Acute Abdominal Pain
Mahsima Shabani
General Approach
- Rule out life threatening causes:
- Obstruction, volvulus, peritonitis, perforation, acute mesenteric ischemia, aortic dissection or AAA rupture, acute MI, ectopic pregnancy,
- History: pain location/radiation/quality/severity/timing, prior episodes, aggravating and alleviating factors (eating, bowel movements, position), nausea/emesis, changes in urine/stool, gas, constitutional symptoms, LMP, sexual history, Alcohol, NSAID and antibiotic use.
- Initial work-up: CBC, BMP, POC Gluc, LFTs, INR, lactate, lipase, U/A, urine hCG, abdominal US
System |
Causes |
Common features |
Workup |
|---|---|---|---|
| Esophagus |
Esophagitis - GERD, EOE, candida, HSV, CMV, pill, functional |
Epigastric pain, nocturnal reflux, odynophagia, dysphagia, thrush, immunocompromised |
Trial PPI, nystatin swish and swallow, consider EGD |
|
Intra-abdominal esophageal rupture |
Upper abdominal pain; recent trauma, endoscopic intervention, severe straining or vomiting (Boerhaave syndrome) |
CXR (free peritoneal air), CT chest and abdomen |
|
| Stomach |
Peptic ulcer disease |
Epigastric pain, better or worse w/ food, ± melena; NSAID use, steroid use |
CBC, EGD, H. pylori testing |
|
Gastritis |
Burning epigastric pain/discomfort, heartburn, N/V, hematemesis, bloating and fullness after meals; NSAID, ETOH abuse |
H. pylori testing, Trial PPI, ± EGD |
|
|
Gastroparesis |
N/V, early satiety, post-prandial fullness, bloating; hx of DM, dysautonomia, abdominal surgery |
Scintigraphy after excluding mechanical obstruction or mucosal disease |
|
| Liver | Hepatitis: Ischemic, Viral, ETOH, trauma, toxins, autoimmune, congestive | RUQ pain, malaise, N/V, anorexia ± jaundice, dark urine, light stools; hx of EtOH, herbal supplement, Tylenol, or IVD use | LFTs, LDH, Alb, INR, ETOH, Tylenol lvl, viral panel, RUQ U/S + dopplers; CT |
| Perihepatitis (Fitz-Hugh-Curtis syndrome) | RUQ pain and tenderness with pleuritic component, referred pain to the right shoulder; ALT/AST usually normal | Bimanual exam, beta-hCG, NAAT for Chlamydia and Gonorrhea, HIV, pelvic US | |
| Liver abscess | Fever with RUQ pain; history of DM, hepatobiliary or pancreatic disease, liver transplant, chronic PPI use | US, CT abdomen, BCx, empiric Abx, US/CT-guided drainage | |
| Budd-Chiari syndrome | Fever, abdominal, ascites, jaundice, GIB, +/- HE; hx of thrombophilia, OCP use, systemic AI disease | Doppler US of liver | |
| Malignancy, HCC, mets | Upper abdominal pain, weight loss, early satiety | Abdominal US, AFP, CT Abdomen(triple phase) | |
| Spleen | Splenomegaly | LUQ pain, +/- left shoulder pain, early satiety | LFT, CBC, smear, CT abdomen |
| Splenic infarct | Severe LUQ pain; hx of hypercoag state, AFib, splenomegaly | ECG for AFib, coags, splenomegaly w/u | |
| abscess | Fever and LUQ tenderness | CT, BCx, broadspectrum Abx, drainage | |
| Splenic rupture | Left shoulder pain worse with inspiration; hx of trauma | CT, surgery | |
| Portal vein thrombus | Abdominal pain, dyspepsia, or GIB; history of cirrhosis | Doppler US, CT abdomen, AC | |
| Biliary | Biliary colic | RUQ or epigastric discomfort +/- N/V, lasts >30mins, worse with food, abdominal exam usually benign, overweight, ♀, 40’s | LFTs, RUQ US |
| Cholecystitis | Prolonged >4hrs RUQ or epigastric pain, guarding, Murphy’s sign, nausea, emesis with fever | LFTs, RUQ US, HIDA scan | |
| Choledocholithiasis/ cholangitis | RUQ pain, N/V with jaundice, fever, +/- hypotension, AMS | CBC, LFTs, RUQ U/S, BCx | |
| Sphincter of Oddi dysfunction | Biliary type pain without other apparent causes with abnormal LFTs (obstructive pattern) during the episode of pain | LFTs, RUQ US | |
| Pancreas | Acute or chronic pancreatitis | Persistent epigastric pain radiating to back, N/V, hx of ETOH use or gallstones, family hx; hx of similar pain weeks prior suggests complications. | Lipase, CT A/P (rarely necessary within 24-48 hrs), RUQ US for gallstones |
| Intestines | Gastroenteritis | Diarrhea with N/V, abdominal pain; sick contact, undercooked food, travel | Supportive care |
| Diverticulitis | Older, h/o diverticulosis, LLQ pain (RLQ common in Asian pts) usually constant and lasted several days +/- N/V, fever based on complications | CBC, CT A/P w contrast | |
| SBP | Fever, abdominal pain and/or AMS; advanced liver disease and ascites | Diagnostic paracentesis | |
| Constipation | Hx of IBS, narcotic use, Zofran use, unable to pass stool, straining | KUB | |
| Bowel Obstruction/Ileus | Prior hernia, abd surgery or malignancy, crampy abdominal pain, N/V, obstipation, distended tympanic abdomen with absent bowel sounds. | KUB (air fluid levels), CT is more sensitive. If concerned, page EGS and consider NGT to suction | |
| GI perforation | Severe abdominal pain, following procedures; can present indolent in immunosuppressed patients | Upright or lateral decubitus KUB/CXR, EGS consult | |
| Acute mesenteric ischemia | Rapid onset, severe, diffuse pain (pain out-of-proportion to exam) with N/V, can follow a recent hypotensive episode; hx of vascular (arterial or venous) disease, AFib, dissection, thrombosis | CBC (leukocytosis), BMP (metabolic acidosis), lactate, CT A/P w contrast (CTA if high suspicion) | |
| Chronic mesenteric ischemia | Post-prandial (intestinal angina) pain with weight loss, N/V, diarrhea | Abdominal CTA or mesenteric doppler ultrasound | |
| Peritoneal Dialysis-related peritonitis | Diffuse abdominal pain and cloudy peritoneal effluent with fever, N/V, abdominal tenderness | KUB, CT abdomen, nephron consult, may require EGS | |
| Celiac disease | Diffuse abdominal pain with steatorrhea, flatulence. | Ttg-IgA, total IgA, DGP IgG, EGD with duodenal biopsies | |
| Colonic nonocclusive mesenteric ischemia | Cramping pain, laterally (most often left), urge to defecate + hematochezia | CBC, BMP, Lactate, CT A/P w contrast +/- colonoscopy | |
| Appendicitis | Periumbilical to RLQ (occasionally epigastric or generalized) with anorexia, N/V, later fever | CBC, CRP, lactate, beta-HCG in women, CT A/P w/contrast | |
| IBD | Diarrhea (can be bloody), urgency, tenesmus, bowel incontinence, weight loss, fevers. Associated extraintestinal manifestations (arthritis, uveitis, pyoderma) | CBC, lactate, ESR, CRP, C-diff, GIPP, stool O&P if recent travel history. CT enterography. | |
| Infectious colitis including C. diff colitis | ABx exposure, diarrhea, abdominal cramping; can present with acute peritoneal signs with perforation and fulminant colitis | C-diff PCR, CBC, KUB (megacolon) | |
| Colorectal cancer | Can present with obstruction and perforation; older adults, IDA, family history of CRC | Colonoscopy | |
| Colonic pseudoobstruction (Ogilvie’s syndrome) | Pseudo-obstruction in elderly pt, signs of obstruction w/o mechanical cause | CBC, lactate, CT A/P w contrast, if no peritonitis supportive care, can try neostigmine | |
| Volvulus | Progressive abdominal pain, nausea, distention, constipation, vomiting | CBC, lactate, KUB, CT A/P w contrast | |
| Typhlitis | Neutropenia, abdominal pain (often RLQ), fever | CBC with diff, CT A/P w/ contrast, blood cx, C-diff; empiric ABx | |
| Helminthic infections | Loose stools with mucus or blood, nocturnal BM common with anemia and eosinophilia; | CBC-diff (eosinophilia), stool O&P | |
| Eosinophilic gastroenteritis | Abdominal pain, N/V, early satiety, diarrhea, weight loss associated with eosinophilia and/or history of food allergy or intolerance | CBC-diff, CMP, EGD | |
| Lactose intolerance | Cramping abdominal pain, bloating, flatulence, and diarrhea. | Hydrogen breath test | |
| OB/Gyn | Ectopic pregnancy | RLQ or LLQ pain with vaginal bleeding, sexually active, 6-8 weeks after LMP, can present with life-threatening hemorrhage if ruptured | Urine hCG, pelvic US, CBC, T&S, OB/Gyn consult |
| Pelvic inflammatory disease/ Tuboovarian abscess | Lateralization uncommon, acute onset lower abdominal or pelvic pain, cervical motion tenderness; often with cervical discharge in a sexually active woman; hx of STI | Bimanual pelvic exam w/ GC NAAT, pelvic US | |
| Endometriosis | Associated with dysmenorrhea, dyspareunia, AUB, pelvic pain and/or infertility; may have bowel or bladder symptoms | TA or TV US, OB/Gyn consult for surgical interventions | |
| Leiomyomas (fibroids) | Symptoms usually related to bulk effect of tumor; infrequently acute pain from degeneration of torsion of pedunculate tumor, can have uterine tenderness | TA or TV US | |
| Ruptured ovarian cyst | Sudden-onset severe focal lower quadrant pain after sexual intercourse; not associated with vaginal discharge | CBC, T&S, TA or TV US, observe if HDS | |
| Ovarian torsion | Acute-onset mod-to-severe localized pain to one side. Often with N/V in a young woman with adnexal mass; usually no vaginal discharge | Pelvic US w/ doppler, OB/Gyn consult | |
| Ovarian hyperstimulation | Abdominal discomfort/distention, diarrhea, N/V in women undergoing fertility treatment | Supportive | |
| Ovarian cancer | Abdominal or pelvic pain with bloating, urinary urgency or frequency, difficulty eating/feeling full quickly. | Pelvic US, CT A/P | |
| Ovulatory pain (Mittelsmerz) | Mid-cycle right or left-sided pain coinciding with timing of ovulation. | Supportive | |
| Kidney | Nephrolithiasis | Usually sharp flank pain but may have back or lower abdominal pain, colicky± hematuria, h/o kidney stones, Crohn’s disease | U/A, CT A/P w/o contrast |
| Pyelonephritis | Usually, flank pain but can be lower abdominal pain, fever/chills, CVA tenderness, usually with dysuria, frequency, urgency. | U/A with culture, BMP, CT A/P w/ and w/o contrast | |
| Cystitis | Suprapubic pain associated with dysuria, frequency, urgency, hematuria | U/A with reflex culture | |
| Urinary Retention | Suprapubic pain with inability to urinate, older man with BPH, anticholinergics | Post-void residual | |
| Renal infarct | Acute flank pain with N/V, +/- fever, HTN; hx of vascular disease or A-fib, coagulopathies | CBC, BMP, UA, ECG (Afib), CT A/P w contrast | |
| Vascular | Myocardial infarction | CAD risk factors, DoE, epigastric pain, diaphoresis | ECG, troponin |
| Aortic Dissection | Vascular Risk factors, sudden onset, tearing painà back | CT dissection rule out | |
| AAA rupture | Vascular risk factors, sudden onset à back, hypotensive, pulsatile abdominal mass; h/o smoking, older man | CT A/P w contrast, consult vascular surgery | |
| Abdominal compartment syndrome | Critically ill patients; burn, trauma, massive ascites, abdominal surgery, intraperitoneal bleeding, associated with new organ dysfunction. | Intra-abdominal pressure measurement (intragastric, intracolonic, intravesical or IVC catheter) | |
| MSK/skin | Herpes zoster | Immunocompromised, dermatomal rash, burning pain | Physical exam, vesicle PCR for zoster |
| Muscle strain | Worse with twisting or bending, h/o trauma, overuse, heavy exercise | Physical exam; rest, NSAIDs | |
| Hernia | Bulge, worse w/Valsalva | CT A/P w/o contrast | |
| Pulmonary | Pneumonia | Productive cough, fever | CXR, CBC, sputum cx |
| Pulmonary embolus | Tachycardia, tachypnea, hypoxemia | ECG, trop, BNP CTA chest | |
| Hematologic | Paroxysmal nocturnal hemoglobinuria | Fatigue, dyspnea, hemoglobinuria, cytopenia | UA w/ microscopy, CBC, smear, retic count, DAT, coags, CMP, LDH, hapto |
| TTP | Non-specific pain, N/V/D associated with neurologic and renal injury, MAHA, thrombocytopenia | UA, CBC, smear, retic count, DAT, coags, CMP, LDH, hapto; ADAMTS13 | |
| Acute intermittent porphyria | Severe, poorly localized with motor/sensory neuropathy, red urine, tachycardia | Urinary PBG | |
| Lead poisoning | "Lead colic”, constipation, anorexia and arthralgia/myalgia, excessive fatigue, headache, anemia | Exposure history (paint, batteries, welding, ammunition), blood lead level | |
| Endocrine | Adrenal insufficiency/crisis | Hypotension, fatigue, lethargy, N/V, weight loss, hyperpigmentation | BMP (↓Na, ↑K, ↓Glu), Cort. stim |
| DKA | Diffuse abdominal pain, N/V; h/o DM | CBC, BMP, U/A, beta– hydroxy butyrate | |
| Hypothyroidism | Accompanied with constipation, fatigue, weakness, and other symptoms of hypothyroidism | TSH, fT4 | |
| Functional | IBS, depression, somatization, functional dyspepsia, anxiety abdominal migraine | Imaging and other workup negative | Diagnosis of exclusion |
| Other | Intra-abdominal abscess | Prior intra-abdominal disease or surgery, fever | CBC, BCx, CT A/P w/ contrast |
| Hypercalcemia | N/V, constipation, ↑ thirst, ↑ urination, bone pain, muscle weakness, confusion, fatigue | BMP, ionized calcium, PTH, Vit D, PTHrp | |
| Angioedema (hereditary or ACEi-related) | Paroxysmal GI colic with N/V/D along with prodromal fatigue, erythematous skin discoloration and angioedema | C4, c1-INH, c1q, discontinue ACEi | |
| Familial Mediterranean fever | Recurrent acute abdomen w/o identifiable cause (repeated laparotomies) with fever, synovitis, pleuritis, erysipelaslike erythema; 1st degree relative with FMF | Genetic testing, colchicine trial |