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Evaluation of Acute Abdominal Pain Reviewed

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Penny Murata, MD
  • CME/CE Released: 4/18/2008
  • Valid for credit through: 4/18/2009
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Target Audience and Goal Statement

This article is intended for primary care clinicians, emergency medicine specialists, and other specialists who provide care to adults with acute abdominal pain.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Identify key components of the history and physical examination in the evaluation of acute abdominal pain in adults.
  2. Report recommendations for studies in the evaluation of acute abdominal pain in adults.


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  • Laurie Barclay, MD

    Laurie Barclay, MD, is a freelance reviewer and writer for Medscape.


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.


  • Brande Nicole Martin

    Brande Nicole Martin is the News CME editor for Medscape Medical News.


    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

CME Author(s)

  • Penny Murata, MD

    Freelancer for Medscape


    Disclosure: Penny Murata, MD, has disclosed no relevant financial relationships.

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Evaluation of Acute Abdominal Pain Reviewed

Authors: News Author: Laurie Barclay, MD CME Author: Penny Murata, MDFaculty and Disclosures

CME/CE Released: 4/18/2008

Valid for credit through: 4/18/2009


April 18, 2008 — Guidelines for the evaluation of acute abdominal pain in adult patients presenting to primary care are reviewed in the April 1 issue of the American Family Physician. This review mandates a thorough and logical approach to the diagnosis of abdominal pain in this setting.

"Abdominal pain is a common presentation in the outpatient setting and is challenging to diagnose," write Sarah L. Cartwright, MD, and Mark P. Knudson, MD, MSPH, from the Wake Forest University School of Medicine in Winston-Salem, North Carolina. "Abdominal pain is the presenting complaint in 1.5 percent of office-based visits and in 5 percent of emergency department visits. Although most abdominal pain is benign, as many as 10 percent of patients in the emergency department setting and a lesser percentage in the outpatient setting have a severe or life-threatening cause or require surgery."

Acute abdominal pain may be caused by a variety of conditions ranging from benign and self-limited disease to surgical emergencies. An optimal approach to diagnose the basis for abdominal pain should rely on the likelihood of disease, complaints, and other features of patient history, findings on physical examination, laboratory tests, and imaging studies.

The location of abdominal pain is a useful starting point that should guide further workup; for example, right lower quadrant pain strongly suggests appendicitis. Although certain findings on history taking and physical examination are helpful, others are of limited value. For example, constipation and abdominal distension are strong indicators of bowel obstruction, but anorexia is of low diagnostic value for appendicitis.

In patients with abdominal pain, symptoms that suggest surgical or emergent conditions include fever, protracted vomiting, syncope or presyncope, and evidence of gastrointestinal tract blood loss.

Special populations may also be at risk for certain conditions causing abdominal pain, and these should be sought after in these subgroups. For example, women are at risk for genitourinary tract disease, and the elderly population may present with atypical symptoms of a disease.

Based on the location of abdominal pain, different imaging studies are recommended by the American College of Radiology as part of the diagnostic workup. Ultrasonography is preferred for evaluation of right upper quadrant pain and suprapubic pain vs computed tomography (CT) for right and left lower quadrant pain. CT with intravenous contrast media is recommended for workup of right lower quadrant pain, and CT with oral and intravenous contrast media is preferred for left lower quadrant pain.

In addition to considering location of abdominal pain, categorizing causes of abdominal pain by organ system and then by specific cause may also be helpful in differential diagnosis. Biliary causes of right upper quadrant pain include cholecystitis, cholelithiasis, and cholangitis; colonic causes are colitis or diverticulitis; and hepatic causes are abscess, hepatitis, or mass. Pulmonary causes are pneumonia or embolus, and renal causes are nephrolithiasis or pyelonephritis.

For epigastric pain, biliary causes are cholecystitis, cholelithiasis, and cholangitis. Cardiac causes are myocardial infarction or pericarditis; gastric causes include esophagitis, gastritis, and peptic ulcer; and early appendicitis may be a colonic cause. Pancreatic causes are mass or pancreatitis, whereas vascular causes are aortic dissection or mesenteric ischemia.

For left upper quadrant pain, cardiac, gastric, pancreatic, renal, and vascular causes are similar to those listed in the previous 2 paragraphs. Periumbilical sources of pain may be early appendicitis, vascular causes may be aortic dissection or mesenteric ischemia, or gastric causes may include small-bowel mass or obstruction in addition to those listed in the previous paragraph.

In the right or lower quadrant or suprapubic region, renal and colonic causes are as listed previously. Additional colonic sources are inflammatory bowel disease (IBD) or irritable bowel syndrome, and gynecologic sources of pain are ectopic pregnancy, fibroids, ovarian mass, torsion, or pelvic inflammatory disease.

In any location, pain originating from the abdominal wall may include herpes zoster, muscle strain, or hernia. Bowel obstruction, mesenteric ischemia, peritonitis, narcotic withdrawal, sickle cell crisis, porphyria, IBD, or heavy metal poisoning may cause diffuse or nonspecifically localized abdominal pain.

"When possible, the history should be obtained from a nonsedated patient," the study authors write. "The initial differential diagnosis can be determined by a delineation of the pain's location, radiation, and movement (e.g., appendicitis-associated pain usually moves from the periumbilical area to the right lower quadrant of the abdomen). After the location is identified, the physician should obtain general information about onset, duration, severity, and quality of pain and about exacerbating and remitting factors."

Specific clinical recommendations for practice, all of level of evidence rating C, are as follows:

  • Appendicitis cannot be ruled out by a normal white blood cell count.
  • In patients with epigastric pain, simultaneous amylase and lipase measurements are recommended.
  • For evaluation of patients with acute right upper quadrant abdominal pain, ultrasonography is the imaging study of choice.
  • For evaluating patients with acute right lower quadrant or left lower quadrant abdominal pain, CT is the imaging study of choice.

"Presentation may differ in older patients, and poor patient recall or a reduction in symptom severity may cause misdiagnosis," the reviewers conclude. "There are several diseases that should be considered in all older patients with abdominal pain because of the increased incidence and high risk of morbidity and mortality in these patients. Occult urinary tract infection, perforated viscus, and ischemic bowel disease are potentially fatal conditions commonly missed or diagnosed late in older patients."

The study authors have disclosed no relevant financial relationships.

Am Fam Physician. 2008;77:971-978.

Clinical Context

Up to 10% of patients in the emergency department for abdominal pain have a serious condition, according to Kamin and colleagues in the February 2003 issue of Emergency Medicine Clinics of North America. The differential diagnosis of abdominal pain is extensive and requires a logical evaluation.

This study provides guidelines for the evaluation of acute abdominal pain in adults, including history and physical examination, diagnostic testing, and special patient populations.

Study Highlights

  • Evaluation of acute abdominal pain depends on the location of pain: right upper quadrant, left upper quadrant, right lower quadrant, left lower quadrant, epigastric, periumbilical, or suprapubic.
  • Initial evaluation requires elimination of serious conditions.
  • Symptoms that might indicate surgical or emergency conditions include fever, persistent emesis, syncope or presyncope, and gastrointestinal tract blood loss.
  • Key components of history are location, radiation, and movement of pain as well as onset, duration, severity, quality, and exacerbating and remitting factors.
  • Most useful findings are right lower quadrant pain in appendicitis (likelihood ratio [LR], 8.4), constipation in bowel obstruction (LR, 8.8), and Murphy's sign in cholecystitis (LR, 5.0).
  • Physical examination:
    • Lack of movement with peritonitis vs inability to stay still with renal colic
    • Fever is consistent with infection but lack of fever does not exclude infection
    • Tachycardia and orthostatic hypotension
    • Pneumonia or cardiac ischemia can cause upper abdominal pain
    • Carnett's sign predicts abdominal wall pain
    • Murphy's sign is present in 65% of adults with cholecystitis
    • Psoas sign predicts appendicitis (LR, 3.2)
    • Rectal examination can detect fecal impaction, mass, occult blood in stool, and retrocecal appendix
    • Pelvic examination can detect vaginal discharge, cervical motion tenderness, and peritoneal signs
  • Recommended laboratory tests:
    • Compete blood count for possible infection or blood loss; white blood cell count more than 10,000/mm3 is 77% sensitive and 63% specific for appendicitis (LR, 2.1)
    • Amylase and lipase levels for epigastric pain
    • Liver chemistries for right upper quadrant pain
    • Urinalysis if hematuria, dysuria, or flank pain
    • Urine pregnancy test in female patients of childbearing age
    • Chlamydia and gonorrhea testing for female patients at risk for sexually transmitted infections
  • Imaging studies are based on location:
    • Right upper quadrant: ultrasonography might not detect acute cholecystitis as well as radionuclide imaging, but is less expensive, faster, and can evaluate beyond the biliary tract
    • Right lower quadrant: CT with intravenous contrast, abdominal or transvaginal ultrasonography for pregnant patients
    • Left lower quadrant: CT with oral and intravenous contrast and abdominal or transvaginal ultrasonography for female patients of childbearing age
    • Left upper quadrant imaging is variable but includes endoscopy or upper gastrointestinal tract series to assess esophageal or gastric conditions or CT
    • Suprapubic: ultrasonography
  • Plain radiographs can detect the following:
    • Free air under the diaphragm indicating gastrointestinal tract perforation
    • Calcifications: 10% of gallstones, 90% of kidney stones, and appendicolith in 5% of appendicitis cases
    • Dilated bowel loops and air-fluid levels indicating ileus or obstruction
  • Transvaginal ultrasonography has 95% sensitivity for detecting ectopic pregnancy if human chorionic gonadotropin level is more than 25 mIU/mL.
  • In women, the differential diagnosis includes ovarian cysts, uterine fibroids, tubo-ovarian abscesses, endometriosis, pregnancy, loss of pregnancy, and ectopic pregnancy.
  • Older patients might present with atypical symptoms or poor recall.
  • Diagnoses more common or often missed in older patients include diverticulitis, sepsis from urinary tract infection, occult urinary tract infection, perforated viscus, and ischemic bowel disease.

Pearls for Practice

  • The initial evaluation of acute abdominal pain in adults depends on the location; symptoms consistent with severe or surgical conditions include fever, persistent emesis, syncope, and gastrointestinal tract bleeding.
  • Recommended imaging studies for adults with acute abdominal pain include ultrasonography for right upper quadrant pain and CT for right or left lower quadrant pain.


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