Abstract
Abdominal pain is often difficult to diagnose. By having a broad differential and methodically eliminating potential diagnoses through a combination of historical features, physical exam findings, laboratory values, and imaging studies, one can better elucidate the cause of abdominal pain.
Keywords
abdominal aortic aneurysm, appendicitis, biliary colic, bowel obstruction, cholecystitis, choledocholithiasis, cholangitis, clostridium difficile , constipation, diabetic gastroparesis, diverticulitis, gallbladder, gastroenteritis, hepatitis, hernia, hemorrhoids, infectious diarrhea, mesenteric ischemia, peptic ulcer disease, pancreatitis, pyelonephritis, pelvic pain, pregnancy, renal colic, spleen, vomiting
1
Why is abdominal pain so difficult to diagnose?
Pain in the abdomen is often referred based on the embryological development of the organs. There are two types of pain: visceral (diffuse crampy and achy pain from distention of the hollow organs) and somatic (localized constant pain from the parietal peritoneum).
2
How should I approach a patient with right upper quadrant (RUQ) pain?
There are three main considerations:
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Gallbladder (biliary colic, cholecystitis, choledocholithiasis, cholangitis)
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Liver (hepatitis, Fitz-Hugh-Curtis syndrome)
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Referred pain (renal colic, pyelonephritis, lower lobe pneumonia, colitis near hepatic flexure, duodenal ulcer)
3
What workup is helpful in evaluating RUQ pain in the urgent care setting?
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Urinalysis (to look for pyelonephritis and assess pregnancy status when indicated)
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Chest x-ray (if indicated)
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Outpatient labs (complete blood count [CBC], metabolic panels, etc.) and a scheduled RUQ ultrasound (Note: If patient is ill appearing or in severe pain, these would need to be done acutely in an emergency department.)
5
Should I order an outpatient CT for my patient with RUQ pain?
Typically not. Ultrasound is the initial test of choice for gallbladder-related pathologies. There is no radiation exposure, computed tomography (CT) will often have a false appearance of gallbladder wall thickening, and other tests such as hepatobiliary iminodiacetic acid (HIDA) scan for gallbladder dysfunction or magnetic resonance cholangiopancreatography/endoscopic retrograde cholangiopancreatography (MRCP/ERCP) for intraductal stone confirmation and extraction are more appropriate. If there is concern for hepatic or biliary mass, then thin-slice CT may be indicated.
6
My patient had a recent cholecystectomy and now is presenting with RUQ pain. What testing should I perform?
This patient will likely need to be evaluated in the emergency department. It is wise to have early consultation with the surgeon for postoperative management. Fever raises suspicion of complications, but local preference will vary between HIDA and CT to evaluate for postoperative biliary leak and abscess.
8
My patient has classic symptoms of peptic ulcer disease (PUD): gnawing, burning pain starting after eating. How do I differentiate between gastric and duodenal ulcers?
Gastric ulcers tend to worsen immediately after eating, whereas the duodenal ulcers tend to immediately improve after eating due to the bicarbonate production and ultimately cause pain several hours after a meal.
10
What is the medication regimen of choice for patients with PUD?
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Use proton pump inhibitors (PPIs) for 4 to 8 weeks.
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Histamine H 2 -receptor antagonists (H 2 blockers) are less effective than PPIs and do not have significant additive effect when combined with PPIs.
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Sucralfate is most effective with duodenal ulcers.
12
Should I order an electrocardiogram (EKG) on patients with epigastric pain?
Patients with “atypical” chest pain often present with vague symptoms including nausea and epigastric pain. It is reasonable on patients over age 30 with vague symptoms or other risk factors (dyslipidemia, hypertension [HTN], diabetes mellitus [DM], smoker, family history, obesity) to use this as a screening exam for low-risk cardiac patients.
15
What does mononucleosis have to do with abdominal pain?
Because mono can cause splenomegaly, patients need to avoid contact sports or be evaluated after minor trauma for a minimum of 4 weeks after onset of illness. Mono can be confirmed using a monospot test or a CBC showing a lymphocytic predominance (>50%).
18
What common disease processes present with flank pain?
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Herpes zoster: often presents with a superficial burning sensation several days prior to the onset of rash. Be sure to carefully inspect for any lesions along a dermatomal distribution.
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Nephrolithiasis: renal colic is typically severe and intermittent in nature. Posterior pain is associated with stones near the kidney, pain along the flank is typically referred as the stone transcends the ureter, and pelvic or scrotal pain is more prominent as the stone approaches the bladder.
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Pyelonephritis: these patients often appear ill, have constant pain, and have had preceding urinary tract infections that may have been partially treated or untreated.
20
How should RLQ pain be approached?
History and physical exam are key. Clinical components such as fever, anorexia, migration of pain to the RLQ, and leukocytosis increase the suspicion for appendicitis. A bimanual exam should be performed to help differentiate between RLQ and right pelvic pain. If the majority of pain appears to be in the pelvic region, ultrasound (US) to evaluate for torsion, cyst, or tubo-ovarian abscess (TOA) is a reasonable first step. If the pain is mainly in the RLQ, then CT is the test of choice. Depending on the degree of pain and what diagnosis you are expecting, the patient may need to be referred to the emergency department.
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