What causes mid-low stomach pain during palpitations?

Mid-Low Stomach Pain Upon Palpation: Differential Diagnosis and Management

Mid-low abdominal pain elicited by palpation indicates peritoneal irritation or intra-abdominal pathology requiring urgent evaluation to exclude life-threatening conditions including appendicitis, bowel perforation, mesenteric ischemia, and diverticulitis.

Immediate Life-Threatening Causes to Exclude

Appendicitis

• Appendicitis is the most common surgical emergency causing lower abdominal pain, accounting for one-third of all acute abdominal pain presentations to emergency departments 1
• Classically presents with periumbilical pain migrating to the right lower quadrant with maximal tenderness at McBurney's point upon palpation 2
• Rebound tenderness (Blumberg's sign) and involuntary guarding indicate peritoneal inflammation 3
• All patients with suspected appendicitis require hospital admission and surgical consultation 2

Bowel Perforation

• Perforated peptic ulcer presents with sudden, severe epigastric pain that becomes generalized with abdominal rigidity and absent bowel sounds, carrying 30% mortality if treatment is delayed 4
• CT abdomen/pelvis with IV contrast shows extraluminal gas in 97% of cases, fluid or fat stranding in 89%, and focal wall defect in 84% 4
• Peritoneal signs (involuntary guarding, rebound tenderness) mandate immediate surgical consultation 5

Mesenteric Ischemia

• Presents with severe abdominal pain out of proportion to physical examination findings, though palpation may reveal diffuse tenderness 1
• High-risk patients include those with atrial fibrillation, atherosclerotic disease, or low cardiac output states 1
• Mortality approaches 60% with delayed diagnosis; triple-phase CT (non-contrast, arterial, portal venous) is essential 1

Common Gastrointestinal Causes

Diverticulitis

• Presents with left lower quadrant pain and tenderness on palpation, often with fever and leukocytosis 1
• Can frequently be managed outpatient with oral antibiotics if no complications, but requires admission if peritoneal signs, abscess, or perforation present 2

Inflammatory Bowel Disease (Colitis)

• Causes diffuse or localized abdominal pain with tenderness on palpation, typically accompanied by diarrhea (often bloody) 2
• May require steroids and/or biologics; admission indicated for severe disease 2

Small Bowel Obstruction

• Presents with cramping abdominal pain, distension, and tenderness on palpation with high-pitched bowel sounds or absent sounds if complete 1
• CT demonstrates dilated bowel loops with transition point 1

Critical Diagnostic Algorithm

Step 1: Assess for Peritoneal Signs

• Involuntary guarding, rebound tenderness, and rigidity indicate peritonitis requiring immediate surgical evaluation 1, 3
• Absent bowel sounds suggest ileus or perforation 4

Step 2: Obtain Imaging Based on Location and Severity

• CT abdomen/pelvis with IV contrast is the gold standard for acute nonlocalized abdominal pain, changing diagnosis in 51% and admission decisions in 25% of patients 1
• Right lower quadrant pain: Consider ultrasound first in young patients to avoid radiation, but proceed to CT if equivocal 1
• Left lower quadrant pain: CT with IV contrast for suspected diverticulitis 1

Step 3: Laboratory Evaluation

• Complete blood count (leukocytosis suggests infection/inflammation) 6
• Comprehensive metabolic panel (electrolyte abnormalities in obstruction) 6
• Serum amylase/lipase if epigastric component (≥4x normal for amylase or ≥2x normal for lipase indicates pancreatitis with 80-90% sensitivity) 4
• Lactate level if mesenteric ischemia suspected 1

Management Based on Etiology

If Peritoneal Signs Present

• NPO status, IV fluid resuscitation, broad-spectrum antibiotics, and immediate surgical consultation 1
• Serial examinations every 2-4 hours if observation attempted 1

If Appendicitis Confirmed

• Hospital admission for appendectomy (laparoscopic preferred) 2
• Antibiotics: piperacillin-tazobactam 3.375g IV q6h or ceftriaxone 1g IV q24h plus metronidazole 500mg IV q8h 2

If Diverticulitis Without Complications

• Outpatient management: ciprofloxacin 500mg PO BID plus metronidazole 500mg PO TID for 7-10 days 2
• Clear liquid diet advancing as tolerated 2
• Admit if fever >38.5°C, peritoneal signs, immunocompromised, or unable to tolerate oral intake 2

If Inflammatory Bowel Disease

• Mild-moderate: mesalamine 2.4-4.8g daily or budesonide 9mg daily 2
• Severe: methylprednisolone 40-60mg IV daily, admit for monitoring 2

Critical Pitfalls to Avoid

• Never dismiss pain out of proportion to examination findings—this is the hallmark of mesenteric ischemia with 60% mortality if missed 1
• Do not rely on FAST ultrasound alone for bowel injury—it misses 20% of bowel injuries on initial evaluation and requires 400-620mL of free fluid to detect 1
• Serial examinations are mandatory in patients with equivocal findings—peritoneal signs from small bowel perforation may take hours to develop due to neutral pH and low bacterial load of small bowel contents 1
• Elderly and immunocompromised patients may have minimal examination findings despite serious pathology—maintain high index of suspicion and lower threshold for imaging 1
• Palpation technique matters: use gentle, systematic approach starting away from painful area to avoid voluntary guarding that obscures true peritoneal signs 3