From the Guidelines
A patient with abdominal pain should undergo a step-up approach for diagnosis, starting with clinical and laboratory examination, and progressing to imaging examinations, with CT scan being the preferred initial imaging modality, as recommended by the WSES 2016 consensus conference 1. The patient's presentation with abdominal pain, nausea, vomiting, and fever, along with laboratory findings of leukocytosis and mildly elevated C-reactive protein, suggests a possible intra-abdominal infection.
- The clinical evaluation should include a thorough physical examination, including assessment of rebound tenderness, guarding, and other signs of peritonitis.
- Laboratory tests, such as complete blood count, blood chemistry, and urinalysis, should be performed to help identify the underlying cause of the abdominal pain.
- Imaging examinations, such as CT scan, should be used to confirm the diagnosis and guide management, as recommended by the ACR Appropriateness Criteria for acute nonlocalized abdominal pain 1. Some possible causes of abdominal pain include:
- Acute appendicitis
- Diverticulitis
- Cholecystitis
- Pancreatitis
- Bowel obstruction
- Intra-abdominal infection The management of the patient should be tailored to the underlying cause of the abdominal pain, and may include:
- Antibiotics for intra-abdominal infections
- Surgery for acute appendicitis, diverticulitis, or other conditions requiring surgical intervention
- Pain management with acetaminophen and ketorolac
- Fluid resuscitation and supportive care for patients with severe abdominal pain or underlying medical conditions. The use of CT scan as the initial imaging modality is supported by the ACR Appropriateness Criteria, which recommends CT scan as the most appropriate imaging examination for patients with acute nonlocalized abdominal pain 1.
From the Research
Case Presentation of a Patient with Abdominal Pain
- Abdominal pain is a common presenting concern in both office and emergency settings, accounting for up to 40% of ailments in ambulatory practice and 5-10% of all ED primary presenting ailments 2.
- The causes of abdominal pain can range from simple to complex presentations, and patients may have various physiological and psychological needs 3.
- A patient presenting with acute abdominal pain may have a broad differential diagnosis, with common causes including gastroenteritis, nonspecific abdominal pain, cholelithiasis, urolithiasis, diverticulitis, and appendicitis 4.
- The evaluation and diagnosis of acute abdominal pain involve considering the pain location, history, and examination findings, as well as recommended tests such as complete blood count, C-reactive protein, and imaging studies like computed tomography or ultrasonography 4.
- In certain cases, point-of-care ultrasonography can aid in the prompt diagnosis of etiologies like cholelithiasis, urolithiasis, and appendicitis, while magnetic resonance imaging may be preferred over computed tomography in pregnant patients with inconclusive ultrasonography results 4.
Common Causes of Abdominal Pain
- Gastroenteritis
- Nonspecific abdominal pain
- Cholelithiasis
- Urolithiasis
- Diverticulitis
- Appendicitis
- Extra-abdominal causes like respiratory infections and abdominal wall pain 4
Diagnostic Approach
- Ensure hemodynamic stability
- Consider pain location, history, and examination findings
- Recommended tests: complete blood count, C-reactive protein, hepatobiliary markers, electrolytes, creatinine, glucose, urinalysis, lipase, and pregnancy testing
- Imaging studies: computed tomography, ultrasonography, or magnetic resonance imaging based on the location of pain and index of suspicion for specific etiologies 4