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GENERAL CONSIDERATIONS

Abdominal pain is a common presenting complaint in both the emergency department and office. It accounts for up to 10% of emergency department visits and is one of the top 10 reasons for presenting to a primary care office. Because of the wide differential diagnoses, accurate diagnosis can be difficult. This usually can be achieved through a detailed history and thorough physical examination. Although most complaints of abdominal pain are related to benign conditions, it is important to identify the patients with severe or life-threatening conditions. A thoughtful and logical approach to the use of diagnostic testing is necessary. Follow-up, continuity, and patient-centered care are important components to the treatment both acute and chronic abdominal pain regardless of etiology.

CLINICAL FINDINGS

A. History

ESSENTIALS OF DIAGNOSIS

  • Acuity, onset, and duration of symptoms.

  • Quality, location, and radiation of pain.

  • Associated symptoms.

History is the most important component of evaluating abdominal pain. Effective communication is necessary for a thorough, accurate history. Adequate time should be allowed for an open-ended history using the method “engage, empathize, educate, enlist.”

1. Onset

Determining the 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 >3 months are considered chronic. Acute pain is often associated with peritoneal irritation, such as seen with appendicitis and abdominal organ rupture, and may require emergency management and consultation with a surgeon. Many patients present to the office with a more gradual onset of their abdominal pain (Table 31–1).

Table 31–1.Common causes of abdominal pain by location.

2. Quality of pain

A patient’s description of the quality of their pain provides important clues to etiology. Pain can be sharp, stabbing, burning, dull, gnawing, colicky, crampy, gassy, focal, migrating, or radiating. Pain described as pressure, such as “an elephant sitting on me,” suggests cardiac ischemia. Focal symptoms help determine both the location and diagnosis.

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