abdominal pain
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Etiology
(also see pelvic pain)
- intra-abdominal disorders
- inflammatory
- mechanical
- vascular
- extra-abdominal
- food poisoning
- pharmacologic agents
- household chemical ingestion
- occupational & environmental exposure
Pathology
- abdominal viscera has splanchnic innervation
- only distension or stretch is recognized
- visceral pain is bilateral, felt in midline
- onset of pain is slow
- visceral pain may progress to involve parietal peritoneum
- parietal peritoneum has somatic innervation
- T6-T12 nerve roots
- localized pain
- parietal pain may be so great as to shadow underlying visceral pain
- visceral peritoneum has no innervation
History
- duration, pattern of progression, location at onset, present location, character of pain (burning, cramping, dull, sharp, constant or intermittent), rate of onset, fever/chills, nausea/ vomiting, hematemesis, temporal relationship of vomiting to abdominal pain, chest pain, constipation, change in bowel habits, obstipation, diarrhea, dysuria, hematuria, hematochezia, melena, anorexia, weight loss, dysphagia, trauma
Clinical manifestations
- rebound tenderness indicates parietal peritoneum involvement
- fever & jaundice suggest hepatobiliary involvement
- cramping suggests relationship to bowel peristalsis
- objective signs of organic disease
- pain or diarrhea awakening patient from sleep
- vomiting
- dysphagia
- blood in the stool
- weight loss
- fever
- abdominal mass or organomegaly
- anemia
- jaundice
- abdominal pain out of proportion to physical findings suggests mesenteric ischemia[3]
- pain scores do not correlated with pathology on abdominal CT[12]
Laboratory
- complete blood count (CBC) with differential
- urinalysis
- serum chemistries
- electrolytes
- urea nitrogen
- creatinine
- glucose
- lipase
- amylase
- bilirubin - conjugated & unconjugated
- transaminases
- albumin
- PT/PTT
- PSA to rule out prostatitis
- fecal occult blood testing
- urine pregnancy test
Diagnostic procedures
(procedures)
- abdominal paracentesis
- GI endoscopy
Radiology
- flat & upright abdominal radiograph
- chest radiograph
- abdominal ultrasound &/or pelvic ultrasound
- ultrasound followed by CT only if ultrasound results are nondiagnostic optimizes sensitivity while minimizing radiation exposure[8]
- early abdominal CT better than plain film[4][6]
- oral contrast needed for r/o appendicitis
- upper &/or lower GI contrast studies
Management
- general measures
- nothing by mouth until diagnosis is made
- pharmacologic agents
- laparoscopy if indicated
- surgery if indicated
- specific measures for specific etiologies
More general terms
More specific terms
- abdominal migraine
- acute abdomen
- chronic abdominal pain
- colic
- epigastric pain
- flank pain
- left lower quadrant pain
- left upper quadrant pain
- right lower quadrant pain
- right upper quadrant pain
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 291-92, 1152-1156
- ↑ Chan & Winkle, Diagnostic History & Physical Examination, Current Clinical Strategies Publishing. Laguna Hills, 1996
- ↑ 3.0 3.1 Medical Knowledge Self Assessment Program (MKSAP) 11, 19. American College of Physicians, Philadelphia 1998, 2021
- ↑ 4.0 4.1 Journal Watch 23(5):40, 2003 Ng CS et al, Evaluation of early abdominopelvic computed tomography in patients with acute abdominal pain of unknown cause: prospective randomized study BMJ 325:1387, 2002 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/12480851 <Internet> http://bmj.com/cgi/content/full/325/7377/1387
- ↑ 5.0 5.1 Journal Watch 23(5):40, 2003 Thomas SH et al, Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective study J Am Coll Surg 196:18, 2003 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/12517545 <Internet> http://www.acep.org/library/pdf/cp402130.pdf
- ↑ 6.0 6.1 MacKersie AB, Lane MJ, Gerhardt RT, Claypool HA, Keenan S, Katz DS, Tucker JE. Nontraumatic acute abdominal pain: unenhanced helical CT compared with three-view acute abdominal series. Radiology. 2005 Oct;237(1):114-22. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16183928
- ↑ 7.0 7.1 Green R, Bulloch B, Kabani A, Hancock BJ, Tenenbein M. Early analgesia for children with acute abdominal pain. Pediatrics. 2005 Oct;116(4):978-83. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16199711
Armstrong FD. Analgesia for children with acute abdominal pain: a cautious move to improved pain management. Pediatrics. 2005 Oct;116(4):1018-9. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16199716
Vane DW. Efficacy and concerns regarding early analgesia in children with acute abdominal pain. Pediatrics. 2005 Oct;116(4):1018. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16199717 - ↑ 8.0 8.1 Lameris W et al Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: Diagnostic accuracy study. BMJ 2009 Jun 26; 338:b2431 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19561056 <Internet> http://dx.doi.org/10.1136/bmj.b2431
Dixon AK and Watson CJ Imaging in patients with acute abdominal pain. BMJ 2009 Jun 26; 338:b1678. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19561055 <Internet> http://dx.doi.org/10.1136/bmj.b1678) - ↑ 9.0 9.1 The NNT: Opiates Given During the Evaluation of Abdominal Pain. http://www.thennt.com/nnt/opiates-during-abdominal-pain-evaluation/
Ranji SR, Goldman LE, Simel DL, Shojania KG Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA. 2006 Oct 11;296(14):1764-74. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17032990 - ↑ Nayor J, Vaidya A, Srivastava A, Seifter JL, Rutherford AE. INTERACTIVE MEDICAL CASE. Tracing the Cause of Abdominal Pain. N Engl J Med 2016; 375:e8. August 11, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27509123 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMimc1512611
- ↑ Schifeling CH, Williams DA. Appropriate Use of Imaging for Acute Abdominal Pain JAMA Intern Med. Published online November 6, 2017 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29114737 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2661707
- ↑ 12.0 12.1 Zitek T, Pellman L, Uribe J, Guillen A. Pain scores are not predictive of radiographically evident intraabdominal pathology in patients with abdominal pain. Acad Emerg Med 2019 Jul 31; PMID: https://www.ncbi.nlm.nih.gov/pubmed/31365769 https://onlinelibrary.wiley.com/doi/abs/10.1111/acem.13841