What is the appropriate management for a patient presenting with abdominal pain?

Management of Abdominal Pain

For patients presenting with acute abdominal pain, obtain a focused history targeting pain characteristics and associated symptoms, perform a complete abdominal examination, order laboratory tests based on pain location, and proceed directly to CT imaging with IV contrast for nonlocalized pain or ultrasound for right upper quadrant pain. 1, 2

Initial Clinical Assessment

History and Physical Examination:

• Document pain location, onset (sudden vs. gradual), duration, quality (sharp, dull, cramping), radiation pattern, and factors that worsen or improve symptoms 2
• Identify associated symptoms: fever suggests infection/inflammation, nausea/vomiting may indicate obstruction, and changes in bowel habits point to gastrointestinal pathology 2
• Measure vital signs immediately—fever indicates possible infection, and hemodynamic instability (hypotension, tachycardia) suggests hemorrhage, sepsis, or bowel perforation requiring urgent intervention 2
• Perform systematic abdominal examination: inspect for distension or surgical scars, auscultate for bowel sounds, percuss for tympany or dullness, and palpate for tenderness, guarding, or rebound (peritoneal signs) 2
• In elderly patients, maintain high suspicion as laboratory values may remain normal despite serious infection, and presentations are often atypical 1, 2

Laboratory Workup

Essential Initial Tests:

• Complete blood count to detect leukocytosis (infection/inflammation) or anemia (bleeding) 2, 3
• Comprehensive metabolic panel including liver function tests, particularly for right upper quadrant pain 3
• Urinalysis to evaluate for urinary tract infection or kidney stones 3
• Pregnancy test (beta-hCG) is mandatory for all women of reproductive age before any imaging 2, 3

Location-Specific Testing:

• Right upper quadrant pain: liver enzymes, bilirubin, alkaline phosphatase 3
• Suspected pancreatitis: serum lipase (more specific than amylase) 3
• Suspected mesenteric ischemia: lactate and D-dimer, though these lack specificity 3
• Fever with abdominal pain: blood cultures if sepsis suspected 3

Common Pitfall: Do not rely solely on laboratory tests for diagnosis—many serious conditions require imaging for definitive diagnosis, and early laboratory findings may be normal 2, 3

Imaging Strategy

Algorithm Based on Pain Location:

Right Upper Quadrant Pain:

• Start with ultrasound as first-line imaging (evaluates gallbladder, bile ducts, liver) 1, 2

Right or Left Lower Quadrant Pain:

• Proceed directly to CT scan with IV contrast (evaluates appendicitis, diverticulitis, colitis) 1, 2

Diffuse or Nonlocalized Abdominal Pain:

• CT abdomen/pelvis with IV contrast is the preferred initial study 1, 2
• CT changes management in 51% of patients and admission decisions in 25% of cases 1
• CT is essential for detecting abscesses, perforations, bowel obstruction, ischemia, and malignancy 1

Avoid plain abdominal radiographs—they have limited diagnostic value and should not be routinely used 2

Special Populations:

• Pregnant patients: ultrasound first-line; if additional imaging needed, use MRI instead of CT 2
• Immunocompromised/neutropenic patients: CT with IV contrast is critical as typical signs of sepsis may be masked 1, 2

Management Considerations

When Infection or Abscess is Present:

• Antibiotics should NOT be routinely administered for all abdominal pain 1
• Antibiotics are indicated only when superinfection is confirmed or intra-abdominal abscess is present 1
• For abscesses: use broad-spectrum coverage against Gram-negative aerobes/facultative bacilli, Gram-positive streptococci, and obligate anaerobes (e.g., fluoroquinolone or third-generation cephalosporin plus metronidazole) 1
• Clinical improvement should occur within 3-5 days; if not, repeat imaging to assess drainage adequacy 1
• Abscesses >3 cm typically require percutaneous drainage; those <3 cm without fistula may respond to antibiotics alone but have high recurrence rates 1

Supportive Care:

• Administer adequate IV fluids for volume resuscitation 1
• Provide venous thromboembolism prophylaxis with low molecular weight heparin 1
• Correct electrolyte abnormalities and anemia 1

Multidisciplinary Approach:

• Involve acute care surgery early for suspected surgical emergencies (perforation, obstruction, ischemia) 1
• For inflammatory bowel disease patients, coordinate with gastroenterology 1

Critical Red Flags Requiring Urgent Intervention

• Peritoneal signs (guarding, rebound tenderness) suggesting perforation 2
• Hemodynamic instability indicating hemorrhage or septic shock 2
• Suspected bowel ischemia or obstruction 1
• Free air on imaging indicating perforation 1

Common Pitfall: In neutropenic patients, do not wait for typical signs of infection—proceed directly to CT imaging as clinical presentation may be subtle despite life-threatening pathology 1