When should an ultrasound be ordered for a young, healthy patient with normal laboratory results and complaints of generalized abdominal pain?

From the Guidelines

In a young, healthy patient with normal laboratory results and generalized abdominal pain, an ultrasound is recommended if the pain persists for more than 2 hours or is accompanied by other concerning symptoms such as nausea, vomiting, or fever 1.

Key Considerations

• The patient's pain is localized to the right lower quadrant or is severe, an ultrasound should be ordered promptly to evaluate for potential conditions such as appendicitis 1.
• In the interim, the patient may be treated with acetaminophen 650mg every 4 hours as needed for pain, but an ultrasound should not be delayed if clinical suspicion for a serious condition remains high 1.

Imaging Approach

• A step-up approach for diagnosis should be used, starting with clinical and laboratory examination, and progressing to imaging examinations if necessary 1.
• Ultrasonography is a useful initial imaging test, especially in patients with right upper quadrant pain or suspected appendicitis 1.
• Computed tomography (CT) may be used if the diagnosis is uncertain or if ultrasonography is inconclusive, but it should be used judiciously due to concerns about radiation exposure 1.

Clinical Judgment

• Clinical findings, such as signs and symptoms, should be used to guide decision-making in the risk stratification of patients with possible appendicitis or other intra-abdominal infections 1.
• The clinician should carefully evaluate the patient's clinical presentation and use their judgment to determine the need for imaging or other diagnostic tests 1.

From the Research

Ultrasound Ordering Criteria

When considering ordering an ultrasound for a young, healthy patient with normal laboratory results and complaints of generalized abdominal pain, the following points should be taken into account:

• The patient's symptoms and physical examination findings should be carefully evaluated to determine the likelihood of appendicitis or other causes of abdominal pain 2, 3, 4.
• Ultrasound can be a useful diagnostic tool in patients with right lower quadrant pain, particularly in pediatric and pregnant patients, due to its lack of radiation 3, 4.
• However, the diagnostic accuracy of ultrasound for appendicitis is limited, and other imaging modalities such as CT scans may be necessary in some cases 5.
• A thorough anamnesis and physical examination are essential in assessing acute abdominal pain, but may not always provide a clear diagnosis 5.

Specific Considerations

• In patients with generalized abdominal pain, a diagnosis of primary peritonitis should be considered, particularly if the patient's condition worsens over time 6.
• Ultrasound may not always be able to diagnose conditions such as rectus abdominis muscle tear, which can mimic appendicitis 3.
• The choice of imaging modality will depend on the patient's symptoms, physical examination findings, and laboratory results, as well as the availability of imaging modalities and the patient's radiation exposure history 4.

Imaging Modalities

• Ultrasound is a useful initial imaging modality in patients with right lower quadrant pain, particularly in pediatric and pregnant patients 3, 4.
• CT scans may be necessary in some cases, particularly if the diagnosis is unclear or if the patient's condition worsens over time 4, 6.
• MRI may also be considered in some cases, particularly in patients who cannot undergo CT scans or who require further evaluation 4.