What is the appropriate workup for a patient presenting with breast and abdominal pain?

From the Guidelines

For a patient presenting with breast and abdominal pain, a comprehensive workup should begin with a detailed history and physical examination to determine the characteristics, timing, and associated symptoms of both complaints. For breast pain, determine if it's cyclical or non-cyclical, unilateral or bilateral, and perform a thorough breast examination looking for masses, skin changes, nipple discharge, or lymphadenopathy. Initial imaging for breast pain should be guided by the patient's age and the nature of the pain, with ultrasound recommended for women under 30 with focal, noncyclical breast pain, and mammography, including digital breast tomosynthesis (DBT), and ultrasound being appropriate for women 30 and older, as indicated by the American College of Radiology Appropriateness Criteria 1. For abdominal pain, identify the location, quality, radiation, aggravating and alleviating factors, and perform a complete abdominal examination checking for tenderness, masses, organomegaly, and peritoneal signs. Basic laboratory tests should include a complete blood count, comprehensive metabolic panel, lipase, and urinalysis. Additional tests may include an abdominal ultrasound or CT scan based on clinical suspicion. If gynecological causes are suspected, pelvic examination, transvaginal ultrasound, and pregnancy test should be considered. It's essential to recognize that breast and abdominal pain occurring simultaneously could represent separate pathologies or potentially related conditions such as inflammatory disorders, metastatic disease, or referred pain. Treatment should be directed at the underlying cause once identified, with appropriate pain management in the interim using acetaminophen or NSAIDs if not contraindicated, as the risk of cancer in a woman presenting with breast pain as the only symptom is low, between 1.2% and 6.7%, as noted in the NCCN Clinical Practice Guidelines in Oncology 1. Key considerations in the management of breast pain include providing reassurance to the patient and treating the pain with symptomatic management, and for focal breast pain, age-appropriate diagnostic imaging is recommended, with diagnostic mammogram with or without ultrasound for those ≥30 years of age, and ultrasound for those <30 years of age 1.

From the Research

Breast Pain Workup

• Breast pain is typically approached according to its classification as cyclic mastalgia, noncyclic mastalgia, and extramammary (nonbreast) pain 2
• The risk of cancer in a woman presenting with breast pain as her only symptom is extremely low 2
• Imaging of mastalgia depends upon the suspected etiology, with cyclical breast pain not requiring an imaging work-up 3
• The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older 3
• Management of breast pain is often supportive, as most breast pain resolves spontaneously, with additional therapies available for severe and resistant cases 2, 3

Abdominal Pain Workup

• Acute abdominal pain is a common presenting concern with a broad differential diagnosis, including gastroenteritis, nonspecific abdominal pain, cholelithiasis, urolithiasis, diverticulitis, and appendicitis 4
• Pain location, history, and examination findings help guide the workup after ensuring hemodynamic stability 4
• Recommended tests may include a complete blood count, C-reactive protein, hepatobiliary markers, electrolytes, creatinine, glucose, urinalysis, lipase, and pregnancy testing 4
• Imaging studies are chosen based on the location of pain and index of suspicion for specific etiologies, with computed tomography with intravenous contrast media often chosen for generalized abdominal pain, and ultrasonography for right upper quadrant pain 4

Combined Approach

• A thorough clinical evaluation, including history and physical examination, is essential for both breast and abdominal pain workups 2, 4, 5
• Imaging and laboratory tests should be used judiciously, based on the suspected etiology and clinical presentation 4, 3, 6
• A multidisciplinary approach, involving breast care specialists and radiologists, may be necessary for complex or severe cases of breast pain 3