What are the guidelines for managing mid abdominal pain?

Management of Mid-Abdominal Pain

For patients presenting with mid-abdominal pain, obtain CT abdomen/pelvis with IV contrast as the primary diagnostic test after ensuring hemodynamic stability, as this changes diagnosis in 51-54% of cases and alters management in 25-42% of patients. 1, 2

Immediate Assessment and Stabilization

Check vital signs immediately for fever, heart rate >100, tachypnea, hypotension, or altered mental status—these indicate potential sepsis, bowel ischemia, or perforation requiring immediate resuscitation. 1, 2

• Establish IV access and initiate fluid resuscitation if hemodynamic instability is present. 1, 3
• Administer low-molecular-weight heparin for VTE prophylaxis, as acute abdominal conditions carry high thrombotic risk. 1, 3, 2

Critical Physical Examination Findings

Look for peritoneal signs first—guarding, rebound tenderness, and rigid abdomen suggest perforation or ischemia and mandate immediate surgical consultation. 1, 3

• Absent bowel sounds indicate ileus or complete obstruction. 1
• Abdominal distension with tympany suggests bowel obstruction. 1
• Visible peristalsis or severe pain after eating suggests mechanical obstruction. 1

Key Historical Features That Change Management

Pain migration patterns matter: Pain that migrates from periumbilical to right lower quadrant strongly suggests appendicitis. 2

• Vomiting before pain onset makes appendicitis less likely. 2
• Recent surgery or prior abdominal operations raises concern for adhesive small bowel obstruction (55-75% of SBO cases). 2
• Age >60 years with atherosclerotic risk factors should prompt consideration of mesenteric ischemia. 2
• Document current medications, especially steroids, immunomodulators, or anti-TNF-α agents, which mask symptoms or increase infection risk. 3

Laboratory Testing Strategy

Order serum lactate levels—elevated lactate strongly suggests bowel ischemia or sepsis. 1, 3, 2

• Complete blood count to assess for leukocytosis or anemia. 1, 3
• C-reactive protein is more sensitive than WBC alone for surgical abdominal disease. 1, 3
• Basic metabolic panel for electrolyte abnormalities and renal function. 3

Imaging Protocol

Single-phase IV contrast-enhanced CT is sufficient—pre-contrast and delayed phases are unnecessary. 2

• Do NOT delay CT for oral contrast, as it delays diagnosis without improving accuracy. 1, 2
• Plain radiographs have limited utility and should generally be avoided, except when bowel obstruction is strongly suspected clinically. 2
• Ultrasonography is first-line only for suspected gallbladder disease, not mid-abdominal pain. 3

Common Imaging Pitfall

Do not obtain repeat CT scans without clear clinical indication—diagnostic yield drops from 22% on initial CT to 5.9% on fourth or subsequent CTs. 2

Differential Diagnosis Framework for Mid-Abdominal Pain

The most common causes in ED patients with generalized/mid-abdominal pain: one-third no diagnosis established, one-third appendicitis, and one-third other documented pathology including small bowel obstruction, pancreatitis, perforated peptic ulcer, and malignancy. 2

Specific conditions to prioritize:

• Mechanical bowel obstruction—look for transition point on CT. 1
• Perforated viscus—if peritoneal signs present. 1
• Mesenteric ischemia—especially in elderly with atherosclerotic risk factors. 2
• Early appendicitis—may present with periumbilical pain before migration. 4, 2

Antibiotic Decision Algorithm

Do NOT routinely administer antibiotics for undifferentiated mid-abdominal pain. 4, 1, 3, 2

Antibiotics are indicated ONLY when:

• Intra-abdominal abscess identified on imaging. 4, 1, 3, 2
• Clinical signs of sepsis present. 4, 1, 3
• Perforation confirmed. 1

When antibiotics are needed, cover Gram-negative bacteria and anaerobes with fluoroquinolones or third-generation cephalosporin plus metronidazole. 4

Pain Management

Provide early analgesia without compromising diagnostic accuracy. 1, 2

Avoid opioids—they worsen constipation, cause narcotic bowel syndrome, gut dysmotility, and increase mortality in chronic abdominal pain. 1

Mandatory Surgical Consultation Criteria

Involve surgery immediately for:

• Signs of peritonitis (guarding, rebound, rigidity). 1, 3, 2
• Free air on imaging. 1, 3, 2
• Complete mechanical bowel obstruction on CT. 1, 2
• Hemodynamic instability despite resuscitation. 1, 3, 2
• Bowel ischemia or mesenteric ischemia. 1, 2
• Failed conservative management after 48-72 hours. 1

Special Population Considerations

Elderly patients may have normal labs despite serious infection—maintain high suspicion and rely on imaging. 2

Immunocompromised patients should be evaluated for opportunistic infections, as immunosuppressive medications mask inflammatory signs. 3

When Functional Disorder is Suspected

If CT is negative, labs normal, and no alarm features present, consider irritable bowel syndrome (IBS) as a working diagnosis. 4

IBS diagnosis requires: At least 12 weeks in the last 12 months of abdominal discomfort or pain with two of the following: relieved by defecation, associated with change in stool frequency, or associated with change in stool consistency. 4

Supportive features for IBS: Female, age <45, history >2 years, frequent past attendance with non-gastrointestinal symptoms. 4

Once functional diagnosis established, repetitive testing is not recommended—refer for psychological support (cognitive therapy) with pharmacological options. 5