See Also
History
1. Abdominal Pain characteristics
  1. Time of onset
  2. Pain localization and radiation
  3. Palliative and provocative factors
2. Associated Symptoms
  1. Nausea or Vomiting
  2. Fever
  3. Anorexia
  4. Diarrhea or Constipation
  5. Bloody stool
  6. Dysuria
3. Past Medical History
  1. Abdominal surgery, procedures or trauma
    1. Consider Small Bowel Obstruction
  2. Cholelithiasis
  3. Diverticulitis
  4. Cardiovascular disease
    1. Consider Mesenteric Ischemia
    2. Consider Abdomnal Aortic Aneurysm
    3. Consider referred cardiac ischemia pain
  5. Diabates Mellitus (Diabetic Ketoacidosis)
  6. Human Immunodeficiency Virus (HIV)
  7. Sickle Cell Anemia
  8. Inflammatory Bowel Disease
4. Social History
  1. Tobacco Abuse
    1. Consider Mesenteric Ischemia
    2. Consider Abdominal Aortic Aneurysm
  2. Alcohol Abuse
    1. Consider Pancreatitis
    2. Consider gall bladder disease
5. Medications
6. Recent Travel (Parasitic infection)
7. Review of Symptoms
  1. Pharyngitis (may mimic surgical abdomen)
  2. Genitourinary
    1. Menstrual History
    2. Obstetrical history
    3. Urinary Symptoms (Dysuria, Hematuria, frequency)
Examination
1. General appearance
  1. Acutely or chronically ill appearing patient
  2. Malnourished patient
  3. Positioning
    1. Retroperitoneal irritation: Thighs flexed
    2. Peritonitis: Lie very still
    3. Bowel Obstruction or Nephrolithiasis: Restless
2. Back Exam
  1. Flank Ecchymosis
3. Cardiopulmonary examination
  1. Assess for Myocardial Infarction
  2. Assess for Cardiac arrhythmia
  3. Arterial Pulses
    1. Femoral pulse
    2. Pedal pulses (dorsalis pedis and posterior tibial)
4. Abdominal examination
  1. Pearls
    1. Do not test rebound tenderness by rapid release
    2. Stethoscope applies pressure and observe response
  2. Observation
    1. Distention, Asymmetry or Peristalsis
    2. Scars from prior abdominal surgeries, trauma
    3. Hernia (and signs of incarceration)
    4. Reduced chest excursion (due to guarding)
  3. Auscultation
    1. Borborygmi: Consider Bowel Obstruction
    2. Silent: Consider surgical abdomen
  4. Palpation
    1. Maximal tenderness
    2. Pulsatile masses (Abdominal Aortic Aneurysm)
    3. Abnormal fullness
    4. Muscle tone
5. Genitourinary examination
  1. Examine for Femoral Hernia
  2. Rectal exam in all patients with Abdominal Pain
    1. Pain on palpation
    2. Occult or frankly bloody stool
  3. Pelvic exam in all women
Labs and Diagnostic Studies
1. Urinalysis
2. Complete Blood Count (CBC)
  1. Leukocytosis lags other findings in elderly
3. Electrocardiogram
4. Pulse oximetry
5. Serum Phosphate (increased in Mesenteric Ischemia)
6. Liver Function Tests
7. Blood Cultures
8. Amylase
  1. Pancreatitis (Lipase preferred)
  2. Bowel Obstruction
  3. Bowel perforation or peptic ulcer perforation
  4. Mesenteric Ischemia
9. Lipase Indications
10. Arterial Blood Gas
Imaging: Protocol
1. Directed imaging where specific cause is suggested
2. Initial non-specific radiology studies
  1. Chest XRay findings
    1. Abdominal free air
    2. Congestive Heart Failure
    3. Pneumonia
  2. Kidney, Ureter, Bladder plain XRay (KUB) findings
    1. Small Bowel Obstruction
    2. Incarcerated Hernia
    3. Appendicitis
    4. Large Bowel Obstruction
    5. Diverticulitis
    6. Volvulus
    7. Mesenteric Ischemia
3. Second-line studies where diagnosis unclear
  1. See available studies below for specific indications
  2. Abdominal CT is most broadly useful study
    1. "Workhorse" of Acute Abdomen evaluation
    2. Sucher (2002) Semin Laparosc Surg 9(1):3
  3. Right upper quadrant ultrasound
    1. First-line study if biliary tract disease suspected
  4. Angiography or MR angiography
    1. Indicated for Mesenteric Ischemia
  5. Upper Endoscopy
    1. Indicated if Peptic Ulcer Disease suspected
Imaging: Available studies
1. Chest XRay
  1. Assess for cardiopulmonary process
  2. Identifies 50-90% of perforated viscus
    1. Free air under diaphragm
    2. Increased sensitivity
      1. Left lateral decubitus XRay
      2. XRay after 500 ml air given via Nasogastric Tube
2. Abdominal XRay (KUB) Indications
  1. Bowel perforation
  2. Bowel Obstruction
  3. Abdominal Aortic Aneurysm
  4. Volvulus
  5. Nephrolithiasis
  6. Abdominal trauma
  7. Mesenteric Ischemia
  8. Cholelithiasis
3. Abdominal Ultrasound Indications
  1. Cholecystitis
  2. Appendicitis (lower efficacy than CT)
  3. Abdominal Aortic Aneurysm (hemodynamically unstable)
4. Abdominal CT Indications
  1. Appendicitis
  2. Diverticulitis
  3. Bowel Obstruction
  4. Pancreatitis
  5. Abdominal Aortic Aneurysm (hemodynamically stable)
  6. Mesenteric Ischemia
5. Angiography or MR Angiography Indications
  1. Mesenteric Ischemia

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This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 5/10/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.