From the Guidelines
The evaluation and management of lower abdominal pain in the emergency department requires a systematic approach beginning with a thorough history and physical examination, followed by selective use of laboratory tests and imaging studies, with a focus on minimizing morbidity, mortality, and improving quality of life. Clinicians should first assess vital signs and perform a focused abdominal exam, noting tenderness, guarding, rebound, and masses. Laboratory tests should include complete blood count, comprehensive metabolic panel, urinalysis, and pregnancy test for females of reproductive age.
- Imaging studies are selected based on clinical suspicion:
- Ultrasound is preferred for suspected gynecological or biliary pathology
- CT scan with IV contrast is optimal for suspected appendicitis, diverticulitis, or bowel obstruction, as it has high diagnostic yield and can identify alternative diagnoses 1
- Pain management should be initiated early with medications like morphine 0.1 mg/kg IV or hydromorphone 0.5-1 mg IV for severe pain, or ketorolac 15-30 mg IV for moderate pain if no contraindications exist.
- Antiemetics such as ondansetron 4 mg IV may be given for associated nausea.
- Specific treatments depend on the diagnosis:
- Antibiotics for infections (e.g., ceftriaxone 1g IV plus metronidazole 500 mg IV for diverticulitis)
- Surgical consultation for appendicitis or bowel obstruction
- Gynecological consultation for ovarian torsion or ectopic pregnancy
- Patients require frequent reassessment, and disposition decisions should be based on diagnosis, response to treatment, and ability to tolerate oral intake, as supported by recent guidelines and studies 1. This approach ensures timely diagnosis and appropriate management while minimizing complications from potentially life-threatening conditions.
From the Research
Approach to Lower Abdominal Pain in ED
The approach to evaluating and managing lower abdominal pain in the emergency department (ED) involves a nuanced approach, considering the likelihood of disease, patient history, physical examination, laboratory tests, and imaging studies 2. The location of pain is a useful starting point and will guide further evaluation.
Evaluation and Management
- Evaluation of lower intestinal disease requires a comprehensive approach, including computed tomography, ultrasonography, MRI, layered imaging, shared decision making, serial examination, and/or close follow-up 3.
- The American College of Radiology has recommended different imaging studies for assessing abdominal pain based on pain location, with ultrasonography recommended for right upper quadrant pain and computed tomography for right and left lower quadrant pain 2.
- For patients presenting with gynaecological lower abdominal pain, parameters such as palpation of a mass/resistance or at least one pathological ultrasound finding can lead to hospital admission 4.
Special Considerations
- In children, the approach to management in ED should include a rapid cardiopulmonary assessment, focused history and examination, surgical consult and radiologic examination to exclude life-threatening surgical conditions, pain relief, and specific diagnosis 5.
- For adult patients with low-risk, recurrent, undifferentiated abdominal pain, the GRACE-2 guideline suggests against repeat CTAP imaging if a prior negative CTAP has been performed within 12 months, and recommends an opioid-minimizing strategy for pain control 6.
Imaging Studies
- Ultrasonography is recommended to assess right upper quadrant pain, and computed tomography is recommended for right and left lower quadrant pain 2.
- An ultrasound abdomen is the first investigation in almost all cases with moderate and severe pain with localizing abdominal findings, while a Contrast enhanced computerized tomography (CECT) abdomen may be a better initial modality in patients with significant abdominal trauma or features of pancreatitis 5.