Abdominal pain is the chief complaint for 5–10% of patients presenting to emergency departments and one of the top 10 complaints in the office. Because of the wide differential diagnoses, accurate diagnosis can be difficult. Detailed history, thorough physical examination, and often, diagnostic testing, are necessary.
ESSENTIALS OF DIAGNOSIS
Acuity, onset, and duration of symptoms.
Quality, location, and radiation of pain.
History is the most important component of evaluating abdominal pain. Effective communication is necessary for a thorough, accurate history. Enough time should be allowed for open-ended history using the method “engage, empathize, educate, enlist.”
Determining onset of pain can help determine the cause of abdominal pain as well as the need for emergent referral. Abdominal pain is categorized as acute, subacute, or chronic. Symptoms lasting more than 3 months are considered chronic. Acute pain is often associated with peritoneal irritation, such as appendicitis, and abdominal organ rupture and may require emergency management and consultation with a surgeon. Many patients present to the office with more gradual onset or chronic abdominal pain (Table 31-1).
Table 31–1.Common causes of abdominal pain by location. ||Download (.pdf) Table 31–1.Common causes of abdominal pain by location.
Ruptured ovarian cyst
Sickle cell crisis
Abdominal wall pain—multiple causes
Ruptured aortic aneurysm
A patient’s description of the quality of the pain provides clues to etiology. Pain can be sharp, stabbing, burning, dull, gnawing, colicky, crampy, gassy, focal, migrating, or radiating. Pressure like pain (“there’s an elephant sitting on me”) suggests cardiac ischemia. Focal symptoms help determine location and diagnosis.
Location and radiation of pain are important. The abdomen is separated into four quadrants—right upper (RUQ), left upper (LUQ), right lower (RLQ), and left lower (LLQ)—or as midepigastric or suprapubic. Some causes of abdominal pain have classic patterns of location and radiation. Pain from the lower esophagus may be referred higher in the chest and confused with pain associated with cardiac conditions.