pain may be dramatically different in older adult patients despite the presence ofa life-threatening condition. As an example, a perforated ulcer may present without the sudden onset of pain (28) (See History’ above) PHYSICAL EXAMINATION Begin the physical examination by assessing the vital signs. Though fever increases the suspicion for infection, there are certain patlent populations, such as older adults and the immunocompromised, that may be unable to mount a fever. Older adult patients with an intraabdominal infection are four times more likely than younger patients to present with hypothermia [2]. An oral temperature may be affected by respiratory rate, whichis often elevated in those with pain [35 Ifthere is concern about an inaccurate reading, check a rectal temperature. An elevated respiratory rate may itself be a compensatory reaction and should alert the clinician to the possibilty of underlying metabolic acidosis. Neat, inspect the patient. While requiring only a few seconds, inspection can provide many clues tothe diagnosis, The patient wha is restless, curled up, and agitated may suggest renal colic, while a patient Wing perfectly stillin bed with knees bent raises concern for peritonitis Inspection may reveal signs of previous surgeries (eg, midline incision scar), abdominal pulsations, oF signs of systemic disease (eg, pallor in shock, spider angiomata in cirrhosis), which can be especially important in those who are unable to provide a history (On auscultation, listen for bowel sounds for two minutes. Bowel sounds are normally heard as two to twelve medium-pitched gurgles per minute, The absence of bowel sounds over two minutes suggests peritonitis. Hyperactive medium-pitched Dowel sounds are associated with blood or inflammation within the gastrointestinal (GI) tact. Periodic rushes of high-pitched “tinkling” bowel sounds or the complete absence of bowel sounds, in the presence of abdominal distention, suggests bowel obstruction (36].A bruit may be heard inthe presence of an abdominal sortie aneurysm (KAA, Palpation of the abdomen enables the clinician to identify che location and degree of tenderness and to detect signs of peritoneal irritation, such as involuntary guarding and rigidity. One approach isto intally perform light palpation inthe area avy from the ste of pain. Palpation can then bbe extended in either a clockwise or counterclockwise rotation towards the area of maximal pain. Once the area of maximal tenderness is localizes, maneuvers to elicit somatic signs can be performed. Ifa specific area of tenderness isnot identfed with light palpation, deeper palpation can be performed to identify other abnormalities such as hepatomegaly, splenomegaly, aortic dilatation, or signs ofa retrocecal appendix, hitpshwuuuplodate.com/contanslavalvation-ohe-adul-with-abdominalpain-in-the-emergency-departmentprint?eearc! roo2arsre024 Evaluation of the adult wth abdominal pain in the emergency department - UpToDate ‘The few studies that have looked at traditional techniques for assessing rebound tenderness suggest that these tests have limited sensitivity ang specificity [37.38], Gentler methods to elicit signs of peritoneal irtation include having the patient cough ar drop their heels to the ground after standing on their toes (32.40). The heel test can also be performed by striking a recubent patient's heel. Studies ofthese tess are limited and their characteristics remain uncertain. Nevertheless, a rigid abdomen is cause for concern, In patients older than 50 years, its worthwhile and safe to attempt to palpate the aorta, To do so, have the patient lie supine with their feet on the streccher and knees bent, thereby relaxing he abdominal wall musculature. Abnormal width of the aortic pulsation suggests the dlagnosis of ‘AAA Depending upon the patient's body habitus and thelr aortic anatomy, the accuracy of the physical examination for detecting an AAA may be limited, bu it can provide important information. ‘Other examination findings to note include Carnetts sign, Murphy's sign, obturator sign, psoas sign, and Rovsing’s sign. In Carnet's sign there Is increased tenderness when the abdominal wall muscles are contracted. Tenderness exacerbated by muscular contraction is mare likely to be ddue to pathology within the abdominal wall. In one small study, Carnett’s sign was found to be 95 percent accurate at distinguishing abdominal wall pain from visceral pain [211 Although insensitive, the psoas, obturator, and Rovsing signs have good specificity for acute appencicis. A positive psoas sign consists of pain elicited when the examiner passively extends the right hip ofthe patient, who les on thelr left side. A postive psoas sign may be seen with a retracecal appendix. patient with @ pelvic appendix may have a positive ebturator sign. Pain elicited when the clinician performs passive Internal rotation of the flexed right thigh represents a positive test Rovsing’s sign consists of pain in the right lower quadrant elicited by palpation of the left lower quadrant, (See ‘Acute appendicitis in adults: Clinical manifestations and differential diaonosis*, section on ‘Shysical examination’) Murphy's sign occurs when a patient abruptly stops a deep inspiration during palpation ofthe right upper quadrant. This test can be useful in some patients with suspected cholecystitis, but its sensitivity may be diminished in older adults [42.831 Perform testicular examinations in men and pelic examinations in females with pain in the lower half ofthe abdomen. No preexamination criteria exist that enable the clinician to determine ifthe pelvic examination wil provide useful information (6. Pain from pelvic inflammatory disease (PID) may not be localized to the suprapubic region. The rectal examination may reveal a mass or gastrointestinal bleeding, but its Usefulness in patients with undifferentiated abdominal pain and no gastrointestinal bleeding has been questioned [44.45]. (See ‘Acute scrotal alninaduls” and "The gynecologic history and pelvic examination”) Physical examination cannot reliably predictor exclude significant disease in older adults (120. Abdominal tenderness may not localize because of changes in the nervous system affecting pain perception. Rebound or guarding may not be present because of lax abdominal wall musculature. In one retrospective study looking at older in-patients with peritonitis, only 34 percent manifested guarding or rebound tenderness [46 Physical examination can be difficult during pregnancy. Pregnant patients may have fewer clinical findings and may not demonstrate peritoneal sighs [47]. Tis may be a result of the gradual growth and stretching of the peritoneal cavity, which desensitizes the pregnant patient to Peritoneal irritation. (See “Approach to acute abdominal pain in pregnant and postpartum women". section an ‘General approach’) Many extraabdominal causes of abdominal pain ex'st and the clinician should not neglect ather parts of the physical examination, Auscultate the heart and lungs. Atrial fsrilation noted on physical exam may increase suspicion for mesenteric ischemia. Localized decreased breath sounds or coarse breath sounds may raise suspicion for pneumonia. Palpate the chest wall, spine, and pelvis. Pain at the costovertebral angles may suggest pyelonephritis. 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