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Diagnosis approach to abdominal pain

HISTORY
Patients should first be asked about the time course of pain, both as past of the evaluation for a surgical abdomen and because once a surgical abdomen has been excluded the remainder of the evaluation will be guided by the chronicity of the symptoms along with the location pain.
The history should include:
– Location of pain
– Radiation of pain
– Factors that exacerbate or improve symptoms sush as food, antacids, exertion, defecation
– Associated symptoms including fevers, chills, weight loss or gain, nausea, vomiting, diarrhea, constipation, hematochezia, melena, jaudice, change of the color of urine or stool, change in the diameter of stool
– Past medical and surgical history, include rick factors for cardiovascular disease and details of previous abdominal surgeries
– Family history of bowel disorders
– Alcohol intake
– Intake of medications including over the counter medications sush as acetaminophen ( paracetamol), aspirin, and NSAIDs
– Menstrual and contraceptive history in women

PHYSICAL EXAMINATION
Physical examination will vary depending upon the location and chronicity of the patient’s symptoms. However, typical examination will be include:

  • Measurement of blood pressure, pulse and tempertature
  • Examination of the eyes and skin of jaundice
  • Auscultation and percussion of the chest
  • Auscultation of the abdomen for bowel sounds
  • Palpation of the abdomen for masses, tenderness, and peritoneal signs
  • Rectal examination including testing of stool for occutl blood
  • Pelvic examination in women with lower abdominal pain

ACUTE VERSUS CHRONIC PAIN
while an arbitrary interval, sush as 12 weeks, can be used to seperate acute from chronic abdominal pain, there is not strict time period that will classify the differential diagnosis unfaillingly. A clinic judgment must be made that considers whether this is an accelerating  process, one that has reached a plateau, or one that is longstanding but intermittent:

  • Pain of less than a fews days duration that has worsened progressively until the time of presentation is clearly acute
  • Pain that has remained unchanged for months or years can be safely classified as chronic
  • Pain that does not clearly fit either category might be called subacute and requires consideration of the differential diagnosis for both acute and chronic pain

Pain in a sick or unstable patient should generally be managed as acute, since patients with chronic abdominal pain may present with an acute exacerbation of a chronic problem or a new  and unrelated problem

ACUTE ABDOMINAL PAIN
Surgical abdomen- The first diagnoses that must be considered in patients with acute abdominal pain are those that may require urgent surgical intervention. The ” surgical abdomen” can be usefull defined as a condition with rapidly worsening prognosis in the absence of surgical intervention. Two syndromes that consititute urgent surgical referrals are obstruction and peritonitis. The latter encompasses most severe abdominal pathology since intraperitoneal hemorrhage or viscus performation typically present with common features of peritotitis.
Patients with acute surgical abdomens will often have a rapid symptom evolution, but patients who have evolved from partial to complete bowel obstruction, and it can be associated with unstable vital signs, fever, and dehydration.
Location and evolution of symptoms are helpful in narrowing the differential diagnosis, as in the classic evolution from visceral and periumbilical pain, to sharp right lower quadrant pain, in acute appendititis. a particularly high level of suspicion should be maintained for severe pathology in immunosuppressed patients and the elderly, where classic signs of peritoneal inflammation may be attenuated.
only after the clinician as satisfied that the abdominal presentation is not an acute surgical emergency can consideration of other diagnostic possibilities begin. Patients should not eat or drink while a diagnosis  of a surgical abdomen remains under consideration.

  1. Obstruction– Obstruction generally presents as pain together with anorexia, bloating, nausea, vomitting, and obstipation. Physical examination may reveal distention and high-pitched or absent bowel sounds. Abdominal percussion reveals tympany from proximally dilated loops of bowel. An abdominal mass, if present, may suggest anetiology for the obstruction.
  2. Peritonitis– Patients with peritonitis of any cause tend to ” look sick” and lie still minimize their discomfort. They may receive little benefit from analgasics. Althought rebound tenderness and its variants are classically thought to reflect peritonitis, abdominal wall rigidity and tenderness elicitable by percussion or very light palpation are also often overlooked features consistent with  a surgical abdomen . Others subtle signs of peritonitis that can be pursued include diminished bowel sounds and pain worsened when an examiner lightly bumps the stretcher.
  3. Initial diagnosis testing- Patients with a surgical abdomen should have the following laboratory measurements:
  • Complete blood count with differential
  • Electrolytes, BUN, Creatinin, and glucose
  • Aminotransferase, alkaline phosphase, and bilirubin
  • Lipase
  • Urinalysis
  • Pregnacy test in women of childearing potential

In the presence of fever or unstable vital signs, blood and urine clutures should be performed.
While these laboratory tests are important , they are not sufficient to rule in or rule out a diagnosis of surgical abdomen, as a surgical abdomen is clinical diagnosis.
Abdominal radiographs are a crucial step in decision making for the suspected surgical abdomen, as proximally dilated loops of bowel are the hallmark of intestinal obstruction, are free intraperitoneal air can confirm a suspicion of hollow organ perforation. Peritonitis is the absence of perforation or obstruction may not yeild any conclusive radiographic findings. Where CT scanning is immediately availble and necessary for further evaluation, as describerd below, abdominal plain films are not necessery, as they do not  provide additional information.

  1. Subsequent diagnostic testing –

Right upper quadrant pain- Pain involving the liver  or biliary tree is generally located in the right upper quadrant, but it may radiate to the back or epigastrium. Because hepatic pain only results when the capsule ( Glisson) of the liver is ” stretchesd “, most pain in the right upper quadrant is related to the biliary tree. Viral  or drug-included hepatitis can sometimes cause  acute right upper quadrant pain as well.
Initial assessment of patients  with right upper quadrant pain must consider serious causes and complications:

  • The presence of the fever and jaundice  in a patient with right upper quadrant pain leads to a clinical diagnosis of ascending cholangitis
  • Acute cholecystitis can also present as a systemically unwell patient with low-grade fever
  • Nonabdominal etiologies of upper abdominal pain must be considered

Once these possibilities have been cosidered, the history can be explored in more detail. Since gallstones are sush as a common cause of relatively benign pain, as well as the serious complications mentioned above, the history for right upper quadrant pain focuses initially on rick factors or gallstone disease and previous episodes of simila pain.

Epigastric pain- Epigastric pain that is relatively sudden in onset is suggestive of pancreatitis, particularly when it radiates to the back and is associated with nausea, vomitting, and anorexia

  1. Nonabdominal etiologies of upper abdominal pain
  2. Diagnostic testing for pancreatitis
  3. Diagnistic testing for dyspepsia

Lower abdominal pain

  1. nonabdominal etiologies of lower abdominal pain
  2. Diagnostic testing

Lower abdominal pain in  women
Generalized abdominal pain

  1. Diagnostic testing

CHRONIC  ABDOMINAL PAIN

  1. Initial diagnostic testing
  2. Subsequent diagnostic testing
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