Evaluation of Abdominal Pain
Adapted from: Frank Landry, MD/Jan 1998
  1. Epidemiology of Acute Abdominal Pain: (See also Table 1)
    Common Symptom in the Ambulatory Care Setting:
  2. History and Physical Exam Findings:
    1. Key History: Age, exact time of onset and associated events (trauma etc), pain distribution and character, radiation of pain, nausea, vomiting, diarrhea, constipation, urination and menstruation: Past history
    2. Keys to Physical Exam: General appearance, pulse, resp rate, temp;
      Exam: Look, Listen, Percuss, Palpate
      Palpate: Warm hands—start away from point of pain; thighs flexed, gentle pressure
      Other: rectal/pelvic exams
  3. Diagnostic Testing: (See also Table 2)
  4. DiagnosisSensitivity:
    Abdominal X-Ray: Most helpful for the following diagnoses:
    Perforation70%
    Bowel Obstruction45-55%
    Biliary Disease20-25%
    Ischemic Bowel20-25%
    Ultrasound: Most useful for:
    Biliary Disease80-90%
    Appendicitis75-85%
    Abdominal CT: Distinct advantage in identifying abdominal path:
    Bowel Obstruction94%
    Biliary80-90%
    Abscess90-95%
    Ischemic Bowel60-70%
  5. Discussion on: Common disorders of the young:
    1. GE Reflux:
      symptoms: varied; acid taste in mouth; "esophageal pain"; am nausea
      Rx: Step 1: Elevate head of bed; Avoid bothersome substances (coffee or other acidic or caffeinated beverages, EtOH)
      Pharm:
      Antacids, such as Gaviscon (mild disease)
      Prokinetics such as Reglan or erythromycin
      H2-receptor antagonists (including Ranitidine, Famotidine, Cimet)
      Proton pump inhibitors, including Omeprazole and Rabepazole (aka Aciphex) - the latter is probably a better choice
      Other: refractory——Surgery
    2. PUD/Dyspepsia:
      Symptoms: mid epigastric "burning" or pain. Lead to Gl bleeding
      Empiric Rx: Full dose H2 blocker 4-6 weeks. No improvement or evidence of bleeding — refer for study (endo vs UGI).
    3. Acute Appendicitis:
      Symptoms: midepigastric pain moving to right lower quadrant. Steady/Severe
      Supporting studies: Elevated WBC; Positive imaging study
      Rx: surgical referral
    4. Biliary Disease:
      Symptoms: steady midepigastric or right upper quadrant pain
      Supporting studies: ultrasound and/or iminodacetic acid (HIDA)
      Rx: surgical referral
    5. Inflammatory Bowel:
      Symptoms: abdominal cramping, fever, bloody diarrhea wt loss-chronically
    6. Irritable Bowel Syndrome:
      Symptoms: more chronic than acute. Alternating diarrhea/constipation. No blood in stool.
      Rx: bulk agents (metamucil vs increasing fiber in diet).
    7. Acute Hepatitis: (your population A probably most common)
      Symptoms: malaise, fever, jaundice, nausea, diarrhea.
      Supporting studies: elevated LFTs, bili. Tender liver. Exposure. Positive serology.
      Rx: supportive
    8. Other:
      Pancreatitis, Ovarian cyst rupture.
TABLE 1. Distribution of Abdominal Pathology
Diagnosis>50 years<50 years
Bowel Obstruction15-30%2-6%
Biliary15-30%2-6%
Cancer4-13%1%
Peptic Ulcer5-10%2-8%
Diverticulitis5-10%<1%
Perforation4-6%1%
Appendicitis3-10%15-30%
Hernia3-4%1-2%
Vascular2-3%<1%
Non Specified15-30%40-50%

 

TABLE 2. Localized Patterns of Abdominal Pain of Intestinal Etiology
Epigastric
Reflux esophagitis
Hiatal Hernia
Foreign Body Obstruction/Mass
GasIritis/GU/Duodenal
Lesion of Transverse Colon
Acute Appendicitis
RUQ
DU
Retrocecal, appendicitis
Lesion of right colon
LUQ
Gastric Perforation
Reflux Esophagitis
Hiatal Hernia
Lesion of left colon
Mid Abdomen
Ileus (small bowel)
Colonoic
UC/Crohn's Disease
Mesenteric Ischemia
Infarction
Intussusception
RLQ
Acute Appendicitis
Meckel's Diverticulitis
Colitis
Cecal Ca
Cecal Volvulus
Gastric/Duodenal Perf
Inguinal Hernia
LLQ
Sigmoid diverticulitis
Carcinoma, Left colon
Sigmoid Volvulus
Inguinal Hernia
(Med Clinics of NA 1993;77:940)

 

TABLE 3. Statistically Significant Likelihood Ratios for Abnormal Abdominal Radiographs: From Eisenberg Ann Surg 1983
FindingLikelihood Ratio (LR)
Predictive of abnormality (LR>1):
Increased, High Pitched B Sounds57
Penetrating Trauma38
Distension10
H/O Abd Surgery7
Blood in Urine6
H/O Renal Calc6
Flank Pain/Tenderness5
H/O Abd Tumor5
H/O Gallbladder Disease4
Gen abd pain and tenderness3
Abd pain < 1 day2
Vomiting2
Predictive of Normality:
H/O Ulcer Disease0.3
Mild Abd Pain0.3
Abd pain > 1 week0.5

 

Selected References:

Bedell SE, Fulton EJ. Unexpected findings and complications at autopsy after cardiopulmonary resuscitation. Arch Intern Med 1986;146:1725-1728.
Looked at autopsy findings of 130 patients dying after CPR. 14% of cases there was a major misdiagnosis discovered—the two diseases most frequently undetected clinically were ischemic bowel and PE which together accounted for almost 90% of misdiagnoses.

Brazaitis MP, Dachman AH. The radiologic evaluation of acute abdominal pain of intestinal origin: a clinical approach. Med Clin NA 1993,77:939-961.
An excellent review of selecting radiologic studies in the setting of the acute abdomen. In evaluating the "difficult case ", the abdominal CT is most helpful.

Eisenberg RL et al. Evaluation of plain abdominal radiographs in the diagnosis of abdmoninal pain. Ann Surg 1983; 197:464-468.
Have you eyer wondered what the value of plain films are in the evaluation of abdominal pain? These authors prospectively studied the relation between clinical data and radiographic abnormalities. If abdominal radiographs would have been limited to those patients who had mod to severe abdominal tenderness, or those with high clinical suspicion of bowel obstruction, renal calculi, trauma, ischemia or gallbladder disease regardless of the degree of tenderness, 54% the examinations would not have been done and all radiographic abnormalities would have been identified.

Other References of Interest:

Brewer RJ. Abdommal pain. An analysis of 1000 consecutive cases in a university hospital emergency room. Am. Surgery 1976:131:219-223.

Irvin TT. Abdominal pain: a surgical audit of 1190 emergency admissions. Br J Snrg 1989;76:1121-1125.

Jess P et al. Prognosis of acute nonsoecific abdominal nain. Am J Surg 1982; 144:338-340.