This post is part of a series called “Cardinal Presentations”, based on Rosen’s Emergency Medicine (8th edition).
Pathophysiology of Abdominal Pain
- Visceral: distension of hollow organs or capsular stretch of solid organs.
- Somatic: parietal peritoneal irritation
- Epigastric: inferior MI
- Pelvic: hip
- Abdominal: lower lobe pneumonia/infarction
- Shoulder: diaphragmatic irritation (ex. perforated duodenal ulcer, splenic pathology)
- Mid-back: aortopathy, pancreatitis
- Flank: renal pathology
- Low back: uterus, rectum
Concerning Historical Features
- Elderly: increased probability for severe disease with poor clinical diagnostic accuracy
- Immunocompromised: HIV/AIDS, uncontrolled diabetes, chronic liver disease, chemotherapy, other immunosuppression
- Pain preceding nausea/vomiting: increased likelihood of surgical process
- Abrupt onset, duration <48h, constant timing
- Prior abdominal surgical history: consider bowel obstruction
- No prior episodes of similar pain
- Recent antibiotic or steroid use: may mask signs of infection
- Cardiac risk factors (HTN, vascular disease, atrial fibrillation: increased risk for mesenteric ischemia or aortic aneurysm
- Heavy NSAID use or anticoagulation: increase concern for gastrointestinal bleeding
- Plain film reserved for those who would otherwise not undergo CT. XR abdomen for bowel obstruction or radiopaque foreign body.
- CT abdomen/pelvis with IV contrast, particularly if elderly or immunocompromised.
- Ultrasound preferred for hepatobiliary pathology
- Bedside ultrasound for identification of IUP, free intraperitoneal fluid, cholecystitis, CBD dilation, ascites, hydronephrosis, aortopathy, volume status.
Causes of Abdominal Pain
- Budhram, G., & Bengiamin, R. (2013). Abdominal Pain. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 223-231). Elsevier Health Sciences.