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abdominal pain

Etiology: (also see pelvic pain) 1) intra-abdominal disorders a) inflammatory - appendicitis - pyelonephritis - abscesses - cholecystitis - urinary calculus - pancreatitis - perforated duodenal ulcer - diverticulitis - inflammatory bowel disease - hepatitis - peritonitis b) mechanical - visceral obstruction - aneurysms - trauma c) vascular - mesenteric ischemia - acute mesenteric arterial occlusion - embolus - thrombosis 2) extra-abdominal - pneumonia - myocardial infarction - shingles - sickle cell anemia - diabetic ketoacidosis - depression - anxiety - porphyria - paroxysmal nocturnal hemoglobinuria 3) food poisoning - bacterial toxins - plant toxins - parasites 4) pharmacologic agents - digoxin - theophylline - iron supplements - erythromycin 5) household chemical ingestion 6) occupational & environmental exposure Pathology: 1) abdominal viscera has splanchnic innervation a) only distension or stretch is recognized b) visceral pain is bilateral, felt in midline c) onset of pain is slow d) visceral pain may progress to involve parietal peritoneum 2) parietal peritoneum has somatic innervation a) T6-T12 nerve roots b) localized pain c) parietal pain may be so great as to shadow underlying visceral pain 3) visceral peritoneum has no innervation History: - duration, pattern of progression, location at onset, present location, character of pain (burning, cramping, dull, sharp, constant or intermittent), rate of onset, fever/chills, nausea/ vomiting, hematemesis, temporal relationship of vomiting to abdominal pain, chest pain, constipation, change in bowel habits, obstipation, diarrhea, dysuria, hematuria, hematochezia, melena, anorexia, weight loss, dysphagia, trauma Clinical manifestations: 1) rebound tenderness indicates parietal peritoneum involvement 2) fever & jaundice suggest hepatobiliary involvement 3) cramping suggests relationship to bowel peristalsis 4) objective signs of organic disease a) pain or diarrhea awakening patient from sleep b) vomiting c) dysphagia d) blood in the stool e) weight loss f) fever g) abdominal mass or organomegaly g) anemia h) jaundice 5) abdominal pain out of proportion to physical findings suggests mesenteric ischemia [3] 6) pain scores do not correlated with pathology on abdominal CT [12] Laboratory: 1) complete blood count (CBC) with differential 2) urinalysis 3) serum chemistries a) electrolytes b) urea nitrogen c) creatinine d) glucose e) lipase f) amylase g) bilirubin - conjugated & unconjugated h) transaminases i) albumin j) PT/PTT h) PSA to rule out prostatitis 4) fecal occult blood testing 5) urine pregnancy test Special laboratory: (procedures) 1) abdominal paracentesis 2) GI endoscopy Radiology: 1) flat & upright abdominal radiograph 2) chest radiograph 3) abdominal ultrasound &/or pelvic ultrasound - ultrasound followed by CT only if ultrasound results are nondiagnostic optimizes sensitivity while minimizing radiation exposure [8] 4) early abdominal CT better than plain film [4,6] - oral contrast needed for r/o appendicitis 5) upper &/or lower GI contrast studies Management: 1) general measures a) nothing by mouth until diagnosis is made b) pharmacologic agents - parenteral analgesics - narcotic & non-narcotic - early administration of morphine does not delay diagnosis [5,7,9] - parenteral anti-emetics - prochlorperazine (Compazine) - metoclopramide (Reglan) - H2-blockers c) laparoscopy if indicated d) surgery if indicated 2) specific measures for specific etiologies

Related

abdominal trauma appendicitis pelvic pain

Specific

abdominal migraine acute abdomen chronic abdominal pain colic epigastric pain flank pain left lower quadrant pain left upper quadrant pain right lower quadrant pain right upper quadrant pain

General

sign/symptom pain [odyn-]

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 291-92, 1152-1156
  2. Chan & Winkle, Diagnostic History & Physical Examination, Current Clinical Strategies Publishing. Laguna Hills, 1996
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 19. American College of Physicians, Philadelphia 1998, 2021
  4. Journal Watch 23(5):40, 2003 Ng CS et al, Evaluation of early abdominopelvic computed tomography in patients with acute abdominal pain of unknown cause: prospective randomized study BMJ 325:1387, 2002 PMID: 12480851 http://bmj.com/cgi/content/full/325/7377/1387
  5. Journal Watch 23(5):40, 2003 Thomas SH et al, Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective study J Am Coll Surg 196:18, 2003 PMID: 12517545 http://www.acep.org/library/pdf/cp402130.pdf
  6. MacKersie AB, Lane MJ, Gerhardt RT, Claypool HA, Keenan S, Katz DS, Tucker JE. Nontraumatic acute abdominal pain: unenhanced helical CT compared with three-view acute abdominal series. Radiology. 2005 Oct;237(1):114-22. PMID: 16183928
  7. Green R, Bulloch B, Kabani A, Hancock BJ, Tenenbein M. Early analgesia for children with acute abdominal pain. Pediatrics. 2005 Oct;116(4):978-83. PMID: 16199711 - Armstrong FD. Analgesia for children with acute abdominal pain: a cautious move to improved pain management. Pediatrics. 2005 Oct;116(4):1018-9. No abstract available. PMID: 16199716 - Vane DW. Efficacy and concerns regarding early analgesia in children with acute abdominal pain. Pediatrics. 2005 Oct;116(4):1018. No abstract available. PMID: 16199717
  8. Lameris W et al Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: Diagnostic accuracy study. BMJ 2009 Jun 26; 338:b2431 PMID: 19561056 http://dx.doi.org/10.1136/bmj.b2431 - Dixon AK and Watson CJ Imaging in patients with acute abdominal pain. BMJ 2009 Jun 26; 338:b1678. PMID: 19561055 http://dx.doi.org/10.1136/bmj.b1678)
  9. The NNT: Opiates Given During the Evaluation of Abdominal Pain. http://www.thennt.com/nnt/opiates-during-abdominal-pain-evaluation/ - Ranji SR, Goldman LE, Simel DL, Shojania KG Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA. 2006 Oct 11;296(14):1764-74. PMID: 17032990
  10. Nayor J, Vaidya A, Srivastava A, Seifter JL, Rutherford AE. INTERACTIVE MEDICAL CASE. Tracing the Cause of Abdominal Pain. N Engl J Med 2016; 375:e8. August 11, 2016 PMID: 27509123 http://www.nejm.org/doi/full/10.1056/NEJMimc1512611
  11. Schifeling CH, Williams DA. Appropriate Use of Imaging for Acute Abdominal Pain JAMA Intern Med. Published online November 6, 2017 PMID: 29114737 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2661707
  12. Zitek T, Pellman L, Uribe J, Guillen A. Pain scores are not predictive of radiographically evident intraabdominal pathology in patients with abdominal pain. Acad Emerg Med 2019 Jul 31; PMID: 31365769 https://onlinelibrary.wiley.com/doi/abs/10.1111/acem.13841

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