Approach to

Abdominal Pain in
the Emergency
Department
Richard Stair, MD, FACEP
Department of Emergency
Medicine
Introduction
 At the end of this lecture you
should:
 Understand the generation and
presentation of types of abdominal
pain
 Develop critical elements of the

history and physical for AP

 Apply knowledge of utility of testing

to diagnostic approach
 Apply management principles to

patient care in the ED

What Do They Have?
 As you go through this
presentation, think about each of
these cases:
 An 18 mo old that suddenly
became inconsoleable from AP
while playing
 A 20 yo man with 12 hours of
diffuse crampy AP that migrated to
RLQ that became sharp
 78 yo woman with h/o chronic
steroid use with sudden sharp AP
and a rigid exam
Acute Abdominal Pain
 Approximately 6% of ED visits
 Admission rates vary by
population, up to about to 65% in
high risk elderly populations
 Most common diagnosis is
NONSPECIFIC (ie, “I dunno”)
 Use H+P, risk factors, and directed
studies to arrive at diagnosis
 MUST rule out emergency
conditions
Abdominal Pain Across
the Ages
 Ages 0-2
 Colic, GE, viral illness, constipation
 Ages 2-12
 Functional, appendicitis, GE, toxins
 Teens to adults
 Addition of genitourinary problems
 Elderly
 Beware of what seems like
everything!
Special Populations

 Elderly/ nursing home patients

 Immunocompromised
 Post operative patients
 Infants
Abdominal Pain in the Elderly

 Diminished sensation of pain in the

elderly
 Comorbid diseases
 Polypharmacy
 Combinations of above result in
many more vague, nonspecific
presentations
 Twice as likely to require surgery
with presentation over age 65
What’s the Problem

 Imprecise pain generation and

transmission to the central nervous
system
 Comorbid diseases
 Developmental stage
 Medications
 Social factors
Understanding the Types of
Abdominal Pain
 Visceral
 Stretch fibers in capsules or walls
of hollow viscus that enter both
sides of spinal cord
 Somatic
 Fibers dermatomally distributed
and enter unilaterally in the spinal
cord
 Referred
 Overlap of fibers from other
locations
Understanding the Types of
Abdominal Pain
 Visceral
 Crampy, achy, diffuse,
 Poorly localized

 Somatic
 Sharp, lancinating
 Well localized

 Referred
 Distant from site of generation
 Symptoms, but no signs
Understanding the Types of
Abdominal Pain
 Location, location, location
 Organs and their corresponding
fiber entry to the spinal cord
 C3-5 – liver, spleen, diaphragm
 T5-9 – gallbladder, stomach,

pancreas, small intestine

 T10-11– colon, appendix, pelvic

viscerat11-l1 – sigmoid, renal

capsules, ureters, gonads
 S2-4 - bladder
History Taking in Abdominal Pain
Presentations
 “OLD CARS”

 O- onset
 L- location

 D- duration

 C- character

 A-alleviating/aggravating factors

associated symptoms
 R- radiation

 S- severity
History Taking for Abdominal
Pain Presentations
 PMH
 Similar episodes in past
 Other medical problems that increase disease
likelihood of problems (ex: DM and gastroparesis)
 PSH
 Adhesions, hernias, tumors
 MEDS
 Abx, NSAIDS, acid blockers, etc
 GYN/URO
 LMP, bleeding, discharge
 Social
 Tob/EtoH/drugs/home situation/agenda
Physical Exam in Abdominal
Pain Presentations
 General appearance
 “Sick versus not sick”
 Mobile versus still

 Obvious pain or discomfort

 “Doorway” impression

 Vital signs
 “That’s why they’re called vital”
Physical Exam in Abdominal
Pain Presentations
 Inspection
 Distention, scars, bruises
 Auscultation
 Present, hyper, or absent
 Actually not that helpful!

 Palpation
 Often the most helpful part of exam
 Tenderness versus pain

 Start away from painful area first

 Guarding, rebound, masses

Physical Exam in Abdominal
Pain Presentations
 Signs
 Iliopsoas
 Obturator
 Rovsing’s
 Murphy’s
 Extra-abdominal exam
 Pelvic or scrotal exams
 Lungs, heart
 Remember it’s a patient, not a part
 Rectal
 Adds very little (despite the angst)
beyond gross blood or melena
Laboratory Testing
 Everybody likes a CBC, but…

 Lacks sensitivity, no specificity

 Little to no change in diagnostic

probabilities
 Should not dramatically alter

approach (tender is still tender)

Laboratory Testing

 Directed approach to lab studies

 There are no “standard belly labs”
 Pregnancy test in women of child
bearing age
 Urine dipsticks
Imaging
 Plain films
 Free air, obstruction, air-fluid, FBs
 Ultrasound
 Rapid “yes or no” ED evaluations
 Formal studies

 May add doppler

 Computed Tomography
 Revolutionized acute care
 Often better than we are!
Common Diagnoses by Quadrant

 RUQ  LUQ
 Cholecystitis  Gastritis
 Biliary colic  Gastric ulcer
 Hepatitis  Pancreatitis
 Pancreatitis  Splenomegaly
 Renal stones  Splenic rupture
 PUD  Renal stone
 Pneumonia  Pneumonia
 PE  PE
 MI  MI
Common Diagnoses by
Quadrants
 RLQ  LLQ
 Appendicitis  Diverticulitis
 Renal stone  Renal stone
 Ovarian cyst  Ovarian cyst
 Torsion  Torsion
 Epididymitis  Epididymitis
 Ectopic  Ectopic
 IBD  IBD
 AAA  AAA
 UTI  UTI
Management of
Abdominal Pain
 Always right to start with ABC’s
 IV access
 Fluid administration
 Antiemetics
 Analgesics
 Directed testing and imaging
 Re-evaluations
 Antibiotics
 Consultants
 Surgeons, OB/GYN, urologists,
cardiologists, etc
Disposition of Abdominal Pain
Patients
 Operating Room
 Hospital bed/observation
 Serial labs
 Serial exams

 Home with abdominal warnings

 The art of emergency medicine
 3 components of discharge plan

 Document, document, document

Now How About Those Cases

 18 mo old had classic presentation

of intussusception, and symptoms
may wax and wane; rectal would
be to look for current jelly stool. Air
enema for diagnosis and reduction.
Involve consultants early in the
course.
Now How About Those Cases

 20 year old with classic

presentation of appendicits, which
likely does not need CT scan. Most
do not present so simply, quite a
wide array of presentations.
General surgery consultation, pain
meds, IVF, and an operation would
all be good, but don’t be shocked if
CT requested.
Now How About Those Cases

 78 yo has perforated abdomen,

with age, multiple problems, and
chronic steroids risks for
perforation. Rapid resuscitation,
plain films to confirm free air,
antibiotics, pain medicine, and a
surgeon as fast as you can would
be good practice.
Take Home Points
 Perform a good history and
physical to guide assessment
 Lab studies have limitations…..and
costs
 Imaging studies also need to be
selected wisely
 Early involvement of consultants
for sick patients
 Treatment initiation, not just
diagnostics