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FREE DEMO: Essential Abdominal Pain Evaluation

Clinical Assessment & Management (DEMO) | 2025 Demo Edition

A Core Concepts Guide for Emergency Medicine | 2025 Update | Try Before You Buy

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The Undifferentiated Abdomen

Abdominal pain is a diagnostic challenge, requiring a systematic approach to distinguish benign from life-threatening causes. The history and physical exam are paramount in guiding an efficient and effective workup.

Location, Location, Location

The location of pain is a powerful clue that narrows the differential diagnosis significantly.

Special Populations

The elderly, immunocompromised, and pregnant patients often present atypically. Maintain a high index of suspicion.

Use arrow keys or buttons to navigate

Differential by Quadrant

Thinking Anatomically

Click to Reveal Common Causes

Understanding the anatomical location of pain helps narrow the differential diagnosis. Click on each quadrant to explore common causes.

RUQ

Gallbladder, Liver

LUQ

Spleen, Stomach

RLQ

Appendix, GYN

LLQ

Diverticulitis, GYN

Epigastric

Pancreas, Heart, Aorta

Diffuse

Obstruction, Ischemia

Initial Approach

The First 15 Minutes

History & Vitals

  • Vitals & General Appearance: Are they stable? Do they look sick (pale, diaphoretic, writhing vs. still)?
  • OPQRST & Past History: Get the full story. Prior surgeries are critical.
  • Key Questions: Ask about last bowel movement, last menstrual period, and any vaginal bleeding/discharge.
  • Pregnancy Test: On any female of child-bearing age. Non-negotiable.

Physical Exam

  • Look, then Listen, then Feel: Uncover the abdomen. Auscultate before palpating.
  • Palpate Smart: Start away from the pain, beginning lightly then going deeper. Have patient bend their knees to relax the abdomen.
  • Check for Peritoneal Signs: Assess for guarding, rebound, and pain with shaking the stretcher (or jumping in kids).
  • Don't Forget the Back & Below: Check for CVA tenderness (pyelonephritis) and perform a testicular exam on all males.

Special Exam Maneuvers

Murphy's Sign

Inspiratory arrest on RUQ palpation (Cholecystitis)

Rovsing's Sign

RLQ pain with LLQ palpation (Appendicitis)

Psoas Sign

Pain with hip extension (Appendicitis)

Obturator Sign

Pain on internal rotation of flexed hip (Appendicitis)

BIG PEARL: Testicular Exam

Always perform a testicular exam on males with abdominal pain. A missed testicular torsion is a catastrophic outcome.

Pain & Symptom Control

Treating the Patient

Provide Relief Early

Analgesia

  • Don't Withhold Pain Meds: Treating pain does not mask the diagnosis or change exam findings.
  • Opioids are First Line: Fentanyl or Morphine are excellent choices. A typical starting dose is Morphine 0.1mg/kg IV.
  • Opioid-Sparing Options: Consider Ketorolac (Toradol) 15-30mg IV for renal colic or inflammatory pain (e.g., appendicitis), especially in younger patients.
  • Write for PRNs: Example: "Morphine 4mg IV, may repeat q15 min x2 doses, PRN severe pain."

Antiemetics & Fluids

  • Treat Nausea: Ondansetron (Zofran) 8mg IV is a standard and effective first-line agent.
  • Rehydrate: Provide IV fluids, especially if the patient has been vomiting. Start with a 1L bolus in young, healthy patients. Use smaller boluses (e.g., 500cc) in older patients or those with heart failure.

Clinical Pitfall: Meperidine

Avoid Demerol (meperidine). It has numerous side effects, including lowering the seizure threshold, and offers no benefit over other opioids like Morphine or Fentanyl.

The Workup: Labs

What to Order and Why

Targeted Blood & Urine Tests

  • CBC

    Consultants always want it, but up to 30% of appendicitis cases have a normal WBC.

  • BMP/Chem-7

    Assess for electrolyte disturbances from vomiting/diarrhea and check creatinine for CT contrast.

  • Lipase

    Essential for diagnosing pancreatitis (>3x ULN is highly specific). Amylase is not needed.

  • Lactate (VBG)

    Crucial screening tool for mesenteric ischemia. An elevated lactate is a major red flag.

  • LFTs

    Look for a cholestatic pattern (elevated Alk Phos/Bili) in biliary colic or cholangitis.

  • Beta-hCG

    The most important test in a female of child-bearing age. Rules out ectopic pregnancy.

  • Urinalysis

    Look for signs of UTI or nephrolithiasis. Note: 20-30% of kidney stones have no hematuria.

  • Coags (PT/INR)

    Standard pre-op lab. May be elevated in liver disease even before LFTs.

Clinical Pearl

A normal white blood cell count does not rule out serious pathology, especially in the elderly or immunocompromised who may not mount a robust inflammatory response.

The Workup: Imaging

Choosing the Right Modality

ACR Appropriateness Criteria

X-Ray (KUB)

Limited utility. Primarily used to look for free air (perforation) or signs of high-grade bowel obstruction.

Ultrasound (POCUS/Radiology)

Excellent for: Gallbladder disease (cholecystitis), GYN pathology (ovarian torsion, ectopic pregnancy), hydronephrosis (kidney stones), AAA screening, and free fluid. The best initial test for RUQ pain.

CT Scan

The workhorse for undifferentiated pain. Excellent for appendicitis (RLQ), diverticulitis (LLQ), abscesses, bowel obstruction, and vascular causes. Use contrast to evaluate infection, inflammation, and vasculature. A non-contrast CT is best for kidney stones.

MRI

Emerging option for pregnant patients or when CT is contraindicated (e.g., appendicitis in pregnancy). High sensitivity without radiation.

Image Wisely

Always consider the patient's age and clinical question. In young women, consider a transvaginal ultrasound first. In children and pregnant patients, ultrasound and MRI are preferred to avoid radiation.

Red Flags

"Can't Miss" Abdominal Pain Diagnoses

Diagnoses with High Morbidity

AAA

Mesenteric Ischemia

Ectopic Pregnancy

Bowel Perforation

Torsion

MI

BIG PEARL: The Elderly Patient

Mortality in elderly patients with abdominal pain approaches 10%, comparable to or exceeding that of STEMI—maintain high suspicion and low threshold for advanced imaging.

Surgical Consult

If your imaging is negative but the patient still has a concerning abdominal exam or looks unwell, get a surgical consult. Nothing is 100%, and clinical gestalt is important.

Summary & Disposition

Key Takeaways

Abdominal Pain Checklist

Core Principles

  • History is King: A detailed history and OPQRST will guide your entire workup.
  • Think Anatomically: Use quadrants to build your differential.
  • Respect Special Populations: The elderly and immunocompromised need an aggressive workup.
  • Don't Miss Torsion: Testicular and ovarian torsion are time-sensitive emergencies.

Immediate Actions

  • Assess for Stability: Vitals first. Address hypotension and tachycardia immediately.
  • Rule out Ectopic: Get a urine pregnancy test on all eligible females.
  • Get an ECG: In patients with epigastric pain or cardiac risk factors.
  • Provide Pain Relief: Don't withhold analgesia.

Discharge Instructions

Document a repeat abdominal exam before discharge. Counsel patients to return immediately for worsening pain, vomiting, or if they just aren't getting better in 12-24 hours. Don't prescribe excessive anti-emetics.

Common Pitfalls

Avoid These Critical Mistakes

Diagnostic Errors to Avoid

Missing the Surgical Abdomen

Never discharge a patient with abdominal pain who "looks sick" or has peritoneal signs, even with a negative workup. Get surgical consultation early.

Cognitive Biases

Avoid anchoring on the first diagnosis that comes to mind. Consider atypical presentations in elderly patients and maintain a broad differential.

Time is Tissue

Don't delay imaging or consultation for suspected ischemic conditions. Mesenteric ischemia and testicular torsion require emergent intervention.

Case Studies

Real-World Application

Clinical Scenarios

Case 1: The Missed AAA

Presentation: 75-year-old male with vague abdominal pain. Normal vitals, soft abdomen.

Mistake: Discharged without imaging because "he doesn't look sick."

Outcome: Returned 12 hours later in shock from a ruptured 8cm AAA. Died in OR.

Lesson: Never discharge elderly patients with abdominal pain without definitive imaging.

Case 2: The Ectopic Pregnancy

Presentation: 22-year-old female with LLQ pain. Missed last period, positive home pregnancy test.

Correct Action: Immediate transvaginal ultrasound revealed ectopic pregnancy.

Outcome: Laparoscopic salpingectomy, patient recovered fully.

Lesson: All females of childbearing age with abdominal pain need pregnancy testing.

Special Considerations

Unique Patient Populations

High-Risk Groups

Elderly Patients

  • Atypical Presentations: May present with confusion, falls, or weakness rather than pain
  • Lower Pain Threshold: Severe pathology may present with minimal symptoms
  • Higher Mortality: Abdominal pain in elderly has 10% mortality rate
  • Lower Threshold for Imaging: CT scan is often the first test

Pediatric Patients

  • Communication Challenges: Young children may not localize pain well
  • Appendicitis: Perforation rate is high due to delayed diagnosis
  • Consider Intussusception: In toddlers with intermittent abdominal pain
  • Ultrasound First: Avoid radiation when possible

Immunocompromised

  • Subtle Signs: May not mount typical inflammatory response
  • Higher Risk Infections: Consider opportunistic pathogens
  • Lower Threshold for Admission: Even with equivocal findings
  • Broad-spectrum Antibiotics: If infection is suspected

Pregnant Patients

  • Always Test for Pregnancy: Even if they say they're not pregnant
  • Radiation Concerns: Use ultrasound and MRI when possible
  • Normal Physiologic Changes: May mask pathology
  • Ectopic Pregnancy: Life-threatening emergency

Diagnostic Algorithms

Systematic Approach

Decision-Making Framework

RUQ Pain Algorithm

1. Ultrasound: Look for gallstones, gallbladder wall thickening, pericholecystic fluid

2. If negative: Check LFTs for cholestasis pattern

3. Consider: Hepatitis, liver abscess, pneumonia, cardiac causes

4. CT if needed: For complications or unclear diagnosis

RLQ Pain Algorithm

1. Pregnancy test: All females of childbearing age

2. Ultrasound: For GYN pathology (ectopic, ovarian torsion)

3. CT if negative: For appendicitis or diverticulitis

4. Consider: UTI, nephrolithiasis, hernias

Diffuse Pain Algorithm

1. Assess stability: Vitals, peritoneal signs

2. If unstable: Immediate surgical consultation

3. If stable: CT scan for bowel obstruction, ischemia

4. Labs: Lactate for ischemia, amylase/lipase

When to Consult

Know When to Ask for Help

Consultation Triggers

Immediate Surgical Consultation

  • Peritoneal signs (rebound, guarding)
  • Hemodynamically unstable
  • Severe pain despite analgesia
  • Signs of sepsis
  • Suspected ischemic bowel
  • Free air on imaging

Urgent Consultation

  • Equivocal CT findings
  • Elderly patient with abdominal pain
  • Immunocompromised host
  • Pregnant patient
  • Failed outpatient management

Specialty Consultation

  • Obstetrics/Gynecology: Female reproductive issues
  • Urology: Renal colic, testicular pain
  • Gastroenterology: Chronic liver disease
  • Cardiology: Suspected cardiac etiology

Safe for Discharge

  • Clear diagnosis with outpatient follow-up
  • Reliable patient with return precautions
  • Resolved symptoms with conservative management
  • Negative workup with low clinical suspicion

Pain Management Revisited

Advanced Strategies

Beyond the Basics

Multimodal Analgesia

  • Combination Therapy: Opioids + NSAIDs + acetaminophen for synergistic effect
  • Regional Blocks: Consider TAP blocks for abdominal pain in appropriate patients
  • Ketamine: Low-dose ketamine (0.1-0.3 mg/kg) for opioid-sparing analgesia
  • Non-Pharmacologic: Heat therapy, positioning, distraction techniques

Special Situations

  • Renal Colic: NSAIDs are first-line; opioids for breakthrough pain
  • Biliary Colic: NSAIDs + antiemetics; avoid opioids if possible
  • Pediatric Patients: Weight-based dosing; consider non-pharmacologic options
  • Pregnancy: Acetaminophen first-line; opioids if necessary

Risk-Benefit Analysis

Weigh the risks of analgesia (masking diagnosis) against the benefits (patient comfort, improved examination). In stable patients, the benefits far outweigh the minimal risks.

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Laboratory Interpretation

Beyond the Numbers

Understanding Lab Results

Common Patterns

Cholangitis Pattern

↑ ALP, ↑ Total bilirubin, ↑ WBC, fever

Pancreatitis Pattern

↑ Lipase (>3x ULN), ↑ Amylase, metabolic abnormalities

Bowel Obstruction Pattern

↑ WBC, metabolic acidosis, dehydration

Ischemia Pattern

↑ Lactate, ↑ WBC, metabolic acidosis

Pitfalls in Lab Interpretation

  • Normal WBC doesn't rule out appendicitis (especially in elderly or immunocompromised)
  • Amylase is less specific than lipase for pancreatitis
  • LFTs may be normal early in acute hepatitis or cholecystitis
  • Beta-hCG can be negative early in very early pregnancy

Imaging Selection Guide

ACR Guidelines in Practice

Choosing the Right Test

Clinical Scenario First-Line Imaging When to Escalate
RUQ pain, suspected cholecystitis Ultrasound CT if complications suspected
RLQ pain, suspected appendicitis CT (preferred) or ultrasound MRI in pregnancy
Suspected bowel obstruction CT abdomen/pelvis Contrast CT for ischemia
Flank pain, suspected stone Non-contrast CT Ultrasound if radiation concern
Pregnant with abdominal pain Ultrasound MRI if ultrasound inconclusive

Radiation Awareness

CT scans deliver significant radiation. Use ultrasound first when appropriate, especially in young patients and women of childbearing age.

Complications

What Can Go Wrong

Recognizing Deterioration

Surgical Complications

  • Perforation: Free air, peritonitis, sepsis
  • Abscess formation: Persistent fever, worsening pain
  • Bowel ischemia: Metabolic acidosis, elevated lactate
  • Hemorrhage: Hypotension, tachycardia, anemia

Time-Sensitive Issues

  • Testicular torsion: >6 hours = orchiectomy risk
  • Ovarian torsion: Tissue death within hours
  • AAA rupture: 90% mortality if not repaired emergently
  • Mesenteric ischemia: Hours to bowel infarction

Medication-Related

  • NSAID gastritis: In patients with ulcers
  • Opioid ileus: Especially in elderly
  • Contrast nephropathy: In patients with renal impairment
  • Allergic reactions: To contrast or medications

Iatrogenic Complications

  • Missed diagnosis: Discharged with serious pathology
  • Delayed consultation: Failure to involve specialists
  • Inappropriate imaging: Radiation exposure or wrong test
  • Inadequate follow-up: No return precautions

Follow-up Care

After the ED Visit

Discharge Planning

Return Precautions

  • Red flags for return: Worsening pain, vomiting, fever, inability to eat/drink
  • Timeframe: Return immediately if symptoms worsen within 24 hours
  • Follow-up: Primary care within 1-2 days for most conditions
  • Specialist referral: Surgery, gastroenterology, or gynecology as indicated

Medication Management

  • Pain control: Prescribe adequate analgesia for 2-3 days
  • Antiemetics: Only if needed; avoid routine prescribing
  • Antibiotics: Complete full courses if prescribed
  • NSAIDs: With food and PPI protection if risk factors present

When to Call the Doctor

Instruct patients to call their physician or return to ED for: severe pain not relieved by prescribed medications, persistent vomiting, high fever (>101.5°F), signs of dehydration, or any new symptoms.

Quality Measures

Measuring Excellence

Performance Indicators

Key Metrics

Time to Analgesia

Door to pain medication ≤30 minutes

CT Utilization

Appropriate imaging per ACR guidelines

Admission Rate

Balanced admission vs. return visits

Patient Satisfaction

Pain control and communication scores

Best Practices

  • Early analgesia: Don't delay pain relief for diagnosis
  • Appropriate imaging: Follow evidence-based guidelines
  • Shared decision-making: Involve patients in disposition plans
  • Clear discharge instructions: Written and verbal communication
  • Timely consultation: Don't delay specialist involvement

Special Populations

Unique Considerations

Pediatric, Geriatric, and Pregnant Patients

Pediatric Patients

  • Communication: Use age-appropriate language; involve parents
  • Pain assessment: Use validated scales (FLACC, FACES)
  • Differential: Intussusception, volvulus, appendicitis, testicular torsion
  • Imaging: Minimize radiation; prefer ultrasound first
  • Red flags: Bilious vomiting, lethargy, inconsolable crying

Geriatric Patients

  • Atypical presentations: May lack classic signs (fever, leukocytosis)
  • High-risk conditions: Mesenteric ischemia, AAA, diverticulitis
  • Medications: Review anticoagulants, NSAIDs, opioids
  • Lower threshold: For imaging and surgical consultation
  • Comorbidities: Consider impact on management decisions

Pregnant Patients

  • Always test: Pregnancy test on all reproductive-age females
  • Ectopic risk: Rule out ectopic pregnancy first
  • Imaging: Ultrasound preferred; minimize CT use
  • Positioning: Left lateral tilt after 20 weeks
  • Consultation: OB/GYN early for any concerns

Critical Reminder

Special populations often present atypically. Maintain a high index of suspicion and lower threshold for imaging and consultation. When in doubt, consult specialists early.

Advanced Considerations

Complications & Atypical Presentations

Complex Scenarios

Complications to Recognize

Perforation

Free air, peritonitis, sepsis. Requires immediate surgical consultation.

Obstruction

Distension, vomiting, absent bowel sounds. May need decompression.

Ischemia

Pain out of proportion, acidosis, elevated lactate. Time-sensitive.

Torsion

Sudden onset, severe pain. Testicular/ovarian torsion needs urgent intervention.

Atypical Presentations

Immunocompromised

Minimal signs despite serious pathology. Lower threshold for imaging.

Post-operative

Consider anastomotic leak, obstruction, or infection. Review surgical history.

Psychiatric Patients

Don't dismiss complaints. Perform thorough evaluation despite psychiatric history.

Substance Use

May mask pain or have altered presentations. Maintain clinical suspicion.

Clinical Pearl

When a patient's presentation doesn't fit a classic pattern, consider: (1) Is this a special population? (2) Are there complicating factors? (3) Could this be an atypical presentation of a serious condition? When uncertain, err on the side of caution with imaging and consultation.

Final Review

Mastering Abdominal Pain

Essential Takeaways

Stay Vigilant

High suspicion for surgical emergencies

Think Anatomically

Location guides the differential

Act Quickly

Time-sensitive interventions save lives

Your Abdominal Pain Mastery Checklist

  • Systematic history and physical exam
  • Early pain control and stabilization
  • Appropriate diagnostic workup
  • Recognition of red flags
  • Timely consultation when indicated
  • Consideration of special populations
  • Clear discharge instructions
  • Quality follow-up care

Quiz Question 1

Test Your Knowledge

An elderly patient with atrial fibrillation presents with severe abdominal pain, but their physical exam is relatively benign. What diagnosis must be considered?

A.
Diverticulitis
B.
Mesenteric Ischemia
C.
Appendicitis
D.
Gastritis

Quiz Question 2

Test Your Knowledge

What is the most appropriate initial imaging modality for a 28-year-old female with RLQ pain and a positive pregnancy test?

A.
CT Abdomen/Pelvis with contrast
B.
Abdominal X-ray
C.
Transvaginal Ultrasound
D.
MRI Abdomen

Quiz Question 3

Test Your Knowledge

A patient presents with RUQ pain, fever, and jaundice. Which lab finding would be most expected?

A.
Lipase > 3x ULN
B.
Elevated Alk Phos & Bilirubin
C.
Large blood on urinalysis
D.
Normal WBC count

Quiz Question 4

Test Your Knowledge

Which of the following is the primary role of a plain abdominal X-ray in the workup of abdominal pain?

A.
Diagnosing appendicitis
B.
Diagnosing cholecystitis
C.
Detecting free air or bowel obstruction
D.
Detecting kidney stones

Quiz Question 5

Test Your Knowledge

In a stable patient with suspected renal colic, which analgesic is a good opioid-sparing option?

A.
Meperidine
B.
Ketorolac
C.
Acetaminophen
D.
Ondansetron

References

Evidence-Based Practice

Key Guidelines and Studies

Rosen's Emergency Medicine (10th Ed.)

Chapter 77: Abdominal Pain. The foundational text for the evidence-based approach presented.

ACEP Clinical Policy: Acute Abdominal Pain (2017)

Provides key recommendations on the evaluation and management of adult patients presenting with acute, non-traumatic abdominal pain.

ACR Appropriateness Criteria®

The American College of Radiology provides evidence-based guidelines for choosing the correct imaging modality for various presentations of abdominal pain.

This presentation is for educational purposes only.

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