From the Guidelines
The diagnostic workup for abdominal pain that occurs before eating should begin with a thorough history and physical examination to identify potential causes, followed by laboratory tests and imaging studies as needed, with the most recent evidence suggesting a comprehensive approach including CT scan of the abdomen and pelvis, and consideration of upper endoscopy and other tests based on clinical suspicion 1. The initial evaluation should include laboratory tests such as complete blood count, comprehensive metabolic panel, lipase, and amylase to assess for inflammation, infection, or organ dysfunction.
- Imaging studies are often necessary, starting with an abdominal ultrasound to evaluate the gallbladder, liver, and pancreas,
- followed by CT scan of the abdomen if needed for more detailed assessment, as recommended by the American College of Radiology 1. Upper endoscopy may be indicated to directly visualize the esophagus, stomach, and duodenum, particularly if peptic ulcer disease or gastritis is suspected.
- For patients with persistent symptoms, additional tests might include a hepatobiliary iminodiacetic acid (HIDA) scan to evaluate gallbladder function,
- or gastric emptying studies if gastroparesis is suspected,
- and Helicobacter pylori testing should be performed if peptic ulcer disease is a consideration, as suggested by recent studies 1. This comprehensive approach is necessary because preprandial abdominal pain can result from various conditions including peptic ulcer disease, biliary disorders, pancreatic conditions, or functional gastrointestinal disorders. The specific pattern of pain before meals often suggests anticipatory anxiety about postprandial discomfort or conditions where an empty stomach exacerbates symptoms, and the most recent evidence from 2022 supports this approach 1.
From the Research
Diagnostic Workup for Abdominal Pain Before Eating
The diagnostic workup for abdominal pain that occurs before eating involves a comprehensive approach, including:
- Patient history: A detailed history is essential to determine the likelihood of disease and guide further evaluation 2.
- Physical examination: Certain elements of the physical examination, such as constipation and abdominal distension, can suggest specific conditions like bowel obstruction 3.
- Laboratory tests: Laboratory tests can help confirm diagnoses, but clinical judgment based on history and physical examination remains crucial 4.
- Imaging studies: The American College of Radiology recommends different imaging studies based on pain location, such as ultrasonography for right upper quadrant pain and computed tomography (CT) for right and left lower quadrant pain 3, 5.
Special Considerations
- Location of pain: The location of pain can guide further evaluation, with right lower quadrant pain suggesting appendicitis 3.
- Special populations: Women are at risk of genitourinary disease, which may cause abdominal pain, and the elderly may present with atypical symptoms of a disease 3.
- Chronic symptoms: For patients with chronic abdominal pain, it is essential to consider the possibility of chronic inflammatory bowel disease (IBD) or identifiable functional conditions 4, 2.
Imaging Techniques
- Computed tomography (CT): CT is the primary technique for diagnosing acute abdominal pain, except in patients suspected of having acute cholecystitis, where ultrasonography (US) is preferred 5.
- Ultrasonography (US): US is the primary imaging technique for patients with suspected acute cholecystitis and can be used as an initial technique in all patients with acute abdominal pain, with CT performed in cases of nondiagnostic US 5.
- Magnetic resonance (MR) imaging: MR imaging is a promising alternative to CT in evaluating acute abdominal pain, but data on its use are still limited 5.