An Approach to Acute Abdominal Pain

hello everyone its erik from strong

medicine today i'm discussing an

approach to acute abdominal pain

diagnostic frameworks for acute

abdominal pain are either based on

anatomic region or by organ system with

a former more common if using the region

to organize the list of possible

diagnoses the abdomen can be divided

into four quadrants with the humble

Lycus at the center however it's

probably even better to divide it into

nine regions right upper quadrant

epigastric left upper quadrant left

flank left lower quadrant suprapubic

rarely called hypogastric right lower

quadrant right flank and parry umbilical

in the center because this nine region

framework is the most common let's take

a closer look at it

when trying to consider what diseases

might cause pain located in a certain

region the simplest principle is to

consider what structures are within that

region so pain in the right upper

quadrant suggests liver or biliary

pathology while pain in the left upper

quadrant it could be from the spleen now

I'm going to go through specific

ideologies while traveling around the


starting in the epigastric region pain

located here can be from gastro

esophageal reflux disease gastritis

peptic ulcer disease gastroparesis most

commonly a complication of diabetes

pancreatitis and occasionally referred

pain from acute coronary syndrome pain

in the left upper quadrant can be from a

splenic infarct splenic abscess or

splenic rupture a sub diaphragmatic

abscess or referred pain from a left

lower lobe pneumonia pain in either

flank can be from Nefera with isis

pyelonephritis which is infection of the

kidney or a perinephric abscess which is

an abscess adjacent to the kidney Perry

umbilical pain is most commonly from

simple viral gastroenteritis but could

also be from a small bowel obstruction

mesenteric ischemia which is like angina

of the guts any ruptured abdominal

aortic aneurysm suprapubic pain can be

from cystitis or a simple urinary tract

infection pelvic inflammatory disease

which is a severe complication of

sexually transmitted infections seen in

women or an ectopic pregnancy which

occurs when an embryo is implanted

somewhere other than the uterus a

condition which results in a non viable

pregnancy and is life-threatening to the


pain in the right and left lower

quadrants have similar pathologies

including ovarian and testicular tortion

a ruptured ovarian cyst a tubo-ovarian

abscess and ectopic pregnancy two

differences between the left and right

lower quadrants appendicitis pain is

located in the right lower quadrant only

unless the patient has an unusual

anatomic variation in the position of

the intra-abdominal organs and

diverticulitis is more common on the

left than on the right last is the right

upper quadrants which i think of as a

more distinctive entity than the others

on account of particularly complex and

numerous potential liver and biliary

pathologies there so let's take a look

at that region a little more closely we

can divide ideologies of right upper

quadrant pain into those from the liver

those from the biliary system and other

ideologies of hepatic pain can be

divided into infectious and

non-infectious under infectious is acute

viral hepatitis and deliver abscess

non-infectious causes include alcohol

and medication induced hepatitis hepatic

congestion from heart failure and bud

Kyary syndrome caused by obstruction of

the hepatic vein biliary pathologies can

also be divided into infectious and

non-infectious under infectious are

acute cholecystitis which is

inflammation and infection of the

gallbladder an acute cholangitis which

is inflammation and infection of the

common bile duct relevant non-infectious

pathologies of the gallbladder include

simple gallstones which lead to a

condition known as biliary colic and

choledocholithiasis a mouthful that

means a gallstone trapped within or

actively passing through the common bile

duct lastly in the other causes of right

upper quadrant pain are referred pain

from a right lower lobe pneumonia and a

right-sided sub diaphragmatic abscess

there are some ideologies of acute

abdominal pain that can be either

generalized or poorly localized

including inflammatory bowel disease

infectious colitis such as C difficile

spontaneous bacterial peritonitis

occurring in patients with chronic

ascites secondary peritonitis typically

occurring from bowel perforation and

diabetic ketoacidosis some relatively

rare but nevertheless important causes

of acute abdominal pain adrenal

insufficiency acute intermittent

porphyria and abdominal migraine

angioedema which sometimes surprises

people since we are more familiar with

angioedema causing swelling of the

mucous membranes of the face and throats

but the same process can occur in the

guts colonic pseudo obstruction herpes

zoster in which the pain can

occasionally precede the onset of the

unilateral vesicular rash by a few days

and a rectus sheath


let's bring back the abdomen picture to

make a few more points about location

some ideologies of abdominal pain have

common patterns of radiation for example

pyelonephritis typically radiates around

the flank to the lateral back while

nefra lathis

radiates to the groin hepatic and

biliary pathology often radiates to the

right shoulder and pain from

pancreatitis and a Triple A can radiate

straight backwards

when it comes specifically to

appendicitis there is a classic

migratory pattern to the pain early

appendicitis triggering just visceral

pain fibers is first felt not in the

right lower quadrant but rather in the

perio umbilical area where it's actual

location is kind of vague and not yet

associated with tenderness in the next

phase as the perineum overlying the

appendix becomes inflamed the pain is

now felt more in the right lower

quadrants and is associated with

significant tenderness and the lead

phase if the appendicitis is not

identified and treated in a timely

fashion perforation occurs leading to

generalized pain along with peritoneal

signs from secondary peritonitis

visceral pain fibers poorly localized

compared to somatic fibers to innervate

the peritoneum as a consequence

despite the specific anatomic framework

are reviewed earlier pain does not

always map neatly to specific abdominal

quadrants or regions for example

visceral pain from foregut structures is

most common in the epigastric region but

can be found in either the right or left

upper quadrants or near the umbilicus

painful mid gut structures can extend

into the epigastrium and super pubic

regions hindgut structures can lead to

pain throughout half the abdomen pain

from the GU system and reproductive

systems can be widespread and even pain

from the liver and biliary system can

extend outside the right upper quadrants

now I'll shift to discussing the

step-by-step evaluation of abdominal

pain starting from the history one of

the most important questions is the

chronology of the pain for example its

acuity of onset and extremely abrupt

onset suggest a bowel perforation or

vascular catastrophe including

intra-abdominal thromboembolism ruptured

triple-a and ovarian or testicular

tortion how long is the pain been

present for and whether it is episodic

or continuous as a general rule episodic

pain suggests a less imminently

dangerous pathology such as biliary

colic peptic ulcer disease GERD chronic

mesenteric ischemia and gastroparesis

but that rule isn't perfect since

intermittent epigastric pain could be an

atypical presentation of acute coronary

syndrome as I just reviewed the location

and radiation of pain is helpful at

narrowing down diagnostic possibilities

determine what the exacerbating factors

are for example pain related in any way

to food intake suggests either upper GI

pancreatic or biliary pathology ask

about the presence of associated

symptoms including nausea and vomiting

diarrhea or constipation

evidence of GI bleed lack of flatus or

passing gas fever jaundice dysuria or

hematuria obviously take a past medical

and surgical history and a gynecological

history to medication history sexual

history for STI risk factors substance

use history particularly alcohol travel

history and a general exposure history

after vitals a focused physical exam

should of course include a thorough

abdominal exam and if any type of

reproductive pathology is on the

differential for a female patient a

pelvic exam

since cardiac and pulmonary disease can

refer to the upper abdomen those exams

should be performed as well

you may notice here that I have not

listed a rectal exam that's because it's

generally not indicated unless anal

rectal or prostatic disease is

specifically suspected

key Labs in the workup of acute

abdominal pain include cbc lfts

metabolic panel and a light pace the

last of which is specifically to help

identify pancreatitis historically

another test called amylase was also

frequently ordered in this presentation

but it's nonspecific and does not

contribute useful information other

frequently considered tests if the

patient is a woman of childbearing age

get a urine HCG to screen for pregnancy

even if she reports no sexual activity

patients are sometimes not forthcoming

and an ectopic pregnancy is not a

diagnosis you or your patient can afford

to miss if a cute bow ischemia is

suspected an elevated lactate would be

consistent with infarction unless the

patient is young healthy and without

cardiovascular risk factors order a

troponin and an ECG

to rule out acute coronary syndrome if

the pain is upper abdominal or where the

patient has concurrent pulmonary

symptoms order a chest x-ray if the

patient reports either dysuria or

hematuria check a UA plus or minus urine

culture depending on suspicion for a

urinary infection and there are numerous

indications for either a CT ultrasound

or rarely other imaging modality while

as a general rule at least in the United

States clinicians over rely on imaging

in most circumstances in my experience

acute abdominal pain is not one of them

point in my approach to symptom videos I

usually present a diagnostic algorithm

that one could follow to arrive at the

single most likely diagnosis but with

acute abdominal pain there are just too

many ideologies to reasonably include in

one algorithm so instead I'm going to

review a handful of illness scripts for

some of the most common diagnoses which

will compare and contrast typical

historical features risk factors common

exam findings and the relevant

diagnostic tests I'll divide these

scripts in half

starting with causes of general and or

more midline pain and will then

separately compare and contrast the four

most common causes of right upper

quadrant pain

first let's compare and contrast public

ulcer disease gastroenteritis small

bowel obstruction appendicitis and

pancreatitis in PUD the pain is

epigastric occasionally radiating to the

back it may be triggered by eating there

is occasionally associated nausea and

vomiting and/or overt signs of GI

bleeding like mallanna but these are

usually absent risk factors include

NSAID use and h pylori infection

physical exam can shield mild to

moderate epigastric tenderness if there

are parents neal science presents the

ulcer has likely perforated and needs a

surgeon routine blood tests are usually

unremarkable unless the patient has

significant bleeding

PUD is diagnosed via EGD which should be

supplemented with testing for HP Laurie

when it comes to gastroenteritis pain is

typically parry umbilical it's often

cramping and associated with nausea

vomiting and diarrhea in most cases

there aren't really significant risk

factors outside of an outbreak the exam

will show mild to moderate Perry on

Biblical or generalized tenderness but

no rigidity or peritoneal science fever

and science of dehydration are common

the only typical abnormal blood test is

an elevated white blood cell count

diagnosis is a clinical one not

requiring any imaging or endoscopy in

just the last several years some US

medical centers have begun employing

stool pcr panels for some patients

presenting with diarrhea in order to

identify the specific pathogen late

gastroenteritis the pain from a small

bowel obstruction is typically

periumbilical and crampy it's associated

with nausea and vomiting abdominal

distension and an absence of flatus risk

factors for an SPO include prior

abdominal or pelvic surgery hernias

foreign body ingestion inflammatory

bowel disease and an intestinal tumor

the exam usually shows abdominal

distension there may be high

pitched rushing bowel sounds there may

be signs of dehydration and a peritoneal

science suggests perforation or

infarction even though in SPO can

usually be diagnosed on history and exam

alone these patients should all get a CT

to identify the location of the

obstruction and to search for potential

causes if for some reason CT is not

available plain films are a reasonable

alternative to definitively confirm the

diagnosis in which case upright and

supine abdominal film should be ordered

plus or minus an upright chest x-ray

which can better identify the presence

of free air

as already discussed pain from the

pendous itis is classically present in

the right lower quadrant but often

begins in the para umbilical region

nausea vomiting in anorexia usually

followed the onset of pain rather than

the other way around if there is severe

generalized pain perforation is likely

there are no major risk factors for

appendicitis on exam the most notable

finding is tenderness and a specific

location called McBurney's points which

is located one third of the distance

along an imaginary line from the

anterior superior iliac spine to the

umbilicus there are some other classic

but less discussed findings such as Rob

Zing's so s and obturator signs patients

are often febrile and once again

peritoneal signs suggest perforation

significant labs in Penta situs include

high white counts and an elevated CRP

while an elevated CRP would be expected

in some other abdominal diseases such as

peritonitis and acute cholecystitis for

some reason it's more discussed as a

feature of appendicitis specifically

there is also a clinical prediction rule

called the Alvarado score which assigns

points to various historical exam and

lab features to give an overall

probability of the diagnosis any patient

with suspected appendicitis should

undergo imaging which can be either CT

or ultrasound the choice of which is

institution clinician and situation

dependent and then there is pancreatitis

in which patients present with

epigastric pain radiating to the back

that's exacerbated by eating and

relieved by sitting up and leaning

forward it's usually associated with

nausea and vomiting this mia is a more

commonly associated symptom in

pancreatitis than with the other

diagnoses in this chart risk factors or

ideologies for pancreatitis include

alcohol and gall stones which together

account for the majority of cases less

common causes include ERCP

hypertriglyceridemia and a variety of

medications on exam severe cases can

present with shock and parry umbilical

or flank

ecchymosis suggests hemorrhage secondary

to pancreatic necrosis

a particularly worrisome sign the most

notable abnormal lab is in very elevated

lipase typically more than three times

the upper limit of normal while a CT

scan is not considered necessary for the

diagnosis it can assess for

complications and help identify gall

stones in the pancreatic duct as a

potential causative factor

now let's run through the illness

scripts of four particularly important

causes of right upper quadrant pain

biliary colic acute cholecystitis acute

cholangitis and acute hepatitis in

biliary colic caused by gall stones

within the gallbladder the pain is

typically episodic lasting 30 minutes to

several hours it's often triggered by

eating there is no associated jaundice

risk factors include female sex

pregnancy obesity rapid weight loss and

diabetes the physical exam is usually

unremarkable as our routine blood tests

a right upper quadrant ultrasound will

show gall stones and help to clinch the

diagnosis but this is a non emergent

study if the clinical presentation is

classic the pain in acute cholecystitis

is progressive over hours nausea and

vomiting are common and since the common

bile duct is not involved there is no

jaundice the most notable risk factor

for acute cholecystitis is the known

presence of pre-existing gall stones on

exam patients are often febrile the

classic finding is an increase in right

upper quadrant tenderness on inspiration

when the diaphragm descends pushing the

liver and gallbladder into the examiners

stationary hands this is known as

Murphy's sign there's also something

called the sonographic Murphy sign in

which pain is worse with inspiration

when the pressure is applied to the

right upper quadrant with an ultrasound

probe at the exact location of the

gallbladder since the examiner can

directly see it on the screen this is

thought to be more specific than the

classic Murphy sign routine lab tests

usually reveal and elevated white counts

with normal or near-normal l.f.t.s a

definitive diagnosis can usually be made

with a right upper quadrant ultrasound

in acute cholangitis the pain is similar

to acute cholecystitis and nausea and

vomiting are also common however

jaundice also occurs risk factors for a

cou cholangitis include benign biliary

strictures and malignant obstruction of

the biliary system including pancreatic

tumors as a very general rule patients

appear more ill than in other common

causes of right upper quadrant pain

but this is less often the case in the

elderly and in those on

immunosuppressive medications common

test findings include a high white count

high bilirubin which is predominantly

direct or conjugated bilirubin high

alkaline phosphatase and there may or

may not be mild to moderate elevation of

ast and alt if after the history exam

and blood tests the pretest probability

of cholangitis is high one can proceed

directly to an ERCP otherwise consider a

right upper quadrant ultrasound and the

last diagnosis to discuss is acute

hepatitis which is acute infection and

or inflammation of the liver the

symptoms of acute hepatitis can be

similar to those of acute cholangitis

though in my experience the onset is

slightly more prolonged risk factors

were more appropriately ideologies here

include hepatitis viruses particularly a

alcohol acetaminophen toxicity and

autoimmune hepatitis there are many

other causes of acute hepatitis but

these for cover the overwhelming

majority in the US and other Western

countries on exam fever is sometimes

present and there can be a variety of

findings related to liver dysfunction

depending upon the severity and acuity

of presentation

Labs include high white count extremely

elevated ast and alt often over 1000

high alphas high bilirubin classically

with direct and indirect being roughly

equal and an elevated INR other tests

you should order include hepatitis virus

serologies and acetaminophen level

though a single number is impossible to

interpret in the absence of a known time

of acute drug ingestion also if another

etiology of the hepatitis has not been

clearly established Auto antibodies for

autoimmune hepatitis are reasonable to


when discussing acute abdominal pain

it's common to hear the term surgical

abdomen use of this term implies that

the underlying etiology requires an

emergent evaluation by a surgeon

specific exam characteristics that are

consistent with a surgical abdomen

include rigidity also known as

involuntary guarding which is the most

concerning of abdominal physical


unusually severe tenderness to palpation

science of peritonitis known as

peritoneal signs include rebound

tenderness this is the finding that pain

caused by slow abdominal pressure

applied by the examiner's hands is not

as severe as a pain caused by the quick

release of that pressure

it includes a positive cough test in

which pain is worsened by coughing the

bed bump test in which it is worsened by

the examiner pumping the bed hard which

works best on a gurney rather than a

sturdy hospital bed or the heel strike

test in which pain is worsened by the

examiner firmly striking the patient's

heel in ambulatory patients the heel

strike test can be done by asking the

patient to stand and jump in place and

absent bowel sounds

none of these findings in isolation

necessarily indicate a surgical abdomen

but seeing multiple of them in a patient

whose history is consistent with a

possible surgical emergency would

suggest this general situation

also not every surgical emergency

presents with a surgical abdomen

specifically emergencies which are extra

peritoneal such as a ruptured aortic

aneurysm the term surgical abdomen is

sometimes used interchangeably with the

term acute abdomen although some

clinicians use the latter term more

broadly to mean any patient with acute

abdominal pain and any notable physical

exam findings irrespective of likely


finally I'll end by listing those

conditions to particularly consider in

patients with abdominal pain who are

presenting with shock at the time of

initial presentation these include acute

cholangitis bowel perforation balan

farken ruptured ectopic pregnancy

ruptured triple-a splenic rupture any

condition with concurrent massive GI

bleed and an acute myocardial infarction

the key takeaway points for this video

acute abdominal pain is one of the most

common presenting symptoms to the

emergency room and urgent care

there are many ideologies ranging in

severity from benign and self-limited to

imminently life-threatening idealogy

czar associated with specific locations

of pain but they do not always map as

precisely to anatomic quadrants as

references typically suggest abdominal

pain can be referred from intrathoracic

pathologies and finally the presence of

rigidity unusually severe tenderness to

palpation peritoneal signs and absent

bowel sounds are consistent with a

surgical abdomen which usually requires

emergent surgical consultation