Kathy R. Reese and Cheryl A. Glass

Definition

A.Abdominal pain is a common and frequently nonspecific complaint. The responsibility is for clinicians to determine if patients can be safely observed and treated symptomatically or if they require further investigation or a specialist referral. Pain in the abdomen is secondary to problems relating to abdominal organs, and it is categorized as follows:

1.Acute pain: Pain of less than a few days that has worsened progressively until presentation.

2.Chronic pain: Pain lasting greater than 12 weeks and remaining unchanged over a period of months to years. Recurrent abdominal pain is also included in this category.

3.Subacute pain: Pain lasting from a few days to several weeks.

4.Emergent pain: Pain that lasts 3 hours or longer, accompanied by a fever or vomiting.

B.Pain may be categorized by the following descriptions:

1.Visceral pain is usually dull and aching in character.

2.Parietal pain is sharp and well localized.

3.Referred pain is aching and perceived to be near the surface of the body.

Incidence

A.Abdominal pain is very common and is present in 75% of adolescent students and in about 50% of all adults with significant variance noted among research studies. Gastroenteritis and irritable bowel syndrome (IBS) are the most common causes of acute pain, and chronic stool retention is the most common cause of chronic pain. Other causes of abdominal pain include the following:

1.Acute appendicitis: Occurs 233:100,000.

2.Acute cholecystitis: Varies according to age, gender, and ethnic origin.

3.Intestinal obstruction, usually small intestines: Accounts for 20% of acute abdominal conditions.

4.Abdominal pain associated with pregnancy: Ectopic pregnancy (6–20:1,000 pregnancies), miscarriage, and abruptio placentae.

Pathogenesis

A.Pathogenesis depends on the origin of pain. Pain may result from inflammation, ischemia, distension, altered motility, obstruction, or ulceration.

Predisposing Factors

A.Abdominal trauma.

B.Motor vehicle accidents with trauma such as ruptured spleen.

C.Dietary intolerances.

D.Pregnancy.

E.Torsion.

F.Psychogenic pain.

G.Sickle cell disease.

H.Infection.

I.Diabetes.

J.Vascular disease.

K.Congenital or acquired abdominal abnormalities.

Common Complaints

Clinical presentation of abdominal pain is dethgermined in part by the site of the involvement:

A.Acute or chronic onset of pain.

B.Vomiting.

C.Diarrhea.

Other Signs and Symptoms

A.Referred shoulder pain.

B.Fever.

C.Nausea and/or projectile vomiting.

D.Rigid abdomen.

E.Abdominal distension.

F.Constipation or diarrhea.

G.Guarding.

H.Rebound tenderness.

I.Biliary pain and right subcostal tenderness.

J.Anorexia.

K.Periumbilical discomfort; consider appendicitis if, within 2 to 12 hours, pain localizes in right lower quadrant (RLQ) at McBurney’s point.

L.Dysuria.

M.Abdominal mass; do not overlook the possibility of pregnancy as the cause of a mass.

N.Melena (most common in peptic ulcer disease [PUD]).

O.Tachycardia.

Subjective Data

Evaluate for a surgical abdomen, defined as a rapidly worsening prognosis in the absence of surgical intervention. Patients should not eat or drink while a diagnosis of a surgical abdomen remains under consideration. Once a surgical abdomen has been excluded, the remainder of the evaluation will be guided by the chronicity of symptoms along with the location of pain.

A.Review onset, duration, course, and quality of pain:

1.When did the pain start?

2.What were you doing when the pain started?

3.Has this ever occurred before?

4.What was the primary diagnosis?

5.What was the previous treatment, and was it effective?

6.Is there anyone else having the same symptoms in your home?

7.Review the progression of pain.

B.Determine pain rating on a 10-point scale, with 0 being no pain and 10 being equivalent to the worst pain the patient has ever felt.

C.Qualify the duration of pain in minutes, hours, days, weeks, or months. Does the pain interfere with sleep?

D.Review the pattern of pain:

1.Review aggravating factors.

2.Review alleviating factors.

3.Does the pain radiate?

4.Does the pain have any relationship to food intake?

E.Questions specific to females:

1.Determine the patient’s last missed period (LMP).

2.Has she had a hysterectomy or tubal ligation?

3.Does she have a recent history of dyspareunia or dysmenorrhea that suggests pelvic pathology?

4.Is there any history of physical abuse?

5.What type of contraception is used? Specifically evaluate for an intrauterine device (IUD).

F.Review the patient’s current medications and drug history, especially antibiotic, laxative, acetaminophen, aspirin, and nonsteroidal anti-inflammatory drug (NSAID) use. Patients taking corticosteroids may have a significant masking of pain.

G.Rule out abdominal trauma from domestic violence, motor vehicle accidents, falls, or assaults.

H.Review bowel habits and note changes: constipation, diarrhea, anorexia, food intolerance, nausea, vomiting, or bloating.

I.Review the patient’s history for sickle cell disease. Any individual of African American or Mediterranean descent presenting with leg or abdominal pain should be questioned regarding sickle cell disease or trait.

J.Review urinary function. Is there any urinary frequency, urgency, dysuria, flank pain, or back pain? If the patient is male, does he have any hesitancy, difficulty starting the urine stream, nocturia, low urinary volume, or any lower abdominal distension indicating urinary retention?

K.Review alcohol intake/history.

L.Has the patient had any unexplained weight loss?

M.Evaluate sexual activity to rule out potential sexually transmitted infection (STI):

1.Evaluate if patients have new partners.

2.Are their partners experiencing any symptoms?

Physical Examination

A.Check temperature, pulse, respirations, and blood pressure (BP); include orthostatic BP.

Tachycardia or hypotension may be signs of a ruptured aortic aneurysm, septic shock, gastrointestinal (GI) hemorrhage, ectopic pregnancy, or volume depletion. Absence of a fever in the elderly or immunosuppressed does not exclude a serious illness.

B.Inspect:

1.Observe general appearance: Facial expressions, walk, skin turgor; refusal to move/writhing, note grimace during exam.

2.Perform eye and mouth exam to rule out iritis and aphthous ulcers of the mouth (extraintestinal manifestations of inflammatory bowel disease [IBD]).

3.Examine the abdomen for the presence of a hernia at the umbilicus, groin, or near the site of prior surgical incisions.

4.Examine the abdomen for overt masses or pulsations.

5.Examine the eyes and skin for jaundice.

6.Observe for any bruising or other signs of domestic violence in the bathing suit areas: breasts, abdomen, back that would be easily covered with clothes.

C.Auscultate:

1.Auscultate for bowel sounds in all four quadrants of the abdomen.

2.Evaluate heart and lungs.

3.Check for bruits of aorta, iliac, and renal bruits.

D.Percuss abdomen for tympanic and dullness sounds.

E.Palpate:

1.Palpate abdomen for masses, rebound tenderness, and peritoneal signs:

a.Before palpating the abdomen, ask the patient to bend the knees and place hands at sides to help with relaxation of the wall musculature.

b.Elderly patients may lack classical peritoneal signs of rebound and guarding.

2.Check the abdomen for tender pulsatile mass at midline; it may indicate abdominal aortic aneurysm (AAA).

3.Palpate back; check for cerebrovascular accident (CVA) tenderness.

4.Perform a bimanual examination in women regardless of whether the patient has had a hysterectomy or is postmenopausal:

a.Evaluate the size and symmetry of the uterus.

b.Evaluate the adnexal areas for presence of appropriately sized, mobile ovaries. A fixed, painful adnexal mass is suggestive of an endometrioma or tuboovarian abscess.

c.Endometriosis is suggested by localized tenderness in the cul-de-sac or uterosacral ligaments, palpable tender nodules, pain with uterine movement, or tender fixation of adnexal or uterus in a retroverted position.

5.Check for obturator sign, or abdominal pain in response to passive internal rotation of the right hip from 90-degree angle hip–knee flexion position. A positive sign indicated pain secondary to irritation of obturator muscle with inflamed appendix.

6.Assess psoas sign or increased abdominal pain occurring when the patient attempts to raise his or her right thigh against the pressure of your hand placed over his or her right knee. Pain is caused by inflammation of the psoas muscle in acute appendicitis.

F.Perform a rectal exam, including testing of stool for occult blood. Failure to perform a rectal examination in patients with abdominal pain may be associated with an increased rate of misdiagnosis and should be considered a medicolegal pitfall.

Diagnostic Tests

A.In all women of childbearing age, assume the woman is pregnant until proven otherwise. Vaginal bleeding with or without abdominal pain should prompt a transvaginal ultrasound and a serum human chorionic gonadotropin (HCG).

B.Complete blood count (CBC) with differential.

C.Comprehensive metabolic profile (CMP).

D.Amylase.

E.Lipase.

F.Urinalysis; consider culture.

G.Stool guaiac or fecal immunoassay test for occult blood.

H.Plain x-ray abdomen.

I.CT abdomen/pelvis.

J.Abdominal ultrasonography.

K.Helicobacter pylori fecal antigen.

L.Coproporphyrin, if lead poisoning is suspected.

M.Chest x-ray.

N.GI series radiography.

O.Endoscopy.

P.Sigmoidoscopy.

Q.Barium enema (BE): Avoid with suspected obstruction.

R.Consider endoscopic retrograde cholangiopancreatography (ERCP) to visualize the distal CBD.

S.ECG to rule out cardiac pain.

T.Consider blood cultures for elderly that present with abdominal pain associated with either fever or hypothermia or when sepsis is suspected.

Differential Diagnoses

Location and duration of abdominal pain can often help significantly in narrowing the differential diagnosis.

A.Right upper quadrant (RUQ) pain:

1.Acute cholecystitis and biliary colic:

a.Biliary tract: Increased serum amylase

b.Ascending cholangitis: Fever and jaundice in a patient with RUQ pain.

c.Acute cholecystitis: Maximal pain in the RUQ or epigastrium, radiating to the scapular region, accompanied by nausea, vomiting, and fever without jaundice. Murphy’s sign, or inspiratory arrest in response to upper quadrant palpation, may be seen with acute cholecystitis. RUQ tenderness to percussion or pressure of the gallbladder is also a suggestive finding.

d.Ketoacidosis: Presents with severe abdominal pain in 8% of instances and may be accompanied by emesis and an elevated white cell count. Acute intraabdominal events such as cholecystitis may be the precipitant of ketoacidosis.

2.Acute hepatitis.

B.RLQ pain:

1.Appendicitis: Often begins with symptoms of dull, steady, periumbilical pain and anorexia before localizing to the RLQ at McBurney’s point.

2.Regional enteritis.

3.Leaking aneurysm.

4.Ruptured ectopic pregnancy.

5.Twisted ovarian cyst.

6.Pelvic inflammatory disease (PID).

7.Ureteral calculi.

8.Incarcerated, strangulated inguinal hernia.

9.Endometriosis.

10.Meckel’s diverticulitis.

11.Abdominal wall hematoma.

C.Left upper quadrant (LUQ) pain:

1.Gastritis.

2.Acute pancreatitis: Epigastric pain that is relatively sudden, boring to the back, and associated with nausea, vomiting, and anorexia.

3.Splenic enlargement, rupture, infarction, aneurysm.

4.Myocardial ischemia.

5.Left lower lobe pneumonia.

6.Renal colic: Radiates to the groin.

D.Left lower quadrant (LLQ) pain:

1.Sigmoid diverticulitis.

2.Regional enteritis.

3.Leaking aneurysm.

AAA may present with a tender pulsatile mass at the abdominal midline. Vascular disorders such as acute arterial insufficiency, due to atherosclerosis or embolus, may present with severe abdominal pain, although mild, constant pain may be the only symptom for several days. Dissection or rupture of an AAA produces severe acute abdominal pain and often radiates to the back or genitalia.

4.Ruptured ectopic pregnancy.

Rupture of the fallopian tube generally causes sudden, acute, and localized abdominal pain. Internal hemorrhage causes syncope and referred shoulder pain, caused by phrenic nerve irritation. Diagnosis before tubal rupture may be difficult because symptoms and physical findings mimic other conditions such as appendicitis.

5.Twisted ovarian cyst.

6.PID.

7.Ureteral calculi.

8.Incarcerated, strangulated inguinal hernia.

E.Generalized abdominal pain:

1.Trauma:

a.Any person with a possible blow to the abdomen should have orthostatic BP taken, careful palpation of the abdomen, serial abdominal circumferences measured, and be considered for abdominal imaging. Serial hemoglobin (Hgb) and hematocrit (Hct) measurements should be obtained, if necessary.

b.In abdominal trauma, the spleen is the most commonly injured organ, especially in blunt abdominal trauma; the onset can be immediate or delayed.

c.Nontraumatic splenic rupture is often associated with acute infectious mononucleosis.

2.Intestinal obstruction: Obstruction that develops slowly over weeks to months may be relatively subtle in presentation.

Acute obstruction presents with severe colicky pain or pain that is wavelike in nature; it makes the pain relentless.

3.Peritoneal irritation: Severe pain due to the rich innervation of the parietal peritoneum. Focal injury results in well-localized discomfort that is described as a sharp aching or burning.

4.Metabolic disturbances may mimic intra-abdominal etiologies.

Porphyria and lead poisoning sometimes simulate bowel obstruction because they can cause cramping, abdominal pain, and hyperperistalsis.

5.Nonspecific dysfunctional abdominal pain and psychogenic abdominal pain are diagnoses of exclusion.

Plan

A.General interventions:

1.If necessary, prepare the patient for emergency transport and hospitalization.

2.Management and follow-up of other causes of abdominal pain are variable and depend on diagnosis.

B. See Section III: Patient Teaching Guide Abdominal Pain:

1.Counsel the patient with chronic or recurrent abdominal pain to keep a pain diary that includes activity, foods, and other pain triggers; duration of pain; and what provides relief of symptoms.

C.Pharmaceutical therapy: Treatment depends on the findings from the history, physical, and testing, as well as the clinical diagnosis.

Follow-Up

A.Variable, depending on diagnosis.

B.Review pain diary.

Consultation/Referral

A.Consult the physician for the patient with acute abdominal pain and pain related to abdominal trauma.

B.For the obstetric patient, consult a physician for any bleeding or abdominal pain.

Individual Considerations

A.Pregnancy: There is no evidence that acute intraabdominal surgical emergencies are more common during pregnancy if ectopic pregnancy is excluded:

1.The presence of peritoneal signs, rebound tenderness, and abdominal guarding is never normal in pregnancy.

2.Bleeding complications include the following:

a.First trimester: Miscarriage and ectopic pregnancy.

b.Second and third trimester: Abruptio placentae.

3.Physiologic changes of pregnancy may affect the presentation and evaluation of abdominal pain. The enlargement of the uterus can impede physical examination, affect the normal location of pelvic and abdominal organs, and mask or delay peritoneal signs. (Refer to section Appendicitis in this chapter.)

4.Severe preeclampsia: The clinical manifestations of liver involvement include RUQ or midepigastric pain, elevated transaminases, and, in severe cases, subcapsular hemorrhage or hepatic rupture.

B.Adults:

1.Obesity distorts the abdominal exam, making organ palpation or pelvic examination difficult.

2.With men older than age 40 and women older than age 50, suspect cardiac origin when presenting with epigastric pain. Consider obtaining ECG for this age group.

Although myocardial infarction (MI) classically presents with anterior chest pressure or pain, the patient may also have a gastritis or heartburn sensation, coupled with nausea and diaphoresis.

C.Geriatrics:

1.Delirium is a common early sign of acute illness or infection in the elderly. It is more common in patients with existing cognitive impairment. At a minimum, patients and family should be asked if the patient has experienced episodes of altered mental status:

a.The Brief Confusion Assessment Method (bCAM) is a well-documented assessment for delirium. The bCAM is available at www.mnhospitals.org/Portals/0/Documents/ptsafety/LEAPT%20Delirium/Help%20Program%20CAM%20Flowsheet.pdf.

2.Elderly patients may have a vague or atypical presentation of pain, including fatigue and chest pain, varying in location, severity, and presence of a fever or nonspecific findings on examination:

a.Classic findings of acute peritonitis, rebound tenderness, and local rigidity occur less in the elderly.

3.Elderly patients may have a vague or atypical presentation of pain, including fatigue and chest pain, varying in location and severity, with possible presence of a fever or nonspecific findings on examination:

a.For dementia or noncommunicative patients, the American Medical Directors Association has endorsed the Pain Assessment in Advanced Dementia (PAINAD) Scale, which scores the following items:

i.Breathing: Examples include normal, labored, hyperventilation.

ii.Negative vocalization: Examples include moaning, negative language, crying.

iii.Facial expression: Examples include smiling, frowning, grimacing.

iv.Body language: Examples include relaxed, tense, rigid, or striking out.

v.Consolability: Examples include extent to which a caregiver is able to console, distract, or reassure.

4.In an older patient, a similar presentation to IBD with abdominal pain and a change in bowel habits can be the first sign of colon cancer.

5.AAA is observed almost exclusively in elderly patients. Risk increases with each decade after 65:

a.Approximately 5% to 10% of men 65 years and older have an AAA.

b.Maintain a high index of suspension in patients who present with a clinical picture suggestive of renal colic or musculoskeletal back pain.

6.Elderly patients with urinary tract infection (UTI) are less likely to have dysuria, frequency, or urgency.

7.Patients older than 65 years have a 30% to 50% risk of gallstones and may not present with significant pain; less than half have fever, vomiting, or leukocytosis.

8.Fever, an elevated white blood cell (WBC) count occurs in less than half of the elderly patients with diverticulitis. Only about 25% of the elderly with diverticulitis present with a guaiac positive stool.

9.The incidence of PUD is more common in the elderly due to the availability and use of NSAIDs. The most common presenting symptom with PUD in the elderly is melena.

10.Although the elderly may state they are having loose liquid stool, evaluate for fecal impaction. Diarrhea rather than constipation is sometimes the only complaint because of the collection of liquid stool distending the proximal colon and passing around the obstructing bolus.

11.MI and pneumonia also commonly present as vague abdominal complaints in the elderly.

12.Weight loss/appetite suppression:—Weight loss is a predictor of mortality. Clinically significant weight loss is considered to be 5% loss of usual body weight in 3 months or 10% in 6 months. Dehydration is more common in the elderly. Signs of dehydration include confusion, muscle weakness, fever, dizziness, poor skin turgor, hypotension, and tachycardia:

a.Monitor weight patterns/body mass index (BMI). (Caution: BMI is not used to identify loss of muscle mass.)

b.Monitor both serum albumin and anemia: Hypoalbuminemia and anemia is not necessarily associated with low bodyweight. It can be caused by decreases in liver protein synthesis:

i.Serum albumin concentration is commonly recommended.

ii.Hgb, prealbumin, and transferrin.

iii.Cholesterol.

13.Depression: Anxiety and depression are common in IBD and are factors that lead to decreased health-related quality of life. A depression screen should be done at each office visit:

a.An online Patient Health Questionnaire-9 (PHQ-9) is available at www.mdcalc.com/phq-9-patient-health-questionnaire-9.

b.The Geriatric Depression Scale, short form, a 15-item questionnaire that can be quickly applied in the clinical setting is available at web.stanford.edu/~yesavage/GDS.english.short.html.

14.Because of polypharmacy a full review of medications, herbals, and over-the-counter (OTC) drugs should be undertaken to identify medications that should be avoided in the geriatric population, duplicate medications, and medications that are able to be to be decreased or deprescribed.

Resource

Rome Foundation: https://theromefoundation.org.

SOAP. – Abdominal Pain