Abdominal pain: Difference between revisions

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''For pediatric patients see [[Abdominal pain (peds)]]. See also [[abdominal pain (geriatrics)]] and [[Abdominal pain in pregnancy]].''
==Background==
==Background==
*Elderly pts
*Patients with immunosuppression often have delayed or atypical presentations
**Surgical emergencies are more common in elderly than in any other pt population
*[[Fever]] is not a reliable marker for surgical disease
**Viral gastroenteritis is uncommon
*Abdominal pain may be particularly misleading in elderly or diabetics
**Conservative admission strategy is strongly advocated
*Consider pain in any abdominal or pelvic region in a female of child-bearing age, including pre-teens, is an [[ectopic pregnancy]] until proven otherwise
*Pts with immunosuppression often have delayed or atypical presentations
*Fever is not a reliable marker for surgical disease
==Workup==
*Urine pregnancy
*CBC
**Note: WBC cannot exclude surgical disease
*Chem
*LFT
*Lipase
**May be normal early in course of pancreatitis
*UA/UCx
*Guaiac
*ECG (>40 yo)
*?CXR
*?Coags
**GI bleeding, end-stage liver disease, coagulopathy
*?Lactate
*?Abd x-ray
**Consider for r/o obstruction, perforation, or severe constipation
*?US
*?CT


==DDX ==
{{Abdominal pain location}}
===Killers===
#[[AAA]]
#[[Mesenteric Ischemia]]
#Bowel Perforation
#[[Small Bowel Obstruction]]
#[[Sigmoid Volvulus]]
#[[Ectopic Pregnancy]]
#[[Placental Abruption]]
#[[ACS]]


===Diffuse===
==Clinical Features==
{{Templated:Abdominal Pain DDX Diffuse}}
*Abdominal pain (see workup by location)
*May be associated with [[nausea]], [[vomiting]] or [[diarrhea]]
*[[Fever]] may be present in pain from infectious etiology


===Epigastric===
==Differential Diagnosis==
{{Template:Abdominal Pain DDX Epigastric}}
{{Abdominal Pain DDX Diffuse}}
{{Abdominal Pain DDX Epigastric}}
{{DDX RUQ}}
{{DDX LUQ}}
{{Abd DDX RLQ}}
{{LLQ DDX}}
{{Pelvic pain DDX}}
{{Extra-abdominal sources of abdominal pain DDX}}


===RUQ===
==Evaluation==
#[[Gallbladder Disease (Main)]]
*Workup is by location:
#[[Appendicitis]] (retrocecal)
**[[RUQ pain]]
#Hepatitis
**[[RLQ pain]]
#[[Pyogenic liver abscess]]
**[[Epigastric pain]]
#Fitz-Hugh-Curtis Syndrome
**[[LUQ pain]]
#Hepatomegaly due to [[CHF]]
**[[LLQ pain]]
#Perforated duodenal ulcer
**[[Diffuse abdominal pain]]
#[[Pancreatitis]]
**[[Flank pain]]
#Herpes zoster
#[[Myocardial Ischemia]]
#[[Pneumonia]]
#Bowel obstruction
#[[Pulmonary Embolism]]


===LUQ===
==Management==
#Gastritis/gastric ulcer
*Treat underlying cause
#Herpes Zoster
*Multiple studies show [[pain medicine]] should not be withheld for fear of masking symptoms
#[[Pancreatitis]]
#Splenic rupture/distension
#[[Myocardial Ischemia]]
#[[Pneumonia]]
#[[Pulmonary Embolism]]
#[[Splenic Infarction]]


===RLQ===
==Disposition==
#[[Appendicitis]]
*Depends on etiology
#[[Abdominal Aortic Aneurysm]] (leaking, ruptured)
*The two most notoriously missed conditions are [[appendicitis]] and [[small bowel obstruction]].<ref>Macaluso CR and McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012; 5: 789–797. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468117/</ref>. When discharging patients with abdominal pain, clear instructions should be given for return if there are red flags.
#Crohn disease (terminal ileitis)
#Diverticulitis (cecal)
#[[Ectopic]]
#Endometriosis
#[[Epiploic Appendagitis]]
#Herpes zoster
#Inguinal hernia
#Ischemic colitis
#Meckel diverticulum
#Mittelschmerz
#Ovarian cyst (ruptured)
#Ovarian Torsion
#[[PID]]
#[[Psoas Abscess]]
#[[Testicular Torsion]]
#[[Kidney Stone]]
 
===LLQ===
{{Template:LLQ DDX}}
 
===Pelvic===
====Abdominal origin====
#Ureteral calculi ([[Kidney Stone]])
#Psoas abscess
#Mesenteric adenitis
#Incarcerated hernia
====Pelvic origin====
#[[Ectopic]]
#Adnexal torsion
#Endometriosis
#[[PID]]
#Myoma (degenerating)
#Ovarian cyst (rupture)
#Tubo-ovarian abscess
#Mittelschmerz
#Endometriosis
#Seminal vesiculitis
 
===Extra-Abdominal===
#[[MI]]
#[[Aortic Dissection]]
#[[PNA]]
#[[PE]]
#[[Testicular Torsion]]
#[[Herpes Zoster]]
#Muscle spasm
#[[Pharyngitis|Strep Pharyngitis]] (peds)
#[[Mononucleosis]]
#[[DKA]]
#[[ETOH Ketoacidosis]]
#[[Uremia]]
#[[Sickle Cell Crisis]]
#SLE
#Vasculitis
#Glaucoma
#[[Hyperthyroidism]]
#[[Methanol Poisoning]]
#[[Heavy Metal]] toxicity
#Addison's Disease
#Porphyria


==See Also==
==See Also==
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*[[Abdominal Pain (Peds)]]
*[[Abdominal Pain (Peds)]]
*[[Abdominal Trauma]]
*[[Abdominal Trauma]]
*[[Abdominal pain in pregnancy]]
*[[Pelvic Pain]]
*[[Pelvic Pain]]


==Source ==
==References==
*Tintinalli
<references/>
 
[[Category:GI]]
*ACEP Geriatric lecture series
[[Category:Misc/General]]
*[[Category:GI]]
[[Category:Symptoms]]

Latest revision as of 22:35, 31 January 2024

For pediatric patients see Abdominal pain (peds). See also abdominal pain (geriatrics) and Abdominal pain in pregnancy.

Background

  • Patients with immunosuppression often have delayed or atypical presentations
  • Fever is not a reliable marker for surgical disease
  • Abdominal pain may be particularly misleading in elderly or diabetics
  • Consider pain in any abdominal or pelvic region in a female of child-bearing age, including pre-teens, is an ectopic pregnancy until proven otherwise

Classification by Abdominal pain location

Side-by-side comparison of quadrants and regions.
Chart of commonly reported referred pain sites.
RUQ pain Epigastric pain LUQ pain
Flank pain Diffuse abdominal pain Flank pain
RLQ pain Pelvic pain LLQ pain

Clinical Features

  • Abdominal pain (see workup by location)
  • May be associated with nausea, vomiting or diarrhea
  • Fever may be present in pain from infectious etiology

Differential Diagnosis

Diffuse Abdominal pain

Epigastric Pain

RUQ Pain

Left upper quadrant abdominal pain

RLQ Pain

LLQ Pain

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Extra-abdominal Sources of Abdominal pain

Evaluation

Management

  • Treat underlying cause
  • Multiple studies show pain medicine should not be withheld for fear of masking symptoms

Disposition

  • Depends on etiology
  • The two most notoriously missed conditions are appendicitis and small bowel obstruction.[2]. When discharging patients with abdominal pain, clear instructions should be given for return if there are red flags.

See Also

References

  1. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  2. ↑ Macaluso CR and McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012; 5: 789–797. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468117/
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