What is the step-by-step approach to evaluating and managing a patient with abdominal pain?

Step-by-Step Approach to Evaluating and Managing Abdominal Pain

A structured, systematic examination approach is essential for accurate diagnosis and timely management of abdominal pain to reduce morbidity and mortality. 1

Initial Assessment

• Vital Signs: Immediately check for signs of hemodynamic instability (tachycardia, hypotension, tachypnea) which may indicate shock requiring immediate intervention 2
• General Appearance: Assess level of distress, positioning (e.g., still vs. writhing), and overall condition to gauge severity 3
• Pain Characteristics: Document location, onset, character, radiation, alleviating/aggravating factors, timing, severity, and associated symptoms 3

Focused History

• Location: Determine quadrant-specific pain which guides differential diagnosis (e.g., right lower quadrant pain suggests appendicitis) 3
• Timing and Progression: Establish acute vs. chronic nature and evolution pattern 2
• Associated Symptoms: Document presence of fever, nausea, vomiting, diarrhea, constipation, urinary symptoms, or gynecological symptoms 3
• Past Medical History: Identify previous surgeries, inflammatory bowel disease, diverticulitis, or other relevant conditions 4
• Medications: Note current medications, especially steroids, immunomodulators, or anti-TNF-α agents which may mask symptoms or increase infection risk 5

Physical Examination

• Inspection: Look for distension, visible peristalsis, scars, hernias, and skin changes 6
• Auscultation: Assess bowel sounds (hyperactive, hypoactive, absent) before palpation 6
• Percussion: Check for tympany (air) or dullness (fluid/mass) and assess for peritoneal irritation 2
• Palpation: Perform in systematic quadrant approach:
  • Begin with areas away from reported pain
  • Note tenderness, guarding, rigidity, rebound tenderness, and masses
  • Assess for Murphy's sign, McBurney's point tenderness, psoas sign, obturator sign 3, 2
• Rectal Examination: Evaluate for masses, tenderness, blood 4
• Pelvic Examination: Consider in women of reproductive age to assess for gynecological causes 3

Laboratory Studies

• Complete Blood Count: Assess for leukocytosis (infection/inflammation) or anemia (blood loss) 5
• Basic Metabolic Panel: Evaluate electrolyte abnormalities and renal function 5
• Liver Function Tests: Check for hepatobiliary disease 6
• Inflammatory Markers: Order C-reactive protein and erythrocyte sedimentation rate to assess inflammation severity 5
• Urinalysis: Rule out urinary tract infection or nephrolithiasis 2
• Pregnancy Test: Perform in all women of childbearing age 3
• Lactate: Order if sepsis or ischemia is suspected 5

Imaging Studies

• Selection Based on Location:
  • Right Upper Quadrant: Ultrasonography is first-line for suspected gallbladder disease 3
  • Right Lower Quadrant/Left Lower Quadrant: CT scan is recommended for suspected appendicitis or diverticulitis 3
  • Diffuse Pain: CT abdomen/pelvis with contrast is most sensitive for various conditions 6
• Imaging Algorithm:
  • Start with ultrasonography when appropriate (especially in young patients, pregnant women)
  • Proceed to CT scan if ultrasound is negative or inconclusive 6
  • Consider MRI for pregnant patients or those with contrast allergies 4

Management Principles

• Resuscitation: Prioritize hemodynamic stabilization with IV fluids in unstable patients 5
• Pain Control: Administer appropriate analgesia; opioids can be safely given without masking examination findings 6
• Antibiotic Therapy:
  • Not routinely indicated for all abdominal pain 5
  • Administer promptly for suspected intra-abdominal infection, abscesses, or sepsis 5
  • Select antibiotics based on likely pathogens (covering gram-negative aerobes and anaerobes) 5
  • Administer within one hour in septic patients 6
• Venous Thromboembolism Prophylaxis: Initiate low molecular weight heparin early, especially in inflammatory conditions 5
• Nutritional Support:
  • Assess nutritional status in all patients 5
  • Provide parenteral nutrition in critically ill patients with intestinal dysfunction 5
  • Consider enteral nutrition when GI tract is functional 5

Special Considerations

• Inflammatory Bowel Disease (IBD):
  • Evaluate in multidisciplinary approach with gastroenterology 5
  • Assess for intra-abdominal abscesses which may require drainage 5
  • Consider medical rescue therapy (infliximab, ciclosporin) in non-responders to steroids 5
  • Weigh surgical intervention for perforation, obstruction, or failed medical management 5
• Elderly Patients:
  • Be vigilant for atypical presentations with minimal symptoms despite serious pathology 3
  • Lower threshold for advanced imaging 1
• Immunocompromised Patients:
  • Consider opportunistic infections 5
  • Note that immunosuppressive medications may mask inflammatory signs 5

Indications for Surgical Consultation

• Peritoneal signs (rigidity, rebound tenderness)
• Free air or fluid on imaging
• Bowel obstruction
• Failed conservative management
• Hemodynamic instability despite resuscitation 5, 1

Common Pitfalls to Avoid

• Delayed Diagnosis: Mortality increases with each hour of delay in treating acute surgical conditions 1
• Inadequate Pain Control: Withholding analgesia does not improve diagnostic accuracy 6
• Overreliance on Laboratory Values: WBC and CRP alone cannot reliably differentiate urgent from non-urgent conditions 6
• Premature Closure: Consider multiple diagnoses, especially in complex patients 2
• Neglecting Reassessment: Serial examinations are crucial for evolving conditions 2