From the Guidelines
The workup for abdominal pain should begin with a thorough history and physical examination to identify the location, quality, timing, and exacerbating/alleviating factors of the pain, followed by selective use of laboratory tests and imaging studies based on clinical suspicion, as recommended by the American College of Radiology 1.
Initial Evaluation
The initial evaluation of abdominal pain should include a thorough history and physical examination to identify the location, quality, timing, and exacerbating/alleviating factors of the pain. This information can help guide the selection of laboratory tests and imaging studies.
- Initial laboratory tests should include complete blood count, comprehensive metabolic panel, lipase, urinalysis, and pregnancy test in women of childbearing age.
- Imaging studies should be selected based on clinical suspicion, with abdominal X-rays for obstruction or perforation, ultrasound for gallbladder or gynecological pathology, and CT scan with contrast for more comprehensive evaluation of acute abdominal conditions.
Imaging Studies
Imaging studies play a crucial role in the evaluation of abdominal pain, and the choice of modality should be tailored to the suspected diagnosis.
- Ultrasound is the initial imaging test of choice for patients presenting with right upper quadrant pain, as recommended by the American College of Radiology 1.
- CT scan with contrast is recommended for evaluating right or left lower quadrant pain, as it provides a more comprehensive evaluation of acute abdominal conditions 1.
- MRI is another emerging technique for the evaluation of abdominal pain that avoids ionizing radiation, and has been shown to have high sensitivity and specificity for diagnosing appendicitis 1.
Additional Tests and Management
Additional tests may include stool studies for infectious causes, H. pylori testing for suspected peptic ulcer disease, and endoscopy for upper GI symptoms.
- For severe or concerning presentations (peritoneal signs, hypotension, tachycardia), immediate surgical consultation is warranted.
- Pain management should be provided with acetaminophen or NSAIDs for mild pain, or opioids for severe pain, while avoiding masking important clinical findings, as recommended by the World Journal of Emergency Surgery 1. This systematic approach helps differentiate between common causes like gastroenteritis, appendicitis, cholecystitis, diverticulitis, bowel obstruction, and more serious conditions requiring urgent intervention, ensuring appropriate diagnosis and treatment while minimizing unnecessary testing.
From the Research
Abdominal Pain Workup
- Abdominal pain is a common presenting concern in both office and emergency department settings, accounting for up to 40% of ailments in ambulatory practice and 5-10% of all ED primary presenting ailments 2, 3, 4.
- The differential diagnosis for acute abdominal pain is broad, with common causes including gastroenteritis, nonspecific abdominal pain, cholelithiasis, urolithiasis, diverticulitis, and appendicitis 3.
- The workup for abdominal pain typically begins with a thorough history and physical examination, with attention to pain location, history, and examination findings to guide further testing 3, 5.
Laboratory Studies and Diagnostic Tests
- Recommended laboratory studies may include a complete blood count, C-reactive protein, hepatobiliary markers, electrolytes, creatinine, glucose, urinalysis, lipase, and pregnancy testing 3.
- Imaging studies, such as computed tomography with intravenous contrast media or ultrasonography, may be chosen based on the location of pain and index of suspicion for specific etiologies 3.
- Point-of-care ultrasonography can aid in the prompt diagnosis of several etiologies of acute abdominal pain, including cholelithiasis, urolithiasis, and appendicitis 3.
Limitations of Laboratory Tests
- C-reactive protein and white blood cell count alone are weak discriminators and cannot be used as a triage instrument in the selection of patients with acute abdominal pain requiring additional diagnostic tests 6.
- A systematic approach to evaluating abdominal pain is essential to providing patients with efficient and accurate care 4.