Assessing Abdominal Pain in June 2019

Volume 21, Number 6

Adults: A Rational, Cost-Effective, Author

and Evidence-Based Strategy

Stephen Colucciello, MD, FACEP
Professor of Emergency Medicine, University of North Carolina
School of Medicine, Charlotte Campus, Charlotte, NC

Peer Reviewers
Abstract
Todd Taylor, MD
Assistant Professor, Assistant Residency Director, Department
The management of abdominal pain has changed significantly of Emergency Medicine, Emory University School of Medicine,
in the past 20 years, with increasing emphasis on identifying Atlanta, GA

patients who are at high risk for occult pathology and worse Nadia Maria Shaukat, MD, RDMS, FACEP
Director, Emergency and Critical Care Ultrasound, Department of
outcomes. Emphasizing safe disposition over diagnosis, this Emergency Medicine, Coney Island Hospital, Brooklyn, NY
issue identifies the important aspects of the history and physical CME Objectives
examination, explores strengths and weaknesses of laboratory
Upon completing this article, you should be able to:
evaluations, and summarizes the pros and cons of the many 1. Describe the life-threatening etiologies of abdominal pain and
types of imaging now available. With abdominal pain still the how they present.
most common chief complaint seen in the emergency depart- 2. Identify the most commonly missed diagnoses in abdominal
ment, a new look at the evolution of assessment strategies is in pain.
3. Identify the “high-risk” patient with abdominal pain.
order, such as new recommendations on the use of oral contrast,
4. Order imaging and laboratory testing that is most appropriate
managing HIV patients on highly active antiretroviral therapy, according to history and clinical presentation.
maximizing use of bedside ultrasound, when and how to offer
pain relief, and the value of serial examinations and observation Prior to beginning this activity, see “CME Information”
on the back page.
to reduce costs and improve care.

Editor-In-Chief
Andy Jagoda, MD, FACEP
Professor and Interim Chair,
Department of Emergency Medicine;
Director, Center for Emergency
Medicine Education and Research,
Icahn School of Medicine at Mount
Sinai, New York, NY
Associate Editor-In-Chief
Kaushal Shah, MD, FACEP
Associate Professor, Vice Chair
for Education, Department of
Emergency Medicine, Weill Cornell
School of Medicine, New York, NY
Editorial Board
Saadia Akhtar, MD, FACEP
Associate Professor, Department of
Emergency Medicine, Associate Dean
for Graduate Medical Education,
Program Director, Emergency
Medicine Residency, Mount Sinai
Beth Israel, New York, NY
William J. Brady, MD
Professor of Emergency Medicine
and Medicine; Medical Director,
Emergency Management, UVA
Medical Center; Operational Medical
Director, Albemarle County Fire
Rescue, Charlottesville, VA
Calvin A. Brown III, MD
Director of Physician Compliance,
Credentialing and Urgent Care
Services, Department of Emergency
Medicine, Brigham and Women's
Hospital, Boston, MA
Peter DeBlieux, MD FAAEM, FACP
Professor of Clinical Medicine,
Louisiana State University School of
Medicine; Chief Experience Officer,
University Medical Center, New
Orleans, LA
Daniel J. Egan, MD
Associate Professor, Vice Chair of
Education, Department of Emergency Memorial Hospital, Miami, FL
Medicine, Columbia University
Vagelos College of Physicians and
Surgeons, New York, NY
Nicholas Genes, MD, PhD
Associate Professor, Department of
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY
Michael A. Gibbs, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Carolinas
Medical Center, University of North
Carolina School of Medicine, Chapel Charles V. Pollack Jr., MA, MD,
Hill, NC
Steven A. Godwin, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Assistant
Dean, Simulation Education,
University of Florida COM-
Jacksonville, Jacksonville, FL
Joseph Habboushe, MD MBA
Assistant Professor of Emergency
Medicine, NYU/Langone and
Bellevue Medical Centers, New York,
NY; CEO, MD Aware LLC
Gregory L. Henry, MD, FACEP
Clinical Professor, Department of
Emergency Medicine, University
of Michigan Medical School; CEO,
Medical Practice Risk Assessment,
Inc., Ann Arbor, MI
John M. Howell, MD, FACEP
Clinical Professor of Emergency
Medicine, George Washington
University, Washington, DC; Director
of Academic Affairs, Best Practices,
Inc, Inova Fairfax Hospital, Falls
Church, VA
Shkelzen Hoxhaj, MD, MPH, MBA
Chief Medical Officer, Jackson
Eric Legome, MD
Chair, Emergency Medicine, Mount
Sinai West & Mount Sinai St. Luke's;
Vice Chair, Academic Affairs for
Emergency Medicine, Mount Sinai Beth Israel Medical Center; Senior
Health System, Icahn School of
Medicine at Mount Sinai, New York, NY
Keith A. Marill, MD, MS
Associate Professor, Department
of Emergency Medicine, Harvard
Medical School, Massachusetts
General Hospital, Boston, MA
FACEP, FAAEM, FAHA, FESC
Professor & Senior Advisor for
Interdisciplinary Research and
Clinical Trials, Department of
Emergency Medicine, Sidney Kimmel Ron M. Walls, MD
Medical College of Thomas Jefferson
University, Philadelphia, PA
Michael S. Radeos, MD, MPH
Associate Professor of Emergency
Medicine, Weill Medical College
of Cornell University, New York;
Research Director, Department of
Emergency Medicine, New York
Hospital Queens, Flushing, NY
Ali S. Raja, MD, MBA, MPH
Executive Vice Chair, Emergency
Medicine, Massachusetts General
Hospital; Associate Professor of
Emergency Medicine and Radiology,
Harvard Medical School, Boston, MA Scott D. Weingart, MD, FCCM
Robert L. Rogers, MD, FACEP,
Assistant Professor of Emergency
Medicine, The University of
Maryland School of Medicine,
Baltimore, MD
Alfred Sacchetti, MD, FACEP
Assistant Clinical Professor,
Department of Emergency Medicine,
Thomas Jefferson University,
Philadelphia, PA
Robert Schiller, MD
Chair, Department of Family Medicine,
Faculty, Family Medicine and
Community Health, Icahn School of
Medicine at Mount Sinai, New York, NY
Scott Silvers, MD, FACEP
Associate Professor of Emergency
Medicine, Chair of Facilities and
Planning, Mayo Clinic, Jacksonville, FL
Corey M. Slovis, MD, FACP, FACEP
Professor and Chair, Department
of Emergency Medicine, Vanderbilt
University Medical Center, Nashville, TN Attending Emergency Physician,
Professor and COO, Department of
Emergency Medicine, Brigham and
Women's Hospital, Harvard Medical
School, Boston, MA
Critical Care Editors
William A. Knight IV, MD, FACEP,
FNCS
Associate Professor of Emergency
Medicine and Neurosurgery, Medical
Director, EM Advanced Practice
Provider Program; Associate Medical
Director, Neuroscience ICU, University
of Cincinnati, Cincinnati, OH
Professor of Emergency Medicine;
Chief, EM Critical Care, Stony Brook
Medicine, Stony Brook, NY
Research Editors
Aimee Mishler, PharmD, BCPS
Emergency Medicine Pharmacist,
Program Director, PGY2 EM
Pharmacy Residency, Maricopa
Medical Center, Phoenix, AZ
Joseph D. Toscano, MD
Chief, Department of Emergency
Medicine, San Ramon Regional
Medical Center, San Ramon, CA
International Editors
Peter Cameron, MD
Academic Director, The Alfred
Emergency and Trauma Centre,
Monash University, Melbourne,
Australia
Andrea Duca, MD
Attending Emergency Physician,
Ospedale Papa Giovanni XXIII,
Bergamo, Italy
Suzanne Y.G. Peeters, MD
Flevo Teaching Hospital, Almere,
The Netherlands
Edgardo Menendez, MD, FIFEM
Professor in Medicine and Emergency
Medicine; Director of EM, Churruca
Hospital of Buenos Aires University,
Buenos Aires, Argentina
Dhanadol Rojanasarntikul, MD
Attending Physician, Emergency
Medicine, King Chulalongkorn
Memorial Hospital; Faculty of
Medicine, Chulalongkorn University,
Thailand
Stephen H. Thomas, MD, MPH
Professor & Chair, Emergency
Medicine, Hamad Medical Corp.,
Weill Cornell Medical College, Qatar;
Emergency Physician-in-Chief,
Hamad General Hospital,
Doha, Qatar
Edin Zelihic, MD
Head, Department of Emergency
Medicine, Leopoldina Hospital,
Schweinfurt, Germany
Case Presentations
As you begin your shift, a 68-year-old woman presents
with severe abdominal pain. She requires 4 mg of mor-
phine before you can even talk to her. Surprisingly, her
abdomen is soft, and not particularly tender. She is tachy-
cardic to the 120s, and her pulse feels irregular. Her blood
pressure is 100/50 mm Hg. It seems strange that her pain
is so incongruent with her exam, and you wonder: What
is the best imaging study to help clarify things?
In the next room, a 24-year-old man with no past
medical history has presented with sudden, severe left
lower quadrant pain followed by vomiting. He has normal
vital signs except for tachycardia and a nontender abdo-
men. He seems too young to have diverticulitis, and since
the pain is on the left side, you doubt appendicitis. A uri-
nalysis is negative for blood, making renal colic less likely.
Pain medication helps, and you wonder whether this is
just gas or further diagnostic testing is needed…
Introduction
An experienced emergency clinician might compare
the painful abdomen to the dark side of the moon—
a terrain both indistinct and enigmatic. The patient’s
history is frequently uncertain and the physical
examination misleading. To further complicate the
issue, “textbook” presentations of serious disease
seem to exist only in print. After an extensive work-
up, patients with severe pain may prove to have
gastroenteritis, while those with a seemingly benign
belly are hiding a surgical catastrophe.
This 20th anniversary issue of Emergency Medi-
cine Practice will once again address the dilemma
of abdominal pain and take another look at the
structured approach to this complaint. The central
principles include: (1) recognizing the high-risk
patient, (2) selecting appropriate testing, and (3) us-
ing flexible clinical pathways. This issue emphasizes
disposition over diagnosis, as it is not as important
to identify an exact cause of abdominal pain as it is
to recognize a surgical abdomen.
Critical Appraisal of the Literature
The broad scope of abdominal pain makes it less
amenable to the large randomized double-blind
studies seen with sepsis, stroke, or pulmonary
embolism. Much of the emergency medicine litera-
ture focuses on incidence, causes, and misdiagnosis
of abdominal pain. Some researchers concentrate
on radiation-reduction strategies or clinical scoring
systems to detect a particular cause of abdominal
pain (such as appendicitis). The American College
of Emergency Physicians Clinical Policy on acute
abdominal pain has been “retired,” being last up-
dated almost 20 years ago. For this update, except
for the most common and deadly conditions, articles
Copyright © 2019 EB Medicine. All rights reserved.
were chosen based more on clinical presentation and
emergency evaluation of abdominal pain rather than
on specific etiologies of abdominal pain.
Epidemiology
Abdominal pain is the most frequent complaint
in United States emergency departments (EDs),
accounting for approximately 8% of all adult ED
visits.1 Between 2007 and 2011, there was a 23%
increase in ED visits for abdominal pain, and the
number has, most likely, continued to increase.2 In
most adults, the rate of admission to the hospital for
abdominal pain ranges from 18% to 42%, but the in-
cidence soars in elderly patients (with “elderly” gen-
erally considered to be ages ≥ 65 years). Historically,
nearly two-thirds of older patients with abdominal
pain required hospitalization, and many underwent
surgery.3-6 In this era of modern imaging, 60% of el-
derly patients with abdominal pain are hospitalized,
20% undergo surgery, and 5% die.7,8
Even at the conclusion of an ED encounter for
abdominal pain, many times the etiology remains ob-
scure. In up to 40% of patients, the origin of abdominal
pain is never determined.9 There is a natural tempta-
tion to “force” a diagnosis on an inscrutable belly;
after all, patients expect a diagnosis. Some irresolute
emergency clinicians yield to impulse and write “gas-
troenteritis” in the diagnosis section of the chart, when
the correct diagnosis should be “abdominal pain of
undetermined etiology,” “undifferentiated abdominal
pain,” or “nonspecific abdominal pain.” Gastroenteritis
is often used as a wastebasket diagnosis, which leads
to premature diagnostic closure. True gastroenteritis
is an acute, self-limited illness caused by a multitude
of agents (infectious or toxic), and both vomiting and
diarrhea are required to establish this diagnosis.
Pathophysiology
Generally, the painful abdomen results from visceral
pain, which can be vague and poorly localized and
often associated with autonomic changes of sweat-
ing or alterations in vital signs. Visceral pain may
result from distention or inflammation of a hollow
organ or ischemia of any internal organ.
When the adjacent peritoneum is irritated, this
somatic pain is better localized. Because of move-
ment of organs and stretched nerve pathways dur-
ing fetal development, pain may be referred distant
from the inciting problem. This gives rise to pain in
the shoulder when the diaphragm is irritated by free
blood or succus in the peritoneal cavity. With aging,
the peritoneum becomes less sensitive and peritoni-
tis becomes a late (or absent) finding.
2 Reprints: www.ebmedicine.net/empissues
Differential Diagnosis
Patients assigned an ED diagnosis of gastroenteritis,
gastritis, urinary tract infection (UTI), pelvic inflam-
matory disease (PID), or constipation are more likely
than others to be misdiagnosed.5,10 Table 1 lists the
dangerous mimics every emergency clinician should
be aware of.
Abdominal pain may arise from many organ
systems, including pulmonary, cardiac, and endo-
crine. While the gastrointestinal and genitourinary
tracts are the most frequent sources, it is perilous
to ignore extra-abdominal and systemic etiologies,
which are outlined in Table 2.
There are 4 subgroups of patients with abdomi-
nal pain that deserve particular focus because they
are often misdiagnosed and are at high risk: (1) The
elderly, (2) the immunocompromised (especially
those with AIDS), (3) women of childbearing age,
and (4) patients with previous abdominal surger-
ies. Changes in the immune system, abdominal
musculature, or peritoneal responsiveness may
leave the elderly and immunocompromised without
peritoneal signs until late in the disease. In women
of childbearing age, the huge overlap in clinical
findings between PID, appendicitis, and ovarian tor-
sion makes misdiagnosis frequent. In addition, the
frequently subtle presentations of ectopic pregnancy
may lead to missed diagnosis and poor outcome.
The Elderly
In older adults, the diagnosis of an acute abdomen
can be complicated by the relative lack of findings
even in the presence of serious disease. Elderly
patients may have no fever, no leukocytosis, and no
localized tenderness despite surgical abdominal dis-
ease.11 In addition, surgical problems in the elderly
are more rapidly life-threatening than in younger
patients.12 Older patients are at risk for vascular ca-
tastrophes (eg, mesenteric ischemia, leaking or rup-
tured abdominal aortic aneurysm, or myocardial in-
farction). These conditions comprise fully 10% of all
cases of abdominal pain in patients aged > 70 years
presenting to a hospital.3-6,10,13 It is commonplace to
routinely admit a 75-year-old patient with chest pain
while discharging the 75-year-old with abdominal
pain and a benign examination. This practice should
change, considering that the morbidity and mortal-
ity of abdominal pain in this age group exceeds that
of chest pain.14-16
With each decade of life in adults, mortality
increases and diagnostic accuracy decreases until, in
octogenarians, the mortality for all patients present-
ing to the ED with abdominal pain is 7% (70 times
that of adolescents). By the time a patient reaches
age 80, the clinician’s ability to make an accurate
initial diagnosis drops below 30%.5,7 These numbers
suggest the need to obtain diagnostic imaging for
most geriatric patients with abdominal pain. In one
study of computed tomography (CT) scans in the el-

Table 2. Important Extra-Abdominal Causes

of Abdominal Pain
Table 1. Abdominal Pain: Dangerous Mimics
True Diagnosis Initial Misdiagnosis Systemic Neurologic
Appendicitis Gastroenteritis, PID, UTI • Diabetic ketoacidosis • Spinal radiculopathy
• Alcoholic ketoacidosis • Abdominal epilepsy
Ruptured abdominal aortic Renal colic, diverticulitis, lumbar
• Uremia • Tabes dorsalis
aneurysm strain • Sickle cell disease
Ectopic pregnancy PID, UTI, corpus luteum cyst • Porphyria Thoracic
Diverticulitis Constipation, gastroenteritis, • Systemic lupus erythematosus • Myocardial infarction/unstable
• Vasculitis angina
pyelonephritis
• Glaucoma • Myocarditis
Perforated viscus Peptic ulcer disease, • Hyperthyroidism • Pneumonia
pancreatitis, nonspecific • Hyperparathyroidism • Pneumothorax
abdominal pain • Henoch-Schönlein purpura • Pulmonary embolism
Bowel obstruction Constipation, gastroenteritis, • Opioid withdrawal • Herniated thoracic disc
nonspecific abdominal pain (neuralgia)
Toxic • Esophageal rupture
Mesenteric ischemia Gastroenteritis, constipation,
• Methanol poisoning (Boerhaave syndrome)
ileus, small-bowel obstruction
• Heavy-metal toxicity
Incarcerated or strangulated Ileus or small-bowel obstruction • Scorpion bite Genitourinary
hernia • Black widow spider bite • Testicular torsion
Shock or sepsis from Urosepsis or pneumonia (in • Renal colic
Infectious
perforation, bleed, abdominal elderly patients); dehydration
• Streptococcal pharyngitis Abdominal wall
infection (in elderly patients)
(more often in children) • Muscle spasm
• Rocky Mountain spotted fever • Muscle hematoma
Abbreviations: PID, pelvic inflammatory disease; UTI, urinary tract • Mononucleosis • Herpes zoster
infection.
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derly, of 104 eligible patients, CT altered the admis- infections of those without AIDS. Patients with CD4
sion decision in 26%, the need for surgery in 12%, counts < 200 cells/mm3 (and especially < 100 cells/
the need for antibiotics in 21%, and changed the mm3) should have acid fast or immunofluorescent
suspected diagnosis in 45%. Overall, CT changed the stains of a diarrheal specimen for Cryptosporidium,
disposition in 25%, with a doubling of the diagnostic Isospora, Cyclospora, and Microsporidium.21-23 Drug-
certainty.17 In another study of patients aged ≥ 80 induced pancreatitis may be fulminant, and mortal-
years with abdominal pain, the CT was positive in ity can reach 10%.24-27 Opportunistic infections can
55% and revealed a clinically unsuspected diagnosis result in obstruction and perforation. In a study of
in 43%.18 abdominal pain in AIDS patients, pain was attribut-
Not surprisingly, this fall in diagnostic preci- able to the immunocompromised state in 65% of the
sion is paralleled by a significant rise in mortality. patients. Causes included gastrointestinal non-
The problem is somewhat attributable to age-related Hodgkin lymphoma, cytomegalovirus (CMV) or
differences in disease prevalence and severity. Table Mycobacterium avium intracellulare enteritis or colitis,
3 summarizes the variation in confirmed diagno- sclerosing cholangitis, Cryptosporidium infection, and
ses, by age. In the elderly, biliary tract disease is the CMV gastritis or esophagitis.26 Nearly 90% of the
single most common cause of abdominal pain.5,19 In patients in this report had CD4 counts < 200 cells/
a study of elderly patients, temperature and labora- mm3. Patients with HIV and AIDS may also have or-
tory screening could not differentiate surgical from dinary afflictions such as appendicitis or renal colic;
nonsurgical disease.14 Clinical impression was more in fact, the incidence of renal colic is greatly elevated
important than laboratory tests in the decision to with the use of protease inhibitors.28
request imaging studies or surgical consultation. Interestingly, scoring systems for appendicitis
Indeed, this article stresses many other important such as the Alvarado score may need to be adjusted
considerations and caveats for assessing abdominal for the HIV population. This score is less specific
pain in elderly patients. in patients with HIV and may incorrectly suggest a
surgical diagnosis. The presentation of appendicitis
Patients With Human Immunodeficiency may be atypical in the HIV/AIDS patient because of
Virus the absence of pyrexia and leukocytosis, along with
The widespread use of highly active antiretrovi- delayed abdominal symptoms. Liberal use of CT or
ral therapy (HAART) has decreased the burden of ultrasound may be necessary to make the diagnosis in
opportunistic infections, along with many of the these cases.29
abdominal pain/diarrheal presentations in patients For more information on ED management of pa-
with HIV.20 Still, the patient with uncontrolled AIDS tients with HIV (including older patients on HAART),
may have unusual conditions, such as bacterial en- see the February 2016 issue of Emergency Medicine
terocolitis, drug-induced pancreatitis, or AIDS-relat- Practice, "The HIV-Infected Adult Patient in the
ed cholangiopathy. The CD4 (cluster of differentia- Emergency Department: The Changing Landscape of
tion 4) count plays a significant role in the spectrum Disease,” at www.ebmedicine.net/HIV.
of AIDs-related diarrheal infections. Patients with
near-normal counts have the same pathogens and Women of Childbearing Age
Women of childbearing age who present with lower
abdominal pain pose a unique diagnostic challenge,
Table 3. Disease Spectrum in Acute as pregnancy-related conditions and gynecologic
Abdominal Pain, by Age5 disorders can complicate making the diagnosis.
Because as many as 13% of female patients with
Confirmed Cause of Age < 50 Years Age ≥ 50 Years abdominal pain are gravid,30 the first step is to diag-
Acute Abdominal Pain (n = 6317) (n = 2406)
nose pregnancy. The clinician must not rely on the
Cholecystitis 6% 21% patient’s menstrual history, supposed birth control
Nonspecific abdominal 40% 16%
use, or tubal ligation to exclude pregnancy. Even
pain
patients who report no history of sexual activity may
Appendicitis 32% 15%
be pregnant.31 Always get a pregnancy test for wom-
Bowel obstruction 2% 12%
Pancreatitis 2% 7%
en between the ages of menarche and menopause
Diverticular disease < 0.1% 6% who present with abdominal pain unless the woman
Cancer < 0.1% 4% is known to be pregnant or has had a hysterec-
Hernia < 0.1% 3% tomy. (Surprisingly, there are 138 English-language
Vascular < 0.1% 2% publications regarding pregnancy, either ectopic or
abdominal, post hysterectomy, but it remains such a
Report of the OMGE Research Committee. F.T. De Dombol, R. Room, rare condition that there is no need to routinely test
L. Pagliaro, R. Lambert. Scandinavian Journal of Gastroenterology. for it.) In addition to ectopic pregnancy, recognize
1988. Reprinted by permission of Taylor & Francis Ltd, that up to 20% of all cases of ovarian torsion occur
http://www.tandfonline.com

Copyright © 2019 EB Medicine. All rights reserved. 4 Reprints: www.ebmedicine.net/empissues

during pregnancy.32 Color-flow Doppler of the ad-
nexa may be required to make the diagnosis.
Once pregnancy-related disease (such as ecto-
pic pregnancy) is excluded, the physician is left to
ponder the question of urinary pathology (UTI or
pyelonephritis), gastrointestinal pathology (gastro-
enteritis, enteritis, or appendicitis), pelvic pathology
(PID), or ovarian conditions. Errors are common,
and one-third of women of childbearing age who
were ultimately found to have appendicitis were
initially misdiagnosed.33 The menstrual history and
presence or absence of gastrointestinal symptoms
cannot reliably distinguish between appendicitis and
pelvic disease.34,35 The question is not clarified by
laboratory testing, and the complete blood cell count
(CBC) test is more likely to deceive than to illumi-
nate.36 The pelvic examination may also be mislead-
ing; up to a quarter of women with appendicitis
may exhibit cervical motion tenderness, a finding
typically associated with PID.37 Abdominal imaging
is often needed to clarify the diagnosis. Radiation-
reduction strategies include the use of pelvic and
abdominal ultrasound prior to, or instead of, pos-
sible CT.
Not just first-trimester gestations demonstrate
puzzling complaints; by the second half of pregnan-
cy, the appendix has moved out of the right lower
quadrant to the extreme right upper quadrant. Such
patients may be most tender just under the ribs or
even in the flank. Because of concerns about radia-
tion to the developing fetus, ultrasound and, increas-
ingly, magnetic resonance imaging (MRI) are being
used in the diagnosis of appendicitis in pregnancy.38
Patients With Prior Abdominal Surgery
Every patient who presents with abdominal pain
must be asked, “Have you ever had surgery on
your belly?” In addition to asking this question,
examine their bare abdomen for scars, since a
surprising number of patients fail to remember or
report past surgeries. Postoperative adhesions are
the leading cause of small-bowel obstruction in
industrialized countries, accounting for some 70%
of cases. Other causes include malignancy, inflam-
matory bowel disease, and internal or external
hernias.39
Patients who have had bariatric surgery, espe-
cially those who underwent a “rerouting” proce-
dure such as Roux-en-Y anastomosis, are especially
prone to surgical causes of abdominal pain. Early
complications of bariatric surgery include surgical
site infections and anastomotic leaks. Anastomotic
leaks usually occur within the first 10 postopera-
tive days and usually present with nonspecific
signs such as fever, tachycardia, and leukocytosis
(often with a clinically benign abdomen).40 Later
complications include small-bowel obstruction,
internal hernias, ventral hernias, and marginal
June 2019 • www.ebmedicine.net
ulcers.41 In these patients, order a CT scan routinely
with intravenous (IV) and oral contrast. Imaging
pain in a patient with prior Roux-en-Y surgery
requires a special bariatric protocol involving a small
amount of oral contrast given on the CT table.42
Emergency Department Evaluation
The wise and humble practitioner recognizes the limi-
tations of clinical diagnosis, and there is a great deal of
potential for error in the diagnosis of abdominal pain.
When initial and final diagnoses are compared, accu-
racy is no better than 50% and 65%, respectively.43-45
My residents tire of hearing the dictum that,
when it comes to appendicitis, there are only 2 types
of doctors: those who have missed appendicitis and
those who are going to miss appendicitis. If you
have not missed a case, it is for 1 of 3 reasons: you
have missed cases but you never found out; you
have not seen enough patients; or you are very
lucky. Missed appendicitis is one of the top 3 causes
of emergency medicine malpractice lawsuits (myo-
cardial infarction and fractures being the others),
even though appendicitis is the actual cause of acute
abdominal pain in less than 5% of cases.46,47 Prac-
tice demographics may also influence the number
of patients you will encounter with appendicitis
(including atypical cases). Rates of appendicitis are
rising among young patients, males, Asians, Hispan-
ics, and Native Americans, while rates are declining
among white and black patients.48
Diagnostic accuracy may be improved by us-
ing a structured chart (Figure 1, page 6, presents a
model). and Computer-aided diagnosis may also
assist, but the advantage of computer-aided diagno-
sis may not rest in the decision algorithm per se, but
rather in the more complete data collection that oc-
curs when such a tool is used.49,50 A targeted history
and physical examination should be paired with
an organized method to interpret the findings by
placing serious ailments foremost in the differential
diagnosis. Think: “worst first.”
Specific diagnoses cannot be finalized or exclud-
ed with a single historical or physical examination
finding. In a study of cases of misdiagnosed appen-
dicitis brought to litigation, several themes recurred.
Patients with misdiagnosed disease had less right
lower quadrant pain and tenderness as well as di-
minished anorexia, nausea, and vomiting.51
History
The patient’s history is key to uncovering the etiol-
ogy of abdominal pain. In malpractice cases brought
for failure to diagnose abdominal conditions,
deficiencies in data gathering and charting were
more responsible for the misdiagnosis than misin-
terpretation of the data.51-53 The use of a standard-
ized history form increases both patient satisfaction
5 Copyright © 2019 EB Medicine. All rights reserved.
and diagnostic accuracy.54 Table 4 outlines some
excellent questions to assist the emergency clinician
in pinpointing possible causes. Nonetheless, while
these questions may help identify the high-risk
patient, no single inquiry can confirm or refute a
surgical emergency. Indeed, a patient can have all
“good” answers to historical questions and still have
a perilous diagnosis.
Be sure to ask about the drive to the hospital—
was the ride itself painful? In the appropriate clinical
setting, the experience of pain on going over a bump
in the road is about 80% sensitive (but only 52%
specific) for appendicitis.55 In a more recent paper,
a positive “speed bump sign” had sensitivity of
97% and specificity of 30% in the diagnosis of acute
appendicitis.56 Despite the possible phenomenon of
recurrent appendicitis, a history of recurring right
lower quadrant pain makes the diagnosis of appen-
dicitis slightly less likely.57 Recognize that “stump
appendicitis” can occur in the appendiceal remnant
after an appendectomy; it is found in 0.15% of all
appendectomies.58
Physical Examination
The physical examination begins with the patient’s
vital signs, but apart from gross hypotension or
Figure 1. Sample Patient Chart for the Patient
With Abdominal Pain
To view a larger version, scan the QR code or go to:
www.ebmedicine.net/APchart
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Copyright © 2019 EB Medicine. All rights reserved.
significant tachycardia, just what do these signs
actually mean?
Vital Signs
Temperature
An elevated temperature is frequently associated
with intra-abdominal infection, but its sensitivity
and specificity vary greatly. Consider obtaining
a rectal temperature for patients at risk for intra-
abdominal infections, as rectal temperatures are
generally more reliable. Do not rely on tympanic
temperatures to rule out fever.59,60 Oral temperatures
are falsely low in patients with rapid breathing—a
frequent occurrence in patients who are in pain.61,62
Table 4. High-Yield Historical Questions in
Abdominal Pain
1. How old are you? Advanced age means increased risk.
2. Was the onset of pain sudden or gradual? Sudden-onset
pain is often torsion (testicular or ovarian), rupture (cyst or, more
catastrophic, aorta), or colic (biliary or ureteral).
3. Which came first—pain or vomiting? Pain first is worse; ie,
more likely to be caused by surgical disease.
4. Is the pain constant or intermittent? Constant pain is worse.
5. Did the pain start centrally and migrate to the right lower
quadrant? This has a high specificity for appendicitis.
6. How long have you had the pain? Pain for less than 48 hours
is worse.
7. How was your ride to the hospital? Pain with a bump in the
road suggests intra-abdominal infection.
8. Do you still have an appetite? Anorexia is more commonly
seen in surgical disease, especially appendicitis and
cholecystitis.
9. Are you pregnant? Test for pregnancy—consider ectopic
pregnancy, torsion, and pelvic ultrasound.
10. Have you ever had abdominal surgery? Consider obstruction
in patients who report previous abdominal surgery, especially in
the presence of vomiting. Bariatric surgery? Even higher risk of
surgical disease.
11. Have you ever had this before? A report of no prior episodes
is worse.
12. Do you have a history of cancer, diverticulosis, pancreatitis,
kidney failure, gallstones, or inflammatory bowel disease?
All are bad.
13. Do you have HIV or AIDS? Consider occult infection, renal
stones, or drug-related pancreatitis.
14. How much alcohol do you drink per day? Consider
pancreatitis, hepatitis, or cirrhosis.
15. Do you smoke/consume marijuana daily? If yes, consider
cannabinoid hyperemesis syndrome.
16. Are you taking antibiotics or steroids? These may mask
infection or cause reactive leukocytosis.
17. Do you have a history of vascular or heart disease,
hypertension, or atrial fibrillation? If yes, consider mesenteric
ischemia and abdominal aneurysm.
18. Have you had CT scans or ultrasounds of your belly before?
If so, what did they show?
www.ebmedicine.net
6 Reprints: www.ebmedicine.net/empissues
 Remember that septic patients with hypother-
mia have worse outcomes then those with elevated
body temperatures.63 Temperature is less useful
in the elderly, compared to younger patients. The
majority of elderly patients with acute cholecystitis
and appendicitis are afebrile, despite higher rates of
perforation and sepsis.16,64-66 Recall that 30% or more
of elderly patients with an active infection may have
little or no fever.67
Respiratory Rate
An elevated respiratory rate can be the result of pain
and subdiaphragmatic irritation. Tachypnea may
also arise from hypoxia (due to pneumonia or acute
respiratory distress syndrome), early sepsis, anemia,
pulmonary embolism, or metabolic acidosis. Sus-
tained tachypnea may warrant evaluation for these
conditions.
Blood Pressure
The patient with frank hypotension may have a
ruptured abdominal aortic aneurysm or may have
septic shock from an intra-abdominal infection. An
earlier sign of impending shock is the shock index
(heart rate/systolic blood pressure). The shock index
is a powerful tool for detecting patients at risk for
deterioration. In one study, a shock index of ≥ 0.7
was the most sensitive screening test for 28-day
mortality in sepsis (including abdominal sepsis). A
shock index ≥ 1.0 was the most specific predictor of
both outcomes.68
An online tool for assessing the
risk of shock is available from
www.MDCalc.com:
• www.mdcalc.com/shock-index
Heart Rate
Tachycardia may represent a response to pain, anxiety,
fever, blood loss, or sepsis, and is a nonspecific marker
for stress. An irregularly irregular heart rate likely
represents atrial fibrillation, which is an important risk
factor for mesenteric ischemia in the elderly.69
Abdominal Examination
Palpation
In the young adult patient, it is rare that a serious
abdominal condition presents without any ab-
dominal tenderness, unlike in the elderly patient, in
whom changes in abdominal wall musculature and
decreased peritoneal sensitivity can mask abdominal
catastrophes. At times, it is difficult to distinguish
tenderness of abdominal organs versus tenderness
of the abdominal musculature. Tenderness that is
greatest when the abdominal muscles are contracted
is likely due to abdominal wall pain.70 Increased
tenderness to palpation when the abdominal mus-
June 2019 • www.ebmedicine.net
cles are contracted (such as when the patient lifts
his head and/or legs off the bed) is known as the
Carnett sign. In a small study, the Carnett sign was
95% accurate for distinguishing abdominal wall pain
from visceral abdominal pain.71
Location of Tenderness
While the area of tenderness theoretically corre-
sponds to the anatomic location of involved organs,
it is important to recognize that this may be mislead-
ing in patients with abdominal pain.72 Patients with
appendicitis are frequently tender at McBurney point,
a spot located several inches medial to the anterior
superior spine of the ileum, on an imaginary line
that connects the spine to the umbilicus. However,
the original study that analyzed the McBurney point
included only a handful of cases (< 10).73 Moreover,
barium enema studies have found that most ap-
pendices lie inferior and medial to this point, and
that, in more than two-thirds of cases, the base of the
appendix lies > 5 cm from this point.74 Importantly,
while most appendices lie within the right lower
quadrant, the tip of the appendix can actually extend
to any quadrant within the abdomen. A patient with
retrocecal appendicitis is usually tender in the right
flank or right upper quadrant. Thus, while 80% of
patients with appendicitis have tenderness in the
right lower quadrant, the disturbing corollary is that
20% of patients with surgically proven appendicitis
have no right lower quadrant pain or tenderness.57
The last case of appendicitis that I missed presented
initially with left upper quadrant pain that devel-
oped into diffuse peritonitis the next day.
Left-sided appendicitis can occur with malrota-
tion or situs inversus totalis.75,76 When faced with a
classic appendicitis history but left-sided tenderness,
palpate the point of maximal intensity of the heart. If
it is on the right chest instead of the left, you may be
dealing with a patient with situs inversus totalis and
a left-sided appendicitis.
Guarding
Voluntary guarding is a response to fear, anxiety, or
even a reaction to a clinician's cold hands. Reassur-
ance and gentle palpation may overcome voluntary
guarding. Involuntary guarding (rigidity) on palpa-
tion is more likely to occur with surgical disease and
is not relieved by physician encouragement.77 The
presence of rigidity nearly quadruples the likelihood
of appendicitis, whereas simple guarding is less pre-
dictive.57 Abdominal guarding may decrease with
age, despite the presence of surgical disease.78
Peritoneal Signs
Peritoneal signs are considered hallmarks of surgical
disease. Peritoneal signs include rebound pain and
pain with cough, pain with shaking the gurney or
striking the supine patient’s heel (heel tap); however,
7 Copyright © 2019 EB Medicine. All rights reserved.
grimacing may be a more accurate finding than a
report of pain by the patient.77
The classic rebound test is performed when
the examiner presses on the abdomen, then sud-
denly releases the pressure. While most emergency
clinicians believe that a positive rebound test is
pathognomonic for surgical disease, this belief
is not supported by the literature. In a literature
review on appendicitis, rebound pain was only
63% sensitive and 69% specific.57 However, another
study showed a sensitivity of 82% and a specific-
ity of nearly 90%.55 Liddington et al prospectively
assessed the usefulness of rebound tenderness in
unselected patients with abdominal pain and found
it had no predictive value.79 Rebound is even less
useful in elderly patients with appendicitis, despite
the frequency of perforation.16,66
An alternative to assessment of rebound pain is
the “cough test,” where the examiner has the patient
cough and then looks for evidence of posttussive
abdominal pain (grimacing, flinching, or grabbing
the belly). Studies have found the cough sign to
be between 80% and 95% sensitive for surgically
proven peritonitis.80,81 Another series showed the
“heel drop” sign (right lower quadrant pain upon
dropping the heels to the ground after standing on
tiptoe) was 93% sensitive for appendicitis.82 Howev-
er, this test can be positive in any cause of peritoni-
tis, including PID.83 Another version of this test can
be performed by forcefully banging on the patient’s
heel. Once again, an elderly patient with peritonitis
may show mild or no peritoneal signs from these
tests in the ED.78
Signs: Murphy, Psoas, Obturator, Rovsing
Some authors argue that the Murphy sign, where a
patient will stop a deep inspiration during palpa-
tion of the right upper quadrant, is very sensitive for
acute cholecystitis and biliary colic. When assessed
in 65 patients, Murphy sign had a sensitivity and
negative predictive value of 97% and 93%, respec-
tively, for acute cholecystitis, but the specificity was
slightly lower than 50%.84 In elderly patients, a posi-
tive Murphy sign is useful, when present, but is less
sensitive than in younger patients.85 The psoas sign
is pain elicited by extending the right lower extrem-
ity towards the back while the patient lies on his left
side. In one study, the psoas sign proved specific
(95%) but not sensitive (16%) for appendicitis.57 Nei-
ther the obturator sign (pain with internal rotation
of the flexed hip) nor the Rovsing sign (pain in the
right lower quadrant precipitated by palpation of
the left lower quadrant) has been rigorously studied.
Auscultation
The character of bowel sounds is most useful in
the diagnosis of obstruction and perforation. Tra-
ditionally, high-pitched, tinkling, or absent bowel
Copyright © 2019 EB Medicine. All rights reserved.
sounds are supposedly associated with acute
small-bowel obstruction, especially in the pres-
ence of distention.86 Abnormal bowel sounds are
associated with adverse outcomes in the elderly.3
However, a recent study in which bowel sounds
were recorded from patients with suspected bowel
obstruction found that accuracy and interob-
server agreement were generally low. The authors
concluded that auscultatory assessment of bowel
sounds should not be the basis for clinical deci-
sions regarding possible bowel obstruction.87
Pelvic Examination
While a pelvic examination is generally routine in
young women with lower abdominal pain, it is also
valuable in those with upper abdominal pain. A
woman with severe PID and perihepatic inflamma-
tion (Fitz-Hugh-Curtis syndrome) may demonstrate
minimal lower abdominal tenderness and a pre-
dominance of findings in the right upper quadrant,
and only pelvic examination observation of cervical
motion tenderness may reveal the true etiology. Left
upper quadrant tenderness may also be caused by
the leakage of pus from the fallopian tubes into the
abdominal gutters.
The pelvic examination can also help differenti-
ate PID from appendicitis. Though women with
appendicitis may have cervical motion and adnexal
tenderness, the presence (or absence) of mucopuru-
lent discharge from the cervix can help diagnosis.
However, with the increasing proportion of chla-
mydial PID infections, only 56% of women with PID
demonstrate mucopurulent cervicitis.88
While emergency medicine training programs
teach the value of pelvic examinations for lower ab-
dominal pain in adult women (particularly for those
aged < 35 years), some recent papers have ques-
tioned its role. A prospective observational study
of 288 women aged 14 to 20 years presenting to an
urban academic pediatric ED was published in 2018.
This study found that a pelvic examination did not
increase the sensitivity or specificity of diagnoses of
chlamydia, gonorrhea, or trichomoniasis, compared
with the history alone.89 Another group questioned
whether the pelvic examination in the ED can be
omitted in the evaluation of lower abdominal pain
in patients with early intrauterine pregnancy con-
firmed on ultrasound, but it was unable to reach a
conclusion, possibly due to insufficient power.90 In
this author’s opinion and 40 years of experience,
because of the large differential in abdominal pain,
the pelvic examination should not be abandoned.
Rectal Examination
The value of the rectal examination in the evaluation
of appendicitis has been questioned. While the exami-
nation may be positive in appendicitis, studies have
found it provided no additional information that was
not available from the abdominal examination.91,92
8 Reprints: www.ebmedicine.net/empissues
The most useful aspect of the rectal examination is
detection of heme-positive stools. In an exhaustive
review of the role of the digital rectal examination
in the ED, Quinn et al questioned its role in most
circumstances and suggested the guaiac sleeve (that
is no more than half a finger in size) be used to test
for occult blood.93 However, these studies do not
signal the demise of the rectal examination. Certainly,
the diagnoses of prostatitis, perirectal disease, stool
impactions, rectal foreign bodies, and gastrointestinal
bleeds all depend, at least to some extent, upon the
digital rectal examination.
Testicular Examination
Though often overlooked, the scrotal/testicular ex-
amination is an essential part of the physical exami-
nation in male patients with abdominal pain. Not
infrequently, testicular torsion presents with isolated
abdominal or flank pain. The scrotal examination
is also important to detect inguinal/scrotal hernias.
In a 2018 review of malpractice cases involving
testicular torsion, almost one-third of the patients
with missed torsion had presented with abdominal
(not scrotal) pain, and in one-fifth of all the cases,
no testicular examination was performed in the
ED.94 Most of the cases of missed torsion occurred
in patients younger than 25 years of age. A review
of 670 patients with testicular torsion showed that
6% of testicular torsion occurred at ages ≥ 31 years.95
In one study of the medical records of 200 males
aged 18 months to 20 years who underwent surgical
exploration for testicular torsion, the authors noted
that in one-third of cases, rotation occurs in the
lateral direction, not the medial direction as has been
traditionally taught.96 If testicular torsion is strongly
suspected, consult a urologist immediately and con-
sider performing manual detorsion.
Serial Examinations
In a group of patients with intermediate initial
probability of appendicitis, Graff et al found that
a 10-hour observation period improved the ability
to distinguish between patients with and without
appendicitis.97 In a 2018 study, re-evaluation within
30 hours for ED patients discharged with nonspe-
cific abdominal pain resulted in a clinically relevant
change in diagnosis and therapy in almost one-quar-
ter of patients. Such prolonged stays would be best
suited to EDs with an observation unit. An elevated
C-reactive protein (CRP) level at discharge of the in-
dex visit predicted change in treatment on the return
visit, as did an increase in CRP of > 25 mg/L be-
tween the index and re-evaluation visit.98 The value
of telephone follow-up has not been well-studied in
the management of abdominal pain, but remains a
cost-effective alternative in low-risk patients. Some
EDs ask moderate-risk patients to return for a re-
check in 8 to 10 hours.
June 2019 • www.ebmedicine.net
Diagnostic Studies
The emergency clinician must not depend on labora-
tory tests or x-rays to provide the diagnosis. Labo-
ratory assays or imaging studies rarely approach
100% accuracy (with the singular exception of the
pregnancy test). Diagnostic adjuncts are most useful
when placed in the context of the patient’s history
and physical examination. While some diagnostic
adjuncts (such as the abdominal x-ray, CBC, and
liver function tests) are overutilized, others (such as
pregnancy tests, urinalysis, and electrocardiogram
[ECG]) are probably underused. Appendix 1 (page
21) summarizes the pros and cons of several types of
diagnostic studies with respect to various conditions.
Laboratory Testing
Complete Blood Cell Count
Question: What is the most frequently requested
study in patients with abdominal pain? Answer: The
most misleading study in abdominal pain—the CBC.
While the CBC is frequently ordered in the evalua-
tion of appendicitis, numerous studies emphasize its
flaws. From 10% to 60% of patients with surgically
proven appendicitis have an initially normal white
cell count.108-111
Neither the absolute neutrophil count nor the
differential reliably exclude or identify appendicitis.
In children, the CBC is even less helpful, and the
count may be normal in the majority of children
with appendicitis whose pain is less than 24 hours
in duration.112,113 Two studies have found that fol-
lowing WBC counts over time cannot distinguish
appendicitis from other causes of abdominal pain.114
In addition, an elevated WBC count detects a mere
53% of severe abdominal pathology.115
While a normal white count may give false
comfort, an elevated white count may imply seri-
ous disease, especially in an elderly patient. How-
ever, in the elderly patient, the white count is often
normal despite a serious intra-abdominal infection
(especially in those with cholecystitis and appen-
dicitis).16,116,117 In the young patient, an elevated
white count does not necessarily add to knowledge
obtained by the history and physical examination,
but it often results in further testing and increased
costs.118 In patients with gastroenteritis, there is no
significant correlation between an abnormal CBC
and the administration of IV fluids, antibiotics, or
hospital admission.119 Furthermore, a study of 100
young women with lower abdominal pain showed
that the CBC (which is often routine for these pa-
tients) changed management in only 2 of the pa-
tients, and in 1 case, it led to the wrong diagnosis.36
C-Reactive Protein
In a meta-analysis of 22 studies, CRP was approxi-
mately 62% sensitive and 66% specific for the diag-
9 Copyright © 2019 EB Medicine. All rights reserved.
nosis of appendicitis.120 It is particularly insensitive
in patients who have had symptoms for < 12 hours.
Serial measurements may be more reliable; one
study showed that appendicitis is rare in patients
who have 2 normal CRPs drawn 12 hours apart.121 A
2017 study of CRP testing in abdominal pain showed
that moderately to severely elevated levels of CRP
(> 6 mg/L) help substantiate the diagnosis of acute
abdomen; however, CRP levels do not help in diag-
nosing a specific cause for acute abdomen.122 An-
other study showed that a low CRP level (0-5 mg/L)
does not out rule positive findings on CT in the
clinical setting of the acute abdomen, but increasing
levels of CRP do predict, with increasing likelihood,
positive findings on CT.123
Lipase and Amylase
A serum lipase is the best test for suspected pancre-
atitis. Amylase is neither sensitive nor specific for
pancreatitis,124 and is routinely elevated in alcoholics
without pancreatitis.125,126 Serum lipase is a more ac-
curate test, especially at a level 3 times greater than
normal.127,128 Nonetheless, both lipase and amylase
may be normal in some patients with CT-proven
pancreatitis, especially if the disease is recurrent (the
so-called “burned out” pancreas). These limitations
notwithstanding, a lipase test is the most useful test
in patients suspected of having pancreatitis. Patients
with significant epigastric tenderness and vomiting
are most likely to benefit from this assay.
Lactate
The greatest value of a lactate level is to detect occult
shock and sepsis criteria. It is often used to screen
for visceral ischemia; however, it is highly nonspe-
cific, and levels can be affected by both kidney and
liver function. When clinical suspicion prompts a
lactate level, such patients are likely to also undergo
subsequent CT scan, surgical consult, and admis-
sion, but not necessarily an operation.129
Table 5. Indications for Abdominal Plain Films for Abdominal Pain
Clinical Findings Suspected Diagnosis
• Sudden-onset pain Perforated viscus
• Rigid abdomen
• Decreased bowel sounds
• Prior abdominal surgery Bowel obstruction
• Abdominal distention
• Abnormal bowel sounds
• High risk for obstruction or volvulus
• Developmental disability Inserted or ingested foreign body
• Psychosis
• Suspicion for swallowed or rectal foreign body
Copyright © 2019 EB Medicine. All rights reserved.
Urinalysis
The urinalysis can be particularly misleading in pa-
tients with abdominal pain, as abnormal urine may
be associated with nonurinary conditions. It may
be tempting to diagnosis cystitis in a patient with ab-
dominal pain and pyuria, but in reality, 20% to 30%
of patients with appendicitis present with blood,
leukocytes, or even bacteria in their urine.130,131
Similarly, while hematuria plus flank pain equals
renal colic to the ingenuous practitioner, at least
one report shows an 87% incidence of hematuria in
ruptured abdominal aortic aneurysm132 (although
most other reports are around 30%). Furthermore,
the presence of gross hematuria can cause a signifi-
cant delay in the diagnosis because the physician
pursues a urinary workup.132 Recall that the absence
of hematuria does not rule out renal colic: at least 6%
of patients with ureteral stones have no hematuria
on microscopic examination or dipstick.133 Older
studies showed even higher numbers.
Imaging Studies
Plain Films
An astute radiologist said that plain films of the
abdomen “should be cast upon the ash heap of his-
tory.”134 The rate of positive findings on abdominal
films is low in unselected patients and, as a rule,
abdominal radiographs do not suggest unsuspected
diagnoses. Importantly, never rely on plain films to
exclude surgical disease. Only a few serious abdomi-
nal conditions have specific radiologic findings.
These include perforated viscus, bowel obstruction,
and, occasionally, bowel ischemia. Table 5 expands
on the indications for abdominal plain films.
In most patients, such as those with suspected
appendicitis or undifferentiated abdominal pain,
plain films are likely to be normal or misleading. In
a large series of such patients, nearly 40% of positive
findings were inconsistent with the final diagnosis.135
Plain films are not indicated in suspected appendicitis
or cholecystitis, and they have limited utility in renal
colic.136 A retrospective study of plain abdominal
radiography in patients aged ≥ 65 years found that
Recommendation
Order upright chest x-ray
Computed tomography is a more useful study
Although plastic or other non–radio-opaque foreign
bodies will not be imaged, many objects of concern
(eg, button batteries, magnets) will be visible
www.ebmedicine.net
10 Reprints: www.ebmedicine.net/empissues
43% of patients with major surgical disorders had
plain films that were either normal or misleading.137
In another study, the sensitivity of plain film radiog-
raphy for small-bowel obstruction was 69%, and its
specificity was 57%.138 However, the combination of
kidney-ureter-bladder (KUB) x-rays and ultrasound is
helpful in evaluating recurrent urinary stone disease.
The finding of either hydronephrosis and/or calcifi-
cation over the ureters provides a sensitivity nearly
equal to that of intravenous pyelogram.139
Views
A single flat plate of the abdomen provides little in-
formation; an upright chest view adequately visual-
izing the area under the diaphragm will more likely
demonstrate free air. An abdominal series should
include at least upright chest and supine abdomen
views. Some authorities believe that these 2 views
will detect all major pathology, such as free air or
obstruction.140,141 Others suggest that an upright
abdomen view adds further information and should
be included in the series.142 Having the patient sit
bolt upright for 5 minutes before obtaining the film
may increase the yield. Look for an air/fluid level in
the stomach, which should be present in most true
erect films taken after 5 minutes in the upright posi-
tion.142 Several studies have shown that free air may
be absent on plain films in one-third to one-half of
all patients with visceral perforation.135,143-145
Ultrasound
There has been a revolution in the use of bedside
ultrasound by emergency clinicians. Ultrasound is
routinely used for evaluating for abdominal aortic
aneurysm, intrauterine pregnancy, and free abdomi-
nal fluid. Ultrasound for gallbladder, kidneys, bowel,
and even appendix evaluations are competencies
being taught in most emergency medicine training
programs.146 A 2017 study showed that, after partici-
pating in a specific 10-hour hepatobiliary ultrasound
training course, novice emergency medicine residents
had attained a moderate to perfect degree of agree-
ment with expert radiologists in detecting the pres-
ence of gallstone, thick gallbladder wall, sonographic
Murphy sign, and common bile duct dilation.147
The ready availability of ultrasound in many
EDs and its relatively low cost make it attractive for
evaluation of many abdominal conditions. (See Ap-
pendix 1, page 21.) Ultrasound can image most solid
intra-abdominal organs, including the liver, spleen,
gall bladder, pancreas, and kidneys. While frequent-
ly ordered for right upper quadrant pain, physicians
must not over-interpret the findings, as the presence
of stones does not mean that the patient’s pain is
biliary in nature, as gallstones may be an incidental
finding. Sonographic signs of gallbladder pathology
such as gallbladder wall thickening, pericholecystic
fluid, ductal dilatation, and a sonographic Murphy
sign are more precise.
June 2019 • www.ebmedicine.net
Ultrasonography is the diagnostic test of choice
for many presumed gynecologic complaints. ED
use of sonography to rule out ectopic pregnancy
has represented a dramatic improvement in patient
care.148,149 Both transabdominal and transvaginal
sonography can be used to evaluate for an intrauter-
ine pregnancy. Sonography does not always rule
out ectopic pregnancy, but can rule in intrauterine
pregnancy. Many patients may not have an ectopic
pregnancy but an early pregnancy that may fall into
a category of pregnancy of unknown location.
Computed Tomography
CT has become the imaging modality of choice for
many abdominal conditions. A 2017 review of sur-
vey data from 2007-2013 National Hospital Ambula-
tory Medical Care Survey (NHAMCS) noted that CT
scans are ordered in almost 29% of abdominal pain
encounters in the ED.2 Between 2001 and 2005, the
use of CT for abdominal pain increased by 122%.2,150
Helical CT is accurate for renal colic, appendici-
tis, diverticulitis, and intra-abdominal abscesses,
and can rule out the diagnosis of abdominal aortic
aneurysm. (See Appendix 1, page 21.) Older data
regarding the use of helical CT with triple contrast
(oral, rectal, and IV) was impressive. In patients with
suspected appendicitis, the CT was 98% sensitive,
specific, and accurate.151 In the case of suspected
appendicitis, triple-contrast helical CT can prevent
unnecessary surgery and prevent needless observa-
tion when an operation is indicated.152
Oral contrast was routine up to the late 1990s, but
most modern studies do not use either oral or rectal
contrast. Recent studies show that IV contrast alone
(no oral contrast given) is adequate for the diagnosis
of most surgical conditions, including appendici-
tis.153,154 The 2018 American College of Radiology
Appropriateness Criteria® for right lower quadrant
pain states that CT of the abdomen and pelvis with
IV contrast is usually appropriate (with no mention
of the need for oral contrast). The Appropriateness
Criteria® mention concerns for delay in diagnosis and
treatment associated with oral contrast and the poten-
tial for increased rate of perforation.155
Until recently, the use of IV contrast was be-
lieved to lead to acute kidney injury from contrast-
induced nephropathy. Current data show that being
ill enough to be admitted to the hospital is a risk fac-
tor for acute kidney injury, and that IV contrast for
CT does not add to this risk.156,157 Fortunately, the
American College of Radiology (ACR) responded to
the literature regarding the low risk from IV contrast
use in the ED. In the ACR 2015 Manual on Con-
trast Media, the authors noted that the concern for
development of contrast-induced nephropathy is not
an absolute contraindication of IV contrast in at-risk
patients, and noted that in some clinical situations,
use of IV contrast may be necessary regardless of the
risk of nephrotoxicity.158
11 Copyright © 2019 EB Medicine. All rights reserved.
 Clinical Pathway for Patients Aged < 50 Years With Abdominal Pain

Peritoneal signs, shock, or

YES Obtain surgical consult (Class II)
“classic appendicitis”a?

NO

Go to clinical pathway “Lower

Female of childbearing potential? YES Abdominal Pain in Females of
Childbearing Potential,” on page 15

NO

Male with tender testicle or

YES Obtain urology consult (Class II)
tender scrotal mass?

NO

Sudden-onset RLQ pain

Consider UTI and/or renal colic
or positive urinalysis for blood, YES
(Class II)
WBCs, or nitrites?
(Note: 20% of patients with appendicitis
may have pyuria)
NO

Option 1 (Class II) Worsening abdominal tenderness,

• Serial ED exams or elevated rectal temperature, or
YES
• Serial exams plus laboratory abnormal CBC, CRP,
evaluation or sedimentation rate?
• Serial ED exams may include a 6- to
12-hour recheck in patients felt to be
NO
at low risk for appendicitis

Discharge home with instructions to

NO Pain and tenderness resolved? YES
return if symptoms recur (Class II)

Option 2 (Class II): Imaging study

+/- laboratory studiesb
• IV contrast CT of abdomen and • Serial abdominal examinations in ED
pelvis (Class II)
• Abdominal ultrasound of RUQ or If studies or
RLQ, depending on location of negative • Surgical consult (Class II)
tenderness or
• Radiolabeled leukocytesc • Repeat examination in 12-24 hours
• Barium enemac (Class II)

a
“Classic appendicitis”: migration of periumbilical pain to RLQ, anorexia, McBurney tenderness, fever.
b
Imaging studies are generally preferred over laboratory evaluation alone; this is especially true in elderly patients. Consider surgical consult prior to
imaging if presentation is typical for appendicitis. Plain films of abdomen are rarely helpful to rule out appendicitis.
c
Rarely used in current era.
Abbreviations: CBC, complete blood cell count; CRP, C-reactive protein; CT, computed tomography; ED, emergency department; RLQ, right lower
quadrant; RUQ, right upper quadrant; WBC, white blood cell.
For Class of Evidence Definitions, see page 14.

Copyright © 2019 EB Medicine. All rights reserved. 12 Reprints: www.ebmedicine.net/empissues

 Clinical Pathway for Patients Aged > 50 Years With Abdominal Pain
(Continued on page 14)

Shock, peritonitis, or toxicity? YES Obtain surgical consult (Class I)

NO

Option 1
YES Order stat:
Pain radiating to flank or back, pulsatile mass,
• Abdominal ultrasound (Class II)
or pain sudden and severe? YES • Abdominal CT (Class II)
Option 2

NO

Option 1
YES Obtain surgical consult (Class II)
High risk for Obtain:
ischemic bowela? • CT angiography of abdomen (Class II)
YES • CBC (Class II)
Option 2 • Lactate level (Class II)
NO • Electrolytes (Class II)

Order acute obstruction series to look for

Diffuse tenderness, rigidity, or absent bowel sounds? YES
free air or obstructionb (Class II)

NO

Persistent vomiting, abdominal distension, high-pitched or Order acute obstruction series to look for
YES
tinkling bowel sounds, or prior abdominal surgery? free air or obstructionb (Class II)

NO

• Order imaging of biliary systemc (Class II)

• Consider liver function tests (Class II)
Epigastric or RUQ tenderness? YES
• Amylase/lipase (Class II)
• CBC (Class Indeterminate)

NO

Continued on page 14

a
High risk for ischemic bowel: presence of cardiac disease (especially congestive heart failure), peripheral vascular disease, dysrhythmias (especially
atrial fibrillation), bloody diarrhea, pain out of proportion to tenderness.
b
Many centers go straight to CT for these indications.
c
Biliary imaging may include ultrasound, nuclear medicine scintigraphy, high-resolution CT.
Abbreviations: CBC, complete blood cell count; CT, computed tomography; RUQ, right upper quadrant.
For Class of Evidence Definitions, see page 14.

June 2019 • www.ebmedicine.net 13 Copyright © 2019 EB Medicine. All rights reserved.

 Clinical Pathway for Patients Aged > 50 Years With Abdominal Pain
(Continued from page 13)

Go to "Clinical Pathway for Patients Aged < 50 Years

Significant RLQ tenderness? YES
With Abdominal Pain” on page 12

NO

Consider:
Significant LLQ tenderness? YES • Surgical consult (Class II)
• Empiric treatment of diverticulitis (Class II) or
• Imaging for diverticulitis (CT with contrast, ultrasound,
NO barium enema) (Class II)

• Consider evaluation for PID, AAA, pancreatitis, ischemic

Upper abdominal or central pain? YES bowel, and extra-abdominal causes of paina
• Obtain CBC, amylase/lipase, electrolytes (Class II)
• Obtain CT or ultrasound of abdomen (Class II)
NO

Persistent pain or tenderness? YES Obtain consult (Class II)

NO

Arrange for follow-up (Class II)

a
Extra-abdominal etiologies include myocardial ischemia, pneumonia, and metabolic disease.
Note: Abdominal pain in the elderly is often associated with significant surgical disease. Extensive laboratory testing may be indicated if the diagnosis is
in doubt and may include CBC with differential, CRP, lipase and/or amylase, electrolytes, and liver function tests. Upright chest x-ray and flat and upright
abdominal films are occasionally helpful but rarely definitive; abdominal ultrasound is generally more informative. High-resolution CT of the abdomen
may be a valuable study if pain persists or the diagnosis remains in doubt. Obtain surgical consultation for patients with persistent pain or tenderness.

Abbreviations: AAA, abdominal aortic aneurysm; CBC, complete blood cell count; CRP, C-reactive protein; CT, computed tomography; LLQ, left lower
quadrant; PID, pelvic inflammatory disease; RLQ, right lower quadrant; RUQ, right upper quadrant; UA, urinalysis; WBC, white blood cell.

Class of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I
• Always acceptable, safe
• Definitely useful
• Proven in both efficacy and effectiveness
Level of Evidence:
• One or more large prospective studies
are present (with rare exceptions)
• High-quality meta-analyses
• Study results consistently positive and
compelling
Class II Class III Indeterminate
• Safe, acceptable • May be acceptable • Continuing area of research
• Probably useful • Possibly useful • No recommendations until further
• Considered optional or alternative treat- research
Level of Evidence: ments
• Generally higher levels of evidence Level of Evidence:
• Nonrandomized or retrospective studies: Level of Evidence: • Evidence not available
historic, cohort, or case control studies • Generally lower or intermediate levels of • Higher studies in progress
• Less robust randomized controlled trials evidence • Results inconsistent, contradictory
• Results consistently positive • Case series, animal studies, • Results not compelling
consensus panels
• Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2019 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Copyright © 2019 EB Medicine. All rights reserved. 14 Reprints: www.ebmedicine.net/empissues

 Clinical Pathway for Women of Childbearing Potential
With Lower Abdominal Pain

Peritoneal signs, • Obtain surgical/obstetric consult

YES (Class I)
toxicity, or shock?
• Pregnancy test (Class I)
• Consider ultrasound, culdocentesis
NO

Pregnancy testa

Rule out ectopic pregnancy:

• Fetal heart tones (Class I)
• Ultrasound demonstrating IUP
Pregnant? YES (Class I)
• Obtain gynecologic consult (Class II)
• Serial quantitative beta-hCG tests
NO (Class II)
• Serum progesterone testing
(Class II)

Clinical PID? Toxicity, peritoneal signs, Obtain gynecologic/obstetric consult

YES YES
(Cervical motion tenderness, persistent vomiting? (Class II)
bilateral adnexal tendernessb)
NO
Consider outpatient management
NO
of PIDc (Class II)

• Consider ovarian torsion or ovarian

Unilateral adnexal
YES cyst
tenderness? • Color-flow ultrasound accurate for
torsion

NO

Go to "Clinical Pathway for

Predominant RLQ
YES Patients Aged < 50 Years
tenderness?
With Abdominal Pain” on page 12

NO

Evaluate for:
• UTI3 (Class II)
• Renal colic (Class II)
• Enteritis (Class II)
• Extra-abdominal causes of pain
(Class II)

a
Any female with a uterus who is between the ages of 12 and 50 is of childbearing potential. Birth control medication or devices or tubal ligation do not
obviate the need for pregnancy testing.
b
Mucopurulent cervical discharge is present in just over half of patients with PID. In equivocal examinations, pelvic ultrasound may help distinguish PID
from appendicitis or other conditions.
c
Appendicitis in women of childbearing age is frequently misdiagnosed as PID or UTI. Neither cervical motion tenderness nor pyuria excludes the
diagnosis of appendicitis. Instruct the patient to return to the ED or see her primary care provider if not better in 24 hours or if her condition worsens.
Abbreviations: hCG, human chorionic gonadotropin; IUP, intrauterine pregnancy; PID, pelvic inflammatory disease; RLQ, right lower quadrant; UTI,
urinary tract infection.
For Class of Evidence Definitions, see page 14.

June 2019 • www.ebmedicine.net 15 Copyright © 2019 EB Medicine. All rights reserved.

 Because of the high mortality associated with
untreated surgical conditions, CT should be virtually
routine in the elderly patient with acute abdominal
pain. In 2 recent studies,159,160 CT:
• Significantly improved diagnosis accuracy
compared to clinical examination and laboratory
studies
• Optimized appropriate hospitalization by in-
creasing the number of discharged patients
• Allowed detection of about one-third of acute
unsuspected abdominal conditions
• Boosted ED management decision-making confi-
dence for elderly patients
Of all of the caveats associated with the use of
CT, the most important remains: Unstable patients
do not belong in a radiology suite. They must first
be resuscitated or managed in some other appro-
priate fashion, usually with bedside ultrasound or
emergency surgical consult. Hypotensive patients
suspected of ruptured abdominal aortic aneurysm
need immediate surgery or, in the case of diagnostic
uncertainty, an immediate bedside ultrasound.
Another caveat in the use of CT (and for the ra-
diologist reading it): CT scans are not 100% accurate.
While there are not many published papers on “miss
rates,” one study showed that almost 13% of abdom-
inal CTs in the ED may be initially misread.161 The
quality of the scanner and experience and training
of the reader impact this number. If your abdominal
pain patient has concerning clinical findings despite
a negative CT, consider surgical consult and/or
ED observation. This is especially true for elderly
patients and patients with prior bariatric surgery, in
whom the diagnosis may remain obscure.
Magnetic Resonance Imaging
MRI is playing an increasing role in the ED evalu-
ation of abdominal pain, primarily because of the
desire to reduce radiation exposure. In young adults,
the diagnostic accuracy of MRI to diagnose appendi-
citis is very similar to CT.162 MRI is especially useful
in pregnant patients.32 Ultrasound is considered the
initial imaging test for the pregnant patient suspect-
ed of having appendicitis, followed by MRI if the
ultrasound is inconclusive.163
Electrocardiogram
While all emergency clinicians recognize that angina
or myocardial infarction can cause epigastric pain, the
cardiac etiology is often missed in patients presenting
with a chief complaint of abdominal pain. Indiges-
tion is a high-risk complaint in the ED. Relief of pain
with the so-called “GI cocktail” does not preclude
myocardial ischemia. In fact, many such patients
“cured” with the cocktail ultimately prove to have
acute cardiac disease.164 Patients aged > 40 years with
unexplained upper abdominal pain and a nontender
Copyright © 2019 EB Medicine. All rights reserved.
or minimally tender abdomen may benefit from ECG.
Obviously, the ECG may be normal in a patient with
an acute myocardial infarction, and troponin tests
may be prudent in addition to an ECG; however, a
normal ECG in a patient with epigastric pain/heart-
burn is at least somewhat reassuring.
Treatment
The treatment of the myriad causes of abdominal
pain is beyond the scope of this article. However,
the treatment of pain is a manageable topic. While
proponents battle, the tide is shifting to more-active
pain management.
Analgesia for Acute Abdominal Pain
Traditionally, emergency clinicians have withheld
analgesia from patients with acute abdominal pain.
Conventional wisdom argued that pain medications
would obscure the etiology of abdominal pain and
mask the need for laparotomy. However, there is a
convincing body of evidence suggesting that admin-
istration of opioids to patients with abdominal pain
is not only safe, but may aid diagnosis.165-168 Analge-
sics may facilitate the history and physical examina-
tion by reducing patient anxiety and relaxing the
abdominal musculature. Small doses of IV opioids
titrated to pain control are unlikely to conceal a sur-
gical emergency.
Morphine 0.1 mg/kg is frequently adminis-
tered for abdominal pain. Some physicians prefer
fentanyl at 1 mcg/kg (or repeated boluses of 50
mcg titrated to response) because it is short-acting,
has the shortest time of onset of any opioid, and is
safe in patients with marginal blood pressure.169
Fentanyl is also increasingly being used intranasal-
ly (atomized) or nebulized. A recent study showed
that, at a dose of 2 mcg/kg through a breath-actu-
ated nebulizer, fentanyl was a safe alternative to
IV morphine (0.1 mg/kg) in the treatment of acute
abdominal pain.170
Nonetheless, patients given medication for
abdominal pain should not be discharged simply
because their pain is gone. In patients receiving
opioids, it may be prudent to perform serial ED ex-
aminations, laboratory and radiologic studies, and
possibly a 10-hour recheck in the ED. My personal
rule (admittedly not evidence-based) is that anyone
with acute (not recurring) abdominal pain who re-
quires parenteral opioids for pain control also gets
abdominal imaging, either ultrasound or CT. This
“opioid = imaging” rule has saved me (and more
importantly, my patients) countless times over the
past 4 decades.
Though opioids play a major role in abdominal
pain, other agents are also being used for a variety
of painful abdominal conditions. Haloperidol is
increasingly employed in patients with gastroparesis
16 Reprints: www.ebmedicine.net/empissues
and cannabinoid hyperemesis syndrome, and some
consider this the drug of choice for these condi-
tions.171,172 For more information on management of
cannabinoid hyperemesis syndrome, see the August
2018 issue of Emergency Medicine Practice, “Canna-
binoids: Emerging Evidence in Use and Abuse” at
www.ebmedicine.net/Cannabinoids.
Low-dose ketamine (0.3 mg/kg over 15 min-
utes) is supplanting morphine for painful conditions
in many EDs. Karlow et al published a 2018 meta-
analysis that is an excellent review on the topic.173
Controversies and Cutting Edge
Clinical Decision Rules
Abdominal pain clinical decision rules tend to focus
on appendicitis. The Alvarado score is the most-used
tool for appendicitis diagnosis. (See Table 6.) Ac-
cording to a 2007 retrospective review of 150 patient
charts by McKay and Shepherd, an Alvarado score
≤ 3 indicates appendicitis is unlikely; for scores 4
to 6, CT is recommended; and for scores ≥ 7, surgi-
cal consultation is recommended.174 There are also
“modified” Alvarado scores that incorporate differ-
ent criteria (eg, CRP) or are for different populations
(eg, children, patients with HIV) that may be appro-
priate in specific settings.29 Recent data suggest that
combining the Alvarado score with bedside ultra-
sound may allow for rapid and inexpensive diagno-
sis of appendicitis.175
Patients with scores < 4 are considered to be
unlikely to have appendicitis. However, consider
serial examinations and early recheck for patients
with low scores since the rule is NOT 100% sensi-
tive, especially in those with tenderness in the right
lower quadrant.
Table 6. Alvarado Score
Score Criteria Score
No Yes Total
Signs
• Right lower quadrant tenderness 0 2
• Rebound tenderness 0 1
• Fever (37.3°C/99.1°F) 0 1
Symptoms
• Migration of pain to right lower 0 1
quadrant
• Anorexia 0 1
• Nausea or vomiting 0 1
Laboratory Values
• Leukocytosis > 10,000 mm3 0 2
• Leukocyte left shift 0 1
Total:
Maximum score: 10
June 2019 • www.ebmedicine.net
An online tool for calculating the
Alvarado score is available from
www.MDCalc.com:
• www.mdcalc.com/alvarado-score-
acute-appendicitis
Clinical Policies
Clinical policies have become ubiquitous, and
they have the potential to decrease practice vari-
ability and reduce costs. Yet, despite the far-rang-
ing interest in clinical policies, few data demon-
strate that they perform any better than individual
physician judgment. Regarding abdominal pain,
reaching an evidence-based conclusion would re-
quire a multi-center randomized trial to compare
outcomes of patients managed with and without
use of a clinical policy.
Disposition
Despite patient expectations, the final diagnosis of
the cause of abdominal pain is less important than
the proper disposition of surgical consult, admis-
sion, imaging, testing, prolonged ED observation, or
discharge home. The emergency clinician must also
recognize the patient who needs surgical consulta-
tion based on high-risk demographics, physical
examination, or worrisome diagnostic studies.
Timing of consultation is also important. Clearly,
patients with suspected ruptured abdominal aortic
aneurysm, testicular torsion, or mesenteric ischemia
require immediate surgical consultation. In many
patients, the definitive diagnosis is best determined
by laparotomy. Those who are clinically stable (eg,
with presumed uncomplicated cholecystitis) can
undergo definitive studies before consultation. CT
scanning and bedside (or radiology suite) ultra-
sound are key elements of abdominal imaging.
Consider some combination of ultrasound and/or
MRI in the pregnant patient.
The ED remains the ultimate safety net. Timely
follow-up in a primary care provider's office is often
impractical, so patients can return to the ED in 8 to
10 hours for re-examination, and sooner, if their pain
worsens. Allow for primary care provider re-evalua-
tion only if you have personally communicated with
them and definitively arranged for re-examination.
Serial examinations improve the diagnostic ac-
curacy at little expense. While the value of a single
CBC or CRP is debatable, a higher level drawn hours
later may prove useful. Tenderness that was benign
or vague on the initial examination may localize to
the right lower quadrant on repeat examination.
Other patients may develop peritoneal signs in the
intervening hours. The choice of a repeat visit in 6 to
8 hours versus placement in a clinical decision unit
(observation unit) is a judgment based both on the
17 Copyright © 2019 EB Medicine. All rights reserved.
likelihood of serious pathology and a judgment of
whether the patient will return.
For those patients without a clear diagnosis who
appear well enough for discharge, the emergency
clinician must stress that sometimes the diagnosis
is not clear, emphasize the importance of follow-up,
and under what circumstances they should return
immediately to the ED. This is true even in the
presence of a supposedly normal CT or ultrasound
result. The accuracy of CT scan and ultrasound are
never at 100% in any published study. Standard
discharge instructions modified by the physician
are a valuable way to underscore these points. (See
Figure 2.)
Observation Units
The role of observation and serial examinations in
the diagnosis of abdominal pain continues to evolve.
ED chest pain centers have proven cost-effective
in the evaluation of chest pain. Can the applica-
tion of observational medicine to abdominal pain
yield similar results? Again, multicenter prospective
studies are lacking. Some patients clearly require
consultation, while others have an obviously be-
nign condition, and both of these groups are easy
to manage. It is the borderline patient who may
benefit from admission to an ED observation unit.
One study looked at 220 patients of all ages admit-
ted with acute abdominal pain. When the diagnosis
on admission was uncertain, the authors employed
a policy of active observation. Ultimately, 39% of the
patients went on to have surgery, with 5% having
negative findings on laparotomy.176 The relative
value of laboratory studies, serial examinations, and
diagnostic imaging must be appraised in order to
identify and manage these patients effectively.
Time- and Cost-Effective Strategies
The cost of evaluating abdominal pain can increase
rapidly during the course of ED evaluation. Before
ordering a test, consider the likelihood that the results
will change management. If the test is unlikely to have
an impact on subsequent care, do not order the test.
The following strategies help contain runaway costs.
• Limit abdominal x-rays. Plain films have lim-
ited value in the diagnosis of abdominal pain.
They are rarely helpful in suspected appendici-
tis, nonspecific abdominal pain, or gallbladder
disease. Restricting films to patients with sus-

Figure 2. Sample Discharge Instructions for the Patient With Abdominal Pain
There are many causes of abdominal pain. Most pain is not serious and goes away, but some pain gets worse, changes, or will not go away. Please
return to the emergency department or see your doctor right away if you (or your family member) experience any of the following:
1. Pain that gets worse or moves to just one spot.
2. Pain that gets worse if you cough or sneeze.
3. Pain with going over a bump in the road.
4. Pain that does not get better in 24 hours.
5. Inability to keep down liquids (vomiting)—especially if you are making less urine.
6. Fainting.
7. Blood in the vomit or stool.
8. High fever or shaking chills.
9. Swelling of the abdomen.
10. Any new or worsening problem.

Follow-up Instructions
Return to the emergency department in ________ hours for recheck.
See your primary care provider if not completely better in ________ days. Come to the ED if you are unable to see them in this time frame.
See your primary care provider in ________ days. Come to the ED if you are unable to see them in this time frame.

Medications
Take the following medications:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Additional Instructions
No alcohol.
No caffeine, aspirin, or cigarettes.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

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 pected radio-opaque foreign body or perforation
is rational and cost-effective. Risk Management
Caveat: Criteria for upright chest films may be
liberalized in the elderly, where early detection
of perforation is likely. Abnormalities are more
likely in this population and are associated with
poor outcome.151
• Limit electrolyte testing. Most patients with
nausea, vomiting, and diarrhea do not need elec-
trolytes. Electrolyte testing doubles ED costs and
quadruples ED length of stay.177 Among adults
aged 18 to 60, clinically significant electrolyte
abnormalities occur in only 1% of those with
gastroenteritis. These abnormalities are predict-
ed by history of diuretic use, liver or kidney dis-
ease, and symptoms lasting more than 24 hours.
Clinically significant electrolyte abnormalities
are not related to orthostatic vital signs. Risk
Management Caveat: Patients with altered men-
tal status, serious underlying medical disease,
the elderly, or those unable to communicate may
require less restrictive criteria.
• Limit microscopic urinalysis and urine cul-
tures. For most patients, obtain a dipstick
urinalysis instead of microscopic urinalysis. It is
less expensive and generally as accurate. Do not
order urine cultures for uncomplicated cystitis
in women of childbearing age.178 Risk Manage-
ment Caveat: The urinalysis is frequently abnor-
mal in many conditions, including appendicitis
and PID. UTI becomes a convenient explanation
for abdominal pain that may actually be due to a
more serious etiology.
• Limit testing in the nontoxic alcoholic patient
with abdominal pain. Ordering a serum amy-
lase is a frequent reaction to abdominal pain in
the alcoholic patient. This test rarely provides
valuable information, as amylase is usually
elevated in alcoholics even in the absence of ab-
dominal pathology. While lipase is more specific
for alcoholic pancreatitis, clinical criteria—not a
number—should determine the need for admis-
sion. In nontoxic patients, skip the laboratory
tests. Instead, look for improvement on serial
abdominal examinations (possibly with the aid
of a GI cocktail) and the ability to tolerate clear
liquids. Risk Management Caveat: Alcoholics
have many reasons for abdominal pain, from the
benign to the catastrophic, including gastritis,
pancreatitis, alcoholic ketoacidosis, perforated
viscus, occult trauma, or other intra-abdominal
calamities. Maintain vigilance for serious con-
ditions in alcoholics and document serial ED
examinations. However, a soft abdomen, normal
mental status, and a healthy appetite usually
indicate a favorable outcome.
• Use CT for renal colic selectively. Not all
patients with a clinical presentation of renal
June 2019 • www.ebmedicine.net
colic need a CT in the ED, particularly if the
patient has a known history of stone disease.
One cost-effective alternative is an ultrasound
performed by the emergency clinician or in ra-
diology. This strategy is sensitive and specific
for detecting obstructing ureteral stones and is
endorsed for patients with a known history of
stones by the American College of Emergency
Physicians “Choosing Wisely” Campaign
(www.choosingwisely.org).179 Patients who are
sent home may have outpatient studies ordered
by the consultant if they fail to improve.
Risk Management Caveat: Two classes of
patients with presumed renal colic are at high
risk. The first is the elderly patient with flank
pain and hematuria. Such patients may have an
abdominal aortic aneurysm and require emer-
gent abdominal CT or ultrasound. The second
high-risk patient is one with a presumed ure-
teral stone and signs of infection. Such a patient
requires IV antibiotics, renal imaging (usually a
helical CT), and emergent urology consultation.
• Increase the use of ED ultrasound. For emer-
gency clinicians with appropriate training, ED
ultrasound is both fast and accurate. The test
characteristics of emergency physician–per-
formed bedside ultrasonography for the detec-
tion of acute cholecystitis are similar to the test
characteristics of radiology ultrasonography.180
Risk Management Caveat: A robust ED ultra-
sound quality assurance program is essential.
When possible, have the ED ultrasound over-
read by an emergency physician with fellowship
training in ultrasound. Alternatively, follow up
with each ED bedside ultrasound to determine
clinical outcomes.
Summary
The painful abdomen will humble the most arrogant
physician. A seemingly benign abdomen can obscure
serious disease. It is elderly patients, immunosup-
pressed patients, young women, and those with pre-
vious abdominal surgery who are especially likely to
suffer misdiagnosis. A structured history and physi-
cal examination may improve accuracy, in addition
to liberal use of CT and ultrasound in the high-risk
populations (elderly, immunocompromised, women
of childbearing potential, and those with previous
abdominal surgery). Contrary to outdated teachings,
judicious use of pain medication may assist in evalu-
ation. Use of haloperidol and ketamine are robust
alternatives to opioids.
Pitfalls in management include over-reliance on
a single study (particularly the deceitful CBC and
the treacherous plain film) and making an unsup-
ported diagnosis. No managed care gnome can
force a physician to document a specific disease on
19 Copyright © 2019 EB Medicine. All rights reserved.
the chart. (Not yet, anyway!) Abdominal pain of
undetermined etiology is preferable to a “forced”
diagnosis of gastroenteritis or constipation. Serial
examinations using either prolonged ED evaluation
or a 10-hour recheck may prevent missed pathology.
Correct disposition (transfer, hospital admission, or
immediate surgery) is more important than a precise
diagnosis in the ED.
Case Conclusions
The 68-year-old woman with severe abdominal pain and
an irregular tachycardia was suspicious for sepsis from
mesenteric ischemia. You recognized that she needed pain
control and fluids along with a full sepsis workup, includ-
ing lactate, ECG, CT abdominal angiography, and an
Risk Management Pitfalls in Evaluating Patients With Abdominal Pain
1. “I didn’t think she needed a CT.”
The CT scan is the most revealing tool in the ED
workup. Maintain a low threshold for obtaining
CT in acute abdominal pain in the elderly.
2. “I wish I’d thought of that.”
Consider the diagnosis of mesenteric ischemia
in older patients. The presence of cardiac or
peripheral vascular disease, bloody diarrhea, or
pain out of proportion to tenderness increases
the chance of mesenteric ischemia.
3. “I didn’t think he needed an ECG—he had
abdominal pain.”
Always consider the diagnosis of myocardial
infarction or acute coronary syndromes in
cases of upper abdominal pain in the elderly,
especially if there is no or minimal abdominal
tenderness.
4. “I thought I could trust the CT scan.”
Usually you can, but occasionally the CT scan
is wrong. If a patient worries you because of
risk factors, history, physical examination, or
laboratory results, perform serial examinations
or consult a surgeon.
5. “She insisted that she couldn’t be pregnant.”
In the mind of a prudent emergency clinician,
women of childbearing age with abdominal
pain are always pregnant—in their tubes.
Perform a pregnancy test on all women between
menarche and menopause if they have a uterus
(unless they have fetal heart tones). Do not omit
pregnancy testing based on reported sexual
abstinence, tubal ligation, or contraceptive use.
Copyright © 2019 EB Medicine. All rights reserved.
almost-certain surgical consult. Her ECG showed atrial
fibrillation, and the CT angio confirmed the diagnosis.
She was emergently taken to the OR, where a dead bowel
segment was resected and she had a surprisingly good re-
covery, thanks to your rapid mobilization of specialty care.
The 24-year-old man with no past medical history
and severe, sudden left lower quadrant pain followed by
vomiting posed a diagnostic dilemma. His abdomen was
nontender and he had normal vital signs with a tachycar-
dia. You remembered that sudden-onset pain is usually
ischemia (torsion) or colic (ureteral stone). His urine had
no blood, so you went back and did a testicular exam,
which revealed a tender right testicle. An emergent Dop-
pler flow study in radiology confirmed a torsed testicle.
Surgical detorsion and orchiopexy was successful, with
excellent patient outcome.
6. “It looked like just another case of PID.”
Consider appendicitis in women of childbearing
potential despite a tender pelvic examination
and/or pyuria. One-third of all such
women who have appendicitis are initially
misdiagnosed as having either PID or a UTI.
7. “I thought it was just gastroenteritis.”
It is preferable to give a diagnosis of
“nonspecific abdominal pain,” “undifferentiated
abdominal pain,” or “abdominal pain of
unknown etiology” than to assign a specific
but unsupported diagnosis. A true diagnosis of
gastroenteritis requires nausea, vomiting, and
diarrhea.
8. “But the CBC was normal.”
Do not rule out the diagnosis of surgical disease
because a patient has a normal WBC count.
Twenty percent of patients with appendicitis
have a completely normal CBC. Plus, never
whine in court.
9. “The pain was in the wrong spot!”
Consider the diagnosis of appendicitis in
patients with right flank and right upper
quadrant pain (and also left lower and, rarely,
left upper quadrant pain). Patients with
retrocecal appendicitis present with minimal or
no right lower quadrant tenderness.
10. “If only I had read the Emergency Medicine
Practice article on abdominal pain, I would
have remembered to examine the testicles of
the young man with abdominal pain.”
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Appendix 1. Pros and Cons of Diagnostic Tools for Abdominal Pain in Various Disease Entities
Appendicitis
Plain Films
• Pros: Rarely, a plain film may demonstrate an appendicolith; useful for
radio-opaque rectal or swallowed foreign body. Do not order.
• Cons: More likely to mislead than illuminate. In general, plain films play
no role in appendicitis diagnosis.
CT With IV Contrast
• Pros: The high sensitivities (approaching high 90s%) are reported from
institutions using latest-generation machines with IV contrast alone.
Oral contrast is unnecessary.
• Cons: Radiation burden. There can be considerable variability in
performance of CT in different institutions. Accuracy depends on
the machine used, body habitus, and experience of the radiologist.
Patients with more body fat are more easily diagnosed due to
periappendiceal fat stranding.
Ultrasound
• Pros: Valuable in women (especially pregnant women) with RLQ pain,
where the differential diagnosis is broad. It is less accurate than CT for
appendicitis. Some hospitals perform ultrasound first and then CT only
if the ultrasound does not show appendicitis. Many children’s hospitals
perform CT only if the ultrasound is nondiagnostic and the child shows
other signs of appendicitis (positive CRP, leukocytosis, persistent RLQ
tenderness, etc).
• Cons: Operator experience and body habitus influence accuracy.
MRI
• Pros: Useful as a second-line test for suspected appendicitis in
pregnancy (after ultrasound).
• Cons: Expensive, not universally available.
CBC
• Pros: Everybody orders it. Nearly all surgical consultants want this test.
May be useful as part of a scoring system such as the Alvarado score.
• Cons: It is as likely to deceive as it is to inform. The CBC is often
normal in patients with appendicitis and is often elevated in patients
with gastroenteritis and nonspecific abdominal pain. In women of
childbearing age, it is especially likely to lead to an incorrect diagnosis.
CRP
• Pros: High sensitivity in a few studies, especially with serial levels. May
be part of modified Alvarado score for appendicitis.
• Cons: Wide range of accuracy among studies.

Bacterial Gastroenteritis
Fecal Leukocytes and Stool Lactoferrin Fecal Leukocytes + Fecal Blood
• Pros: Rapid and inexpensive, but probably not useful. • Pros: More accurate when taken together.
• Cons: Infectious Diseases Society of America no longer endorses use • Cons: Clinical picture of fever and visible blood or mucus is as accurate
of fecal leukocyte examination or stool lactoferrin detection to establish as laboratory testing.
the cause of acute infectious diarrhea.107

Abdominal Aortic Aneurysm

CT With IV Contrast
• Pros: Readily available. Accurate in many studies. Modern multidetector
CT has a sensitivity and specificity approaching 100% for aortic
pathology.103
• Cons: If patient is clinically unstable, imaging may lead to the patient
coding in the CT scanner. Notify surgeon of unstable patients with
suspicion of AAA. Immediate bedside ultrasound should be routine if
diagnosis is suspected.
• CT may miss some aorto-enteric fistulas, inflammatory aneurysms,
and aorto-venous fistulas.103,104
Angiography
• Pros: Traditional (though outdated) standard. Fairly accurate in the
stable patient.
• Cons: If patient is clinically unstable, leaving the ED may result in a
frantic resuscitation. Notify surgeon of unstable patients with suspicion
of AAA. Immediate bedside ultrasound is helpful in cases of unclear
diagnosis. Angiography can give false negative due to intraluminal clot.
Ultrasound
• Pros: Accurate bedside test, diagnosis available within a minute.
Sensitive for aneurysm. Emergency clinician can perform it reliably.
Study of choice for unstable patient.
• Cons: Accurate for aneurysm but insensitive to retroperitoneal blood.
May also miss small amounts of intraperitoneal blood; one study found
that leakage of AAA was detected by ultrasound in only 4%.105 Poor at
identifying complications of AAA and branch vessel involvement.
MRI
• Pros: Accurate in the stable patient. Identifies most complications,
although it is less studied than CT or angiography.
• Cons: If patient is clinically unstable, MRI is contraindicated; do not
take the patient to radiology. Notify surgeon of unstable patient with
suspicion of AAA. Immediate bedside ultrasound is helpful in cases of
unclear diagnosis.

Bowel Obstruction
Plain Films CT With IV Contrast Only
• Pros: The reported accuracy of radiography for the diagnosis of small- • Pros: Accurate. Can identify transition point, which can be important if
bowel obstruction varies from 50% to 86%; easily available. the etiology is a mass (eg, cancer).
• Cons: Often misses early or proximal obstruction. Not worth even the • Cons: Radiation burden.
small radiation of plain films.
Ultrasound
• Pros: Sensitivity of 94% with similar specificity.
• Cons: Slightly less accurate than CT. May miss other pathology.

Abbreviations: AAA, abdominal aortic aneurysm; CBC, complete blood cell (count): CRP, C-reactive protein; CT, computed tomography; ED, emergency
department; IV, intravenous; MRI, magnetic resonance imaging; RLQ, right lower quadrant.
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Appendix 1. Pros and Cons of Diagnostic Tools for Various Disease Entities (Continued)
Biliary Tract Disease
CT With IV Contrast Magnetic Resonance Cholangiopancreatography (MRCP)
• Pros: Good for common duct stones. • Pros: High diagnostic accuracy for the detection of choledocholithiasis.
• Cons: Not as sensitive for cholecystitis as ultrasound. Radiation • Cons: Expensive, time-consuming, and not as available as ultrasound.
burden.
Endoscopic Retrograde Cholangiopancreatography
Ultrasound • Pros: Can diagnose and treat.
• Pros: Ultrasound is often the first study of choice for RUQ pain and • Cons: Expensive and invasive; rarely necessary.
pelvic pain in women of childbearing age. Best for gallbladder anatomy.
Associated criteria: gallbladder-wall thickening, edema, pericolic Radionuclide Scanning
fluid; sonographic Murphy sign specific for diagnosis of cholecystitis. • Pros: Best for assessing gallbladder function. Helpful when diagnosis is
Overall, > 95% sensitive for cholelithiasis and about 85% sensitive for suspected but CT/ultrasound are inconclusive.
cholecystitis. Can be performed by an emergency clinician at bedside. • Cons: Not as immediately available as ultrasound. Not an ideal ED test
• Cons: The presence of gallstones alone does not imply pain is stone- with regard to availability and time to perform.
related. Has a 5%-10% false-negative rate, especially if the patient has
a common bile duct stone.99

Diverticulitis
CT With IV Contrast Only Barium Enema
• Pros: Accurate in selected patients. Can detect abscess formation and • Pros: Accurate in selected patients.
perforation. • Cons: Less accurate in ED due to no prior bowel prep. May increase
• Cons: Radiation burden. risk of perforation if performed acutely. Rarely done in the modern era.

Ultrasound
• Pros: Accurate in selected patients.100-102
• Cons: Operator/reader-dependent.

Pancreatitis
CT With IV Contrast Amylase
• Pros: Useful if there is suspicion of gallstone pancreatitis (especially • Pros: A cut-off of > 3 times the normal value is more specific for
if female and/or nondrinker), pseudocyst, or pancreatic phlegmon/ pancreatitis.
abscess (fever, mass, severe toxicity). Also, CT grade can predict risk • Cons: Amylase is routinely elevated in alcoholics, even in absence of
of abscess formation, cancer staging, and mortality. pancreatitis. Many laboratories have eliminated amylase in the “belly
• Cons: Imaging rarely necessary in ED for alcohol-related pancreatitis. labs” in favor of lipase.

Ultrasound Lipase
• Pros: Sensitive and specific with no associated radiation. Good for • Pros: More specific for pancreatitis than amylase.
stone-related pancreatitis and pseudocyst formation. • Cons: May be normal early in acute pancreatitis as well as in chronic
• Cons: Slightly less sensitive than CT. Poor image with ileus or pancreatitis.
increased bowel gas.

Intestinal Infarction/ Ischemia

Plain Films
• Pros: Can obtain immediately at bedside and may reveal thumbprinting,
if lucky.
• Cons: Most films are normal or reveal ileus or bowel obstruction, falsely
reassuring the emergency clinician and surgeon. Not generally useful;
do not order.
Urinary Stone Disease
Kidney, Ureter, Bladder (KUB) X-Ray
• Pros: Readily available but not recommended. Can occasionally be
used in conjunction with ultrasound to image size and exact location
of stone.
• Cons: Poor sensitivity/specificity.
Helical CT, Unenhanced (Noncontrast)
• Pros: Very accurate for stone disease. Can evaluate other pathology,
such as abdominal aortic aneurysm, appendicitis, and perinephric
abscess. Study of choice for suspected first stone.
• Cons: Ultrasound is often considered a better study for recurrent stone
disease. Radiation burden.
Angiography, CT, MRI
• Pros: Accurate; available in most institutions. CT angiography has the
best balance of availability, timeliness, and accuracy.
• Cons: None are completely accurate in establishing the diagnosis and
have equivalent reported sensitivities.
Ultrasound
• Pros: Rapid ED test to detect stone. Can be performed at bedside
by emergency clinician. Useful in recurrent stones and useful in
pregnancy to detect obstruction. Can also detect abdominal aortic
aneurysm.
• Cons: Cannot always localize stone. Less sensitive if no obstruction.
IV Pyelogram
• Pros: Rarely used for renal colic; ultrasound and CT are better options.
• Cons: Cannot evaluate other organ systems. Will miss abdominal aortic
aneurysm. Basically obsolete.

Abbreviations: CT, computed tomography; ED, emergency department; IV, intravenous; MRI, magnetic resonance imaging; RUQ, right upper quadrant.
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Appendix 1. Pros and Cons of Diagnostic Tools for Various Disease Entities (Continued)
Ectopic Pregnancy
Ultrasound (Transabdominal; > 6 Weeks’ Gestation)
• Pros: An IUP is the best evidence against ectopic pregnancy. Rapid,
inexpensive, readily available. Can be performed at bedside.
• Cons: 1 in 30,000 chance of a heterotopic pregnancy (IUP plus an
ectopic pregnancy). More often seen with use of fertility drugs or
history of PID.
• Transabdominal ultrasound less able to visualize early IUP.
Ultrasound (Endovaginal; > 4.5 Weeks’ Gestation)
• Pros: More sensitive than transabdominal ultrasound for early IUP. Skill
is easily learned by the emergency clinician.
• Cons: See transabdominal ultrasound regarding risks of heterotopic
pregnancy. Many studies are nondiagnostic (ie, no IUP and no adnexal
mass). May need repeat examination in several days, along with serial
measurements of beta-hCG level.
Beta-hCG
• Pros: Bedside urine test is rapid and accurate. Negative test essentially
rules out the diagnosis of ectopic pregnancy.
• Cons: Rare false-negatives with very early pregnancy (days after
conception). Ectopic pregnancy is not excluded by low (or high)
beta-hCG level. Doubling of beta-hCG in 48 hours does not rule out
ectopic pregnancy; about 10% of ectopic pregnancies may double the
beta-hCG level.
• Serial beta-hCG levels and the ultrasound discriminatory level can
be used together over a several-day period to identify IUP.91,106 For
more information on diagnosis and management of ectopic pregnancy,
see the January 2019 issue of Emergency Medicine Practice,“First
Trimester Pregnancy Emergencies: Recognition and Management” at
www.ebmedicine.net/FirstTri.

Testicular Torsion
Color Doppler, Radionuclide Scanning • Cons: Clinical examination is the best initial screen for testicular
• Pros: Both have comparable sensitivities and specificities and are torsion. If testicular torsion is strongly suspected, immediately consult
accurate in making the diagnosis. a urologist and consider manual detorsion. Delay in operation to obtain
an imaging study may result in loss of an otherwise viable testis.

Urinary Tract Infection

CT, Ultrasound Bacteriuria
• Pros: CT and ultrasound are both sensitive to stone disease. • Pros: Fairly sensitive for UTI in adults.
Ultrasound is sensitive for obstruction. CT is excellent for detecting • Cons: False-positives and false-negatives occur. Some laboratories
perinephric abscess and size and location of stone. read bacteria on nearly all urinalyses.
• Cons: The emergency clinician does not need to order advanced
imaging studies for all cases of simple pyelonephritis. Clinical suspicion Leukocyte Esterase
plus a urinalysis compatible with pyelonephritis warrants treatment. • Pros: Inexpensive, easily available, more sensitive than nitrites.
Suspicion for an infected stone, sepsis, or perinephric abscess • Cons: Not specific for UTI.
prompts consultation and CT or ultrasound. Other considerations for
imaging include history of prior stones, risk factors for stone formation
Nitrite Test
(obesity, gastric bypass, polycystic kidney disease, etc), sudden-onset
• Pros: More specific than leukocyte esterase.
pain or hematuria, diuretic use, or strong family history of stones.
• Cons: Not sensitive for UTI.

Urine WBC (> 10 cells/HPF)

• Pros: Fairly sensitive for UTI in adults.
• Cons: False-positives and false-negatives occur with all routine tests.

Pelvic Inflammatory Disease (Salpingitis)

Ultrasound • Cons: Generally unnecessary; clinical diagnosis is key. WBC is more
• Pros: Helpful to rule out tubo-ovarian abscess in high-risk patients with likely to mislead than illuminate in the distinction between PID and
mass on pelvic examination, AIDS patients with PID, or toxicity. Useful appendicitis.
in patients with unclear diagnosis, especially appendicitis versus PID.
• Cons: Not necessary for routine ED diagnosis of PID. Many patients ill Cervical WBC
enough to need ultrasound will need consultation. • Pros: Found in > 90% of patients with PID.
• Cons: Visual examination of the cervical os alone is adequate to detect
WBC, ESR, CRP mucopurulent cervicitis, except in cases of chlamydial PID.
• Pros: Inexpensive, widely available. Serial CRP and ESR tests are
more accurate than a single level.
Ovarian Torsion
Color-Flow Doppler
• Pros: Excellent test.
• Cons: Not widely available 24/7; operator-dependent.

Abbreviations: AIDS, acquired immunodeficiency syndrome; CRP, C-reactive protein; CT, computed tomography; ED, emergency department; ESR,
erythrocyte sedimentation rate; hCG, human chorionic gonadotropin; HPF, high-power field; IUP, intrauterine pregnancy; PID, pelvic inflammatory
disease; UTI, urinary tract infection; WBC, white blood cell.
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27 Copyright © 2019 EB Medicine. All rights reserved.
 ateness Criteria right lower quadrant pain-suspected ap- 169. Which
Frakes MA,of Lord WR, Kociszewski
testsC,should
et al. Efficacy of
CME Questions 5. the following not be
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pendicitis. J Am Coll Radiol. 2018;15(11s):S373-S387. (Practice fentanyl analgesia for trauma in critical care transport. Am J
used to assess for popliteal artery injury?
guidelines) Emerg Med. 2006;24(3):286-289. (Retrospective chart review;
156. Wilhelm-Leen E, Montez-Rath a. X-raypatients)
series of the knee
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Online! G. Estimating 100 trauma
the risk of radiocontrast-associated nephropathy. J Am Soc 170. b. Duplex
Deaton ultrasound
T, Auten JD, Darracq MA. Nebulized fentanyl vs
Nephrol. 2017;28(2):653-659. (Risk estimate using Nation- c. CT angiogram
intravenous morphine for ED patients with acute abdominal
Current
wide subscribers
Inpatient Sample)receive CME credit absolutely pain:Arteriogram
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157. Aycock RD, Westafer theLM,following
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egory I credits, 4 AAFP Prescribed credits, or 4 AOA 28 studies, 171. Roldan CJ, Chambers KA, Paniagua L, et al. in the reduc-
Randomized
107,335 participants) Take This Test Online! tion of all
controlled types of knee
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trial comparing is: com-
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158. American College of Radiology; ACR Committee on Drugs a.
binedAxial loading therapy to conventional therapy
with conventional
for current andMedia.
and Contrast archived
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c. Posterior force on the proximal tibia
withmedia/ACR/Files/Clinical-Resources/Contrast_Media.pdf.
your smartphone or visit trial; 33 patients)
d.
Accessed May 10, 2019. (Practice guidelines)
www.ebmedicine.net/E1217. 172. WitsilTraction/counter-traction
JC, Mycyk MB. Haloperidol, a novel treatment for can-
159. Millet I, Sebbane M, Molinari N, et al. Systematic unen- nabinoid hyperemesis syndrome. Am J Ther. 2017;24(1):e64-
hanced CT for acute abdominal symptoms in the elderly 7. When
e67. (Case should
studies;a4knee or ankle joint be reduced
patients)
patients improves both emergency department diagnosis 173. Karlow
in the N, Schlaepfer
field by EMS CH,before
Stoll CRT, et al. A systematic
transport?
and prompt clinical management. Eur Radiol. 2017;27(2):868- review and meta-analysis of ketamine as an alternative to
a. Significant deformity
877. (Prospective; 401 patients) opioids for acute pain in the emergency department. Acad
160. Samaras N, Chevalley T, Samaras D, et al. Older patients b.
EmergSevere and unremitting(Meta-analysis;
Med. 2018;25(10):1086-1097. pain 3 studies,
in the emergency department: a review. Ann Emerg Med. c. Open dislocation
261 patients)
2010;56(3):261-269. (Review) 174. d.
UnluerConcern
EE, Urnalfor ischemia
R, Eser U, et al.distal to theofinjury
Application scoring
161. Howlett DC, Drinkwater K, Frost C, et al. The accuracy of systems with point-of-care ultrasonography for bedside di-
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8. What type of knee dislocation is the most com-
1. What is the
who present most
with commonabdominal
non-traumatic type of hip pain:disloca-
results of a (Evaluation)
mon?
UK
tion?national audit. Clin Radiol. 2017;72(1):41-51. (Retrospec- 175. McKay R, Shepherd J. The use of the clinical scoring system
tive; 50 patients) a. Medialin the decision to perform computed tomog-
by Alvarado
a. Lateral
162. Kinner S, Pickhardt PJ, Riedesel EL, et al. Diagnostic accu- b.
raphyAnterior
for acute appendicitis in the ED. Am J Emerg Med.
b. Medial
racy of MRI versus CT for the evaluation of acute appen- 2007;25(5):489-493.
c. Posterior (Retrospective review; 150 patient charts)
c.
dicitisAnterior
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d. Lateral
d. Posterior (Prospective; 48 patients)
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e. Rotational
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what to do next? Radiology. 2018;288(3):728-729. (Review) 9. What other injury
in the evaluation of acuteshould be excluded
adult gastroenteritis. Annbefore
Emerg
164. which
Wrenn K,of the CM,
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Gongaware complications?
J. Using the “GI cocktail”: Med. 1989;18(3):258-260.
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of an ankle 281dislocation?
patients)
a. Compartment
a descriptive study. Annsyndrome
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a. Hip fracture
b. Further blood
(Retrospective; loss
97 patients) complicated urinary tract infection. Infect Dis Clin North Am.
b. Calcaneal fracture
165. c.
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Katz Subtalar
A. ACEP ondislocation
the Choose Wisely Campaign. Emer-
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1997;15(6):775-779. (Prospective; 48 patients) d.
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Medicineshaft
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3. Which
in patientsofwith
theacute
following
abdominal hip dislocations
pain. should
Acad Emerg Med.
10. aspx?PostID=136. Accessed May 10, 2019. (Website)
What potential complication from a dislocated
not be reduced by
1996;3(12):1086-1092. an emergency
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168. b.
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c. Long-term osteoarthritis
d. No dislocation should be reduced without
patients)
d. Compartment syndrome
orthopedic consultation

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1. The elderly patient with acute abdominal pain:
a. Will almost always have an elevated white
count
b. Will almost always demonstrate peritoneal
signs
c. Will usually benefit from CT scanning
d. Will usually have a reliable physical
examination
2 The most common causes of sudden-onset
abdominal pain are:
a. Biliary and ureteral colic
b. Mesenteric ischemia
c. Appendicitis
d. Urinary tract infection
3. What is the percentage of patients with surgi-
cally proven appendicitis who did NOT have
right lower quadrant pain?
a. 5%
b. 10%
c. 20%
d. 30%
4. In the abdominal examination, involuntary
guarding:
a. Can be a reaction of fear or anxiety
b. Can be mitigated with reassurance
c. Is less common in elderly patients
d. Makes surgical disease less likely
June 2019 • www.ebmedicine.net
5. The testicular examination:
a. Is unnecessary if lower abdominal pain is
isolated
b. Is unnecessary if flank pain is isolated
c. Is not helpful in patients older than 20 years
d. Is necessary in male patients with
abdominal pain
6. The CBC:
a. Is always elevated in cases of appendicitis
b. Can distinguish between surgical and
nonsurgical disease
c. Can distinguish between pelvic
inflammatory disease and appendicitis
d. Is often misleading
7. MRI:
a. Should be routine in appendicitis workups
in the elderly
b. Is especially useful in pregnant patients after
an inconclusive ultrasound
c. Is unreliable for the diagnosis of
appendicitis
d. Is the study of choice post bariatric surgery
8. Pain medication given to patients with abdom-
inal pain:
a. Is contraindicated, because it obscures
surgical disease
b. Should always be an opioid
c. Allows the patient to be discharged if pain is
relieved
d. May include haloperidol and ketamine
9. What is the best test for appendicitis?
a. CBC
b. Plain film of the abdomen
c. Alvarado score combined with ultrasound
d. C-reactive protein
10. This question has been deleted.
29 Copyright © 2019 EB Medicine. All rights reserved.
Copyright © 2019 EB Medicine. All rights reserved. 30 Reprints: www.ebmedicine.net/empissues
June 2019 • www.ebmedicine.net 31 Copyright © 2019 EB Medicine. All rights reserved.
 CME Information
Date of Original Release: June 1, 2019. Date of most recent review: May 10, 2019. Termination
date: June 1, 2022.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical
Education (ACCME) to provide continuing medical education for physicians. This activity has been
December 201
Volume 20,
8
Number 12
planned and implemented in accordance with the accreditation requirements and policies of the
agnosis ACCME.
Influenza: Di nt in the
Authors
P, FAAEM Icahn School of Medic
ine
MBA, FACE ine,
AL Giwa MD, sor of Emergency Medic

me
and Manage partment
Assistant ProfesNew York, NY

Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA
at Mount Sinai, P
MPH, FACE Hackensack Meridian
egbe, MD, ine,
Chinwe Oged sor of Emergency MedicUniversity, Nutley, NJ;

nc y De Associate
Profes at Seton Hall Jersey

Emerge
l of Medicine Rutgers-New
Medicine,

Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their
Health Schoo of Emergency
Professor
Associate l, Newark,
NJ
Medical Schoo r,
MD Medical Cente
Murphy, Metrowest
Charles G. Emergency Medicine,
Abstract
participation in the activity.
ic
nt diagnost Depar tment
of
of the curre l- MA
t be aware and the avai Framingham,
clinicians mus for influenza ensive
Emergency ic recommendations
ers
Peer Review
This compreh influenza am, MD nd School
of Medicine,
and therapeut to guide management. Maryla

Specialty CME: Not applicable. For more information, please call Customer Service at 1-800-249-
Abrah of
enza viruses, Michael K. sor, Univer
sity

able resou
rces
class ificat ion of influ patie nts, and the Clinical Assist
ant Profes
nes the of high -risk MD
review outli gy, the identification enza are Baltimore, of
tions of influ
tment
, MD tion, Depar
Daniel J. Egansor, Vice Chair of Educa
pe- of
siolo varia ng s College
pathophy on. Seasonal testing duri en- Profes sity Vagelo
e of vaccinati rationale for limiting Associate Univer
Columbia

5770.
Medicine,
importanc ns of influ Emergency ons, New York,
NY
as well as
the between strai al and Surge
discussed, Differences ving optim Physicians cian CME
Information”
prevalence. the challenges in achie the currently , see “Physi
ing this activity back page.
riods of high , as well as for use of Prior to beginn on the
discu ssed ndat ions men ts

ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency
za are mme iral treat
tiveness. Reco venous antiv aking with
vaccine effec intranasal, and intra
ed decision-m
available oral, as well as utilizing shar treatment. Maricopa
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Physicians for 48 hours of ACEP Category I credit per annual subscription.
are provided and bene fits Pharmacy
Residency, AZ
Phoenix,
rding risks tti, MD, FACEP Medical Center,
patients rega MPH, MBA
Alfred Sacche Professor, e, Joseph D.
Toscano,
MD
ncy
Hoxhaj, MD, Jackson Assistant Clinical ncy Medicin ent of Emerge
Shkelzen of Emerge Chief, DepartmRamon Regional
l Officer, Department n University, San
MD Chief Medica FL Thomas Jefferso Medicine, San Ramon
, CA
Hospital, Miami,

AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been
Daniel J. Egan,
of
Vice Chair Memorial Philadelphia,
PA Medical Center,
Professor, ncy
Associate
hief
Editor-In-C, MD, FACEP Department
of Emerge
Eric Legom
e, MD e, Mount r, MD e, al Editors
Education,
Columbia
University
Chair, Emerge
ncy Medicin Luke's; Robert Schille ent of Family Medicin Internation
Medicine, and Sinai St. Chair, Departm Senior on, MD
Andy Jagoda Interim Chair, e; of Physicians West & Mount ic Affairs for Medical Center; Peter Camer Alfred
or and
ncy Medicin Vagelos College Sinai Beth Israel
Medicine and Director, The Centre,
NY Academic

reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of
Profess Academ
of Emerge New York, Vice Chair, Mount Sinai Faculty, Family of
Department for Emerge
ncy Surgeons, Medicine, Icahn School NY Emergency
and Trauma rne,
Emergency School of nity Health, New York, ity, Melbou
Director, Center ion and Research, Genes, MD, PhD
of , Icahn NY Commu
Mount Sinai, Monash Univers
Nicholas Department Health System New York, Medicine at
Medicine Educat e at Mount Professor, Mount Sinai, Australia
of Medicin Associate Icahn School Medicine at FACEP
Silvers, MD, or of Emergency
Icahn School NY ncy Medicine, MD, MS Scott MD
York, New

approval begins 07/01/2018. Term of approval is for one year from this date. Physicians should
Sinai, New Emerge Sinai, Keith A. Marill, Profess Andrea Duca, Physician,
e at Mount Department Associate of Facilities
and
Emergency
hief of Medicin Professor, Attending
Editor-In-C Associate Medicine,
Harvard Medicine, Chair Clinic, Jacksonville,
FL
Giovanni XXIII,
ciate York, NY ncy le Papa
Asso MD, FACEP FACEP of Emerge , Massachusetts Plannin g, Mayo Ospeda
of Gibbs, MD, Medical School l, Boston, MA FACEP Bergamo,
Italy
Kaushal Shah, Department Michael A. Department MD, FACP,
Professor, or and Chair, e, Carolinas l Hospita M. Slovis, ent s, MD
Associate Icahn School Profess Genera Corey Departm e Y.G. Peeter
Physician,

claim only the credit commensurate with the extent of their participation in the activity. Approved for
Medicine, MA, MD, Chair,
Emergency Sinai, New
ncy Medicin ity of North Pollack Jr., Professor and Medicine, Vanderbilt Suzann
Emergency
of Emerge Charles V. e, TN Attending Almere,
of Medicin
e at Mount Univers
Medical Center, of Medicine, Chapel , FAHA, FESC of Emergency l Center, Nashvill g Hospital,
FACEP, FAAEM for
University Medica Flevo Teachin
York, NY Carolina School & Senior Advisor ands
Professor y Research
and MD of The Netherl
Hill, NC InterdisciplinarDepartment of Ron M. Walls, Chair, Department Peralta, MD
Editorial Board
FACEP s,
Godwin, MD, and

4 AAFP Prescribed credits.

l Professor Brigham and l Hugo of Emergency Service
, MD, FACEP ent of Steven A. Department Clinical Trials, Sidney Kimmen Medicine,
Saadia Akhtar and Chair, Medicine, Emergency Medica Chair , Buenos Aires,
Professor,
Departm Professor Assistant Emergency of Thomas
Jefferso l, Harvard Hospital Italiano
Associate Associa te Dean ncy Medicine, l College Women 's Hospita
Medicine, of Emerge ion, Medica PA , MA
Emergency ion Educat Philadelphia, School, Boston Argentina
Education, Dean, SimulatFlorida COM- University, ul, MD
te Medical s, MD, MPH ncy rs Rojanasarntik
for Gradua r, Emerge ncy Univers ity of FL S. Radeo Edito Dhanadol an, Emergency
Critical Care
nville, l Physici
Program Directo cy, Mount Sinai Jacksonville,
Jackso Michae
Professor
of Emerge , Attending ngkorn
Associate King Chulalo Red Cross,

AOA Accreditation: Emergency Medicine Practice is eligible for 4 Category 2-A or 2-B credit hours
Medicine ResidenYork, NY MD MBA l College IV, MD, FACEP Medicine,
New Habboushe, of Emergency Medicin e, Weill Medica New York; William A. Knight ial Hospita l, Thai
Beth Israel, Joseph or ity, Memor e,
Univers ent of ncy of Medicin
Assistant Profess ngone and of Cornell
Director, DepartmYork
FNCS
Professor
of Emerge Thailand; Faculty Thailand
Brady, MD e NYU/La Research Associate Medical University,
William J. ncy Medicin Medicine, l Centers,
New York,
Medicine,
New Neurosurgery, Chulalongkorn
of Emerge Director, Emergency Medicine and
Professor Bellevue Medica , Flushing,
NY Practice s, MD, MPH
e; Medical LLC Advanced Medical Stephen H. Thoma

per issue by the American Osteopathic Association.

MD Aware Hospital Queens Director, EM
and Medicin
Management,
UVA NY; CEO, ; Associate ncy
& Chair, Emergel Corp.,
Emergency Medical FACEP MD, MBA,
MPH
Provider Program University Professor
Operational Henry, MD, Ali S. Raja, Emergency cience ICU, Hamad Medica
Medical Center; rle County Fire Gregory L. or, Departm ity
ent of
Vice Chair, l Director, Neuros ati, OH Medicine, , Qatar;
Clinical Profess Executive husetts Genera ati, Cincinn Medical College
Director, Albematesville, VA ncy Medicine,
Univers
; CEO, Medicin e, Massac or of of Cincinn FCCM Weill Cornell an-in-C hief,
Emerge te Profess rt, MD, Physici
Rescue, Charlot n Medical
School
ment, Hospital; Associa e and Radiolo
gy,
Scott D. Weinga Medicine; Emergency l Hospital,
MD of Michiga e Risk Assess Medicin Emergency Hamad Genera
Brown III, Medical Practic MI Emergency l School, Boston
, MA Professor of Stony Brook

Needs Assessment: The need for this educational activity was determined by a survey of medical
Calvin A. Compliance, Critical Care, Doha, Qatar
Physician Inc., Ann Arbor, Harvard Medica Chief, EM
Director of and Urgent
Care FACEP, Stony Brook,
NY
Credentialing ncy , MD, FACEP Rogers, MD, Medicine, Edin Zelihic,
MD ncy
ent of Emerge John M. Howell or of Emergency Robert L. ent of Emerge l,
Services, Departm and Women's Clinical Profess Washington FAAEM, FACP or of Emergency Editors Head, Departm Hospita
Medicine,
Brigham George Director Assistant
Profess Research Medicine,
Leopoldina
, MA Medicine, gton, DC; University
of D, BCPS Germany

staff, including the editorial board of this publication; review of morbidity and mortality data from the
Hospital, Boston Washin
University, Affairs, Best Practic
es, Medicin e, The
Medicine,
r, Pharm
Aimee MishleMedicine Pharma cist, Schwei nfurt,
ic School of
ux, MD of Academ l, Falls Maryland Emergency r, PGY2 EM
Peter DeBlie Clinical Medicine, Fairfax Hospita MD
Professor
of ity School
of Inc, Inova Baltimore, Program Directo
State Univers nce Officer, Church, VA
Louisiana
Chief Experie New

CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Medicine;
Medical Center,
University
Orleans, LA

First Trimester Pregnancy January 2019

Emergencies: Recognition Author
Volume 21, Number 1 Target Audience: This enduring material is designed for emergency medicine physicians, physician
and Management Ryan Pedigo, MD
Director of Undergraduate
Medical Education, Harbor-UCLA
Center, Torrance, CA; Assistant
David Geffen School of Medicine,
Medical
Professor of Emergency Medicine,
assistants, nurse practitioners, and residents.
Los Angeles, CA
Abstract
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-
Peer Reviewers

Jennifer Beck-Esmay, MD
Timely management of patients Assistant Residency Director,
presenting to the ED while Mount Sinai St. Luke’s – Mount

making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most
their first trimester of pregnancy in West, New York, NY Sinai
can
the patient and the fetus. Common improve outcomes for both Taku Taira, MD, FACEP
obstetric problems encoun- Associate Director of Undergraduate
tered include vaginal bleeding Medical Education; Associate

and miscarriage, ectopic preg-
nancy and pregnancy of undetermin
and vomiting of pregnancy, ed location, and nausea
including hyperemesis gravidarum
Optimal diagnostic approaches
and management strategies
critical presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Clerkship Director, LAC +
USC Department of Emergency
Keck School of Medicine, Los Medicine,
Angeles, CA
Prior to beginning this activity,
. see “CME Information”
on the back page.

Discussion of Investigational Information: As part of the journal, faculty may be presenting inves-
covered, including which are
antiemetics are safe to give This issue is eligible for
nancy. Common nonobstetri in preg- 2 Pharmacology CME credits.
c problems include asymptoma
bacteriuria, urinary tract infections tic
including pyelonephritis,
and acute appendicitis. This
aging modalities available
risks of ionizing radiation
article also reviews the various
for pregnant patients and
im-
reviews the
tigational information about pharmaceutical products that is outside Food and Drug Administration
approved labeling. Information presented as part of this activity is intended solely as continuing
as well as various contrast
media.

Editor-In-Chi ef
Andy Jagoda, MD, FACEP
Professor and Interim Chair,
Department of Emergency
Medicine;
Director, Center for Emergency
Medicine Education and Research,
medical education and is not intended to promote off-label use of any pharmaceutical product.
Daniel J. Egan, MD
Associate Professor, Vice Shkelzen Hoxhaj, MD, MPH,
Chair of MBA Alfred Sacchetti, MD, FACEP
Education, Department of Chief Medical Officer, Pharmacy Residency, Maricopa
Emergency Memorial Hospital, Jackson Assistant Clinical Professor,
Medicine, Columbia University Miami, FL Department of Emergency Medical Center, Phoenix, AZ
Vagelos College of Physicians Medicine,
and Eric Legome, MD Thomas Jefferson University, Joseph D. Toscano, MD

Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence,

Icahn School of Medicine
at Mount
Sinai, New York, NY
Associate Editor-In-Chief
Surgeons, New York, NY
Nicholas Genes, MD, PhD
Associate Professor, Department
of
Emergency Medicine, Icahn
School
Chair, Emergency Medicine,
Mount
Sinai West & Mount Sinai St.
Luke's; Robert Schiller, MD
Vice Chair, Academic Affairs
for
Emergency Medicine, Mount
Health System, Icahn School
Sinai
Philadelphia, PA
Chief, Department of Emergency
Medicine, San Ramon Regional
Medical Center, San Ramon,
Chair, Department of Family CA
Medicine,
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Senior International Editors

transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating
Kaushal Shah, MD, FACEP of Medicine at Mount Sinai, of Faculty, Family Medicine and
New Medicine at Mount Sinai, New
Associate Professor, Department York, NY York, NY Community Health, Icahn School Peter Cameron, MD
of Keith A. Marill, MD, MS of
Emergency Medicine, Icahn Medicine at Mount Sinai, New Academic Director, The Alfred
School Michael A. Gibbs, MD, FACEP Associate Professor, Department York, NY
of Medicine at Mount Sinai, Scott Silvers, MD, FACEP Emergency and Trauma Centre,
New Professor and Chair, Department of Emergency Medicine, Harvard
York, NY Monash University, Melbourne,

of Emergency Medicine, Carolinas
Medical Center, University
Editorial Board Carolina School of Medicine,
of North
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Hill, NC
Associate Professor, Department
of
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Corey M. Slovis, MD, FACP,
FACEP Ospedale Papa Giovanni XXIII,

Emergency Medicine, Associate
Dean
for Graduate Medical Education,
Program Director, Emergency
Medicine Residency, Mount
Beth Israel, New York, NY
Sinai
Steven A. Godwin, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Assistant
Dean, Simulation Education,
University of Florida COM-
Professor & Senior Advisor
for
Interdisciplinary Research
and
Clinical Trials, Department
of
Emergency Medicine, Sidney
Kimmel Ron M. Walls, MD
Medical College of Thomas
Professor and Chair, Department
of Emergency Medicine, Vanderbilt
University Medical Center, Nashville,
TN
any relevant financial relationships and to assist in resolving any conflict of interest that may arise
Bergamo, Italy
Suzanne Y.G. Peeters, MD
Attending Emergency Physician,
Flevo Teaching Hospital, Almere,

Jacksonville, Jacksonville,
William J. Brady, MD FL
Joseph Habboushe, MD
Professor of Emergency Medicine MBA
Assistant Professor of Emergency
and Medicine; Medical Director,
Medicine, NYU/Langone and
Emergency Management,
Jefferson
University, Philadelphia, PA
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MPH
Associate Professor of Emergency School, Boston, MA
Medicine, Weill Medical College
from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty
Professor and Chair, Department
The Netherlands
Emergency Medicine, Brigham of
and
Women's Hospital, Harvard Edgardo Menendez, MD,
Medical FIFEM
Professor in Medicine and
Emergency
Medicine; Director of EM, Churruca

Medical Center; Operational
UVA
Medical
Director, Albemarle County
Fire
Rescue, Charlottesville, VA
Calvin A. Brown III, MD
Bellevue Medical Centers,
New York,
NY; CEO, MD Aware LLC
Gregory L. Henry, MD, FACEP
Clinical Professor, Department
of
for this CME activity were asked to complete a full disclosure statement. The information received
of Cornell University, New Critical Care Editors Hospital of Buenos Aires University,
York; Buenos Aires, Argentina
Research Director, Department William A. Knight IV, MD,
of FACEP,
Emergency Medicine, New FNCS Dhanadol Rojanasarntikul,
York MD
Hospital Queens, Flushing, Associate Professor of Emergency Attending Physician, Emergency
NY

Director of Physician Compliance,
Credentialing and Urgent Care
Services, Department of Emergency
Medicine, Brigham and Women's
Emergency Medicine, University
of Michigan Medical School;
CEO,
Medical Practice Risk Assessment,
Inc., Ann Arbor, MI
is as follows: Dr. Colucciello, Dr. Shaukat, Dr. Taylor, Dr. Mishler, Dr. Toscano, Dr. Jagoda,
Ali S. Raja, MD, MBA, MPH Medicine and Neurosurgery, Medicine, King Chulalongkorn
Medical
Executive Vice Chair, Emergency Director, EM Advanced Practice Memorial Hospital; Faculty
of
Medicine, Massachusetts Provider Program; Associate Medical Medicine, Chulalongkorn University,
General
Hospital; Associate Professor Director, Neuroscience ICU, Thailand
of University
Emergency Medicine and of Cincinnati, Cincinnati, OH

Hospital, Boston, MA John M. Howell, MD, FACEP
Clinical Professor of Emergency
Peter DeBlieux, MD
Medicine, George Washington
Professor of Clinical Medicine, University, Washington, DC;
Director
Louisiana State University of Academic Affairs, Best
School of Practices,
and their related parties report no relevant financial interest or other relationship with the
Radiology, Stephen H. Thomas, MD,
Harvard Medical School, Boston, MPH
MA Scott D. Weingart, MD, FCCM Professor & Chair, Emergency
Robert L. Rogers, MD, FACEP, Professor of Emergency Medicine; Medicine, Hamad Medical
Corp.,
FAAEM, FACP Chief, EM Critical Care, Stony Weill Cornell Medical College,
Brook Qatar;
Assistant Professor of Emergency Medicine, Stony Brook, NY Emergency Physician-in-Chief

manufacturer(s) of any commercial product(s) discussed in this educational presentation.

Medicine; Chief Experience Inc, Inova Fairfax Hospital, ,
Officer, Falls Medicine, The University Hamad General Hospital,
University Medical Center, of
New Church, VA Maryland School of Medicine, Research Editors Doha, Qatar
Orleans, LA
Baltimore, MD
Aimee Mishler, PharmD, Edin Zelihic, MD
BCPS
Emergency Medicine Pharmacist, Head, Department of Emergency
Program Director, PGY2 EM Medicine, Leopoldina Hospital,

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Copyright © 2019 EB Medicine. All rights reserved. 32 Reprints: www.ebmedicine.net/empissues

 Calculated
Decisions
Clinical Decision Support for Emergency Medicine Practice Subscribers
Alvarado Score for Acute Appendicitis
The Alvarado score for acute appendicitis predicts the likelihood
of a diagnosis of appendicitis.
Click the thumbnail above
to access the calculator.
Points & Pearls
• The Alvarado score is more accurate at the ex-
tremes than for equivocal scores, so it is unclear
whether the score is better than clinical gestalt.
• Symptoms may overlap with other diseases; ie,
higher scores are found in patients with nonap-
pendiceal inflammatory conditions, such as di-
verticulitis or acute pelvic inflammatory disease.
It is important to consider the whole clinical
picture in making the diagnosis of appendicitis.
• There are several modifications of the Alvarado
score in use; these modifications may be appro-
priate in specific settings, such as for pregnant
patients, children, or in low-resource facilities
with limited or no laboratory testing capability,
but the original score remains the best studied
and validated in a general population.
Critical Actions
Clinicians should use clinical judgment in nonclassic
presentations of appendicitis.
Evidence Appraisal
The Alvarado score was initially described in 1986
by Dr. Alfredo Alvarado in a retrospective study at a
single center in Philadelphia. In 305 patients aged
CALCULATOR REVIEW AUTHORS
Ayomide Loye, MD
Department of Emergency Medicine, Philadelphia
University/Thomas Jefferson University, Philadelphia, PA
Xiao Chi Zhang, MD, MS
Department of Emergency Medicine, Philadelphia
University/Thomas Jefferson University, Philadelphia, PA
CD1
POWERED BY
Why to Use
Acute appendicitis is a common surgical
emergency in the United States. Diagnostic
accuracy for appendicitis is increased with the
use of CT scanning; however, there are risks
and disadvantages associated with CT scans,
including radiation exposure, contrast-related
complications, and cost. The Alvarado score
is a well-established and widely used clinical
decision tool that may help reduce the need for
CT scans in diagnosing appendicitis.
When to Use
The Alvarado score can be used for patients
with suspected acute appendicitis (typically,
patients presenting with right lower quadrant
pain).
Next Steps
• Cutoffs differ by study, but one validated
stratification assigns the highest risk to
Alvarado scores ≥ 9 in men and a score of
10 in women; the lowest-risk scores were
≤ 1 in men and ≤ 2 in women (Coleman
2018).
• In patients whose score indicates high
risk, treatment without obtaining CT
imaging should be considered. Alternative
diagnoses should be considered in patients
whose score indicates low risk. In patients
with equivocal scores, CT scanning should
be considered to help clarify the diagnosis.
Abbreviation: CT, computed tomography.
www.ebmedicine.net
4 to 80 years, 8 predictive factors were identified
to stratify the risk of acute appendicitis. Increasing
scores were found to correlate with increasing risk
for appendicitis, as determined by final surgical
pathology.
In 2007, McKay et al studied a retrospective
cohort of 150 patients (aged ≥ 7 years) presenting
with abdominal pain, with the aim of stratifying risk
specifically for the use of computed tomography
(CT) scanning for diagnosis. They found 35.6% sen-
sitivity for appendicitis based on equivocal Alvarado
scores (defined as scores of 4-6) compared with
90.4% sensitivity based on CT scan in this group.
They concluded that patients with equivocal scores
would benefit from CT scanning.
Similarly, Coleman et al (2018) conducted a ret-
rospective review in which the Alvarado score was
applied to a cohort of 492 patients (median age
= 33 years), and found that 20% of the patients
were in either the high-risk group (defined as scores
≥ 9 in men or a score of 10 in women) or the low-
risk group (scores ≤ 1 in men and ≤ 2 in women).
These patients spent a cumulative total of > 170
hours awaiting CT scanning that was ultimately
unnecessary. The authors found that scores of 0 or
1 had 0% incidence of acute appendicitis and that
100% of men with a score ≥ 9 and 100% of women
with a score of 10 had acute appendicitis confirmed
on surgical pathology.
Pogorelić et al (2015) prospectively studied 311
pediatric patients and applied both the Alvarado
score and the pediatric appendicitis score (Samuel
2002). Receiver operating characteristic analysis
showed similar accuracy between the scores, with
area under the receiver operating characteristics
of 0.74 (95% confidence interval, 0.66-0.82) for the
Alvarado score and 0.73 (95% confidence interval,
0.65-0.81) for the pediatric appendicitis score. The
authors concluded that the scores may be useful in
emergency settings, but neither score is superior to
the clinical gestalt of a pediatric surgeon.
Emergency Medicine Practice • June 2019
Use the Calculator Now
Click here to access the Alvarado score on MDCalc.
Calculator Creator
Alfredo Alvarado, MD
Click here to read more about Dr. Alvarado.
References
Original/Primary Reference
• Alvarado A. A practical score for the early diagnosis of acute
appendicitis. Ann Emerg Med. 1986;15(5):557-564.
DOI: https://doi.org/10.1016/S0196-0644(86)80993-3
Validation References
• Coleman JJ, Carr BW, Rogers T, et al. The Alvarado score
should be used to reduce emergency department length of
stay and radiation exposure in select patients with abdomi-
nal pain. J Trauma Acute Care Surg. 2018;84(6):946-950
DOI: https://doi.org/10.1097/TA.0000000000001885
• McKay R, Shepherd J. The use of the clinical scoring system
by Alvarado in the decision to perform computed tomog-
raphy for acute appendicitis in the ED. Am J Emerg Med.
2007;25(5):489-493.
DOI: https://doi.org/10.1016/j.ajem.2006.08.020
• Pogorelić Z, Rak S, Mrklić I, et al. Prospective validation of
Alvarado score and Pediatric Appendicitis Score for the
diagnosis of acute appendicitis in children. Pediatr Emerg
Care. 2015;31(3):164-168.
DOI: https://doi.org/10.1097/PEC.0000000000000375
Other References
• Kalan M, Talbot D, Cunliffe WJ, et al. Evaluation of the modi-
fied Alvarado score in the diagnosis of acute appendicitis: a
prospective study. Ann R Coll Surg Engl. 1994;76(6):418-419.
https://www.ncbi.nlm.nih.gov/pubmed/7702329
• Ohle R, O'Reilly F, O'Brien KK, et al. The Alvarado score
for predicting acute appendicitis: a systematic review. BMC
Med. 2011;9:139.
DOI: https://doi.org/10.1186/1741-7015-9-139
• Samuel M. Pediatric appendicitis score. J Pediatr Surg.
2002;37(6):872-881.
DOI: https://doi.org/10.1053/jpsu.2002.32893
• Körner H, Söndenaa K, Söreide JA, et al. Incidence of acute
nonperforated and perforated appendicitis: age-specific and
sex-specific analysis. World J Surg. 1997;21:313-317.
https://www.ncbi.nlm.nih.gov/pubmed/9015177
Copyright © MDCalc • Reprinted with permission.
CD2 Copyright © 2019 EB Medicine. All rights reserved.
 Shock Index
The shock index may be a more sensitive indicator of occult
shock than heart rate or blood pressure alone, especially in
patients with trauma or acute hemorrhage.
Click the thumbnail above
to access the calculator.
Points & Pearls
• The shock index is calculated as heart rate di-
vided by systolic blood pressure.
• There are currently no large-scale prospective
studies validating the use of the shock index to
guide resuscitative intervention.
• A shock index value > 1.3 has been shown to
correlate with an increased risk of mortality (like-
lihood ratio of 5.67) and hospitalization (likeli-
hood ratio of 6.64) (Al Jalbout 2019).
• A pediatric age-adjusted shock index is more
accurate than the shock index for identifying the
most severely injured patients aged ≤ 16 years
(Acker 2015).
Evidence Appraisal
The shock index was first proposed in the literature
in 1967 by Allgöwer and Burri as a measure of shock
severity. More recently, the shock index has been
studied futher with modern protocols.
In a large retrospective study by Mutschler
et al (2013), 21,853 patients were identified in a
trauma registry. Each patient’s shock index value
was calculated based on vital signs taken on arrival
at the emergency department. The degree of shock
was found to correlate with increasing shock index
values. The need for blood products, fluids, and
vasopressors was also found to increase with higher
shock index values.
A retrospective study by Cannon et al (2009),
performed at a single Level I trauma center, identi-
fied 2445 patients admitted over a 5-year period.
Patients with a shock index value > 0.9 were found
to have a significantly higher mortality rate (15.9%)
when compared with patients with a normal shock
index (6.3%)
In a retrospective registry study by Vandromme
et al (2011), the authors identified 8111 patients
with blunt trauma who were admitted at a single
Level I trauma center over an 8-year period. The
CALCULATOR REVIEW AUTHOR
Kamal Medlej, MD
Department of Emergency Medicine, Massachusetts
General Hospital, Boston, MA
CD3
Why to Use
Blood pressure and heart rate, when used
individually, fail to predict accurately the
severity of hypovolemia and shock in major
trauma. Massive transfusion of blood products
can be associated with significant risk when
initiated on the wrong patient. Identifying
patients who are likely to require massive
transfusion can be difficult, and objective
measures such as the shock index can help. The
shock index has also been shown to be more
sensitive than the ABC (assessment of blood
consumption) score for massive transfusion
(Schroll 2018).
When to Use
Clinicians should consider using the shock index
in the following scenarios:
• For patients presenting with hemorrhage
and trauma, to identify patients who are
at increased risk for needing massive
transfusion.
• For patients requiring endotracheal
intubation, to help identify patients at risk of
postintubation hypotension.
• For patients with suspected sepsis.
The shock index has been found to be as
sensitive as the SIRS criteria to identify patients
at risk for sepsis (Berger 2013). However, a large
randomized controlled trial showed that use of
the shock index to guide fluid resuscitation in
sepsis did not demonstrate an improvement in
mortality (Yearly 2014).
Next Steps
The accuracy of the shock index for identifying
trauma patients in need of massive blood
transfusion has not yet been prospectively
investigated.
Abbreviation: SIRS, systemic inflammatory response syn-
drome.
www.ebmedicine.net
shock index value for each patient was calculated
from recorded prehospital vital signs, and patients
with a shock index value > 0.9 were found to have a
1.6-fold higher risk for massive transfusion.
In a retrospective study of 542 patients who un-
derwent emergency intubation, Heffner et al (2013)
identified a pre-intubation shock index value ≥ 0.9
to be independently associated with peri-intubation
cardiac arrest.
A retrospective study of 2524 patients at a
single center who were screened for severe sepsis
found that a shock index value ≥ 0.7 performed as
well as the SIRS (systemic inflammatory response
syndrome) criteria in negative predictive value and
was the most sensitive screening tool for hyperlacta-
temia and 28-day mortality (Berger 2013).
Of note, in the ProCESS (Protocolized Care for
Early Septic Shock) trial (a large, multicenter pro-
spective randomized controlled trial that enrolled
1341 patients), the investigators compared 3 dif-
ferent protocols for resuscitation of septic patients,
including a protocol that used a shock index value
≥ 0.8 as a fluid resuscitation goal; the study found
no significant difference in mortality between the 3
intervention groups (Yearly 2014).
Use the Calculator Now
Click here to access the shock index on MDCalc.
Calculator Creator
Manuel Mutschler, MD
Click here to read more about Dr. Mutschler.
References
Original/Primary Reference
• Allgöwer M, Burri C. The “shock-index.” Dtsch Med
Wochenschr. 1967;92(43):1947-1950.
DOI: https://doi.org/10.1055/s-0028-1106070
This edition of Calculated Decisions, powered by MDCalc, is
published as a supplement to Emergency Medicine Practice
as an exclusive benefit to subscribers. Calculated Decisions
is the result of a collaboration between EB Medicine,
publisher of Emergency Medicine Practice, and MD Aware,
developer of MDCalc. Both companies are dedicated to
providing evidence-based clinical decision-making support
for emergency medicine clinicians.
Emergency Medicine Practice (ISSN Print: 1524-1971, ISSN Online: 1559-3908, ACID-FREE) is published monthly (12 times per year) by EB Medicine (5550 Triangle Parkway, Suite
150, Norcross, GA 30092). Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is
intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used
for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Copyright © 2019 EB Medicine. All rights
reserved. No part of this publication may be reproduced in any format without written consent of EB Medicine. This publication is intended for the use of the individual subscriber only
and may not be copied in whole or part or redistributed in any way without the publisher’s prior written permission.
Emergency Medicine Practice • June 2019
Validation References
• Mutschler M, Nienaber U, Münzberg M, et al. The Shock
Index revisited – a fast guide to transfusion requirement? A
retrospective analysis on 21,853 patients derived from the
TraumaRegister DGU®. Crit Care. 2013;17(4):R172.
DOI: https://doi.org/10.1186/cc12851
• Cannon CM, Braxton CC, Kling-Smith M et al. Utility of the
shock index in predicting mortality in traumatically injured
patients. J Trauma. 2009;67(6):1426-1430.
DOI: https://doi.org/10.1097/TA.0b013e3181bbf728
• Vandromme MJ, Griffin RL, Kerby JD, et al. Identifying
risk for massive transfusion in the relatively normotensive
patient: utility of the prehospital shock index. J Trauma.
2011;70(2):384-390.
DOI: https://doi.org/10.1097/TA.0b013e3182095a0a
Other References
• Heffner AC, Swords DS, Neale MN, et al. Incidence and fac-
tors associated with cardiac arrest complicating emergency
airway management. Resuscitation. 2013;84(11):1500-1504
DOI: https://doi.org/10.1016/j.resuscitation.2013.07.022
• Berger T, Green J, Horeczko T, et al. Shock index and early
recognition of sepsis in the emergency department: pilot
study. West J Emerg Med. 2013;14(2):168-174.
DOI: https://doi.org/10.5811/westjem.2012.8.11546
• Yearly D, Kellum J, Huang D, et al. A randomized trial of
protocol-based care for early septic shock. N Engl J Med.
2014;370(18):1683-1693.
DOI: https://doi.org/10.1056/NEJMoa1401602
• Schroll R, Swift D, Tatum D, et al. Accuracy of shock index
versus ABC score to predict need for massive transfusion in
trauma patients. Injury. 2018;49(1):15-19.
DOI: https://doi.org/10.1016/j.injury.2017.09.015
• Al Jalbout N, Balhara KS, Hamade B, et al. Shock index as
a predictor of hospital admission and inpatient mortality in
a US national database of emergency departments. Emerg
Med J. 2019;36(5):293-297.
DOI: http://dx.doi.org/10.1136/emermed-2018-208002
• Acker SN, Ross JT, Partrick DA, et al. Pediatric specific shock
index accurately identifies severely injured children. J Pedi-
atr Surg. 2015;50(2):331-334.
DOI: https://doi.org/10.1016/j.jpedsurg.2014.08.009
Copyright © MDCalc • Reprinted with permission.
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