Acute Abdomen

Workbook
IHOP

I = Infection
= Intussusception
= Ischemia

H = Hemorrhage

O = Obstruction

P = Perforation

Bruce S. Zitkus
EdD(c), RN, ANP-BC, FNP-BC, CDE

Royal College of Nursing

Nurse Practitioner Conference,
September 7 & 8, 2007
Daventry, Northamptonshire, UK

The information contained in this presentation was obtained from multiple sources. It is the
responsibility of the user to update themselves on current medical concepts and treatments as well as
the current medical practices in the states where they practice as a healthcare professional.

Zitkus - 2007 1
 Abdominal Pain Progress Note
Name:________________________________________ Age:_____ Date:______________ Allergies: NKDA PCN ASA Sulfa Mycins Quins _________
Chief Complain: ______________________________________________________________________________________Pain Level Current __/10 Max __/10
____________________________________________________________________________________________________Type: ___ Generalized ___ Localized
___________________________________________________________________________________________________ Type of onset: __Acute __Gradual
____________________________________________________________________________________________________Location: __RUQ __LUQ __RLQ __LLQ
Pain Aggravating Factors:_______________________________________________________________________________ Quality: __Sharp __Dull __Burning
Pain Alleviating Factors: __________________________________________________________________________________ __Achy __Tearing

PMH: PMH: __ CAD __HTN __ Diabetes __ COPD __ Chol __Ulcer __GI Disease Other: _____________________________________________________
PSH: __ CABG __ Append. __ Hyst __ Chole ___ D&C __ Hernia Other: _____________________________________________________________________
Recent Procedures: __PAP __Colonoscopy __Endoscopy __CT Scan __MRI __ECHO __Stress Test Other: ________________________________________
Social Hx: _____ Smoker (Quit __ yrs) / Drugs / ETOH (Hx / Social) Other: __________________ LMP: __________ G __ P __ A __ Pregnant/Postmenopausal
Meds: _______________ _______________ _______________ ______________ _______________ _______________ ______________
_______________ _______________ _______________ ______________ _______________ _______________ ______________

REVIEW OF SYSTEMS:
General: __ NEG __ Wt loss / gain __ fever __ chills __ night sweats GU: __ NEG __ pattern change __ incontinence __ hematuria
Neuro: __ NEG __ HA __ Forgetfulness __ LOC __ Weakness MS: __ NEG __ Joint pain __ fractures __ muscle pain __ back pain
HEENT: __ NEG __ Sore throat __ sinusitis NECK: __↓ JVP ___JVD Skin: __ NEG __ lesions __ cancer __ rashes __masses __ changes
CVS: __ NEG __ chest pain __ palpitations __ SOB __ leg pain Endo: __ NEG __ poly –dipsia / -phagia / -uria; __ cold / heat intol.
Lungs: __ NEG __ wheeze __ cough __ bronchitis __ pneumonia Psych: __ NEG __ insomnia __ fatigue: _________________________
GI: __ NEG __ bleeding __ bowel changes __ heartburn __ GERD __ N/V Hem: __ NEG __ easy bruising __ transfusion hx __

BPL ____/____ PHYSICAL EXAM

VITALS: BPR ____/____ P____ R ____ T ___ Wt _____ Ht ____ Wst Circ ____ BMI____ || Alert __ Anxious __ Distress: NAD __ Mild __ Mod__ Severe___
HEENT __ Icterus/pale conjunctiva NECK / BACK __ cervical
lymphadenopathy (R / L)
__ Nares patent __ Pale / boggy / errythematous __ Neck supple __ carotid bruit (R / L) ___Dec / Inc JVP
__ TM intact __ Pharyngeal edema / exudate __ Non-tender __ neck / back tenderness
__ Pharynx normal __ TM effusion / rupture (L / R / BL) __ FROM __ trap muscle spasm / dec. ROM
__ PERRLA __mm __ Sinus tenderness (Max / Front / Eth) __ dec. ROM (L / R / ext / flex)

RESPIRATORY __ respiratory distress CVS __ irregularly irregular rhythm

__ No resp. distress __ rales (L / R / BL) __ RRR __ extra systoles (occ / freq)
__ Breath sounds nl __ wheezing (L / R / BL) __ S1S2 __ murmur grade ___/VI systolic/diastolic
__ ___________________________ __ _______________________________

ABDOMEN __ tenderness RUQ / LUQ / RLQ / LLQ RECTAL __ Tenderness

__ BS +, NT, ND, soft __ hepatomegaly / splenomegaly __ Tone __ Prostate enlarged
__ No organomegaly __ obese / distended / hard __ Prostate nl (male) __ Rectal mass / discharge
__ Visible Peristalsis __ Fluid Wave __ Masses / hemorrhoids
__ Absent Bowel Sounds __ Stool guiac positive
__ Murphy's __ Psoas __Obdurator __ _______________________________
__ Britton’s __ Markle __ Blumberg
__ Kehr’s __Fist Percussion

SKIN __ cyanosis / diaphoresis / pallor EXTREMITIES __ pedal edema

__ color NL / no rash __ skin rash ________ __ spider nevi __ Pulses 2+ __ tenderness to palpation
__ warm, dry__ ulceration __ puncture __ laceration __ Normal ROM __ Homan’s Sign
__ Strength 5/5__ Sensation Intact
GU: __ hernia, mass __ SLR: L ___ R ___
__ NL male __ lesions, rash __ ______________________________
__ PAP __ CVA tenderness

NEUROLOGICAL/PSYCHOLOGICAL
Higher Functions Cranial nerves__ facial droop (R / L)
__ alert __ no response __ eyes open __ II-XII non-focal __ tongue deviation (R / L)
__ oriented x3 __ abnormal response to pain __ nl reflexes 2+ __ unequal pupils R __mm L __mm
__ Mood / affect normal __ disoriented to time/place/person

Cerebellar __ normal as tested __ abnormal Romberg test __ abnormal finger-nose-finger __ abnormal gait

CLINICAL IMPRESSION: 1) ABDOMINAL PAIN r/o ______________________________________________________________________________________

ADDITIONAL DIAGNOSES: 2) _________________ 3) ____________________ 4) __________________ 5) ___________________ 6) ____________________

DIAGNOSTICS: Radiology: __ CXR __ KUB __ US __ CT Scan (Abd / Pelvis / Chest) __ MRI: ___________ Cardiology: __ EKG __ ECHO __ Stress

Labs: __ CBC __ SMAC ( ) __ PT/INR __Thyroid Panel __ Chol __ LFT’s __ Amylase/Lipase __ UA __ Urine C&S __ β-hCG __ Lactic Acid __ Stool

Education: Diabetes Exercise STE Prostate CA/BPH SBE Smoking Cessation Colonoscopy CA Lipids HTN CAD COPD LBS CervSprain Nutrition

1) ___________________________________________ 4) _______________________________________________

2) ___________________________________________ 5) _______________________________________________ _____________________

3) ___________________________________________ 6) _______________________________________________ Signature

Zitkus - 2007 2
 Abdominal Pain
Parietal Pain Visceral Pain Hollow Organ Pain
• Pain is localized & intense • Pain is poorly localized • Pain occurs during peristaltic activity.

– Irritant felt precisely where &
when applied
– Noxious stimuli irritate
the parietal peritoneum
– Pain is steady & constant
– Relieved with legs up in
fetal position
– Aggravated by cough or
movement
– Usually felt in the ventral
midline of the abdomen
– Noxious stimuli irritate an
abdominal viscus
– Viscera are sensitive
mostly to stretch & ischemia
– Visceral pain is dull, cramping,
gnawing or burning sensations
– Pain caused by stretching &
distention of hallow organ
– Intermittent muscle contractions
– Intensity depends on circumference
of lumen
– Crescendo – Decrescendo
– Colicky

Examples: Examples:
Examples:
– AAA – GI Tract (gastroenteritis / diarrhea)
– Mesenteric Ischemia (initial)
– Appendicitis – Ureters (stone)
– Obstruction
– Cholecystitis – Gallbladder / Biliary tract (stones)
– Pancreatitis
– Diverticulitis – Bladder (UTI)
– Pregnancy, Ectopic
– Pancreatitis – Fallopian tubes (Ectopic pregnancy /
– Splenic Rupture
– Perforation infection)
– Splenic Rupture

Solid Organ Pain Referred Pain Helpful Hints

• Pain is constant
– Usually solid organs are
insensitive to pain
– Pain occurs when the
capsule surrounding the
organ or an adjacent
structure becomes
involved
Examples:
– Liver
• Hepatic congestion
– Spleen
• Trauma / inflammation
– Pancreas
• Pancreatitis
– Kidney
• Trauma / inflammation
– Lungs
• Trauma / inflammation
• Referred pain has both visceral
and spinal components.
– These are found in the
dermatome corresponding to
the viscera’s message
entrance into the spinal cord.
– Both Vague & Precise Pain
can be felt by the patient
Examples:
– AAA
• Back, flank, abdomen, groin
– Appendicitis
• Epigastrium, periumbilical, RLQ
– Cholecystitis
• Epigastrium, RUQ, R scapula
– Pancreatitis
• Epigastrium, abdomen, back,
flanks
– Perforation
• Epigastrium, abdomen, shoulder
– Pregnancy, Ectopic
• Abdomen, shoulder
– Splenic Rupture
• Eight organ systems within single cavity
– Pain is memorable
– Patient can describe onset & evolution
• Pain History
– Time of onset
– Location of the pain
– Radiation
– Factors that lessen or increase the pain
– Quality of the pain
– Changes in stool frequency / character
– Associated symptoms
• Weight loss
• Fever
• Nausea / vomiting
– Character of vomitus
• Flatulence / Constipation / Diarrhea
• Jaundice
• Bloating
• Medical / Surgical History
– Hx of CAD / PAD
– Prior abdominal surgeries
– Family hx of abdominal pain syndromes
• Sickle cell anemia
• Mediterranean Fever
• Porphyria
• Medications
– Steroids, pain meds, NSAID’s, Erythromycin

• RUQ, abdomen, shoulder

Zitkus - 2007 3
 Physical Exam Clues
Physical Examination Clues Potential Diagnoses
General
Appearance: Sunken eyes, rapid & shallow respirations………………………………. Dehydration / Bleed / Obstruction / Peritonitis
Writhing in bed……………………………………………………………………………….. GI / Stones / UTI / ectopic pregnancy / infection
Stillness in bed………………………………………………………………………………. AAA / Appendicitis / Cholecystitis / Diverticulitis / Ectopic
Pregnancy

HEENT / Skin
Icterus………………………………………………………………………………………… Hepatitis / Cholangitis / Choledocholithiasis
Spider Nevi………………………………………………………………………………….. Bacterial Peritonitis
Blindness……………………………………………………………………………………. Aortic dissection
Sunken cheeks & hallow-eyed appearance (post repeated vomiting)……………….. Obstruction / Peritonitis
Pallor of cheeks, tongue, lips & fingernails……………………………………………… Hemorrhage
Flaring of the alae nasi…………………………………………………………………….. Pneumonia / Peritonitis
Cool, moist, clammy skin…………………………………………………………………... Potential shock

Respiratory
Restriction……………………………………………………………………………………. Peritoneal effusion
Percussion dullness, ↓ breath sounds, ↓ tactile fremitus……………………………….. Pleural effusion
Percussion dullness, ↓ breath sounds, crackles…………………………………………. Pneumonia / consolidation

CVS
↓JVP………………………………………………………………………………………….. Volume depletion (Bleed / perforation)
Dysrhythmia, S4, mitral insufficiency murmur……………………………………………. MI

Abdomen
Visible peristalsis……………………………………………………………………………. Bowel obstruction
Bulging flanks………………………………………………………………………………… Ascites
Caput Medusa……………………………………………………………………………….. Portal hypertension
Loss of liver dullness……………………………………………………………………….. Perforated viscus
Rigid abdomen, guarding, rebound tenderness…………………………………………. Peritonitis
Shift dullness, fluid waves………………………………………………………………….. Ascites
Absent bowel sounds………………………………………………………………………. Paralytic ileus / late bowel obstruction
Visible hernia………………………………………………………………………………… Strangulated hernia
Carnett’s Sign ………………….(↑ tenderness to palpation of contracted abdomen)... Suggests abdominal wall cause of pain
Murphy’s Sign………………….(Palpation of RUQ / pt takes deep breath)…………… Cholecystitis
Psoas Sign……………………..(Flexion of thigh against resistance)………………….. Retrocecal appendicitis
Obturator Sign………………….(Flexion of thigh with internal / external rotation)…… Retrocecal appendicitis / local abscess / hematoma /
inflammatory fluid in pelvis
Fist Percussion Sign………….(Percussion over anterior wall of chest)………………. Acute inflammation in diaphragm / liver / stomach or spleen
Rovsing’s Sign………………...(Palpation of LLQ causes pain in RLQ)……………….. Appendicitis
Britton’s Sign…………………..(Cremasteric reflex produced by RLQ pressure)…….. Appendicitis
Epicritic Hyperesthesia……….(Skin sensitivity to pin touch)…………………………… Appendicitis
Markle Sign…………………….(Jar tenderness / heel-drop)…………………………… Peritoneal inflammation / appendicitis / cholecystitis / abscess /
acute diverticulitis / abdominal organ infarction
Blumberg Sign………………….(Rebound tenderness)………………………………… Same as above in Markle sign
Kehr’s Sign……………………..(Referred pain to shoulder)……………………………. Cholecystitis, perforation
Cullen’s Sign…………………...(Periumbilical ecchymosis)……………………………. Retroperitoneal bleed
Subcutaneous Crepitus……….(Small fluctuant nodules felt)…………………………. Gas gangrene, air under skin
CVA Tenderness……………….(Tap over posterior diaphragm / costal margin)……. Kidney stones

Rectal
Tenderness…………………………………………………………………………………... Retrocecal or pelvic appendicitis / prostatitis / diverticulitis / tubo-
ovarian pathology
Mass…………………………………………………………………………………………... Rectal carcinoma / hemorrhoid
Rectal Fissure………………………………………………………………………………... Crohn’s Disease
Occult blood………………………………………………………………………………….. Ischemic colitis / peptic or duodenal ulcer

Pelvic
Tenderness…………………………………………………………………………………... Ectopic pregnancy / Ovarian cyst / PID
Mass…………………………………………………………………………………………... Ovarian cyst / tumor / abscess

Zitkus - 2007 4
 Special Populations: Points to Remember
Important Points Abdominal Pain Causes

Geriatrics • ↓ immune function • Biliary tract disease (~ 30-50% >65 yrs have gallstones)
(60 & >) • Co-morbid conditions – 25% have no significant pain / 50% have no fever, vomiting or leukocytosis
– DM, malignancy • Appendicitis (initial incorrect dx occurs in 40-50%)
• ↓ physiologic reserve – Less common (~10% >60% have acute appendicitis)
– CAD, pulmonary disease – 20% present with anorexia, fever, RLQ pain & leukocytosis
• ↑ asymptomatic pathologies • Diverticulitis (Diverticula present in 50-80% >65)
• ↓ sensorium – 85% occurs in left colon
– Advanced symptoms – Often afebrile, <50% have ↑ WBC, & ~ 25% have guiac positive stool
• Poor historians (?dementia) • Mesenteric Ischemia (< 1% cause of abdominal pain)
• Previous surgeries (adhesions) – Mortality ranges 70-90% with delay of diagnosis
– Recurrent postprandial abdominal pain (intestinal angina)
– Severe abdominal pain (without tenderness to palpation) & vomiting / diarrhea
• Abdominal Pain Stats – Risk factors: Atrial Fibrillation, atherosclerotic disease, ↓ ejection fraction
– Appendicitis (5%) • Bowel Obstruction (Accounts for 12% of abdominal pain)
– Gallstones (10-30%) – Distention of the colon > 9cm may cause perforation
– Intestinal obstruction (25%) • Inguinal hernias most common cause of bowel obstruction
– Perforation: Diverticula (5-10%) • Large bowel volvulus (15%)
– Perforation: PUD (10%) • Small bowel obstruction 2° adhesions
– Rupture of AAA (2%) – Risk factors: inactivity & laxative use
– Strangulated hernia (20%) – Malignancies (Colon CA): 30% men & 40% women
• AAA (30% of AAA patients misdiagnosed initially)
– Patients come in with S&S of renal colic or MS back pain
– Dx in stable patient – mortality 25%; Dx in shock patient – mortality 80%
• Peptic Ulcer Disease (Users of NSAID’s are 5-10 times more likely to develop PUD)
– ~ 35% of patients have no pain; most common presenting symptom is melena
– Perforation is often painless & free air on KUB / CXR is absent in > 60% of patients
• 35-40% will have rigid, board-like abdomen (with or without shock)
• Gastroenteritis (2/3rd of all deaths in those >70 occur from gastroenteritis)
– Diagnosis of exclusion in patients with vomiting & diarrhea

Pediatrics • Most common reason to bring • Infections

child to ER – Viral (stomach flu) or bacterial (gastroenteritis)
• Infants / Young children (S&S) • Viral quickly / bacterial may need AB to treat
– Crying, facial expressions, curling up • Food Related
• Toddlers – Food poisoning, food allergies, excess food ingestion, gas production
– Talk about their pain • Poisoning
• Adolescents – Soap, lye, medications
– May be reluctant to talk about pain • Surgical
• Symptoms (clues): – Appendicitis, bowel obstruction
– Duration of pain (simple cause <24hr) • Medical
– Location of pain – Diabetes, black widow spider bite
• Simple = periumbilical
• Concern = Away from umbilicus
– Appearance of child
– Vomiting (>12-24 hrs call HCP)
• Green / yellow call HCP
• Blood / darker color to ER
– Diarrhea
• Often sign of viral cause
• Blood in stool call HCP or to ER
– Fever
• May or may not be a problem
– Groin pain
• ? Testicular torsion: to ER
– Urination with abdominal pain
• ? Infection: to HCP or ER
– Rash & abdominal pain
• Contact HCP

Obese • Palpation of abdomen • Panniculus

Individual – Imagine shape & size of organs – Tenderness thought to be in the upper abdomen may actually be in the lower abdomen
– Mark costal margins, iliac spines &
pubis (allows one to know where the
true anterior abdominal wall is)

Zitkus - 2007 5
 Important Points
Pregnancy / • Pregnant woman & abdominal pain
Gynecologic – Must evaluate mother & fetus
pain
• Fetal distress may suggest
obstetric etiology (placental
abruption, uterine rupture)
• Monitor uterine contractions
during exam
– Physiologic changes of pregnancy
• N/V, constipation, ↑ urination,
pelvic & abdominal discomfort
common in normal pregnancy
(must differentiate)
• Peritoneal signs often absent 2°
lifting & stretching of anterior
abdominal wall. Uterus can
obstruct & inhibit movement
of omentum (↓ or no pain)
• Differentiation between
extrauterine vs. uterine
tenderness, examine pt in the
right or left decubitus position
Trauma • Injuries may not manifest during initial
evaluation
• Common causes: MVA, pedestrian
accidents, falls, industrial & recreational
accidents
• Caused by 2 mechanisms:
– Compression forces
• Direct blow / external
compression against object
• Usually causes tears or
hematoma to subcapsular region
of solid viscera
• May deform hollow organs,
create internal pressure, with
possible rupture
– Deceleration forces
• Usually causes stretching / linear
shearing of fixed organs rupturing
support structures
• AMPLE mnemonic for triage history
– Allergies
– Medications
– Past medical history
– Last meal / intake
– Events leading to ER visit
Zitkus - 2007
Abdominal Pain Causes
• Appendicitis
– First Trimester: Appendix usually located at McBurney’s point
– 2nd & 3rd Trimesters: Moved upward & laterally – closer to the gallbladder
• Cholecystitis
– Epigastric / RUQ pain, nausea and/or vomiting of 1-4 days duration
– Usually not associated with fatty meals or symptoms found in non-pregnant women
– Initial presenting symptom may be labor; 1st trimester symptoms may appear like
hyperemesis, while 3rd trimester symptoms may appear as HELLP Syndrome
• Hemolysis, Elevated Liver enzyme levels & Low Platelet count
• Ectopic Pregnancy
– Symptoms: late menses, abdominal / pelvic pain with cramping, +/- vaginal
bleeding, shoulder pain, faintness, painful fetal movements
– PE: Abdominal pain minimal to severe; shoulder pain 2° free peritoneal fluid;
syncope; vaginal bleeding
• Perforated Gastric Ulcer
– Acute epigastric pain, shoulder pain, vomiting & shock
• Pyelitis
– Common ~ 4th month of pregnancy
– Chills, fever (103°F ), usually right CVA & loin pain, frequency & pain with
urination; abdominal muscles are not rigid; urine +bacteria
• Ovarian Cyst Torsion
– Abdominal pain, fever, vomiting, & tender hypogastrium; rounded swelling aside of
uterus
• Fibroid Degeneration
– Pain at fibroid site, slight fever, nausea and/or vomiting
• Uterine Rupture
– Rare; signs of shock & internal hemorrhage
• Peritonitis
– Hypogastric pain / tenderness, nausea and/or vomiting, bilateral tenderness of
uterine fornices, fever (103°F)
• Compression Forces
– Liver & spleen most commonly injured organs
– Large & small intestines are also commonly injured
• Deceleration Forces
– Hepatic tear along ligamentum teres
– Intimal injuries to renal arteries
– Mesenteric tears with thrombosis & splanchnic vessel injuries
• Physical Examination:
– Inspection
• Note abrasions / ecchymotic areas, injury patterns (seat belt abrasion),
respiratory
pattern (abdominal breathing ? Spinal cord injury), Bradycardia (?
Intraperitoneal
blood), Cullen sign [periumbilical ecchymosis] / flank bruising (?
Retroperitoneal
hemorrhage)
– Auscultation
• Abdominal bruit (? Vascular disease / traumatic AV fistula)
– Palpation
• Note masses, tenderness, deformities
• Fullness & doughy consistency: Intra-abdominal hemorrhage
• Crepitus: Rib fractures / splenic or hepatic injuries
• Pelvic instability: GU injury / pelvic &/or retroperitoneal
hematoma
• Distention: Gastric dilatation
• Involuntary guarding / rigidity: Peritonitis (intra-abdominal hemorrhage)
• Sensory exam (touch): Eval spinal cord injury (↓ sensation to
touch / pain perception)
– Percussion
• Tenderness: Peritoneal sign
– Rectal / Vaginal Exams
• Bleeding / injury
6
 Medical Causes of Acute Abdominal Pain
Symptoms Medical Illness Clues
• Epigastric pain / upper abdominal pain, tenderness, vomiting Acute coronary syndrome Chest pain, shoulder / neck / jaw
MI / CHF/ Pericarditis pain, left arm pain; EKG / CXR

• Attacks of acute abdominal pain Acute porphyria UA – dark red / brown on standing;
send for porphyrins
No fever, chronic constipation

• Abdominal pain: continuous, severe & maximal in epigastrium Adrenal Insufficiency Soft, non-tender abdomen
• Anorexia, N/V, high fever
↓ sodium, ↓ hydroxycorticoid levels,
↑ potassium
Pigmentation changes / vitiligo
Steroid resolve abdominal pain

• Generalized abdominal pain – diffuse, severe, crampy Arachnidism Spider bite (Black Widow): red spot, swelling, urticaria
• Abdomen with severe rigidity at bite site
Outhouse, wood/junk pile, or cluttered basement
Separate muscle pains in legs, chest & back

• Severe abdominal pain & vomiting with rigid & tender abdomen Diabetic coma UA for glucose, ketones

• Abdominal pain, recurrent fever, polyserositis Familial Mediterranean Fever HA precedes pain attack
Inherited disease (check family hx)
Pain diffuse & may last 6-72 hrs
N/V, unilateral chest pain, arthralgias & myalgias
common
CXR = pleural effusion
KUB = signs of peritonitis

• Abdominal pain, vomiting, diarrhea, syncope Food poisoning Symptoms start shortly after eating

• Acute abdominal pain, N&V, fever with tender abdomen Hemolytic crises CBC

• Abdominal wall pain localized / segmented, pain boring & knife-like Herpes Zoster With or without dermatomal rash
Serum HSV IgG (PCR analysis)

• Abdominal pain (may be severe / colicky) & with vomiting Influenza Review of history for general symptoms of influenza
• Malaise > fever

• Abdominal tenderness, rigidity, dullness in left hypochondrium Leukemia Irregular fever, anemic appearance
Leukocyte count

• Abdominal pain localized and steady, burning, accentuated by Nerve root pain MRI / CT scan spine at level of pain
prolonged standing or sitting in one position

• Abdominal pain with rigidity Osteomyelitis Tenderness over spine

MRI / CT of spine

• Abdominal pain, N/V Periarteritis Nodosa Symptoms also include: fever, malaise, loss of
weight, cardiac symptoms

• Severe attacks of abdominal pain with vomiting / diarrhea Pernicious anemia CBC

• Abdominal pain, rigidity with possible vomiting Pleurisy / Pneumonia Accompanying chest pain
CXR / CT of chest

• Vague abdominal pain, distention, free fluid Tuberculous peritonitis Gradual onset of symptoms, no
rigidity/tenderness, hx of TB; + PPD

• Abdominal distention & vomiting simulating intestinal Uremia (Kidney failure) Flatus after enema
obstruction HTN
Vomiting not feculent

Zitkus - 2007 7
 Diagnostic Tests for Acute Abdominal Pain

Labs Recommended
Potential Diagnosis Studies Recommended * Note: All women of child-bearing age should have a
pregnancy test performed

Abdominal Aortic Aneurysm CT Scan / Ultrasound N/A

Appendicitis CT Scan / Ultrasound CBC, C-reactive protein, UA

Alkaline Phosphatase, Bilirubin, ALT,

Biliary Tract Disease Ultrasound / HIDA scan / CT Scan
AST, GGT // Misc: AMA, ANCA, ASCA

SMAC, BUN, Creatinine, CBC, Lactate

Bowel Obstruction or Perforation Abdominal x-ray (KUB) / CT Scan
dehydrogenase, UA

Not reliable, however, CBC, LFT’s,

Cholecystitis Ultrasound / HIDA Scan / CT Scan Bilirubin, Alkaline Phosphatase, Amylase,
Lipase, UA

Diverticulitis CT Scan CBC, CMP, LFT’s, Lipase, UA

Ectopic Pregnancy Beta-hCG / Ultrasound Beta-hCG, Progesterone

Gastroenteritis N/A Stool for culture & WBC, CBC

Hernia Clinical diagnosis / CT Scan CBC, CMP, UA

CBC, CMP, Lactic Acid, PT/ aPTT, Protein

Intestinal Ischemia / Infarction CT Scan / CT Angiography
C & S, Antithrombin III

Ovarian Torsion Clinical diagnosis / Doppler Ultrasound Beta-hGC, GC & chlamydia cultures, CBC

Pancreatitis Ultrasound / CT Scan CBC, CMP with LFT’s, Amylase, Lipase

Beta-hGC, CBC, ESR, UA, GC &

Pelvic Inflammatory Disease Ultrasound
chlamydia cultures

Pyelonephritis CT Scan UA, Urine C&S, GC & chlamydia

Renal Colic CT Scan UA, electrolytes

Testicular Torsion Clinical diagnosis / Doppler Ultrasound UA, CBC, CRP

Urinary Tract Infection N/A UA, Urine C&S, GC & Chlamydia

Highlighted = Tests of choice

Source: Graff, L.G., Robinson, D. Abdominal pain and

emergency department evaluation. Emerg Med Clin
North Am. 2001;19:123-136.

Zitkus - 2007 8
 Abdominal Pain Differential Diagnosis by S&S / Diagnostic Data

Common Pain Sites Possible

Differential DX Diagnostic Labs Radiology
Major Signs & Symptoms Clues

AAA, Acute • Tearing pain (may • Triad of: • Abdominal • Pre-op labs • Ultrasound
radiate to back, 1. Hypotension mass with but for (screening tool)
flank or groin) 2. Pulsatile aortic pulse diagnostic • CT Scan (pre-op)
• Syncope abdominal • Hx of PVD / consider- • MRI / MRA (dye
• Severe: Frank mass COPD / HTN ations none allergy)
Shock 3. Abdominal (smoking) needed • Aortography
- Cyanosis & Pain • LE mottling /
mottling of LE’s • ↓ LE pulses pulseless
- Altered mental • Imminent rupture:
status - Abdominal /
- Tachycardia & back pain
Hypotension - Vomiting /
Syncope
- Claudication

Appendicitis, • Epigastric, • Triad of: • Psoas • Leukocytosis • KUB

Acute periumbilical pain 1. Anorexia (74- • Obturator (~10-18,000) • Ultrasound
with migration to 78%) • Rovsing's • CRP ↑ • CT scan*
RLQ after 6-8 hrs 2. Periumbilical • Cutaneous • UA: ↑ spec
• Nausea (61-92%) pain with hyperesthesia gravity,
Vomiting (50%) vomiting • Rectal exam hematuria,
• Slight temp (one 3. Then RLQ pain pain due to pyuria,
(96%)
degree elevation) pelvic albuminuria
• Diarrhea / appendix
constipation (61-
92%)

Cholecystitis, • Acute, sudden • Recurrent pain • Murphy’s • Leukocytosis • US * (90-95%

Acute epigastric / RUQ attacks following (~12-15,000) sensitive)
pain radiating to meals (1-6 hrs) • Slight ↑ ALT / • CT* for dilated CBD
shoulder or back • Biliary colic: AST • Tc HIDA * during
• N/V crescendo pain • Slight ↑ acute pain
• Elevated temp amylase (94% sensitive)
(32%) with • ERCP (CBD
• RUQ fullness on gangrene stones)
palpation (20%)

*GS = Gold Standard Zitkus - 2007 9

 Abdominal Pain Differential Diagnosis by S&S / Diagnostic Data

Differential Common Pain Sites Possible Labs Radiology

DX Diagnostic
Major Signs & Symptoms Clues

Diverticulitis, • LLQ pain (but may • ↓ bowel sounds • Rebound • CBC • KUB (eval
Acute occur in RLQ) • Palpable mass tenderness Leukocytosis perforation)
- severe, abrupt in LLQ LLQ • ESR • CT Scan with
onset • Constipation / • Rectal exam • UA: WBC’s, contrast *
- worsens over Diarrhea pain RBC’s if • Colonoscopy (not
time • Fever & chills fistula in acute cases)
- worse after • Anorexia, N/V present
eating • LFT’s /
- relief with BM / Electrolytes
flatus (rule outs)

Ischemia, • Acute periumbilical • Absent bowel • Sine qua non • CBC • KUB (usually
Acute pain not sounds in region of MI – nl abd Leukocytosis normal)
Mesenteric proportional to • N/V frequent exam with >15,000 (75%) • CT Angiography *
physical findings • Diarrhea severe abd • ↑ BUN • CT Scan of
• Pain initially of • Advanced M.I. pain (hypovolemia) abdomen/pelvis
visceral nature - Increased abd • Abdominal • Metabolic
• If embolus, pain is distention bruits acidosis
sudden - Ileus • Lactic acidosis
• Pain with eating - Frank peritonitis • ↑ LFT’s /
(abd angina) - Shock Bilirubin

Obstruction, • Pain crampy & • Nausea / • Hyperactive • SMAC 6 (? ↑) • KUB (flat/upright) *

Small intermittent Vomiting BS (early) • ↑ BUN - Dilated bowel
Bowel - short / colicky w - Bilious / fecal • Hypoactive (dehydration) loops
bilious vomiting • Fever / BS (late) • ↑ Creatinine - Absent / minimal
(proximal Tachycardia • Fever (>100 (dehydration) bowel gas
obstruction) (? degrees F) • CBC: Mild • CT Scan abd/pelv*
- progressive /abd Strangulation) • Tachycardia leukocytosis - If fever, pain,
distention (distal (>100 bpm) tachycardia,
obstruction) • Peritoneal leukocytosis
• Diarrhea (early) signs • US (may exclude
• Constipation (late) • Occult blood in SBO)
stool
(strangulation
/ malignancy)

*GS = Gold Standard Zitkus - 2007 10

 Abdominal Pain Differential Diagnosis by S&S / Diagnostic Data

Differential Common Pain Sites Possible Diagnostic Labs Radiology

DX Major Signs & Symptoms Clues

Pancreatitis • Sudden onset of • Distended • Tenderness with • ↑ Amylase / • KUB (Ileus)

, Acute epigastric pain abdomen palpation Lipase* • CXR (pleural
radiating to back & • Symptoms occur • Pain worse in supine • Hyperglycemia effusion)
flanks after heavy position & • Hypocalcemia • US/CT/MRI
• Pain constant boring meal or binge of lessened in sitting / • CBC – abdomen
• Nausea / Vomiting ETOH fetal position Leukocytosis • ERCP
(75-90%) • Steatorrhea

Perforation, • Peptic Ulcer •Peritonitis: • Breathing patterns • CBC with • Erect CXR’s
Acute Perforation: - Tachycardia - Note abdominal leukocytosis • Supine / Erect
Intestinal - Sharp, severe, - Fever movements • ↑ RBC volume KUB
(Gastric, sudden-onset - Generalized abd • Examine abdomen (bleed) • US of
Duodenal, epigastric pain tenderness for signs of • LFT’s / abdomen
Intestine) - Shoulder pain - Tenderness with injury, abrasion, BUN/Creatinine • CT of
- Hiccup late percussion ecchymosis abdomen
symptom • Intra-abdominal • Lying immobile with • Peritoneal tap
• Appendix Perforation Hemorrhage knees flexed,
- Ill for several hrs - Abdominal board-like abd
- Localized to RLQ fullness
- Pain before - Doughy
vomiting by 3-4 hrs consistency

Pregnancy, • Tubal: • Abdominal: • Amenorrhea • β-hCG (serial • US vaginal /

Ectopic - Abdominal - GI symptoms, followed by quant)* abd / pelvic*
tenderness, pelvic fetal mvmts vaginal bleeding • CBC (blood • CT scan
&/or shoulder pain, marked/painful, - continuous loss) • MRI
syncope, palpation of - intermittent • Serum • Endovaginal
tenesmus, irregular fetal parts - irregular progesterone color Doppler
vaginal bleed • Cervical: • Urine flow imaging
• Ovarian: - Enlarged cervix, pregnancy
- Abdominal pain & dark tissue test
cramps, pelv mass, seen through
vaginal bleeding external os
continuous vag
bleeding

Splenic • Presentation highly • Shock • Hypotension is a • CBC as • FAST (focused

Rupture variable - Tachycardia, grave sign baseline only abd sono
- LUQ tenderness tachypnea, • Abdominal trauma technique)
- Left shoulder pain restlessness, • CT Scan
- Diffuse abdominal anxiety • Angiography
pain with free • Pallor
intraperitoneal
blood

*GS = Gold Standard

Zitkus - 2007 11