From the Guidelines
The recommended workup for a female patient in her 50s presenting with generalized abdominal pain should begin with a thorough history and physical examination, followed by basic laboratory tests including complete blood count, comprehensive metabolic panel, urinalysis, and pregnancy test if premenopausal. Initial imaging should include an abdominal ultrasound, which is non-invasive and can identify gallstones, ovarian masses, and other common pathologies, as suggested by the American College of Radiology Appropriateness Criteria 1. If the diagnosis remains unclear, a CT scan of the abdomen and pelvis with contrast would be appropriate to evaluate for inflammatory conditions, malignancies, or vascular issues, as recommended by the ACR Appropriateness Criteria for acute nonlocalized abdominal pain 1.
Additional tests to consider include:
- Amylase and lipase to rule out pancreatitis
- Stool studies if diarrhea is present
- An EKG to exclude cardiac causes that may present as abdominal pain Gynecologic evaluation is particularly important in this age group, as ovarian pathology including malignancy becomes more common, with ovarian cysts, uterine fibroids, pelvic inflammatory disease, and ovarian neoplasm being common causes of postmenopausal pelvic pain 1. Colonoscopy may be indicated if there are concerning symptoms such as weight loss, rectal bleeding, or change in bowel habits, especially if the patient is due for colorectal cancer screening.
This comprehensive approach is necessary because abdominal pain in middle-aged women has a broad differential diagnosis including gastrointestinal, gynecologic, urologic, and vascular etiologies, and the presentation can be atypical compared to younger patients. Severe abdominal pain out of proportion to physical examination findings should be assumed to be acute mesenteric ischemia until disproven, as recommended by the World Society of Emergency Surgery 1. A step-up approach for diagnosis should be used, tailored to the clinical setting, resources, and patient’s age, beginning with clinical and laboratory examination and progressing to imaging examinations, as suggested by the WSES 2016 consensus conference 1.
From the Research
Recommended Workup for Generalized Abdominal Pain in a Female Patient
The recommended workup for a female patient in her 50s presenting with generalized abdominal pain involves a systematic approach to evaluate the patient and initiate a management plan.
- The workup should start with a detailed history and physical examination to identify any red flag features that may indicate a more serious condition 2.
- The location of pain is a useful starting point and will guide further evaluation. For example, right lower quadrant pain strongly suggests appendicitis, while right upper quadrant pain may suggest cholelithiasis or other hepatobiliary disorders 3, 4.
- Laboratory tests such as complete blood count, C-reactive protein, hepatobiliary markers, electrolytes, creatinine, glucose, urinalysis, lipase, and pregnancy testing may be recommended to help guide the diagnosis 4.
- Imaging studies such as computed tomography (CT) with intravenous contrast media or ultrasonography may be chosen based on the location of pain and index of suspicion for specific etiologies. CT is often chosen for generalized abdominal pain, left upper quadrant pain, and lower abdominal pain, while ultrasonography is the study of choice for right upper quadrant pain 3, 4, 5.
- In patients who have female reproductive organs, diagnoses such as ectopic pregnancy, pelvic inflammatory disease, and adnexal torsion should be considered 4.
- Point-of-care ultrasonography can aid in the prompt diagnosis of several etiologies of acute abdominal pain, including cholelithiasis, urolithiasis, and appendicitis 4.
Key Considerations
- The diagnostic accuracy of clinical assessment is insufficient to identify the correct diagnosis but can discriminate between urgent and nonurgent causes 5.
- Patients suspected of nonurgent diagnoses can safely be reevaluated the next day 5.
- Antibiotic treatment should be started within the first hour after recognition of sepsis, and administration of opioids (analgesics) decreases the intensity of the pain and does not affect the accuracy of physical examination 5.