Bilateral Upper Abdominal Pain in Females: Evaluation and Management
CT abdomen and pelvis with IV contrast is the most appropriate initial imaging study for evaluating bilateral upper abdominal pain in females, as it can screen for a broad range of life-threatening pathologies including perforation, ischemia, pancreatitis, and biliary disease. 1
Initial Clinical Assessment
Critical Laboratory Testing
- Obtain β-hCG testing immediately in all women of reproductive age to rule out pregnancy-related complications before proceeding with imaging 1, 2
- Complete blood count to assess for leukocytosis indicating infection or inflammation 3, 2
- Comprehensive metabolic panel including liver function tests (ALT, AST, alkaline phosphatase, bilirubin) 2
- Serum lipase (more specific than amylase for pancreatitis) 2
- C-reactive protein and procalcitonin for inflammatory response assessment 3
- Urinalysis to evaluate for urinary tract infection or nephrolithiasis 2
Physical Examination Priorities
- Assess vital signs for fever, tachycardia, hypotension, or tachypnea which may indicate infection, bleeding, or surgical complications 3
- Check for resonant liver percussion note over the right upper quadrant, which indicates pneumoperitoneum and requires urgent surgical evaluation 4
Imaging Algorithm
Primary Imaging Modality
CT abdomen and pelvis with IV contrast is usually appropriate for nonlocalized or bilateral upper abdominal pain as it can detect:
- Abdominal abscesses 1
- Bowel perforation (89% sensitivity for urgent abdominal conditions) 4
- Pancreatitis 3
- Cholecystitis 3
- Mesenteric ischemia 5
- Diverticulitis 5
Alternative Imaging Considerations
- If the patient is pregnant, ultrasound is the primary imaging modality, followed by MRI without contrast if ultrasound is inconclusive 1
- MRI abdomen and pelvis without and with IV contrast can provide clinically useful information if CT is contraindicated 1
- CT without IV contrast is appropriate if the patient cannot receive IV contrast 1
Role of Ultrasound
- Ultrasound is useful for evaluating specific conditions including cholecystitis, cholangitis, liver abscess, and gynecologic pathology 1
- In pregnant patients, ultrasound has excellent sensitivity and specificity (97% and 95% respectively) for appendicitis when combined with MRI 1
- Transvaginal or transabdominal pelvic ultrasound should be performed if gynecologic etiology is suspected (ectopic pregnancy, ovarian torsion, pelvic inflammatory disease) 1, 5
Limited Role of Plain Radiography
- Conventional radiography has limited diagnostic value (49% sensitivity for bowel obstruction) but maintains utility for detecting pneumoperitoneum 4
- Upright chest radiograph is the best initial test if free intraperitoneal air is suspected clinically 4
Critical Differential Diagnoses in Females
Gynecologic Causes to Consider
- Ectopic pregnancy (requires β-hCG testing first) 1, 2
- Ovarian torsion 1
- Pelvic inflammatory disease 1
- Tubo-ovarian abscess 1
Life-Threatening Conditions Requiring Urgent Diagnosis
- Bowel perforation 4
- Mesenteric ischemia (consider lactate and D-dimer if suspected) 2, 5
- Acute pancreatitis 3, 5
- Complicated appendicitis 1, 5
Post-Surgical Considerations
- In post-cesarean or post-operative patients with severe upper abdominal pain, CT abdomen and pelvis with IV contrast is usually appropriate to evaluate for postoperative abscesses, leaks, or hemorrhage 1, 3
- Consider diagnostic laparoscopy if clinical suspicion for surgical pathology is high despite negative imaging 3
Common Pitfalls to Avoid
- Failing to obtain pregnancy testing before imaging can lead to delayed diagnosis of ectopic pregnancy and unnecessary radiation exposure 2
- Do not rely on conventional radiography as the primary diagnostic tool for acute abdominal pain evaluation 2, 4
- In pregnant patients, avoid CT when ultrasound and MRI are available, though the risk from a single CT is very low 1
- Do not delay imaging in hemodynamically stable patients when serious pathology is suspected 5